The widespread use of physical restraints is an issue of increasing concern in today’s nursing practice. Physical restraints can be defined as any physical or mechanical device to involuntarily restrain the movement of the whole or a portion of a patient’s body as a means of controlling their physical activities (Howells and Hollin, 1989). The use of restraints is a contentious issue and there are both positive and negative outcomes. In light of the negative outcomes, a study in 2005 of the Pennsylvania state hospital system reported that all hospitals in the region planned to totally eliminate restraint interventions, positing that ‘these traumatising procedures produce significant barriers to recovery and have no clinical value’ (Smith, Davis and Bixler, 2005, p. 1116). This caused intense disputation across other states, however, with one author arguing that this aim ‘is laudable in idealism but lacking in clinical reality’ (p.576). One of the clinical realities proposed was that it would increase the use of PRO-RE-NATA medications and the trans-institutionalisation of aggressive persons with serious mental illness to prisons, where seclusion and restraint are much more frequent and damaging to patients than in hospitals (Liberman, 2006). Despite these two contrasting viewpoints on the management of violence and aggression, nurses must deliver care based on the best available evidence or practice (Nursing and Midwifery Council, 2008). Therefore, the aim of this paper is to critically analyse the evidence base for the safe and effective use of interventions when managing violence and aggression. Further, in this paper, I will be reflecting upon personal incidents: therefore, I feel it is appropriate that I write in the first person (Webb, 1992).
I have recently been involved in nursing a patient who was a serious suicide risk; she had made a very serious attempt by slashing her throat which needed 64 internal and external stitches. She was being nursed on level four enhanced observations with two members of staff constantly within an arm’s length reach of her. The reason for this was that she was an ongoing risk of suicide as she repeatedly attempted to reopen the wound by tearing it apart with her fingers. This led to her being physically restrained and, due to her continued resistance, usually being put on the floor and rapidly tranquillised. This would happen several times in the day and sometimes she would spend the whole day in restraints. The patient had a history of severe sexual abuse and would often scream that members of staff were trying to rape her while she was being restrained. Given her past abuse, I began to question the validity, appropriateness and efficacy of these interventions; in times of acute distress, the patient was being restrained by perhaps up to five members of staff, usually mostly males. I began to explore alternative treatment options that might be more appropriate, ethical and supportive for the client. One option that was posited by the multidisciplinary team was the use of mechanical restraints. However, the staff members were dubious about this option, as none of them had ever implemented such an intervention and they lacked knowledge of this area of clinical practice. Therefore, this paper will critically analyse the evidence base for the use of mechanical restraints for managing violence and aggression, particularly violence and aggression towards the self.
According to Dale (personal communication, 2009), the starting point when assessing the appropriateness of mechanical restraints is the Code of Practice of the Mental Health Act 1983. This states that ‘mechanical restraints are not a first-line response or standard means of managing disturbed or violent behaviour in acute mental health settings. Its use is exceptional. If any forms of mechanical restraint are to be employed a clear policy should be in place governing their use. Restraint which involves tying (whether by means of tape or by using a part of the patient’s garments) to some part of a building or its fixture should never be used’ (Department of Health, 2008, Para 15.31).
It is clear from this guidance that mechanical restraints are not standard practice and the code does not give any clear guidelines apart from the above. NICE (2005) have produced a clear policy declaration governing the use of physical interventions; however, it does not allude to mechanical restraint within these guidelines. Further, the Inquiry Report (2003) into the death of Mr. Bennett rejected any consideration of the use of mechanical restraint, although its own findings revealed that the lengthy use of physical restraints was a major factor in his death. Moreover, culturally, nurses in the United Kingdom (UK) struggle to substantiate mechanical restraint as an option to managing violence and aggression. The term &lsqu
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