Review of Related Literature: Assessment of the Professional Standards on Restraint and the Actual Restraint Practices of Nursing Staff in a Mental Healthcare Facility



In the medical arena, it is important that individuals that are involved must have specialization in order to have unparalleled opportunity and capability to address the critical issues that face the world’s current health care system. The role of the nurse as a vital member of the healthcare team through collaborative professional practice must always give priority through caring its patient. The primary goal of being a nurse is to assist individuals in the achievement of an optimal level of wellness. When it comes to mental patients, their special characteristics call for a more sensitive approach in taking care of their needs, hence, nursing practice in the mental institutions demand more from health attendants. Such challenge is experienced in the daily tasks nurses have to accomplish in order to ensure that the needs of these patients are met.

The trend in psychiatric nursing involves the use of various methods of restraint to control aggressive behaviour and prevent harm to the person, other patients and hospital staff. Restraint is still practiced despite the fact that there are alternative means of dealing with the aggressive behaviour of patients. The use of restraint became controversial with the number of reported deaths resulting from the use of restraint. This opened-up various issues on the applicability of restraint in present psychiatric procedures, review of the policy and standards of psychiatric professional organizations in considering the provisions of law, review of the policy and actual psychiatric practices of nursing staff in mental health facilities, and the standard of qualification and skills training of hospital staff on restraint. All these issues point to the necessity of evaluating the propriety and continuity of restraint as a psychiatric practice.

This research will look into the existing studies on restraint in psychiatric hospitals. The issues tackled, the methods and the theories applied will be noted from the researches and commentaries obtained from journals and books in support of the findings of the study.


Critical Appraisal

Nursing is the process of caring for, or nurturing, for an individual known as the “patient”. More specifically, nursing refers to the functions and duties carried out by persons who have had formal education and training in the art and science of nursing. To promote the restoration and maintenance of health in their clients, nurses become more particular in enhancing their knowledge through integrating with health and biological sciences (1993).

As an applied discipline, the vocation of nursing evolves within a dynamic body of knowledge. The quality of nursing practice is dependent on the knowledge of individual practitioners as well as their willingness to engage in professional relationships and behaviours. Nurses are required to have the skills and know-how to explore, confirm, and direct the progress of nursing practice. Necessary measures are observed in order to uphold professional development in the field of nursing so as to improve the knowledge base, which is the foundation upon which clinical practice decisions are made, progressive education which comprise of the continuing learning activities that are crafted to benefit the individual and the profession, mentoring and networking which are the professional relationships that are instituted with the intent of supportive growth for the individual as well as the profession, research which is the qualitative and/or quantitative investigation of the factors which affects the professional nursing practice, and lastly career development which are purposeful, planned strategies that are designed to boost short and long term professional goals.

In a journal article written by  (1999), a lot of academicians and practitioners of psychiatric medicine have claimed that people in the legal as well as in the psychological communities are until now experiencing difficulties in addressing such scenario with great uncertainty particularly the reality that civil confinement is executed for the dangerous mentally ill patients (I1990; 1992). For the individuals ( 1989;1976; 1985; and 1986) who agreed on involuntary hospitalization of the mentally ill emphasized that the impermanent lack of freedom is a valid response in order to protect the population from the dangers that psychiatric persons may inhibit.

  Definition and Concepts                Restraint has been defined by the Health Care and Financing Corporation as “any physical method of restricting a patient’s freedom of movement, physical activity or normal access to his/her body.” (International Organization of Psychiatric-Mental Health Association 2001) There are different kinds of restraint which are: 1) chemical restraint-the use of a drug or medication to control behavior or to restrict freedom of movement; 2) mechanical restraint-use of implements in restraint procedure such as leather or cloth restraints, papoose board, calming blanket, and body carrier; 3) physical restraint-involves a staff member in bodily contact with the patient without the use of any mechanical apparatus; 4) preventive aggressive devices-use of wrist-to-waist and ankle-to-ankle devices that allow a patient to move but limiting his/her ability to harm others; 5) seclusion is one form of restraint where a patient is confined in a room; 6) time-out is also a form of restraint where a patient is given a time to calm down by excluding him/her from the activity causing stress (American Academy of Child and Adolescent Psychiatry 2002).   Standards on the Use of Restraint

Caring may be fundamental to the continuance of civilization. In the past, numerous definitions of caring in nursing have been presented. The most commonly accepted of it is that of  He said that the moral idea of nursing consists of transpersonal and human-to-human attempts to protect, enhance and preserve humanity ( 1998).

               The International Organization of Psychiatric-Mental Health Association (ISPN) issued its position on the use of restraint and seclusion on psychiatric officials. Selection and restraint should be employed only as a last resort when less restrictive methods no longer ensure the safety of patients, families and hospital staff. The organization also espouse the proper training for psychiatric staff in analyzing situations and delivering good judgment on the proper manner of handling aggressive patients and use all other options before resorting to restraint. There should be immediate evaluation of whether the use of restraint has a beneficial effect on the patient. The use of restraint should also be documented to develop a database of its use and effects.


Beliefs of Nursing Staff on Restraint

                    A study conducted to survey the beliefs of staff members on seclusion and restraint on child and adolescent patients in both public and private psychiatric hospitals showed that there is a general belief among staff members regardless of position that there is seldom or occasional positive effect of using seclusion and restraint among the patients. However there is an unexplained significant difference between the response of hospital staff from public and private hospitals. Staff from private hospitals reflected a higher incidence of the positive effects of seclusion and restraint than staff from public hospitals. The hospital staff also distinguished the different aggressive behavior of patients in answering the question of propriety of seclusion and restraint. Physical aggression towards staff, physical aggression towards peers, self-injury, and threats of violence got two digit percentages reflecting the belief that seclusion and restraint are justified in these circumstances with physical aggression towards staff considered as the greatest justification for the coercive practice. Non-compliance with staff directives, hallucinations and hyperactivity are actions which cannot justify seclusion or restraint. The research reflects the lack of sufficient guidelines for the use of seclusion and restraint (Curtis 1996).                A different report on belief is shown in the research paper of (2000) in the first of four generalizations on the use of restraints. First is the use of seclusion and restraint is prevalent in psychiatric hospitals and there is a positive response from the nursing staff interviewed on the use of seclusion and restraint for aggressive patients. The use of restraint is viewed as an effective means of containing an individual, maintaining safety and provides an opportunity to achieve control. Control is seen as the most salient justification of the belief in the use of restraints because the other reasons given can easily be achieved through alternative means while control is easily regained with restraints. Second is that there exist a variety less restrictive means of dealing with aggressive behavior such as time-out, verbal intervention and medication. Third is the presence of inconsistencies in psychiatric nursing practice and clear guidelines or procedures. Fourth is the need to develop theoretical framework on which future studies will be based to help in standardization of psychiatric nursing practices.                In a research conducted by (2004), psychiatric nurses were studied regarding their perceptions about the coercive measures in acute psychiatric setting using the survey method. They found out that the respondents view coercive measures such as forced medication, four-point restraints, and patient seclusion of patients as ethically problematic particularly to the female nurses who work on closed wards. The authors concluded that although the psychiatric ward ethical standards in the country have been closely studied, majority of the nurses who participated in the study perceived that coercive measures employed in the institution are not ethically problematic. They recommended further research on the topic and continuous education among nursing schools and personnel focusing on ethical practices. They likewise challenged the concerned individuals to consider alternative ways of effective and legitimate measures applied in mental institutions which will provide sound ethical decisions and moral reflections.                  The small-scale academic investigation initiated by (2004) explored the claims and statements shared by patients and nurses as approved by the National Health Service Research ethics Board and the Research Ethics Committee of University of East London revealed that the narratives of the nurses and the patients are contradictory. They suggested confirmatory research that will further evaluate and assess the results of their study as well as more training on the part of the nurses in managing violent behavior in the hospital. The study also resulted to the construction of a grounded theory highlighting the concept of control and five other related variables (the construction of identity of the perpetrator of violence; nurses’ dual role of caring and controlling; aspects of parentalism involved in control; following set policies and procedures; and segregation from mainstream society) that influence the characterization and description of the environment of a particular mental institution. The researchers made use of the interview method in order to generate qualitative data for their study so as to provide in-depth analysis of the actual setting in the psychiatric ward they studied.      

The literature review conducted by  (2005) regarding the perception and behaviours of nurses toward aggression in health care revealed that most of the studies conducted from the year 1980 analyzed the concept of cognition and attitude from the framework of The Theory of Reasoned Action. Most of the studies also utilized the self-report questionnaire as the most common method to gather data and information on their research endeavours which upon analysis, lacked certain standards of validity. The authors claimed that out of the total 74 researches investigated, two thirds focused on cognitions and only one fourth highlighted the concept of attitudes towards aggression. They further stated that the use of different instruments in the studies they used made it difficult to compare the results generated by the said researches.

  Issues on Restraint

It cannot be denied that one of the world’s major problems is to ensure the health of millions of people.  Although there are may professionals who are certain about their works and whom can be considered as an exemplary member of the healthcare professionals, there are still issues that can be attached on them professionally.  The individual healthcare professional’s ability to do what is proposed with proper competence, ability and skill is, of course, very crucial in ensuring safe clinical care.  But professional competence is only part of the picture since nobody is perfect.  Good people with good skills and good intentions, sometimes commit mistakes.  As part of this professional issue, to be a nurse is to observe a dynamic based of caring based on a theoretical body of knowledge. 

               As a response to the deaths of patients related to restraint procedures the American Academy of Child and Adolescent Psychiatry (2002) made a summary of the causes of these reported deaths and gave recommendations on how further deaths can be prevented. The AACAP found out that 40% of the deaths were caused by asphyxiation when excess weight, towel or sheet is put over the head of a person to prevent spitting or biting that obstructed the air passage of the patients. Strangulation, cardiac arrest or fire account for the other reported deaths. The contributory circumstances include restraining patients with deformities which prevents the proper application of restraint and the lack of continuous observation of the patients. The root cause of the deaths were: 1) inadequate patient assessment; 2) inadequate care planning which do not consider alternative methods to restraint; 3) use of restraints as punishment; 4) inappropriate room or unit assignment; 5) lack of patient observation and monitoring procedures; 6) staff issues in training; 7) inadequate staff levels; 8) staff competency and credentialing problems; 9) equipment failure and improper use of restraint.                The causes of the deaths were within the control and could have been prevented by mental health regulatory bodies and hospital staff. The AACAP (2002) gave the following recommendations: 1) revising patient assessment procedures to consider age, gender and individual situations in employing restraints; 2) promote staff training in alternatives to restraint and the proper application of restraint; 3) revise staffing model; 4) revise the observation and monitoring procedures for patients to constantly keep watch over patients in restraints, modify qualifications or credential requirements to ensure that hospital staff have adequate training and experience in dealing with psychiatric patients; 5) allow patients to rotate when using supine restraints and not cover the entire face during therapeutic holding; 6) discontinue the use of high neck vest and waits restraints; 7) ensure that smoking materials are not accessible to patients in restraint.   Reducing and Minimizing Restraint          The nurse functions in an interpretative and anticipatory nature, where in it involves the patient in making decisions about his/her physical or physiological condition, the personal monitoring of patients that undergoes a life threatening situation and giving service to patients where in their life supporting treatment mechanisms are malfunctioning or underlying a critical process (Zalumas 1995). These practices form a well define perspective is holistic in manner, may the nurse be in a deferent environment, from community to a hospital setting. Clearly the main thrust of nursing is to help clients attain and regain optimal health wellness; in this sense the nurse would be reputable by their accountability.                Accountability of nurses appears as a mode of moral conduct that are foremost in the understanding of those willing to be informed by means of nursing health care and service (Thompson, 1997). When nurses do a health service task, the nurse carries a responsibility performing it.  A registered nurse in practice of the profession is accountable to what was done. Accountability is not just a mere sense of licensed to be achieved but accountability must be an integral and essential element of a responsible practice.                There are several methods of reducing restraint that involves the cooperation of the various aspects of the psychiatric hospital from the organization in general to its heads and then to the nursing and other staff. Reducing the use of restraint requires a change in the policy of the hospital towards restraint. If the hospital will adopt alternative ways of dealing with aggressive behavior then the hospital staff will not employ restraint. The change in policy should be clearly communicated with hospital staff and the staff should be well informed and trained of alternative methods to change the restraint practice of hospital staff. A strong leadership is also needed to affect change in the use of restraint. Giving sufficient training and sharing experience on alternatives to restraint is a form of hospital staff empowerment which results to nursing staff who are in control and aware of their responsibilities. A motivated nursing staff is more likely to employ greater levels of tolerance and is more likely to employ persuasive methods rather than coercive techniques. Hospital staff should have adequate training and the hospital should develop and delineate areas of expertise of the nurses based on experience and skills (Delaney 2001).                Reducing the use of restraint should also consider the point of view of patients and their parents or family members. The hospital should have a record of the situations or objects that cause a particular patient to become aggressive and adjust activities to minimize the patient’s exposure to aggression stimulants or to help the patient deal with the stimulant. Nursing staff should be able to anticipate and prevent or minimize aggression. Hospital staff should also gather document the perception of patients and their family members on restraint and discuss with them the situations of activities which makes them calm (Delaney 2001).          Minimization of the use of restraint is the psychiatric standard currently issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS). Ethical and legal standards also give patients that freedom to be free from restraints. Thus in actual practice restraints should be avoided and these should only be used only if necessary. Because of this discretion given to nursing staff to use restraints only when necessary, nursing staff should be well-equipped with the required knowledge, skills and experience to be able to determine when restraints are necessary and the proper means of employing these restraints (Napierkowski 2002).                Obligations of the nurse to be knowledgeable about the rights of their patients, be it moral and legal, the nurse is also accountable in protecting the patient that is in cause. In assessing the patient’s information, the nurse also is handed out to explain and present the implications of the decisions. Such situations like this, the nurse would act as a surrogate relative to the patient on addressing and understanding the problem. Accountability’s main role in professionalism is to recognize the situation of the patient in a self-determined manner.                (1995) conducted a research study which explored the general attitudes towards the use of physical restraint in psychiatric nursing as well as the contributions of the 1985 Ritchie Report and the 1991 Report of the Committee of Inquiry into Ashworth Hospital regarding the debate on the use of control and restraint within psychiatric institutions. He focused on and evaluated the ethical justifications as well as the ethical and political objections in the use of such methods in managing aggressive and self-injurious behaviors in contemporary mental health nursing practice. The research study found out that the development of new therapeutic approaches which would allow more negotiation between nurses and patients and would recognize the possible benefits of hearing out the claims of clients regarding their perceived unhelpful therapeutic interventions could reduce the difficulty in dealing with the majority of violent situations exhibited by the patients.

            An exploratory account of registered nurses’ experience of patients aggression in both mental health and general nursing settings revealed that verbal and ‘minor’ types of aggression are the most problematic, that repeated use of chemical and physical restraint is apparent and that mental health nurses seem to consistently take control of aggressive situations while general nurses tend to rely more heavily upon the input of medical staff, mental health teams and the police when intervening violent and aggressive tendencies and tantrums of patients ( 1999).

               A study conducted by (2004) showed that the lack of shared rhythm among patients during therapeutic discussions greatly affect their treatment conditions. They argued that in psychiatric care, although cooperation of the health attendants and the patients’ significant others are considered as one of the most important forms of intervention during group meetings through narratives, participation on the part of the patients should be given primacy. Such one-sided programs within the institutions is characterized and evident in the health care professionals’ controlled facilitation of the meeting where their opinions are more heard as they dictate the direction of the discussion and its overall pacing. The lack of shared rhythm in cooperation could be identified in the health care professionals controlled the storytelling by sticking to their opinions, by giving the floor or by pointing with a finger and visually scanning the participants, by interrupting the speaker or by allowing the other experts to sit passively.

             (2000) found out that physical intervention in response to violence and aggression among mental health patients is extremely high and is inversely proportional to the confidence level of the psychiatric staff to control and manage such situations. All staff who participated in the study received training in Strategies in Crisis Intervention and Prevention (SCIP) who after the three-month program felt more confident in the management of risk and crisis, and more supported by their organization. However, although there was no significant effect on the lesser incident of aggressive behaviour among patients after the training, the information gathered showed a greater tendency to use physical intervention in controlling the patients compared to other available techniques of addressing the need to manage the patients accordingly.  

               Meanwhile,(2002) studied the subjective effects of restraint among the staff and patients when violence and aggression in psychiatric inpatients units occur using the interview method. Data gathering procedures were conducted after restraint was executed to a particular patient. They found out that patients want the attention of the staff which they feel they do not get as making them feel upset, distressed and ignored before such incidents and then isolated and ashamed afterwards. Postincident debriefing is highly considered but patients are scared of being restrained reawakening distressing memories of past traumatic events. 

 (1998) continued the study on the past research conducted regarding the development of natural therapeutic holding as a form of non-aversive alternative to control and restraint in managing aggression and violence among people with learning disabilities. In their research study, they showed the programs utilized by mental institutions explaining the core values and importance of such techniques by describing the theories, aims and application of such methods. The case study method was used in order to present the concepts of individual risk management and pro-active intervention strategies analyzing the practical applications of such measures. The case study shows that over a relatively short period of time, an individual with severe learning disabilities who is aggressive and violent learns alternative coping strategies to aggression and violence through the application of natural therapeutic holding.  The authors concluded that the use of natural therapeutic holding as an intervention strategy in aggression and violence management for people with learning disabilities (a) provides staff with safe, professional and ethical skills to manage their clients and patients and that (b) as a therapy, natural therapeutic holding can make patients learn coping strategies which is better and more effective than the violence they exhibit. 

The exploratory research investigation undertaken by  (2005) focused on the impact of the use and implementation of physical interventions to people with intellectual disabilities and challenging behaviour through physical intervention techniques as well as how the service users and the staff alike felt regarding such practice. There were eight user/staff pairs who were interviewed about their experiences of physical intervention within a week of mutual involvement in a behavioural incident which required restraint use as the qualitative approach was utilized in order to obtain the opinions and perceptions on a non-pain compliance approach to physical intervention. The results illustrated that the user and the staff experiences were intrinsically intertwined which highlighted the interactional nature of their physical intervention. The results further demonstrated that the experiences during the physical intervention are dependent not solely on the applications of techniques but rather on the interaction among the users and the staff. The authors concluded that the service user and staff experiences were clearly affected by their appraisals of each other’s behaviour throughout the physical intervention process.  

 (2002) provided a literature review on service-user and professional issues which reviewed studies and researches conducted in the psychiatric and therapeutic communities which showed a range of conducted studies which dealt with advocacy, sexuality, abuse, offending, victimology, emergency, management of behaviour, law, social exclusion, models of disability and research ethics. Lack of studies utilizing the perspective and approaches of economics, ethics treatment and confidentiality, as well as the role of society in deciding for the disabled people is apparent.

 (2005) highlighted the importance of revisiting the relevant issues which pertain and addresses the essence of scientific integrity, health care objectives, as well as medical professionalism in the midst of increasing attention to evidence-based medical practices, the continuous advances in medical technologies and the rapid distribution and diffusion of innovative ideas and information. The incidents of harmful medical interventions which resulted to the continuous spread of mental disability among the community calls for a more case-intensive investigations so as to ascertain the exact conditions of the mental health institutions. Such was the subject of  (2005) study in his aim to ensure that long-term health and well-being for patients and the community remains the primary goal of medicine. His critical approach to studying the services and conditions provided to mental health patients he challenged the people in the medical field and profession to be the trustworthy advisors for individual patients and credible advocates of medical practice by subjecting them in the evaluation and assessment of the general population regarding their commercial interests on medical research, medical education and clinical practice.

   (2004) in his academic paper suggested and acclaimed the use of nursing-based evidence approach rather than the traditional evidence-based approach in pursuing researches and academic endeavours in mental health nursing. He said that although mental health nursing is dominated with the knowledge borrowed from the disciplines of psychiatry, pharmacology and behavioural sciences which all use the evidence-based approach, a new way of utilizing the nursing-based approach was highlighted and upheld in his study. He argued that the qualitative research and investigative design in mental health cases and practices is more fitting because the specialty’s primary interests  human experiences of illness/health care and human relationships, are most often than not critically researched and investigated using the quantitative research paradigm. In his study, he proved that the qualitative investigation is indispensable in the mental health nursing studies and researches. He highlighted that the work of nurses with clients and the explication of phenomena, referred to as the nursing-based evidence, calls for diverse range of knowledge and thus, diverse research approaches. Such approach values multiple approaches to knowledge development offering a way to articulate its distinct contribution to the health care of people who are suffering from mental incapacity and illness which in the long run could greatly advance the mental health nursing discipline.



Being a nurse, privacy, dignity and confidentiality should be maintained. You tend to know the very private information of the patients but you should never break the tradition of having a good impression to nurses. Nursing is such a noble profession. Being in this field, one should be ready to serve, have enough patience and give your wholehearted care to the patients especially in situations where the patients have complicated diseases. 

Commitment, dedication, hard work and patience, these are the qualities entwined to the holistic profession of nursing. Nursing as it is being portrayed is primarily a task-oriented profession (1999). Nurses existed and come hand in hand with in the portals of the medical world and health care service. With this kind of profession nursing has been accountable for its distinct kind of professionalization through the form of education and wide dynamism of research. This view has a big recognition on the moral standards and diverse ethics of nursing. 

The above literature provides a brief and illustrative look into the previous studies and researchers that were conducted by individuals from the medical field highlighting the concepts and context in which issues, beliefs, perceptions and evaluations on control and restraint physical intervention among patients with mental illness during aggressive and violent incidents were investigated fully alternative ways of addressing the need to meet the demands and requirements of the patients as well as the legal and medical communities were analyzed in order to execute rightful means of providing for the need of the mentally ill individuals.

For further studies and researches dealing with the concepts of control and restraint in mental institutions, the critical qualitative approach of looking at the topic in terms of the communication and interplay between and among the patients, staff of the mental hospitals could be an ideal focus of the study. The extent of implementing and executing control and restraint in a mental ward as dictated by the economic, political and cultural environment in the mental nursing institutions will be an interesting field of study. The role of power between and among the nursing staff and the patients could be looked into in order to fully explain and therefore, understand the position and the stakes of both the institution and its patients.  


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