Transcript The Use of Physical Intervention in Acute Mental Health Care: Decision-making and Rationalisation among Healthcare Staff Dr Helen Prosser Centre for Social Justice Research University of.

The Use of Physical Intervention in Acute
Mental Health Care:
Decision-making and Rationalisation
among Healthcare Staff
Dr Helen Prosser
Centre for Social Justice Research
University of Salford
Professor Liz Perkins & Dr Richard Whittington
Health and Community Care Research Unit
University of Liverpool
Context
• Physical intervention (PI) is “a skilled hands-on
method of physical restraint involving trained
designated healthcare professionals (aiming) to
prevent individuals from harming themselves,
endangering others or seriously compromising
the therapeutic environment.” (NICE, 2005:9)
• Why did we study decision-making among
healthcare staff?
– A local acute NHS Trust wanted to better understand
why physical restraint is used and in what
circumstances in order to inform efforts to effect
change and safer practice
• Although intended as a protective strategy, PI
a controversial aspect of psychiatric care.
• PI has caused physical injury, fatalities and
experienced by service users as distressing
and abusive.
• Incompatible with claims of best practice and
values of respect, dignity and autonomy.
 PI should be restricted to a very small number
of highly risky situations.
Restraint
• Vertical - The service user is physically
restrained in a standing or sitting position.
• Horizontal – The service user is physically
restrained by taking the individual down to the
floor. Training, emphasises that horizontal
restraint should be avoided wherever possible,
while restraining on the floor in a prone/facedown position should be used as an absolute
exception.
Aim and Objectives
• To explore the factors that influence the use of
horizontal and vertical physical restraint
– To explore the circumstances in which physical
restraint occurs from the perspective of nursing staff.
– To explore how nursing staff account for the decision
to use physical restraint.
– To explore nursing staffs’ experiences, feelings and
attitudes towards the use of physical restraint.
Study Design
Setting
Sampling
Data
Collection
Analysis
An acute Mental
Health Trust in
NW England
Purposive sampling;
recruitment based on
staff involvement in
a recent episode of
restraint
30 participants
17 individual
semi-structured
interviews
(critical incident
technique)
4 focus groups
- 3 nursing
staff; 1 ward
managers
Interviews/focus
groups audio-recorded
& transcribed verbatim
Thematic content
analysis
Findings
• In the majority of incidents, the service user
was moved to the floor and restrained in a
horizontal position.
• Antecedents – aggression/violence, self-harm,
absconding & the planned administration of
medication
Definitions of Restraint
• A management strategy to prevent harm
and protect the safety of the service user
and others in the context of aggressive
and violent incidents:
– I suppose it’s about controlling the situation, taking
control of situations, it’s about safely managing
situations…. Safety, maintaining safety to either self
or others. (Interview 5)
• A strategy of ‘last resort’
Discursive Accounts of PI
• 5 inter-related themes through which PI is
rationalized
– The specifics, severity and magnitude of service
user behaviour
– Routinisation
– Control
– Risk perception and uncertainty
– Individual staff ideologies, values and approaches
Service User Behaviour
• Staff perceptions of the
severity of the
behaviour
• Step-wise approach in
some incidents
Initially he was standing up, we
had his arms, trying to get his
arms down his side, just to stop
him from lashing out and hitting
us, that was proving
unsuccessful because of his
fitness and the excitement of the
patient himself. He was quite
threatened by this and I think
that made him a lot more hostile
to us initially, and it finished up
we just had to pull him on the
floor just to make sure. (I:6)
 Actual or threatened violent assault
OR
 Sudden and unexpected acts of violence or
aggression
= immediate horizontal restraint
– she was going to hit him…..we just restrained her, we took her
down. (I:3)
– He carried on walking towards the dining room at first I thought
he might be trying to go for the front door, even though they are
automatically locked. I placed again my hand on him to try and
ask him to come back to his room, with his other arm he went
to swing at me and the other member of staff grabbed him, we
restrained him. (I:3)
Routinisation
Instinctive/Intuitive;
standardized ‘rules of
thumb’
Normative practice
she actually lashed out at myself, so
she raised her fist and attempted
to strike me, so then we put hands
on automatically… …I didn’t think
she was a major risk anyway, to
anyone I think she lashed out then
on the spur of the moment, but
once we got the situation under
control and was able to speak to
her for 5 minutes, I felt safe she
was no longer a risk to anyone
(I:17)
I suppose you have to
see it as part of the
job, it goes with the
territory. (I:9)
Routinisation through lack of
options
A Necessary Evil
You need it because it’s for your safety and
other people’s safety. Because, you just
need it there because if you didn’t have
it, people could get hurt. I mean I know
it’s not the nicest thing, and it is
uncomfortable, but you have got to look
at it, at the safety aspects of what could
happen if we don’t use restraints. (I:2)
We had to use restraint,
there was no other option of
controlling him. (I:12)
Taking Control
• A technique to rapidly
suppress aggressive
and violent behaviour
• A management
strategy to maintain
order and stability in
the organisational
setting
Actually I have never used vertical
restraint. In most situations I have
been in I have always had to take
the person down to the floor, you
have more control when you take
people down to the floor. (I:4)
It’s a lot easier to manage an incident
when you are restraining someone
on the floor, because they have
got less movement, they’re more
restricted, you’ve got more control,
people become more compliant a
lot quicker. (I:12)
When you are working on a ward like
this, I am always well aware that
shouting, screaming, commotions
on a ward affects all the other
patients and there is a lot of people
here with anxiety problems and
things, so I felt I needed to calm the
situation down. (I:17)
• ‘Us & Them’ approach
• PI a site for the contention of
power and control between staff
and service user
The physical resistance. You know every
time you loosen your hold or take any
pressure away, if he is trying to get up
and fight you then you say, ‘no, just lie
still, we don’t like to do this anymore
than you do, erm, just relax, let the
medication work.’ (I:6)
The minute you lay hands
on, the incident that
originally got you to that
point, is lost, it then
becomes a situation of well
you know, get off me, I will
calm down when you get off
me, and then the retort from
the staff side is well no,
when you have calmed
down, and the service user
then says well I will calm
down when you get off me,
and it then becomes a
stalemate … (I:1)
Risk Perception and Uncertainty
Intensity &
magnitude of
behaviour
Knowledge of
Service user
Personal
Experience &
Risk tolerance
Risk
Perception
&
Uncertainty
Meaning &
significance of
behaviour
Likelihood of
harm
Risk Perception and Uncertainty
• Assessment of the concurrent level of threat, the
attribution of intent and the interpretation of a given
behaviour are critical mediators:
– if she hadn’t been put on the floor at that time, she probably would
have lamped someone. She would have punched them, so we had to
get her on the floor to restrain her, to calm her down. (I:13)
• Ability to control risk
– At the time of the incident I thought it was quite dangerous, it was a
quite dangerous situation considering I was, it was only me and in
between 2 doors, really. (I:12)
– I didn’t feel I was in a great deal of danger, per se, certainly not in this
instance. I always felt I was in control of the situation…it sounds odd in
the sense that I was physically and verbally threatened, but I always
felt that certainly two of us could control that situation. (I:14)
Risk Perception and Uncertainty
• Tolerance of risk & uncertainty
• Restraint a strategy for resolving risk ambiguities
– I mean you know its fear of getting smacked, let’s just get it over with
now and cut down the possibility of getting smacked. (I:10)
– I don’t think you can take the chance to think well maybe they won’t
strike out again. I don’t think you can wait to be hit. I think you just
automatically…when someone is actually aggressive towards you,
putting hands on keeps everyone safe. (I:17)
• Knowledge of service user
– The previous night he’d actually attacked another member of staff and
punched him three times in the head, so I was already on alert... We
had to take him down to the floor. He was still non-compliant,
struggling and because of the previous event and the fact that he was
still being verbally abusive we decided we had no option but to take
him down to the floor. (I:8)
Tension between urgency and
safety
Well really on restraining
and taking someone down,
we wouldn’t know how it
happens because it
happens that quick, that
you just, it’s just a scrap to
be quite honest. It is a
scrap. I mean you get
taught all these methods
…It doesn’t work. To be
quite honest it’s dog eat
dog. You get them down,
which you don’t want to say
that do you, you don’t want
to, but you have got to. If
you don’t, if she hadn’t
been put on the floor at that
time, she probably would
have lamped someone.
She would have punched
them (I:13)
Ideologies, values and approaches
Negative Attitudes
Anger, aggression, lack of patience,
over-zealous
Importance of inter-relationships
between staff and service users
Effective communication,
interpersonal skills, rapport
I spent virtually about an hour and a half talking to
her, on and off throughout the hour and a half and in
the end it worked, she just walked away and calmed
herself down. (I:10)
There are different staff
attitudes and some staff can
be aggressive, which doesn’t
help the situation. If you’re
highly charged and you’ve
got a member of staff who
comes in bluntly, saying
‘calm down’, it can have the
opposite effect. Some staff
are better at dealing with
patients than others, it’s their
attitude. (I:9)
Ideologies, values and approaches
PI rationalised by perceptions of
mental state and personality
attributes
• Mental illness = violence &
aggression
• Reinforcement of restraint
it’s driven by mental illness, and basically they are
not so much aware of what they are doing,
they are not really responsible for what they
are doing, and because of their mental illness
you don’t know how far they would go, so
they are really dangerous, … (I:17)
Conclusions
• Accounts reveal the ambivalent constructs of PI
as a protective device and as a strategy for
management and control.
• PI a routine part of mental health care rather
than part of ‘best practice’ - a ‘necessary evil’
rather than a last resort.
Pervasive Cycle
Routinisation
of PI
Staff beliefs:
mental illness=
unpredictable
violence/aggression
Reinforces staff
beliefs
Use of PI
Implications for Practice
• Improved training: rebalancing the
amount of time devoted to early
intervention skills
• Improved reflective practice: a system of
mandatory clinical supervision and
rigorous post-incident review
• Incident and trends analysis with a view
to highlighting good practice