An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint

In the process of undertaking a meta-synthesis of qualitative studies of free-standing midwife-led units, the authors of this paper encountered a number of methodologically and epistemologically unresolved issues. One of these related to the assessment of the quality of qualitative research. In an iterative approach to scoping this issue, we identified eight existing checklists and summary frameworks. Some of these publications were opinion based, and some involved a synthesis of pre-existing frameworks. None of them provide a clear map of the criteria used in all their reviewed papers, and of the commonalities and differences between them. We critically review these frameworks and conclude that, although they are epistemologically and theoretically dense, they are excessively detailed for most uses. In order to reach a workable solution to the problem of the quality assessment of qualitative research, the findings from these frameworks and checklists were mapped together. Using a technique we have termed a 'redundancy approach' to eliminate non-essential criteria, we developed our own summary framework. The final synthesis was achieved through reflexive debate and discussion. Aspects of this discussion are detailed here. The synthesis is clearly rooted in a subjectivist epistemology, which views knowledge as constructed and hermeneutic in intent, encompassing individual, cultural and structural representations of reality.

The author reviewed the literature published since 1972 concerning restraint and seclusion. The review began with a computerized literature search. Further sources were located through citations from articles identified in the original search. The author synthesized the contents of the articles reviewed using the categories of indications and contraindications; rates of seclusion and restraint as well as demographic, clinical, and environmental factors that affect these rates; effects on patients and staff; implementation; and training. The literature on restraint and seclusion supports the following. 1) Seclusion and restraint are basically efficacious in preventing injury and reducing agitation. 2) It is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint. 3) Restraint and seclusion have deleterious physical and psychological effects on patients and staff, and the psychiatric consumer/survivor movement has emphasized these effects. 4) Demographic and clinical factors have limited influence on rates of restraint and seclusion. 5) Local nonclinical factors, such as cultural biases, staff role perceptions, and the attitude of the hospital administration, have a greater influence on rates of restraint and seclusion. 6) Training in prediction and prevention of violence, in self-defense, and in implementation of restraint and/or seclusion is valuable in reducing rates and untoward effects. 7) Studies comparing well-defined training programs have potential usefulness.

This paper reports a study to investigate the nature and prevalence of inpatient aggressive behaviour directed at staff and other patients and, in the case of patient self-harm, the methods used by nursing staff to manage this. Aggressive behaviour poses a threat to the physical and psychological health of psychiatric nursing staff. The fear that results from working in a climate of potential danger can also have a damaging impact on patient care. Nursing staff on five acute inpatient wards in one hospital in the United Kingdom collected data on aggressive incidents using the Staff Observation Aggression Scale - Revised during a 10 month period from June 2001 to April 2002. There were 254 incidents of aggression recorded. Staff were most commonly targeted and were involved in 57 x 1% of incidents. The most frequent provocation of the aggression was the patient being denied something such as leave from the ward (29 x 5% of incidents). The most frequent means used by patients was verbal aggression (60% of incidents), the most frequent outcome for the victim was feeling threatened (59% of incidents), and verbal interventions were used most frequently to manage the aggressive behaviour (43 x 7%). Despite many incidents involving verbal aggression in both staff- and patient-targeted aggression, 35 x 9% of incidents involving staff and 25% of incidents involving other patients resulted in seclusion. It is estimated that in a 12 month period at the hospital in this study a nurse would have a one in 10 chance per year of receiving any kind of injury as a result of patient aggression. Despite the predominance of verbal over physical aggression, the fear generated from working in such an environment and a difficulty in understanding the causes of patient aggression may motivate staff to manage aggressive incidents with physical methods such as seclusion and restraint on a frequent basis.