Should we use restraint on mental health wards?

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

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  • 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)

Seated restraint – Twitter.com

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 health.com

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.

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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.

Face down restraint – BBC.co.uk

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)

Telegraph.co.uk

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?

Many mental health nurses lack knowledge and skills

Even early on in my mental health nursing career, as a student in fact, it was clear to me that some mental health nurses needed to find another job. They won’t though. They know they have a cushy job working for the NHS. It’s notoriously difficult to dismiss staff, even if you do follow the Trust Policies exactly.

Smashing Magazine

I saw many a nurse who lacked the knowledge and skills necessary for nursing and who was totally unaware of it. They belong in the unconscious incompetence group in the square and this makes them potentially dangerous. If they’re not even aware, or have never been told that they are incompetent, they’ll continue to perform poorly and make mistakes, some of which could be fatal, in terms of nursing.

The fact that these nurses were oblivious to their incompetence is bad enough, but for this not to have been picked up by their managers is almost criminal. One major problem was that our managers were all previously nurses and 99.9% had no secretarial, admin, book-keeping, human resources or management experience. Therefore managers lacked the knowledge and skills to manage staff. That’s another post.

Some of our nurses were just plain lazy too, maybe because of their incompetence, so I’ll start off with them.

Tenor.com

The number of times I approached a nurse sitting on their lazy fat arse, watching t.v., particularly if they were on what’s called a bank shift (we had a bank of staff who covered extra shifts where needed), infuriated me. I’d suggest, if they were qualified, they go and help with medication. “Oh, but I’m just bank shift today,” they’d exclaim. I’d ask if they were getting paid a wage this week, “Yes,” they’d laugh, looking at me curiously.

“Okay, good. Now get up and go do something to earn it.” I’d smile.

Even bank nursing assistants tried the “I’m only bank today.” Somehow that translates as you don’t have to do any work on a bank shift? And “I’m just bank this morning. I’m on blah blah ward this afternoon/evening so I’ll be exhausted. Oh, and I need to leave early.”

“That’s not my problem whether you’ll be tired, nor is where you’ll be working later, you committed to a shift and I need you to carry it out.” I’d insist.

“Well you need to call my manager to tell them I can’t leave early,” they’d cry.

“No. You need to tell your manager and let them know that you booked an extra shift on our ward, knowing you were working on your own ward later.” I’d remind them.

“Evelyn never had a problem with me working double shifts, and she let me go early.” tried one nurse.

“Evelyn no longer works here. And there will be no more double shifts and leaving early from now on.” How these staff got away with all this for years, I can only guess.

However, the thing I detested most was when you said to nurses, “Put your newspaper down, spend some time with your patients, talk to them……..”

I got “I don’t know them, I’m just a bank nurse.” or “I don’t know what to say.” How hard is it to start a damn conversation? I always wondered at uni, why we had to have copious lessons in communication skills. Now I know.

Lazy Doctors

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Some Doctors were just as bad, particularly during the night shift. You’d call them to assess a patient in A&E and they’d say “I’m over at Rosemary ward (situated five minutes down the road from the main hospital) with a patient. I’ll be there in about an hour,” which really meant two. Hhmmm, Rosemary ward – every night you called for a Doctor – they only had eight patients.

Obviously I was aware that Doctors worked long hours and the needed breaks, but we were working with agitated and chaotic patients here, many who needed medication prescribed immediately. Without medication, patients sometimes had to be restrained, which wasn’t fair on them, or the Team – soooo a change in tactics was needed. “Okay, no problem Doc. I’ll put that in the notes. Thank y…….”

“Okay, okay. I’ll be there” and so they were, ten minutes later.

Kobi was just plain lazy

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We had one nurse, a lump of lard called Kobi, who was as round as he was tall and he just lumbered around the ward, stuffing his face non-stop. As part of our jobs, we are expected to carry the bleep for Rapid Response (RRT where you have to attend any emergency on A&E or another ward) and to help restrain patients when necessary. Before I joined Daffodil ward, Kobi had long since refused to do these two tasks because he said he had sore knees. His colleagues thought this was unfair as they were having to pick up the slack, and I agreed.

I appreciate that staff will be sick or in pain at times, but there are policies and systems in place to manage this i.e. assess for other underlying health problems, further training, offer Occupational Therapy or other support and plan a time frame in which to return to full duties or assess the need for more time, then review. You can’t just decide you won’t do these tasks.

When we met to discuss this issue, I gave him some options to consider and offered support. He puffed and panted “I was manager (for a private mental health hospital) for two years before, you know. I have a right to refuse to do things as I see fit. I will speak to my union, you know.”

Healthline.com

“Yes, I’m aware that you were a Manager and yes, of course, please speak to your union. Let them know what we’ve discussed, the support I’ve offered you and the three-month time frame for review. I’ll put what we’ve discussed in writing later today.” He never did go to his union and his knees got better but unfortunately, he didn’t.

Kobi was neglectful

During one morning handover, Kobi reported that Betty had fallen from her chair in the night and that she was assessed before being supported back to her chair. We could see Betty sitting in the day room and she looked rather uncomfortable, so I asked “Ah, was she bruised or anything? What did the Doctor say?”

“Pftt, she didn’t need a Doctor. She was all okay. She say her shoulder hurt, but she always complain about it.”

“Why didn’t you call the Doctor, Kobi? She always complains about her left shoulder – because. she’s. in. pain. Kobi. This time, she’s holding her right shoulder.”

“I assessed her and she was okay. I tell you. I was manager before, I can make a judgement call.”

Everybody knows that if a patient falls, a Doctor must always be called to assess for injury or pain and to prescribe any further treatment or pain relief. What on earth made him think that on this occasion, he did not need a Doctor to visit the ward?

US News Health

At that, I left the nursing office and went to speak with Betty to ask if she was in pain and at the same time, take a look at her shoulder. She didn’t have to take her cardigan off fully because as I slid the top of the sleeve towards her shoulder, she yelped and I caught sight of the almighty black and blue bruise. “Get Betty over to A&E immediately please Lauren. Kobi, when you’ve finished handover, come to see me.” I silently fumed.

“Er, no! I can’t. I have to take my grandson to school. Then I’m off ’til Monday,” he croaked and he looked quite flustered. I immediately rang my Modern Matron for advice and she agreed there wasn’t much we could do until he returned. In the meantime, the rest of the staff had to complete his paperwork, fill out the incident form and someone had to sit with Betty over at A&E.

Eventually we met again and he was given his first written warning (I would have dismissed him).

Kobi was a risk to patients

Not a month later, he let a patient into the bathroom on her own and she almost drowned in the bath. This elderly patient, Esme, couldn’t have been more than 4′ 6″ and obviously wasn’t long enough for her feet to reach the end of the bath. She was in the habit of filling the bathtub to the top and it was written in her care plan that 1) she must be supervised in the bathroom at all times, 2) she had to request the key to the bathroom door, to alert staff that she wanted to have a bath and 3) she was not to have a bath during the night.

Telegraph.co.uk

This lardy arse excuse for a man said that, despite the clear care plan, he wanted to give Esme some privacy so he just popped back and forth every minute to check on her. Yet another nurse said he sat in the office for about thirty minutes while she went round the ward to do the half hourly checks. It was this nurse who heard Esme splashing around, almost drowning, and called for help to open the door as Esme had locked it from the inside. Oh but he did real good this time; he called the Doctor!

As instructed by the Human Resources Department, he was given his second written warning, which I didn’t think was good enough so they removed him from our ward, only to be placed elsewhere – a male ward, so he would be at less risk of causing harm to a patient.

Rachel just panicked

During a restraint one day, where it took more nurses than usual to restrain a new admission patient, I was on the floor trying to engage the patient and give assurances that we were indeed trying to help him. Rachel, a ward nurse, had gone to draw up the medication and had been gone for over ten minutes; the patient was becoming more agitated and the restraint team were tiring.

Rachel eventually returned and with the patient’s underwear down, she cleaned and marked the injection site. She pressed the plunger so the needle went in slightly and pulled it back out, as is correct. She was ashen faced when she saw blood in the barrel, which means that she’d hit a blood vessel*. This isn’t a huge problem as long as you stop, remove the needle and press on the injection site to stop it bleeding. She didn’t. She pressed the plunger and the needle went in.

*A broken blood vessel can cause internal bleeding within the muscle and the patient may feel pain and stiffness in the muscle. If a blood vessel breaks, scar tissue or blood clots can form and if a blood clot starts to wander and reaches the heart or lungs, the consequences can be life-threatening.  Injections that hit an artery can be particularly dangerous.

Rachel started panicking and was tearful, so I lead her away while the rest of the team continued and someone called for the Doctor. I got Rachel a coffee and sat her in my office to calm down before joining the Doctor, who confirmed there was no real damage done and the patient would be informed later.

TheSun.co.uk

I returned to my office and downloaded an Incident Form so I wouldn’t forget to complete it later. I turned to Rachel and said not to worry as everything was fine, “Talk me through what happened,” I said kindly, as I felt bad for her. The floodgates opened and she wailed “You were rushing me and I made a mistake……….. It wasn’t my fault……”

“Hey, no one’s blaming you Rachel. Mistakes happen. I just want you to talk me through it.” We have protocols to follow with damaged injection sites and I wanted Rachel to discuss what happened, so that she would learn from it. There would be no follow up other than if she were to make the same mistake again. Only then would she be requested to attend the “Safe medication” course.

Rachel wasn’t prepared to let me explain, “If there’s nothing wrong, why am I in your office? And why have you got the incident form out?” She screamed defensively. “I don’t need this. You don’t know what’s going on in my life.”

“No, I don’t. But you can tell me……….” too late. She’s up and out the door, storming into the staff room, telling everyone on her way, “she’s picking on me.”

The long and short of it – she went off sick with work-related stress. Me, my manager and the HR department tried to contact her at regular intervals, even visiting her home, in accordance with Trust Policy, to no avail.

Almost a year later, without my knowledge or any reference request, she was back in our hospital, working on the Mother and Baby Unit.

Oh dear. Even HR make mistakes – she was still officially employed by the Trust. And who in hell thought she’s be suitable to work with newborn babies!

Who do you think ought to be responsible for incompetent and lazy staff?