Incidents involving violence and aggression are a frequent occurrence in adult mental health inpatient settings. They are managed by use of restrictive interventions (coercive practices) such as restraint, seclusion, injection of sedating drugs and constant observation.

The use of coercive and restrictive practices carries significant risks, including physical and psychological harms to both patients and staff. Interventions are costly in terms of staff sickness and litigation as well as the extra staffing resources required to implement them.

There remains a lack of research around patients’ perceptions before, during and after the use of restrictive interventions. A new review by Tingleff et al (2017) aimed to synthesis existing patient-focused research to understand their perspectives in greater detail.

Methods

A systematic literature review was undertaken. Four databases (CINAHL, PubMed, EMBASE & PsycINFO) were searched from 2000 to February 2017. A block search approach was undertaken. 4,880 records were screened against a predetermined criteria, resulting in 62 full texts being examined.

Thematic analysis of included texts (n=26) occurred. Studies were critically appraised (using the CASP checklists), but the outcome of this was not reported.

Results

• 26 peer reviewed studies were identified.
• Six themes (although seven reported in the paper) and associated sub-themes were identified from the thematic analysis.
• These themes were mapped to the timeline for restrictive intervention practice, namely before, during and afterwards.

Before coercion

• Being subjected to professionals’ control
  • This theme focused on the interactions between staff and patients. Triggers seemed to centre around power, loss of autonomy and controlling behaviours by staff.
• Protest behaviour
  • This usually occurred in response to perceived staff attempts at controlling the situation, and sometimes included actions like refusing medication.
  • There were two reported sub-themes which seemed to increase the potential for restrictive interventions:
    • Environment (being un-therapeutic)
    • Communication (particularly poor information provision).

During coercion

• Being subjected to professionals’ control
  • This theme related to the psychological and physical effects of being controlled against your will and the feelings particularly associated with trauma that resulted from these experiences. The published literature on this theme mainly reported on the negative impact associated with coercion.
  • The sub-themes were:
    • Physical discomfort; pain primarily a result of the coercive intervention
    • Physical environment, which related mainly to seclusion rooms and environments.
    • Control was also evident in the Interactions with professionals and its sub-theme communication (which also featured in the After Coercion theme – see below). It was evident from the literature that professionals repeatedly failed to interact in a therapeutic or compassionate manner, examples included lack of concern and empathy. Communication was limited and often didn’t include a rationale or description of the practices being undertaken.
• Impact of coercive measures
  • Some patients did report that restrictive interventions did have positive benefits; for example by preventing an escalation in violence or self-harm, where the resulting interventions maintained patient safety.

After coercion

• Interactions with professionals/Communication
  • When staff appeared to withdraw following an incident, this clearly impacted on the debrief and subsequent communication. Staff withdrawing and communicating less also damaged the therapeutic relationship between the patient and staff.
• Physical discomfort
  • This included the effects and side effects of medication, as well as the physical and psychological effects of restraint, or seclusion.
• Other consequences
  • The published literature suggested that longer term psychological outcomes resulted in subsequent trauma and potential delays to recovery.

Conclusions

The authors concluded:

The results from the study indicate that the majority of patients in the reviewed studies associated the use of coercive measures with “negative perceived impact”.

In order to enhance care during the process of coercion, greater sensitivity to the patients’ view of the situation is desirable at each point in the coercive process.

Discussion

This review has attempted to synthesise recent qualitative research focused on patients’ views of restrictive interventions. It clearly highlights how little we know about the preferences of psychiatric patients at times when staff intervene to maintain an individual’s safety, or indeed potential alternatives to prevent restrictive interventions being used.

It’s concerning that there is such a limited literature on patients’ views and perceptions around this topic. We still do not plan interventions with the preferences of those likely to receive them in mind. An increased focus on reducing restrictive interventions has resulted in a plethora of interventions (for example Safewards, NoForceFirst, 6 Core strategies (PDF)), but we still don’t know which work most effectively and are preferred by patients.

The review also highlights how much staff influence and trigger the use of restrictive interventions, clearly further work is needed to understand this more. There are known triggers that can escalate a situation such as the use of PRN medication, staff attitudes and ward rules. Whilst there is an international focus on reducing restrictive interventions, studies currently focus on individual interventions, but not the whole picture.

More focus on differences in practices across cultures and gender could yield significant improvements in practice. For example, women are more likely to be restrained, with potential for greater physical and psychological damage, particularly given improved understanding around childhood trauma. We should present opportunities to learn more about individual staff who excel at preventing restraint, as well as identifying those staff who struggle. This area really demands further research and this should be combined with a greater emphasis on de-escalation skills and training.

Limitations

• The review did not include grey or related literature
• Critical appraisal was carried out on the included studies, but the outcomes of this were not reported
• A lack of standardisation to practice, and differences of methods used across the world makes a synthesis of this kind difficult
• It was also unclear whether patients were involved in the review process itself, which is clearly important for a review of this nature.

Links

Primary paper

Tingleff EB, Bradley SK, Gildberg FA, Munksgaard G, Hounsgaard L. (2017) “Treat me with respect”. A systematic review and thematic analysis of psychiatric patients’ reported perceptions of the situations associated with the process of coercion. J Psychiatr Ment Health Nurs. 2017;00:1–18. https://doi.org/10.1111/jpm.12410

Other references

CASP http://www.casp-uk.net/criticalappraisal