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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 98-104

Restraints practices among psychiatric nurses in state mental health-care setting, Karnataka, India


1 Prof and HoD, Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India
2 PG Student, Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India
3 Department of Psychiatry, Mysore Institute of Medical Sciences and Research, Mysore, Karnataka, India

Date of Web Publication21-Jan-2020

Correspondence Address:
Dr. Sunanda Govinder Thimmajja
Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neurosciences, Dharwad - 580 008, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IOPN.IOPN_25_19

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  Abstract 


Background: Using physical restraints are a highly preferred practice in psychiatric wards. The main reason to use physical restraints in psychiatric wards is to prevent injury to patient and others and reduce violent behavior among mentally ill patients. Purposes: The purpose of the study is to determine the use of physical restraints and ongoing practices among nurses working at psychiatric wards. Methods: This was a descriptive, cross-sectional study done involving fifty psychiatric nurses. Nurses who agreed to participate in the study filled out structured self-report questionnaire prepared by the investigators. Results: The mean number of patients cared by each nurse per month was 52.88 and mean number of patients restrained by nurse per month was 7.74. Twenty percent of nurses reported that they use alternatives before employing restraint practices. Ninety percent of nurses reported using roll of gauze as a restraint material. A good number of nurses (68%) reported that the restraint procedure is limited to <2 h. Only 4% nurses reported receipt of written orders for use of restraints. There was a significant association between age of the nurses with number of patients cared. Conclusion: For a better nursing care, it is very important to develop a restraint practice protocol.

Keywords: Mental health-care setting, protocol, psychiatric nurses, restraints, restraints practices


How to cite this article:
Rentala S, Thimmajja SG, Nanjegowda RB, Bevoor P. Restraints practices among psychiatric nurses in state mental health-care setting, Karnataka, India. Indian J Psy Nsg 2019;16:98-104

How to cite this URL:
Rentala S, Thimmajja SG, Nanjegowda RB, Bevoor P. Restraints practices among psychiatric nurses in state mental health-care setting, Karnataka, India. Indian J Psy Nsg [serial online] 2019 [cited 2020 Mar 30];16:98-104. Available from: http://www.ijpn.in/text.asp?2019/16/2/98/276348




  Introduction Top


In ancient societies, restraints originated as a natural response to dangers posed by mentally disturbed individuals.[1] Throughout the history, the use of restraints has been associated with punishment, custodial care, institutional abuse, and neglect.[1]

Restraint can either be physical or chemical in nature. A physical restraint is a mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot get rid of easily and that which restrict freedom of movement or normal access to one's own body. A chemical restraint is a medication used to control abnormal behavior or restrict the patient's movement and is not a standard treatment for patient's condition.[2]

The major reason for the use of restraints in hospitals is the protection of the patient, others or both,[3] to handle violent and maladaptive behavior,[4] manage patients with severe mental disorders,[5] prevent injury and reduce agitation and aggression,[4] and often medication and verbal therapies are insufficient to control potentially dangerous patients.[3]

In 1994, Fisher reviewed the literature and concluded that restraint and seclusion were helpful in preventing injury and reducing agitation among patients and that it was impossible to run a program caring for mentally ill individuals without the use of these restraints.[6]

Although this restraint intervention is inherently designed to protect patients from harm to self or others, it is associated with many potential complications. Many studies have shown the negative effects of physical restraint on both patient and health-care personnel.[7]

A review by Mohr et al. 2003[8] concluded that the use of restraints puts patients at risk for physical injury and death. A survey of 142 patients identified the frequency of potentially harmful events and associated psychological distress. This clearly shows that commonly used interventions are traumatic to patients,[9] cause emotional effects and in some cases may also lead to death.[10] This procedure further stimulates aggression among patients and damage to the therapeutic relationship between the health-care personnel and the patient.[11] It is also contrary to the treatment principles and patient dignity.[12]

Background of the problem

Studies show that in many countries, >20% of psychiatric patients are restrained physically at some point during their hospitalization.[12] Study carried out a literature review to identify information on the use of seclusion and restraint among psychiatric inpatients wards in 12 different countries the reported incidence of physical restraint varied from 0% in Iceland to 35.6% in Austria, this literature shows that there is a wide variation in incidence rate of physical restraint use between countries. Therefore, it is essential to explore the physical restraint rate and patterns of using physical restraint.[13]

In India, there is a lack of studies on use of restraints and seclusions. A study conducted in the Indian setting reported that restraint was used as a method of control for violent, suicidal, agitated, and delirious patients. In the nursing home setting, the prevalence rates range from 19 to 84.6% and 34% have been reported in rehabilitation settings. There is a felt need in development of indigenous guidelines on restraint and seclusion.[14]

One of the studies conducted in India reported that restraint must not be imposed in any form as a means of punishment, discipline, the convenience of or retaliation by staff, or because of a lack of staff presence or competency. Training should be developed to allow standardized and safe restraint techniques to be taught throughout India.[15] There is no relevant nursing guideline for physical restraint use has been published in India. Understanding restraints practices among psychiatric nurses helpful in developing strategies that would reduce restraints practices.

Assessment of restraint practices is necessary before developing a minimizing program or indigenous guidelines to provide quality care in psychiatric hospitals. Thus, the present study was conducted with the purpose of determining the use of physical restraints and ongoing alternatives to restraints practices among staff nurses working at psychiatric hospital.


  Materials and Methods Top


This study was descriptive and cross-sectional in nature. The sample comprised 50 registered nurses working at Mental Health Care setting, Karnataka, India, a State Government Mental Hospital Care setting, with 212 beds the main objective of this institution is to provide quality services to patients. The clinical services consist of inpatient, outpatient, emergency, and rehabilitative services. Both voluntary and involuntary admissions along with forensic cases are catered to. The data were collected during June 2016. Inclusion criteria were: (a) registered nurses (b) with minimum 6 months experience in psychiatric wards and (c) are willing to participate. A total of 57 staff nurses working, among them 3 were on long leave, 54 staff nurses were approached, 4 refused to participate, and remaining fifty gave the consent to participate. Convenience sampling technique was used to select the samples.

Ethical consideration

Participation was voluntary and written informed consent was obtained from the participants. The study protocol was approved by the Institute's Ethics Committee.

Assessment

All nurses who fulfilled the inclusion criteria were administered the sociodemographic pro forma and self-reported structured questionnaire on restraint practices among nurses. The structured questionnaire was developed by the investigators based on the current literature and the investigators observation on the restraining practice.

Sociodemographic pro forma: It includes questions on their age, gender, qualification, total year of clinical experience, and total years of experience in psychiatric wards.

The structured questionnaire on restraint practices among nurses includes 22 questions under three subheadings.

  • General information regarding use of restraints – 2 questions
  • Use of alternatives prior to restraining patient – 10 questions
  • Nursing care practices regarding use of restraints – 10questions.


Responses were marked as Yes or No and scored in frequency and percentages. Content validity of the tool was assessed by panel of seven experts from the department of psychiatry, clinical psychology, and psychiatric nursing. Panel members were asked to rate each question for its appropriateness. Applicability of the instrument was assessed by administering the tool to five psychiatric nurses. All the participants stated that questions were easy to respond to. Data were analyzed using descriptive and inferential statistics.


  Results Top


The sociodemographic characteristics of the study participants are presented in [Table 1]. The mean age of the study participants was 38.84 (standard deviation [SD] 10.02). Participants were predominantly women (62%). Forty-two percent of the participants studied up to B. Sc. (N). The mean total experience was 8.50 (SD 8.13) and mean psychiatric experience was 5.72 (SD 6.40). [Table 2] presents general information regarding the use of restraints. The mean numbers of patients cared by each nurse per month is 52.88. The mean number of patients restrained by each nurse per month is 7.74.
Table 1: Demographic characteristics of the sample (n=50)


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Table 2: General information regarding use of restraints


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Use of alternatives prior to restraining the patient is presented in [Table 3]. Twenty percent of nurses reported that they are using alternatives before employing restraint practices. All the nurses reported use of chemical restraints and also reported that they do not have any management protocol in the ward for the use of alternatives prior to the use of restraints. [Table 4] depicts nursing care practices related to restraints use. Patients with violent behavior (72%) were mostly restrained patients in this study. Majority of the nurses (90%) reported using gauze as restraint materials. Ninety-four percent of the nurses report that they use four-point restraints (immobilization of all four extremities). Majority (72%) of the nurses reported that restraints are used more frequently during the afternoon and night shifts (2 pm to 8 am). Pulse and color of the restrained extremity (92%) were the mostly monitored factors during restraint use. Most of the nurses (68%) reported that the restraint procedure is limited to <2 h. Only 6% nurses' reported receipt of written orders for restraint application. Forty percent of the nurses reported the documentation of restraints procedure in the case files. Twenty percent of the participants reported that consent is taken from family members for restraint application.
Table 3: Use of alternatives prior to restraining the patient


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Table 4: Nursing care practices related to restraints use


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A one-way ANOVA test and t-test was conducted to compare the age, gender, qualification, experience, and psychiatric experience of the participants with the mean number of patients cared and mean number of patients restrained [Table 5]. There was significant association between age and number of patients cared at the P < 0.05 level for the three age groups. Post hoc comparison test indicated that the mean number of patients cared by 31–40 years (M = 61.69, SD = 26.62) was significantly different than the below 30 years age group (M = 43.82, SD = 14.65). There was no significant association between gender, qualification, experience, and psychiatric experience with number of patients cared and restrained.
Table 5: Comparison of demographic characteristics with respect to mean number of patient's cared and mean number of patients restrained


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  Discussion Top


Nurses in the psychiatric wards provide care to the patient who exhibits violent and nonadaptive behaviors, to manage these behaviors nurses use a variety of therapeutic and nontherapeutic approaches. One of these approaches is physical restraint. In this study, use of physical restraints and ongoing alternative practices among nurses working in psychiatric wards at a state-run mental health-care setting, Karnataka, India, were discussed. In this study, mean number of patients restrained by each nurse per month was 7.74. Coercive interventions are generally used to treat, cure, or control the psychotic patients. Several studies emphasized use of physical restraint as a means to control nonadaptive behavior of patients.[16] Physical restraint can also be exercised in the case of psychiatric patients who are unable to control their emotions and behaviors.[4] Mental Health Care Bill 2013 stated that physical restraint or seclusion may only be used when it is the only means available to prevent imminent and immediate harm to person concerned or to others.

In this study, mostly patients with violent behavior (72%), absconding behavior (12%), patients who receive sedation (10%), and agitated behavior (8%) were subjected to physical restraints. A study revealed that violent behavior is the most frequently cited indication for restraints use.[17] Another study conducted on physical restraint practices among intensive care unit (ICU) nurses in Turkey revealed that patients who were mostly agitated (96%) and those who receive sedation (4.8%) were subjected to restraints. The reasons for restraint use must be addressed with special policies in the hospitals.[18]

In this study, only 20% of the staff reported using alternative methods before restraining the patient. This could be on account of lack of knowledge regarding the effectiveness of alternative methods to deal with violent patients. A better understanding of this would allow nurses to diagnose and treat the patient while ensuring the safety of other staff and patients. The Joint Commission on Accreditation of Healthcare Organizations and numerous advocacy groups are also advocating the use of alternative methods prior to restraints.[19]

The present study showed that there was no protocol in the ward for the use of alternatives prior to restraining patients. It is important that health-care professionals aware and follow proper protocol and measures when restraining a patient to ensure safety of the patient.[20] Failure to follow proper protocol can have legal consequences for health-care professionals.[21] All mental health-care organizations need to have standard protocols and train their staff in adopting alternatives to restraints.[22] The present study revealed that 90% of staff use roll of gauze as a restraint material for physically restraining patients. Only 10% reported using special physical restraint material like padded cloth with strings for restraining the extremities. The main reason expressed by nurses is lack of standardized material. A study reported that 92% of the nurses use the roll of gauze directly on patient's wrists or ankles.[18]

In this study, 94% of the nurses reported using four-point physical restraints. A study conducted on ICU nurses revealed four-point restraints as the most preferred (50.8%) type of restraint.[17] Although the present study is not conducted in an ICU care facility, the use of four-point restraints was found to be higher than the previous study.[18]

The present study revealed that higher (72%) use of restraint practices in the afternoon and night shifts when compared to the morning shift. This may be on account of lesser number of nurses working in the afternoon and night shifts compared to the day shifts. Previous study on ICU nurses reported high rate (49.2%) of restraint practices during night shifts.[18] Further studies suggest that reduced nurse: patient ratio may also result in the increased use of both physical and chemical restraints.[23]

According to the literature, airway opening, mental status, safety, sleep cycle, pain and physical disorientation, hydration, elimination, and nutritional needs must be assessed once in every 2 h.[18] In the present study, nurses reported that pulse and color of restrained extremity were mostly (92%) assessed during the physical restraining procedure. Nurses should not only look for physical signs of possible damage but also focus on meeting nutritional and elimination needs.[18]

In the present study, majority nurses reported (68%) the usual duration of physical restraint procedure to be <2 h. Restraining patients for >2 h without interruption is not a reliable nursing practice.[23]

In this study, only 40% of nurses reported documentation of reason and sites for restraint procedure.[24] This shows that minority of nurses' documented inadequate details on physical restraints use. The results of the present study are consistent with other studies where nursing documentation of physical restraints has been found less than adequate.[18],[25]

A physician order is required to physically restrain a patient. The order should include date, time, and duration of the procedure; it should be renewed by physician every 24 h.[17],[26] In the present study, only 6% nurses reported taking written orders from physician. The study results were similar to that of previous studies, where most of the nurses did not receive any order from physician either for application or removal of restraints.[18],[25]

In this study, 80% of the nurses did not take written or oral consent from the family members for restraining the patient, remaining 20% of nurses reported taking oral consent from the family members for the restraining procedure. All the nurses reported that written consent forms for family members pertaining to restraint procedures are not available in the ward. In the present study, only 12% of nurses attended education regarding restrains use. There is a need to educate staff on the least restrictive methods, such as one-to-one, to prevent the overuse of restraints.[27] Making it mandatory for every nurse to attend regular in-service education or training in restraint procedures should reduce the restraint use practices in psychiatric setup.

This study has some limitations. This study was based on self-reported information on use of physical restraints. Nursing staff may be unwilling to admit the use of such restraints, and the percentages reported may be an underrepresentation of actual use. Consequently, more research is required. Given the small sample size, there is a need to confirm the findings with larger sample. Outcome measures relied on participant self-reporting, estimation of number of mentally ill patients subjected to physical restrains by actual observation will strengthen study validity.

Implications of the study

In view of the outcomes of the present study described above, it is important that all mental health-care settings should have protocol on use of restraints. Nursing staff and other health care personnel should attend regular in-service education programs; it should include how to assure safety to patients, the consequences of restraint use, alternative methods to restraints, care of patient with restraints, and ethical and legal implications involved in restraining procedure. Other recommendations to facilitate minimal restraint use involve including restraints topics in both diploma in nursing and graduate and postgraduate psychiatric nursing subject curriculum.


  Conclusion Top


This study revealed that restraining is a highly preferred practice in psychiatric wards. Use of alternative procedures before restraining the patient is minimal. Mostly violent patients are subjected to restraining. All the nurses in psychiatric setup must have training on an annual basis at a minimum on verbal deescalation techniques and the prevention and management of violent behavior. A protocol that describes the ways of applying restraints must be developed. Educating nurses about restraint practices will reduce misuse of physical restraints in psychiatric setup.

Acknowledgment

The authors would like to thank the staff nurses who are participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Department of Health and Human Services: Centers for Medicare and Medicaid Services. Condition of Participation: Patients' Rights; 2002. Available from: http://a257.g.akamaitech.net/7/257/2422/12feb20041500/edocket.access.gpo.gov/cfr_2004/octqtr/pdf/42cfr482pdf. [Last accessed on 2005 Dec 13].  Back to cited text no. 2
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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