2 Background
2.1 Patients’ and care providers’ experiences and opinions on
Patients’ and care providers’ views on the use of restraints in mental health services are divided. Most of the referred studies are from western countries that are comparable with respect to social relations, cultures and practices. Wynn (2004) found in a Norwegian study that some patients expressed an understanding attitude toward the reasons for restraining them and further that restraints helped them to calm down.
Bak et al. (2012) found that up to 10% of patients requested restraints to prevent themselves from acting out. In the study of Larue et al. (2013) patients considered seclusion and restraint helpful in situations characterized by loss of control. In another study, Jacob et al. (2016) found that patients’ experiences of mechanical restraints were largely negative, but some patients considered restraints to have a positive impact on their mental health and general well-being. Furthermore, studies show comments that were positively oriented toward the grounds for being restrained as safety and security. This opinion was enhanced when patients saw care providers as being concerned about their needs during and after the restraint event and further presented a willingness to help and provide psychological comfort (Chien et al., 2005; Jacob et al., 2019). Chien et al. (2005) even concluded that restraint could be a therapeutic intervention on the condition that care providers provide psychological and informational support to patients during the procedure.
On the contrary, other studies indicate that mechanical restraint is the most intrusive and consequently the least approved coercive measure, according to patients (Bak et al., 2012; Huf et al., 2012; Nyttingnes et al., 2016; Whittington et al., 2009). Sailas and Fenton (2000) found in their Cochrane review, ‘no controlled studies to support the continued
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5
2 Background
2.1 Patients’ and care providers’ experiences and opinions on restraints
Patients’ and care providers’ views on the use of restraints in mental health services are divided. Most of the referred studies are from western countries that are comparable with respect to social relations, cultures and practices. Wynn (2004) found in a Norwegian study that some patients expressed an understanding attitude toward the reasons for restraining them and further that restraints helped them to calm down.
Bak et al. (2012) found that up to 10% of patients requested restraints to prevent themselves from acting out. In the study of Larue et al. (2013) patients considered seclusion and restraint helpful in situations characterized by loss of control. In another study, Jacob et al. (2016) found that patients’ experiences of mechanical restraints were largely negative, but some patients considered restraints to have a positive impact on their mental health and general well-being. Furthermore, studies show comments that were positively oriented toward the grounds for being restrained as safety and security. This opinion was enhanced when patients saw care providers as being concerned about their needs during and after the restraint event and further presented a willingness to help and provide psychological comfort (Chien et al., 2005; Jacob et al., 2019). Chien et al. (2005) even concluded that restraint could be a therapeutic intervention on the condition that care providers provide psychological and informational support to patients during the procedure.
On the contrary, other studies indicate that mechanical restraint is the most intrusive and consequently the least approved coercive measure, according to patients (Bak et al., 2012; Huf et al., 2012; Nyttingnes et al., 2016; Whittington et al., 2009). Sailas and Fenton (2000) found in their Cochrane review, ‘no controlled studies to support the continued
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which is claimed to be a core stone in treatment and care (Bigwood &
Crowe, 2008; Jansen et al., 2020; Knowles et al., 2015).
With respect to care providers’ moral views of restraints, they believe them to violate patients’ integrity, but they justify the restraint decision with care and control (Hem, Gjerberg, et al., 2018; Wynn, 2003). In a Norwegian study, there were extensive differences between different groups of care providers. Physicians had less moral doubt about using coercion, followed by nurses, while the psychologists were most critical towards coercion (Molewijk et al., 2017; Aasland et al., 2018). It seems, however, that individual opinions and attitudes were strong influences, as there were indications that use of coercion was not always in compliance with legislation (Husum et al., 2011; Aasland et al., 2018).
Still, the participants presented a non-coercive dialogical resolution as more likely than a coercive and authoritative one.
In summary, patients and care providers have divided experiences and views on restraints use. It is difficult to say whether patients who have an understanding attitude toward restraint use actually experience restraint as beneficial, or if they – based on previous experiences and inequality in the power-dependence relationship (Emerson, 1962) – have learnt that restraint is the only solution. Consequently, they have not been supported in developing alternative, more appropriate coping skills (Slade, 2009).
Accordingly, restraint measures are intrusive and lead to negative consequences for all involved. Patients and care providers have demanded debriefings after restraint events in recent decades (Nolan et al., 1999; Petti et al., 2001; Wynn, 2004). Systematic debriefing procedures (PIRs) have been implemented, initially in the US in the early 2000s, and later in other western countries, often combined with other interventions in S/R reduction programs such as Six Core Strategies (Huckshorn, 2004; Huckshorn, 2006) and the Safewards model (Bowers, 2014).
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use of seclusion or restraint in clinical practice’ (p.8). Therefore, they recommended finding alternative strategies to manage excitement and aggression.
Patients report psychological consequences such as distress, fear, regret, loneliness. They also reported that being restrained evoked memories of previous traumatic events (Cusack et al., 2018; Nyttingnes et al., 2018;
Nyttingnes et al., 2016; Strout, 2010). Furthermore, they report that coercion is often accompanied by a feeling of dehumanisation and humiliation, (Norvoll & Pedersen, 2016; Nyttingnes et al., 2018;
Nyttingnes et al., 2016; Terkelsen & Larsen, 2016; Wilson et al., 2017).
According Hartling et al. (2013) and Hartling and Lindner (2016), humiliation is one the most common and dangerous emotional experiences in society and thus a trigger for violence.
Severe physical consequences of restraint use have been documented, such as heart problems, aspiration, rhabdomyolysis, thrombosis and even death (Cusack et al., 2018; Mohr et al., 2003; Rakhmatullina et al., 2013).
Based on the potentially grave consequences of restraint use, service users and user organisations argue that coercion and restraint should be de-legitimised (Rose et al., 2017).
Care providers’ attitudes toward coercive measures demonstrate a tension between a phenomenon that is considered as indispensable, but at the same time is connected to discomfort (Al-Maraira & Hayajneh, 2019; Bigwood & Crowe, 2008; Norvoll et al., 2017; Perkins et al., 2012). In ward units, milieu therapists – mainly nurses – play a central role in fostering a culture that promotes safety for all, but also in dealing with the prevention of coercion and to manage coercion events when considered inevitable (Kaucic, 2017; Riahi et al., 2016). Nurses report coercion-related consequences such as being distressed, feeling fearful, role conflicts and decreased job-satisfaction (Bigwood & Crowe, 2008;
Jansen et al., 2020; Krieger et al., 2020; Wilson et al., 2017). In addition, they report negative impacts of restraints on the therapeutic relationship,
7
which is claimed to be a core stone in treatment and care (Bigwood &
Crowe, 2008; Jansen et al., 2020; Knowles et al., 2015).
With respect to care providers’ moral views of restraints, they believe them to violate patients’ integrity, but they justify the restraint decision with care and control (Hem, Gjerberg, et al., 2018; Wynn, 2003). In a Norwegian study, there were extensive differences between different groups of care providers. Physicians had less moral doubt about using coercion, followed by nurses, while the psychologists were most critical towards coercion (Molewijk et al., 2017; Aasland et al., 2018). It seems, however, that individual opinions and attitudes were strong influences, as there were indications that use of coercion was not always in compliance with legislation (Husum et al., 2011; Aasland et al., 2018).
Still, the participants presented a non-coercive dialogical resolution as more likely than a coercive and authoritative one.
In summary, patients and care providers have divided experiences and views on restraints use. It is difficult to say whether patients who have an understanding attitude toward restraint use actually experience restraint as beneficial, or if they – based on previous experiences and inequality in the power-dependence relationship (Emerson, 1962) – have learnt that restraint is the only solution. Consequently, they have not been supported in developing alternative, more appropriate coping skills (Slade, 2009).
Accordingly, restraint measures are intrusive and lead to negative consequences for all involved. Patients and care providers have demanded debriefings after restraint events in recent decades (Nolan et al., 1999; Petti et al., 2001; Wynn, 2004). Systematic debriefing procedures (PIRs) have been implemented, initially in the US in the early 2000s, and later in other western countries, often combined with other interventions in S/R reduction programs such as Six Core Strategies (Huckshorn, 2004; Huckshorn, 2006) and the Safewards model (Bowers, 2014).
6
use of seclusion or restraint in clinical practice’ (p.8). Therefore, they recommended finding alternative strategies to manage excitement and aggression.
Patients report psychological consequences such as distress, fear, regret, loneliness. They also reported that being restrained evoked memories of previous traumatic events (Cusack et al., 2018; Nyttingnes et al., 2018;
Nyttingnes et al., 2016; Strout, 2010). Furthermore, they report that coercion is often accompanied by a feeling of dehumanisation and humiliation, (Norvoll & Pedersen, 2016; Nyttingnes et al., 2018;
Nyttingnes et al., 2016; Terkelsen & Larsen, 2016; Wilson et al., 2017).
According Hartling et al. (2013) and Hartling and Lindner (2016), humiliation is one the most common and dangerous emotional experiences in society and thus a trigger for violence.
Severe physical consequences of restraint use have been documented, such as heart problems, aspiration, rhabdomyolysis, thrombosis and even death (Cusack et al., 2018; Mohr et al., 2003; Rakhmatullina et al., 2013).
Based on the potentially grave consequences of restraint use, service users and user organisations argue that coercion and restraint should be de-legitimised (Rose et al., 2017).
Care providers’ attitudes toward coercive measures demonstrate a tension between a phenomenon that is considered as indispensable, but at the same time is connected to discomfort (Al-Maraira & Hayajneh, 2019; Bigwood & Crowe, 2008; Norvoll et al., 2017; Perkins et al., 2012). In ward units, milieu therapists – mainly nurses – play a central role in fostering a culture that promotes safety for all, but also in dealing with the prevention of coercion and to manage coercion events when considered inevitable (Kaucic, 2017; Riahi et al., 2016). Nurses report coercion-related consequences such as being distressed, feeling fearful, role conflicts and decreased job-satisfaction (Bigwood & Crowe, 2008;
Jansen et al., 2020; Krieger et al., 2020; Wilson et al., 2017). In addition, they report negative impacts of restraints on the therapeutic relationship,
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practice (Bowers et al., 2007; Husum et al., 2011). Variations in Norway have however decreased in the period 2017 – 2018 (Norwegian Health Directorate, 2020; Norwegian Ministry of Health and Care Services, 2019). The reported variations are however not unambiguous enough to conclude changes in practice.
Norwegian mental health services are now under political pressure from national governments to reduce the use of restraints as a national committee has proposed that mechanical restraint should be removed from the services within three years (Norwegian Health Directorate, 2020; Norwegian Ministry of Health and Care Services, 2019).
To my knowledge, the Six Core Strategies are still not implemented in any Norwegian mental health services. However, staff training in de-escalation has been conducted in Norwegian services for years, but the outcome of this training is unclear, as in most studies, staff training is a part of a program and the effect of each component is muddled (Guzman-Parra et al., 2020; Scanlan, 2010; Väkiparta et al., 2019). Guzman-(Guzman-Parra et al. (2020) suggest that it is important that all components in the Six Core Strategies be applied when the aim is S/R reduction.
Following other western countries, a few Norwegian mental health services implemented PIR procedures after PIRs were featured in a Norwegian public report on strengthening human rights in mental health services in 2011 (NOU 2011:9). The inspiration for the committee’s proposal to implement PIRs was Danish legislation that for several years had instated PIRs as a mandatory procedure after use of coercion (The Danish Mental Health Care Act §4).
The guidelines to the later Norwegian law revision (2017) stated that the aims of the PIRs were learning, prevention of new restraint events and quality development (Norwegian Health Directorate, 2017). Quality is not further defined in the guidelines, which incidentally state that people with mental health challenges shall be offered services characterised of knowledge-based practice and good quality. Regarding the concept of knowledge-based practice, I rely on the descriptions in 8