What would you think if you were visiting a family member or friend on a mental health ward and you saw someone being physically restrained?
Latest guidance from the Department of Health (DH)
Positive and Proactive Care places an increasing focus on the use of preventive approaches and de-escalation for managing behaviour that services may find challenging. All restrictive interventions should be for the shortest time possible and use the least restrictive means to meet the immediate need based on the fundamental principles in Positive and Proactive Care.
Nursing staff should act within the principles set out in Positive and Proactive Care, and use all restrictive interventions in line with the MHA Code of Practice 2015, Mental Capacity Act 2005, Human Rights Act 1998 and the common law.
What is restraint
Restraint is used by trained healthcare staff to stop or limit a patient’s movement. Restraint may be used without the patient’s consent.
Restraint might be needed if a patient is violent or agitated – so that he doesn’t harm himself or others.
Three types of restraint
- Physical restraint limits specific parts of the patient’s body, such as arms, legs. or head.
- Chemical restraint is medicines used to quickly sedate a violent patient. This might be given as oral medication (a tablet) or intramuscular (an injection).
- Seclusion is placing the patient in a room by himself. The room is locked and kept free of items that could cause injury. The walls are padded and there is normally a large rubber bed to reduce risk of harm to the patient. A member of the team will watch him at all times when he is in seclusion.
Control and Restraint training (C&R)
As mental health nurses and nursing assistants, we have a full week (9-5pm) of Control and Restraint (C&R) training and let me tell you, it’s exhausting – when you’re only 5′ 4″ and you’re trying to restrain your 6′ 6″ colleague. As well as our mental health nurse training, we are taught de-escalation skills during C&R. You always attempt de-escalation techniques first. You might offer the patient some oral medication to reduce his/her agitation, to stop the violence, stop the voices, bring them down from an extreme high or calm them down enough to speak to them clearly and rationally etc.
De-escalation
While working in any specific area, nurses ought to be visible and taking in what’s going on around the ward, the bathrooms and bedrooms. They should be discreetly observing patients, mindful of any signs of agitation or conflict between patients. It’s always much easier to verbally de-escalate if you intervene quickly; either distract the patients, possibly asking one to move away from the area. Your colleagues should be made aware of possible escalation so that they can help and support you if necessary. Humour is quite useful sometimes – I used to tell the big lads “If you were one of my boys, you’d get my wee size three’s up your backside,” and they’d laugh.
If an incident starts to escalate out of control, someone calls Rapid Response (RRT) to the ward and a team of 7-8 members of staff (one from each ward, and normally men?) will come running. There will a Lead RRT member who ought to take control by first finding out who or what the problem is, if it’s not already visible i.e. two patients fighting.
The RRT will be in the nursing office deciding the plan of action. First might be just to speak to the patient(s) involved. I can understand how the patient might ‘give in easily’ when they see such a big team of people, practically surrounding them, and comply with what’s asked of them i.e. accept some oral medication.
Sometimes a male patient sees this big team as a threat and might challenge them – some male patients have said “I know I can’t get them all, but I’ll effin’ hurt one of them.”
Jason was admitted as a voluntary patient
I was manager on Lilly Ward, a mixed sex acute in-patient ward and a tall and handsome young lad was admitted informally late one afternoon. He came up to the ward with his dad, a Rastafarian who told me that Jason had been smoking cannabis and he’d been hearing voices for a few weeks. “I take the stuff myself. I know the weed. But no. Its no good for him. I don’t want to leave him here but I want him to learn. Its bad, smoking all the days with his new friends.” I told dad to go, Jason would be fine with me.
I took Jason into the nursing office to explain his admission was voluntary and that he would be under observation for a few days to see what’s happening for him. He said he hadn’t slept for three days as the voices wouldn’t let him. The voiced scared him and I could see he was hallucinating as we were speaking. I asked whether he wanted some medication to help him sleep which he declined. As we chatted, I learned that he had a close family who he loved dearly and his mum was his hero. “You’re a bit like her you know. Calm and friendly and smiling. Just like my mum.” He said shyly, which endeared him to me.
I could see the panic rising in Jason and as I’d already explained to him, I’d hate to see him ending up a Section of the Mental Health Act but if he was unwilling to comply, this is what would happen. I’d seen so many young lads come through the system saying that all their friends smoked cannabis and it did them no harm. However, it was my job to explain that while cannabis doesn’t cause Schizophrenia, if you are already vulnerable to mental health problems, the cannabis might trigger it.
By now he was losing focus and I knew he needed medication. Offering oral meds first and an explanation of what they do may help a patient feel more in control of the situation, but I’d tried for over an hour with Jason. I’d also explained that if wouldn’t accept it, we’d have no choice but to give him medication by injection. He was becoming increasingly agitated, banging his head on the wall, and my colleagues were becoming concerned that I was cornered in the office. I wasn’t worried for myself at that point, I felt sure that, following our lengthy discussion, he wouldn’t harm me.
Rapid Response Team to Lilly Ward, please
The noise of his head cracking the wall was unbearable and RRT were called as this boy was going to really hurt himself. Jason saw them running in and jumped to his feet. I told him needed to leave the office as the Team would be coming in, so he let me past. As soon as I’d left the office three of the Team went in to restrain Jason. It was awful because it was such a tiny space and as they all went down to the floor, I could hear Jason calling out for me, crying and apologising. I was distraught for him, but I still had to get the medication drawn up quickly and to inject Jason, for his own safety. He was given 2 mg Lorazepam which has a sedative effect and 5 mg Haloperidol, an antipsychotic.
Once the medication took effect, after a couple of minutes, the Team helped Jason up and walked him to his bedroom, where he’d sleep for some hours. The Team met to debrief, to ensure nobody was injured and to discuss whether there was anything we could have done differently. We believed we had done the right things and that there was no need for seclusion on this occasion. The ward Doctor placed Jason on Section 2 of the MHA (1983) which meant he would detained for up to twenty eight days and could be treated without his agreement.
To restrain someone, you would initially use three members of the Team; one to take each arm and one to direct the patient’s head. If the patient cannot be held like this, the next step would be to go down to your knees then onto the floor where two other Team members would hold the legs. The patient’s safety is always uppermost in your mind. Really and truthfully, if anyone gets hurt during a restraint, it’s generally staff as your knees and elbows hit the floor.
Risks of restraint
There are risks, of course. Patients often struggle against physical restraint, which could cause skin wounds or block the blood flow. It can also increase the patient’s heart rate and breathing rate which again, can be life-threatening. Medication could cause low blood pressure, shallow breathing or heart rhythm problems. Some antipsychotics can also cause side effects like stiffness and shakiness, restlessness (akathisia), movements of the jaw, lips and tongue (tardive dyskinesia), slowness and sleepiness.
Nursing staff have to regularly assess for side effects as well as:
- vital signs, such as heart rate, breathing rate, and blood pressure
- patient’s physical comfort
- patient’s skin for injury
- monitor patient’s behavior
- allow the patient to leave seclusion (if used) as soon as he is calm and cooperative
All necessary paperwork and an incident form must be completed and a care plan put in place.
It’s good practice if the nursing team on the ward go round checking on other patients to see how they are if they’d witnessed the restraint. It can be really frightening and assurances might need to be given.
Mental Health Act (1983)
More often than not, the patient will feel quiet groggy when they wake but will still feel a little calmer. The nursing team will then try to engage the patient and let them know of their Rights under the MHA (1983), letting them know they can appeal against this Section and give them the appropriate paperwork to do so.
Patients would frequently be brought into A&E on Section 136 of the MHA (1983) by the police and RRT would be called to assist if the patient was violent or agitated. This means a restraint may have to take place there instead of on the ward and the patient would then, once sedated, be moved to Seclusion for a period of time.
Most nurses don’t like having to restrain patients – male or female. Just think how a patient who’s been physically or sexually assaulted in the past must feel. They’re already confused, distressed, experiencing delusions or hallucinations or mania then they’re being restrained, having their underwear pulled down and having injections forced upon them.
There have been some unusual restraint situations too. When the RRT arrived at the dining area on our ward, the patient was standing on a table, naked and masturbating. Another young man knew that RRT were on their way to see him, he ran to the bathroom, got naked and smothered himself in shampoo so that the Team wouldn’t be able to get hold of him.
The restraint I hated most, was when we had to get a baby from his mother’s arms; she was psychotic and at risk of hurting her child. I’ll never forget her blood curdling screams as we took the baby away from her.
I always found the females the most difficult to restrain. With the men, you know they’ll punch, kick or headbut, but the women – they’ll do that and kick, scratch, nip, pull hair, spit and bite…… Thankfully, I didn’t have to do many.
Do you think patients should be restrained? Or is there another way?
I was trained in restraint as well when I worked at residential treatment facilities for mentally ill and/or abused children and teens. I was terrible at it. We had no back-up like you’re describing, and the stress of knowing I have no upper body strength made me feel inadequate and uncomfortable with the whole concept.
Reading about Jason, it seems he had choices that he rejected–the big one being that he never should’ve smoked pot. The next big one being that he should’ve taken meds for sleep, since he was running on empty. It sounds as if he was being stubborn despite being reasonably aware of the situation. There’s nothing you could’ve done differently. I’ve never understood why some schizophrenic people never want to take their meds. I take mine with religious fervor.
Unfortunately, restraint is probably necessary, but I think it should never be done by anyone who gets off on the power. As someone who’s been a patient, trust me–patients can tell who cares (like you) and who doesn’t. That’s important. In an ideal world, everyone doing restraint would care. I guess that’s key!
Lol, yep he could have stopped smoking pot. I often ask people “Why does someone with schizophrenia stop taking medication?” The answer, I suppose is they’re like the rest of us. Once you feel better you stop taking your meds. It takes the youngsters who smoked a few admissions on Section before the realised that the medication helps them stay out of hospital.
Oh I think we had a few ‘bully boys’ who loved asserting themselves over patients. I always told them not to stand feet wide apart, arms crossed – how intimidating does that look?
Again, you’re right – patients know who care. I said to nurses, look they’ve got not much to do all day but watch you guys, how you act and speak to patients – they know who the baddies are, definitely. Thanks for your input Meg 🙂
I worked on inpatient for 5 years and I think there were only 2 patients that needed physical restraints during that time. There was a security “code white” team for rapid response to violent incidents, but we generally avoided that by calling security for standby anytime things started to escalate. That way I was usually able to get medication into people without them having to be held down.
Wow, that’s amazing. Unfortunately, here in the UK, security are not allowed to touch a patient and patients knew it so there was no point in calling them. I don’t know why we had them anyway. If one turned up for an incident (just to have a nosy) I’d tell them to leave. No, it was down to nursing staff which is horrible because it can have a detrimental impact on relationships with patients. Thanks for your comments Ashley, much appreciated.
When I have been a patient on the Mental Health ward I have seen restraints used. Mostly because a patient has been violent.
One time a person was brought in by the police and was highly agitated. Somehow, he managed to grab a fire extinguisher broke a glass, sprayed the extinguisher and caused many of us to run to another room.
I believe they a good thing for the staff to use. It protects them but it also protects all the other patients under their care.
Oh yes. We had to remove fire extinguishers to safer areas on our wards. What kind of restraints were used?
I believe it was some sort of strap.
Thank you, sounds awful.
Reading this article it is so sad. It is so hard to believe the extent that the medical profession needs to go sometimes. We are human beings and sometimes I feel that is overlooked. I am not sure of the difference in medical care in other parts of the world with where I live which is Canada. Other then the cost. I have been given the chance to represent Mental Health on the advocacy board at a local hospital. One of my goals is to look at how we are treated.
That’s great Lisa, you go for the advocacy board. All input will be welcomed there.
Wow, I bet you have an interesting view of the drub debate 🙂
When you say Lily ward do you mean Lillie Ward in London?
In terms of restraint it’s a difficult one. It is definitely a last resort and there is no doubt that some staff need to get better at early intervention. It’s an upsetting thing to see. But I do think it’s necessary sometimes especially if other patients are at risk.
However I wish ‘teams’ were called less quickly because as you explain it can escalate situations because people feel under threat. I watched situations become violent as a small female was surrounded by seven big males.
I did once have the team called on me when I was on the ward and these four massive guys appeared and it was terrifying and did nothing to deal with the route causes of why I was upset. In reality I just needed someone to talk to and was acting out to get attention (which I realise sounds immature but being trapped in a ward cuts off a lot of your means of communication and expression).
Hi and thank you for your comment Morag. I’ve changed ward names to protect people’s identity. I agree, staff ought to spot conflict, violence and agitation much sooner so that they can de-escalate and no restraint would be necessary.
I’m really sorry you had to go through this – it must have been awful. And I get it, it’s not being immature, people want their needs met quickly on mental health wards and if staff are ignoring them……………!
On separation: Just from the heart I would say ‘never!’, from practice: it is needed sometimes. It is just so traumatizing for patients and staff.
As for Jason, I don’t understand what happend there? Was there some incentive to his agitation? It’s so sad for him and for the dad.
As for mothers and baby’s, I worked on the Mother-Baby unit and I always visited the mothed when she was in separation with the baby. It was so wonderfull to be able to do that. The sad part was that once in seclusion, medication was necessary and the breast feeding needed to be stopped. So there was a new mother in seclusion, without baby, with milkproduction and a psychosis. But I really loved to care for them!
I would do everything I could, even get them out of seclusion. When I worked weekends I called the psychiatrist and she always helped me in favor of the mother and I could ‘fix’ the situation and make a schedule with the mother to have everything ‘much better’ on Monday. I was so sneeky and I loved it!
In another ward we had no seclusion (not always easy not to have that option) but we had a ‘time-out’ room. That could be stripped but was really not very safe. People would go there to rest, to get out of their rooms, to be closer to the bureau, to die sometimes or to attent when somebody had a new hip and needed more care for a while. If safe they could have books, a radio, the door was never closed and there was no window to peak in. On yet another ward we had the classic separation but we built the smallest garden to it, so people could have a cigarette and some fresh air a few times a day. It was with glass, so they could see other people but they were alone in that garden. What materials did you have in the separation room? Were there things allowed like books or just nothing?
Oh and the longest time that I’ve known someone being in separation, was over a month! It was so draining, so hard, so needed. When the system doesn’t work like it should those things happen too! (it was someone on drugs and he needed to be in a forensic setting, there was no way to have him on the ward but we tried anyway)
Yes, our one long stayer was drug-related, psychosis and also anger! Everytime someone opened the door, the guy would throw himself at them!
There was absolutely nothing in the seclusion room. Mainly, once they had been medicated, they woul d sleep for a while and then be out the next day. We only ever had one or two long stayers in seclusion. We only had one seclusion room each – 1 for female and the other for males which was nightmare when trying to get a patient from downstairs, 200 yards along a corridor 🙁
That’s horrible! We had a clock, a chalk board and chalk. Sometimes magazines were allowed. And visit from family was also possible.
Good for you. That would be awful for new mothers, being in seclusion. I don’t think I ever saw that fortunately.