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ORIGINALS

Mechanical restraints as experienced by nursing staff at a child and adolescent psychiatric unit*

Susana Marqués Andrés^1
1Nurse Specialized in Mental Health. University degree in Psychology. Hospital de Basurto, Bilbao (Spain)

Mail delivery: Susana Marqués Andrés. Autonomía 67, A, 3º E. 48012 Bilbao (España)

Manuscript received by 8.01.2007
Manuscript accepted by 28.03.07

Index de Enfermería [Index Enferm] 2007; 58: 21-25
*This paper obtained the First Prize for Nursing Work 2005, awarded by the Association of Nurses of Bizkaia

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Abstract

Introduction: The restraint is a technique widely used by nurses in hospitals under medical supervision. Its use in psychiatric units adolescent patients can result in emotionally conflictive. When referring to the restraint, it is necessary to explain motives, situations, professional expectations, type of patient and their specific problems. The minors who are admitted to a psychiatric unit in order to be mentally evaluated, experience great frustration, usually expressed through aggressive behaviour when they realise that they will have to spend a few days in hospital. Objectiv: To acknowledge the existence of the medical team of the psychiatric unit for children in Basurto Hospital (Bilbao), regarding the restrain for adolescents.
Method: The phenomenology is the main theory which we focus on. The design is descriptive-interpretative, based on qualitative methodology. Results: The results of the study have been divided into three categories, which are in turn divided into its respective categories: (a) The restraint procedure = corporal sensations, thoughts and performances. (b) The questioning = individual assessment, the team's observation, the view of its usage, the use of criteria. (c) The usage of the technique = the effects of the surroundings, the negative reinforcement, last alternative. There is a negative feeling surrounding the usage of the restraint; negative feelings due to unknown comments, and others as a result of the relevant cognitive assessment. Both of these have influenced the following decisions regarding the use of the technique. Conclusions: It is necessary to take into account all the criteria in order to work together as a team and to try and find the best method to use this technique.
Key-words: restraint, seclusion, behavioral disorders.

Introduction

    Referring to restraint globally is not very concrete. The reasons for restraint vary and expectations in each case will also differ.
    The core topic in this research is the subjective experience of nursing staff when using mechanical restraints on adolescent inpatients in a child and adolescent psychiatric unit.
    The use of restraint affects nursing staff personally, causing personal, professional and humanitarian inconveniences. Therefore, social considerations, as well as subjective and personal experience, have a bearing on the decision to use mechanical restraint.
    Personal considerations for using the method depend on the given interpretations. The Milgram¹ experiment may have something to do with them, since nursing staff often become the executor of the legitimate authority. They deny responsibility for their own behavior when accepting the establishment of an organized social hierarchy. They also experience a fear of using cruelty when obeying treatment guidelines. They question taking on board "mechanical restraint devices" and feel obliged to think twice about their own behavior, controlling it and answering for it. Thus, our initial consideration was that "nurses are ethically and legally liable for the care they provide or should provide in the course of their professional duty",² which implies taking the opportunity and appropriateness of using mechanical restraint into consideration.
    Considerable bibliographic silence surrounds mechanical restraint. In Spanish it is only mentioned in seven papers^2-8 in the CUIDEN database. The method is used in all hospitals, although there are references of less. We have one reference from Greece⁹ and another on practice based on evidence in the magazine published by the Joanna Briggs Institute in Australia.¹⁰ A few more can be found in the MEDLINE database.
    People under age who are admitted to a psychiatric unit in order to be mentally evaluated feel great frustration, usually expressed through episodes of psychomotor agitation and anger attacks when they realize that they will have to spend a few days in hospital. Sometimes they have been tricked into coming and other times they realize that they need to be hospitalized. Recurring to mechanical methods of restraint is a painful resort in such situations¹¹ but it may be of the essence and necessary to ensure a safe environment and preserve them from physical harm, as well as their companions and the nursing staff. Using restraints may leave a bitter aftertaste of having "trampled" on a person's human rights. However, construing it as a tool may help to remove "disastrous" emotional overtones.
    The main theory which we focus on is phenomenology, according to which subjective phenomena can only be understood from the standpoint of individual experience.¹² This paper seeks to learn about the experience of the members of the nursing team in a Child and Adolescent Psychiatric Unit (CAPU) at the Basurto Hospital, in Bilbao (Spain). The Unit was chosen for several reasons: it has easy access, the author belongs to it, and it provides an opportunity to approach the topic with inside knowledge. It is a new Unit, with two and a half years of experience. The team is enthusiastic and highly motivated, in the process of cohesion, self-analysis, self-criticism, and on-going improvement of daily practice, particularly in the use of mechanical restraint and therapeutic alternatives to it. Currently, the mentioned unit follows a protocol (Fernández, Vivanco and Marqués: Protocolo de alteración de conducta. XIII Nacional de la Sociedad Española de Psiquiatría Forense. Badajoz, April, 2005). Some opinions and experiences have probably changed due to the method, since it is being used as a criterion for unanimity. Likewise, the discussion that arose from this paper proved useful in making group actions cohesive.

Participants and method

    The design is descriptive-interpretative, based on qualitative methodology within the context of phenomenology.
    The sampling used was intentional. All team members were asked to take part when the work began in March 2005, in order to study the group's general feeling. In all, 12 members of the team, six nurses and six auxiliaries nurses, took part. The only criterion for inclusion was acceptance of the proposal to take part in the study.
    Their ages were similar, around 45, with over fifteen years of hospital experience. One nurse came from psychiatrics and the rest from several different hospital units. Team members all began to work in the CAPU at the same time, with no other experience with adolescents than their own children and family.
    The conversations, which were recorded, lasted from one to two hours, depending on the characteristics of each staff member, and were transcribed literally, in full. The conversations sought controversial and opposite opinions on common topics, in order to validate the outcomes of the dialogue when it was already saturated. An in-depth interview was used to gather data, trying to keep it spontaneous, loosely structured and based on a brief initial script.
    Thoughts and sensations brought on by mechanical restraint was the initial question we used to break the ice. Beyond doubt, subjectivity on the method used by the Unit's nursing team emerged from the conversation.
    To add to the validity of the data, literal transcriptions of the interviews were returned to each nurse participant so they could read, correct, add to or delete any parts of the conversations that they considered to be wrongly interpreted or private. The content was not analyzed until all of the material was returned and the participants indicated that they fully accepted the manuscript.
    The procedure described by Colaizzi¹³ was used to analyze the content of the conversations. The last item, the meeting to express their opinions, was changed due to fit the participants' schedule. The steps followed were to:
1. Read the literal transcription corrected by the participants, which gave an overall view of their experiences.
2. Identify the aspects related to the study topic, and to key words and sentences.
3. Determine the meaning of each significant word and sentence.
4. Classification of the topics considered to be important to the study into groups. These are the researcher's interpretations¹³ which go beyond the literal discourse, are coherent with it, and exemplify its meaning.
5. Integrate the participants' ideas into an in-depth descriptive and analytical report.
6. Deliver a written report on the outcome of the research to the participants so they could write down their impressions on the findings and on the way they were interpreted and return them.
    The flexibility of the entire process was a methodological requirement. It led us to consider that another person could make a different classification and even arrive at a different definition to the one given in this paper.
    Slight corrections were made to the literal quotes in order to make them easier to read. In some cases, repetitions of concrete words, drawn-out syllables and the tics inherent to any conversation were deleted to avoid disagreeable feelings along the lines of "I don't express myself well".

Results

    We classified the experience with mechanical restraint into three categories with their respective sub-categories, as follows:
-The intervention: mechanical restraint: It consists in any expression of conduct deployed during the restraining phenomenon. The sub-categories we describe are: physical sensations, thoughts, feelings and performance.
-Questioning the intervention: The team makes a self-analysis on how they acted before deciding to use restraint, without forgetting the method's "disagreeable" emotional after-taste. The sub-categories are: individual assessment, how the team is perceived, self-criticism for using restraint, the employment of unanimous and objective criteria, differences in assessment.
-Usefulness of the method: Sometimes mechanical restraint can be useful as a constraint that gives time to think and drain contained angry emotions. The sub-categories are: timely restraint, taunting the milieu in a play to the limits, negative reinforcement and last resort.

Intervention: mechanical restraint. Behavior evidences one's emotional and cognitive reality. It goes beyond what can be seen, as a result of the BEHAVIOURAL TRIAD: physical sensations (physiological reality), thoughts (interpretation of reality), and performance (what one does, based on what was felt and thought). The triad leads to one's response. This process is automatic, irrational and immediate. Self-analysis serves to gather information on the process. It makes one to stop to think, remember what one did, enumerate the results and assess the usefulness of what one achieved. With this information, changes can be made in one's behavior the next time.
    Descriptions of the physical sensations caused by restraint evidence a deep-seated unease among the nursing staff that use the method. This uneasiness has considerable impact on whether to use it as a tool. Nurses feel compelled to seek justifications with clearly emotional overtones when making their cognitive assessments. Although some nurses have not had a bad experience, the general feeling is that it is quite disagreeable.
     My voice trembles and paleness. (E)
     My heart is in my throat. (F)
    Thoughts refer to the force involved in mechanical restraint, feelings of having used aggression, and the resulting uneasiness among the nursing staff.
    "If it is someone strong, you get in a bad mood. I mean, you have to hurt them. It leaves you with the feeling that you've been physically aggressive. (A)
    These feelings start the process of analyzing the experience. "Remorse" caused by guilty feelings is also frequent, although it is often denied. To deny an experience implies ignoring physical sensations. The literal expressions are quite significant.
    Jeez, maybe if I had taken a step back at the beginning it wouldn't have come to this. Or maybe not, but you have this doubt and you say, well, maybe next time I'll step back and see what happens. (E)
    Afterwards I feel annoyed with myself because somehow I have this feeling, let's see, not guilt but like you feel you could have avoided it and that maybe you could have controlled them some other way. But then, when you think about it, you see it's the only way, the best way for everyone, including them. (F)

Questioning the intervention. An individual assessment of restraint also takes place. It depends mainly on the personal emotional significance as well as the use of restraint. It determines whether the situation will be judged as serious enough to justify the use of restraint. The conviction that no other tools are available calms the disagreeable feeling left by using it.
    "It [restraint] is a failure. A professional failure, although I'm not sure [that other strategies exist, but] maybe I have the wrong idea about mechanical restraint when I shouldn't have them. I think it's rude. (E)
    The questioning goes deeper into how the team perceives the way restraint is carried out in order to respect and defend the adolescents' rights at all times. Obviously, it goes into the number of people needed, group unity, the allocation of tasks to each member, approaching the patient, preparing the bed with the restraint devices, and so on. However, it also goes into other aspects, such as quickness, calmness, keeping silent to avoid refuting or answering the youngster's messages, soothing words for the youngster and for the staff so they will not break down once the decision to use restraint has been taken.
    Before and during restraint [the aim] is to control the situation and hurt the kid as little as possible. It's not all a matter of strength. I think a lot of other factors enter into it, like doing it as quickly as possible and the rapport between the staff who are restraining. I've learned, with children in particular, to shut up because the patients tend to say the rudest things they can think of. (B)
    Self-criticism is an obligation and a necessity when working with habits and behavior. It is used by the team to obtain feedback that will allow them to improve the practice of restraint, change certain actions, discharge emotions, revise criteria, and seek alternative means of approach.
    It's true that next time I'm going to use more resources because I analyze whether I have used every possibility or done all I could have done. (B)
    Maybe we should study and reorganize our ability to endure, to listen, to be calm. I don't want to answer back. (I)
    No matter how clear the restraint procedure is in general, it is obvious that there is still a lack of criteria for some aspects of restraint. For instance, why it should be done, how long should it last, and which aspects of interaction and communication with the youngster determine when restraint should be removed. All this could become a reason for confrontation, particularly when restraint is no longer seen as an external means of control when internal means cannot be used. Even when the procedure is straightforward, issues still arise regarding how to use restraint and staff attitudes.
    "Within the lack of strict rules that I apply, they can pull a lot of shit on me and fool around because nothing happens, but when they push it to the limit, well, some people don't allow it and others aren't affected, even when they do the same as I do. (E)
    The differences in judging whether or not a situation requires restraint are worth mentioning. There may be personal differences when it comes to evaluating a circumstance, depending on a particular skill for holding without having to use a restraint, or for using restraint as an initial resort that subsequently becomes a problem. Or to use avoidance as an alternative, that is, to not do anything, thereby solving the problem by avoiding confrontation with the patient. Any strategy may be appropriate, controversial or unnecessary. However, constant questioning of daily practice is useful in that it provides feedback on professional decisions and performance. Besides self-criticism, hetero-criticism on how to improve is also employed in an open, trusting and safe environment so no one will feel personally called into question in the decision.
    "You work better when you feel complicity than when you're on the defensive, you know? I like it [complicity] much more, but you don't always feel that way, right? (C)

Usefulness of the method. The method enables us to learn where the limits are. Sometimes, timely restraint can prevent uncontrolled agitation. When youngsters become worried, impulsive and out of control, verbal control may provide them with different references to reality than the ones that moved them to act: most often, attributions to external, stable circumstances beyond their control. When they feel unable to control themselves, an invitation to isolation with the possibility of restraint is usually accepted, even asked for. It is of the essence to understand provocation, without giving in to it, as a means for drawing attention in order to discharge unease and purge guilty feelings along the lines of "I deserve it". Thus, adolescents show that they are completely unable to ask verbally for what they really need or are used to getting, without becoming agitated and provocative.
    "I remember one restraint that we expected to be very violent and then, well, I did ask for advice but I took the initiative, right? So I called everyone, we took him to his room and so on. And, well, in the end I felt good because we managed to talk and restraint wasn't needed. So then you feel fine, which is what I mean that, when you are sure that you have to use restraint and then even so you manage to reach the kid, you feel great. (C)
    Taunting the milieu is sometimes a way of obtaining from the outside what cannot be tolerated in one's interior:
    1) Punishment to atone for guilt and "badness".
    2) Control one's lack of control.
    3) Stop feelings of impotence by fighting against the restraint as a way of diminishing the physiological responses that are triggered by the anger caused by frustration or a feeling of being abandoned. Through mechanical restraint, they realize that the only thing they can do is think, after their hyper-activity has been stopped, along with their impulsiveness, opposition and negative feelings, and open or veiled attacks against their peers and staff, taunting, insults, and spoiled behavior. From this point of view, restraint could be seen as a way of providing instruction, guidance, models and molds, attention, restriction and exemplification that allow them to learn. Rules are made so they will learn to govern themselves by external references, and be able to govern their moral conscience.
    The ones working here, we have to know what to say, "Well, not now, not now". You have your reasons for saying no, and on top of that for the kid to say, "That's true, today is not about what I want. What can we do, yesterday it was my turn but not today". Generally, most of us can do that now. And that's good. We retain the authority we're supposed to have. (E)
    This is restraint as a negative reinforcement, not a punishment. It frees the adolescents from their anxiety over their situation. It calms them down by allowing them a "catharsis" that normally they cannot do. When their movements are restricted by restraint, they can let go. They do so with a feeling of belonging, without feeling ashamed of yelling and kicking, without group repression. It is the need of the youngsters and of the nursing staff. Subsequently, staff members help the youngsters to interpret their feelings, find the best ways to express unwanted and disagreeable ones, and to analyze their behavior. From that point of view, restraint can be useful to adolescents as an analytical tool.
    For one reason or another, you feel that they are asking for it. It's a way to draw attention. (A)
    In any case, in our Unit we tend to use mechanical restraint on adolescents as a last resort. The team uses every strategy known to them to delay or avoid the need for restraint, and gives youngsters every possible opportunity to think of the consequences of their behavior.
    In general, we are tolerant with them until we are overwhelmed, until we get to the point where of exhaustion. I think we also become more tolerant as we learn how to control our own insecurity. I find that when we have to restrain is when they have gone beyond the emergency and when they have gone so far that there is no way of bringing them down. (A)

Discussion

    The subjectivity derived from applying restraint is based on a learned, blind and automatic cognitive assessment.¹⁴ It is the result of a classification process and personal attributes and has an impact on how restraint is experienced. It conditions subsequent approaches and decision-making on the issue.
    When assessing the need to use restraint in certain situations, one must ask: Is this a first choice method or a last resort? What should I assess in a restraint and how can I assess it? How do I assess the decision: on the basis of an interpreted attitude or on the description of concrete behavior? What does agitation mean to me? In mental health care, proper use of any method requires discussion and uniform criteria. When uneasiness determines decision-making, it is even more important to exchange experiences.
    Organization, cohesion and consensus provide a feeling of safety when one needs to intervene, particularly when personal subjectivity plays a core role in interpreting behavior.
    Analyzing restraint implies knowing how it can be done and how to improve it, when it should be used and when it should end, how to use it and what to do while it is being done, and then to analyze its usefulness, assessing the outcomes with a person who has undergone it. Mechanical restraint of adolescents with behavior disorders is probably one of the most complex methods that can be used. Medical sessions are needed to pool existing data and personal experiences that allow staff to "discharge" uneasy feelings about using the method.
    Some people defend that restraints in psychiatry should be exemplary¹⁵ in order to mold behavior: respect for others' rights, obey the limits, tolerate frustration. However, methods¹⁶ that are more appropriate and didactic exist, based on active listening and empathy, which allow adolescents to express important feelings, and confused, mixed-up or wrong ideas. In short, so they can express their psychological constellation and make decisions. Learning alternatives to restraint requires time and effort. It means learning to read the milieu with the adolescent and other team members, in terms of objective and contrasted behavior.
    Empirically, the mechanical restraint seems that it has an analytical utility when handling itself like final alternative in behavioral alterations. After it the behavior of the transgressors changes, beginning to respect the limits, at the moment in the unit. It is an element more than it makes possible the reflection. Probably because during the time of restraint, they cannot do more than to think, to analyze, self-critic, to criticize, to plan and to decide.
    Silence during restraint is an ethical and professional imperative. To argue, explain and answer back means reinforcing the arguments for continuing disruptive behavior caused by the emotional turmoil that triggered the process. Adolescents, incapable of tolerating frustration, express their anger inadequately, causing a physiological "high"¹⁷ that forces them to defend themselves by attacking. Professionals need to be trained to identify their experience and, above all, their reactions.
    The symbology of NO is an aim that the team needs to be clear about in order to guide the youngster. Difficulties in obeying that symbology may lead to confuse the care of the adolescent. Saying no is a way to teach them to tolerate frustration and to seek and deploy more appropriate options that adjust to their reality. It enables them to learn from their mistakes,¹⁸ assuming changes and uncertainty.
    On the other hand the nurses are a referring one of adult different from the customary one. The security that maintains the personnel with the adolescents with respect to certain behaviors and the reflection of the possible consequences, allows to introduce doubts that slant the security of the young person, making possible to start up different facings.
    To deny one's feelings is to reject one's own experience. It is a way of being outside of reality. Communicating paradoxical messages confuses the receptor, prevents group unity and encourages unresolved issues to grow larger. It is the beginning of much-feared division within the group.

Acknowledgement

    My sincere acknowledgement of the support and collaboration of the nursing team at the Child and Adolescent Unit of Basurto Hospital for sharing their opinions, experiences and criticism. Their contribution makes this paper worthy of attention. Any errors are only attributable to the author, for not knowing how to understand the feelings they expressed.

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