Restraint is defined by the U.S. Joint Commission on Accreditation of Healthcare Organization as “any method (chemical or physical) of restricting an individual's freedom of movement, physical activity, or normal access to the body” (Negroni, 2017, p. 100). Physical restraints are “any manual strategy or physical or mechanical equipment that immobilizes or reduces the ability of [an individual] to move his or her arms, legs, body, or head freely” (Negroni, 2017, p. 100). Seclusion is “a control measure that consists of confining an individual to a location for a specific period of time and from which the person may not leave freely” (Goulet, Larue, & Lemieux, 2018, p. 120).
The traditional justification for using restraint and seclusion among psychiatric patients is derived from paternalism (O'Brien & Golding, 2003). Beauchamp and Childress (2001) defined paternalism as “the intentional overriding of one person's preferences or actions by another person, where the person who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose preferences or actions are overridden” (p. 178). The paternalistic view justifies the use of restraint and seclusion to protect patients from their non-autonomous actions. Sjöstrand and Helgesson (2008) supported the paternalistic justification; they stated that patients with psychiatric disorders are considered incompetent and cannot make independent decisions. Hence, others need to make decisions and intervene for the patient.
Use of restraint and seclusion in psychiatric settings is a controversial measure, with some arguing that the control of patient behavior seems to be unethical (Välimäki et al., 2017). Several countries have begun legislative efforts to control or reduce use of restraint and seclusion in clinical psychiatric settings (Gallagher, 2011; Hughes & Lane, 2016). However, psychiatric literature has reported that legislative and policy change is inadequate in terms of reducing use of restraint and seclusion (Gallagher, 2011). Because of these findings, health care providers should be encouraged to create or design a treatment culture that emphasizes minimal use of restraint and seclusion measures when handling aggressive psychiatric patients (Keski-Valkama et al., 2010; Marx & Baker, 2017). Use of restraint and seclusion should be monitored closely and ethical questions regarding restraint and seclusion should be continuously evaluated (Huckshorn, 2012). One systematic review revealed that limited evidence exists for mental health researchers to decide whether use of coercive measures such as restraint and seclusion is considered ethical, effective, and safe for short-term management of aggressive behavior of psychiatric patients in clinical settings (Nelstrop et al., 2006).
The purposes of the current literature review were to critically review studies related to the use of restraint and seclusion in psychiatric settings across different cultures, identify the ethical principles behind using restraint and seclusion, and generate a clear view about patients' perspectives and factors that influence use of restraint and seclusion worldwide.
A comprehensive literature review was conducted using MEDLINE, CINAHL, PsycINFO, and ProQuest online databases to answer the question: what is known regarding the use of restraint and seclusion in psychiatric settings? Keywords used were restraint, seclusion, coercive measures, control measures, culture, perspective, attitudes, and mental health. Identified literature was discussed based on substantive topical themes regarding restraint and seclusion, including reported types, frequency, and duration; ethical issues; patients' perspectives and associated factors; and staff attitudes. Studies related to nursing and other health-related disciplines and studies reported in English were included. A date range was not used, as the process was exploratory. A total of 62 articles were included in the review.
Identified studies on restraint and seclusion were mostly quantitative and descriptive, with only one experimental design. Most studies were conducted in acute psychiatric inpatient units in the United States and Europe.
Reported Types, Frequency, and Duration of Restraint and Seclusion
The results showed variations in the types, frequency, and duration of restraint and seclusion across different countries. In the United Kingdom, seclusion is rarely used and is substituted by physical restraint. Furthermore, mechanical restraints are avoided in the United Kingdom (Jarrett, Bowers, & Simpson, 2008). Countries such as Austria, Germany, Japan, and Norway used mechanical restraint more often than seclusion, whereas seclusion was used more often in Finland, the Netherlands, New Zealand, and Switzerland. In Iceland, mechanical restraint and seclusion were outlawed and physical restraint was used instead (Steinert et al., 2010).
Reported levels of restraint and seclusion in the literature vary. Use of seclusion varied between less than 1% of admissions in Norway and Wales (Keski-Valkama, 2010) and 15.6% of admissions in New Zealand (El-Badri & Mellsop, 2002). Use of physical restraint varied between 1.2% of admissions in the Netherlands (Abma, Widdershoven, & Lendemeijer, 2005) and 8% in Germany (Steinert, Bergbauer, Schmid, & Gebhardt, 2007). Furthermore, use of physical restraint varied between 2.5% of admissions in several European countries and 7.5% in the United Kingdom (Keski-Valkama, 2010). Eastern countries seem to fall in the average range in preliminary international statistics on implementation of restraint and seclusion. The World Health Organization (WHO) in collaboration with the Jordanian Ministry of Health (MOH) collected information on the mental health system in Jordan to improve the system and provide a baseline for monitoring change. They reported that 10% of psychiatric patients admitted to Jordanian MOH hospitals were restrained or secluded at least once in the past 1 year (WHO & Jordanian MOH, 2011).
The mean duration of seclusion was 3 hours in Norway and 294 hours in the Netherlands. The mean duration of mechanical restraint was 7.9 hours in Norway and 1,182 hours in the Netherlands (Abma et al., 2005; Keski-Valkama, 2010).
Ethical Issues Regarding Use of Restraint and Seclusion
Nursing practice has several dimensions of care, of which ethical issues are an essential part. For health care professionals to arrive at thoughtful and balanced decisions concerning their patients, health care professionals should reflect on the ethical aspects of the decision, as well as their attitude toward their patients (Goethals, Dierckx de Casterlé, & Gastmans, 2012).
Coercive measures are widely used among psychiatric health care providers as means of preventing suicidal behaviors and helping patients regain control over their psychiatric symptoms. Moreover, these measures are used in situations in which a patient's aggressive behavior threatens the safety of self or others (Vieta et al., 2017). Despite longstanding traditions of using restraint and seclusion in psychiatric care, use of these measures is a controversial area of practice (Välimäki et al., 2017). Use of restraint and seclusion to maintain patients' safety may undermine patient autonomy and violate human rights. As a result, use of restraint and seclusion has been increasingly challenged (Hui, 2015). On the contrary, Hui (2015) and Prinsen and Van Delden (2009) argue that respecting autonomy and human dignity are not sufficient reasons to reduce or eliminate use of restraint and seclusion. Due to these varying viewpoints, nurses may experience difficulty balancing their responsibilities of protecting patients' rights and preventing harm to patients and staff. Coercive interventions such as restraint and seclusion are common psychiatric practices that create ethical dilemmas for nurses (Keski-Valkama et al., 2010).
Keski-Valkama et al. (2010) found that policymakers, the public, and mental health care providers were concerned about the ethical treatment of mental health patients and legal debates over the use of restraint and seclusion. The researchers recommended avoiding use of restraint and seclusion as control interventions in routine care and using them as last-resort measures. Furthermore, they did not view restraint and seclusion as treatment options, even in dangerous or emergency situations (Keski-Valkama et al., 2010). Hence, more evidence is needed to support the development of clinical alternatives that will reduce the use of restraint and seclusion and improve personalized care plans (Canadian Institute for Health Information, 2011; Keski-Valkama et al., 2010).
Patients' Perceptions of Restraint and Seclusion
As previously mentioned, restraint and seclusion in psychiatric units are used to protect patients from hurting themselves or to protect staff members or other patients from being hurt. Restraint and seclusion have been used worldwide to ensure safety when patient behaviors are difficult to manage or control (Presley & Robinson, 2002). Previous research has found that decreasing use of restraint and seclusion results in increasing incidences of assault on staff members and other patients (Khadivi, Patel, Atkinson, & Levine, 2004).
However, negative outcomes regarding the use of restraint and seclusion have been found. One study reported that restraint and seclusion that take place in contained environments result in delayed development of life skills necessary outside of these environments (Donat, 2005). Patients often view restraint and seclusion as bullying and traumatic (Sheline & Nelson, 1993; Walsh & Randell, 1995). In addition, some patients reported that restraint and seclusion evoked memories of previous traumatic events (Wynn, 2004). Moreover, in one qualitative study, patients noted that restraint and seclusion during treatment boosted their feelings of stigmatization, thus increasing recovery time (Robins, Sauvageot, Cusack, Suffoletta-Maierle, & Frueh, 2005). In addition, restraint and seclusion caused patients to feel angry, lonely, rejected, and abandoned (Bonner, Lowe, Rawcliffe, & Wellman, 2002; Gaskin, Elsom, & Happell, 2007).
Although nurses considered restraint and seclusion effective techniques to calm patients' agitation and prevent harm, patients considered these measures to be punishment. Keski-Valkama et al. (2010) discovered that 66.3% of patients viewed restraint and seclusion as punitive measures that limited their autonomy. In addition, Keski-Valkama et al. (2010) showed that forensic psychiatric patients are more likely to view seclusion as a punitive measure. In contrast, one study indicated that some patients viewed restraint and seclusion as helpful techniques (Larue et al., 2013).
Multiple factors contribute to use of restraint and seclusion. According to Kong and Evans (2012), psychiatric mental health nurses reported using restraint and seclusion for various reasons, including “being too busy, lack of resources, beliefs and concerns, lack of education, differences and inconsistencies, and relationship issues” (p. 176). Furthermore, Knox and Holloman (2012) found that use of restraint and seclusion among nurses in acute and emergency wards is significantly higher than in chronic care wards, as patients who are chronically ill may develop a rapport with staff over a period of time.
In addition, patient characteristics influence use of restraint and seclusion. One patient characteristic that affects the use of restraint and seclusion is migration status. Use of restraint and seclusion is related to cultural traditions, norms, and issues (Knutzen, Sandvik, Hauff, Opjordsmoen, & Friis, 2007). One study showed that patients who are immigrants have higher incidence of restraint (21.6%) than native patients (12.9%) (Knutzen et al., 2007). Another study demonstrated that immigrants were less likely to be voluntarily admitted due to the higher likelihood of restraint and seclusion (Berg & Johnsen, 2004). Two additional studies conducted in psychiatric emergency care settings indicated that patients' cultural background significantly contributed to their likelihood of being restrained or secluded (Telintelo, Kuhlman, & Winget, 1983; Zun, 2003).
Moreover, patients' clinical background was found to affect the duration of restraint and seclusion (Noda et al., 2013). Patients with brief psychotic episodes are less likely to have long durations of restraint and seclusion (Noda et al., 2013). Thus, patients with complicated or prolonged psychiatric conditions, such as schizophrenia or bipolar disorder, would have longer durations of restraint and seclusion.
Another patient characteristic that influences restraint and seclusion is gender. Previous studies have found that male patients are more likely to be restrained or secluded (Zun, 2003). In addition, male patients have significantly longer durations of restraint and seclusion than female patients (Noda et al., 2013). However, one study revealed that there was no difference between male and female patients regarding the incidence and duration of restraint and seclusion (Knutzen et al., 2007).
Furthermore, patient age was a significant factor affecting the incidence and duration of restraint and seclusion. A study conducted by Zun (2003) showed that most patients who were restrained were between ages 31 and 40, whereas only a few were older adults (Zun, 2003). Another study supported this finding, indicating that patients ages 18 to 29 were more vulnerable to restraint and seclusion (Knutzen et al., 2007). Moreover, younger patients were more likely to have longer durations of restraint and seclusion (Noda et al., 2013). In addition, patients with low socioeconomic status are more likely to be restrained or secluded (Khandelwal, Deb, & Krishnan, 2015).
Staff Members' Attitudes Toward Restraint and Seclusion
Restraint and seclusion are associated with several negative consequences for patients and staff members. Due to nurses' direct role in using restraint and seclusion, it is important to understand their attitudes toward restraint and seclusion to reduce the use of these measures (Happell & Harrow, 2010).
van Doeselaar, Sleegers, and Hutschemaekers (2008) conducted a prospective study using the Professional Attitudes Toward Seclusion Questionnaire (PATS-Q) with a sample of 540 Dutch professionals in mental health care who had previously used seclusion to determine their attitudes regarding use of seclusion. Results showed that professionals' attitudes fell into three major categories: transformers, maintainers, or doubters. Transformers included professionals who had little faith in seclusion, were strongly in favor of alternative strategies, and wanted to change seclusion practices. Maintainers considered safety to be more important than their personal beliefs about seclusion, believed alternatives were less effective than seclusion, and did not believe they needed to reduce seclusion rates, despite their ethical objections. Unlike transformers and maintainers, doubters comprised individuals who believed that seclusion was valuable as an intervention despite ethical considerations; however, they were also interested in alternative options. Furthermore, Husum (2011) investigated the attitudes of Norwegian staff members toward restraint and seclusion and found similar results, including staff members who desire and work toward reducing use of restraint and seclusion, staff members who do not have clear opinions regarding restraint and seclusion, and those who oppose alternatives to restraint and seclusion.
An experimental study by Mann-Poll, Smit, van Doeselaar, and Hutschemaekers (2013) used the PATS-Q to determine whether professionals from four acute admission wards in an adult mental health institute changed their attitudes toward seclusion after implementation of a seclusion reduction program. Professionals' attitudes toward seclusion were assessed at the start (2004) and end (2008) of the program. The main elements of the program included development of multidisciplinary teams, on-the-job training on topics such as risk taxation and proactive working, weekly meetings with an external supervisor, monitoring and feedback for seclusion rates, and participating in national and international conferences. Findings indicated that after implementation of the program, during which professionals reflected on ethical questions about the necessity and desirability of the use of seclusion, they were significantly more knowledgeable about ethical issues and benefits of using alternatives to seclusion. Results also indicated an increase in criticism of seclusion, and an increased willingness to change their seclusion practices, thus allowing them to be categorized as transformers. Findings indicated that participation in similar training reduction programs may be influential on attitudes of mental health workers (Mann-Poll et al., 2013). However, as individual participants in the four wards changed over time due to regulatory rotations, it would not have been beneficial for researchers to analyze attitude changes on individual levels. Therefore, conclusions were drawn on a group level. According to Ramadan (2007), there is a need to use less restrictive or alternative measures before using restraint and seclusion. These measures may include environmental manipulation and de-escalation techniques. Environmental manipulation involves minimizing environmental stimuli after assessing patients' triggers. For example, environmental manipulation may include improving patients' comfort, training staff about emergency psychiatric care and crises management, and giving respect and sufficient time to patients.
Happell et al. (2012) investigated the relationship between attitudes toward seclusion and levels of burn-out, staff satisfaction, and therapeutic optimism. The sample comprised 54 staff members recruited using convenience sampling from one adult health service inpatient unit. Findings indicated that nurses played a large role in deciding whether to seclude patients; 72% of participants indicated that the decision to seclude a patient was made by a nurse. Only 6% of participants reported that seclusion should never be used. Happell et al. (2012) found that nurses experienced feelings of satisfaction when a patient was punished by seclusion. However, in cases in which individuals asked to use the seclusion room, nurses did not perceive seclusion as an accomplishment, as it was not their decision, indicating that nurses' attempts to create a therapeutic environment were unsuccessful. Furthermore, when staff members were asked about when seclusion should be used, they provided various responses, raising doubts about whether seclusion is used only as a last resort. However, results of this study cannot be generalized, as the sample was a convenience sample recruited from only one unit.
In Kuwait, Elgamal (2006) conducted a study to explore the effect of gender, educational level, and years of experience on the attitudes of 62 nurses toward restraint. This study is significant as it reflects attitudes of nurses within Arabic and Islamic cultures. Data analysis revealed that nurses displayed aggressive attitudes and admitted that force is typical on the unit. Use of continuous restraint is more frequent among male nurses and nurses working on male wards. Regarding level of education, nurses with less education or less experience preferred to use restraint and were more likely to display aggressive attitudes. In contrast, nurses with higher levels of education or more experience were significantly more likely to report conservative attitudes toward constraint, preferred short restraint times, and disagreed with the use of restraint for hyperactive patients. Results also indicated that nursing staff members with less education and experience should be targeted for future educational programs on alternatives to restraint and seclusion.
In the review process, the current authors found numerous limitations to definitions of seclusion and restraint. In particular, there was discrepancy in the definition of types of restraint, with physical and mechanical restraint often used inconsistently and interchangeably. Most studies did not specify or define which type of restraint and seclusion they had targeted, and numerous studies combined different types of restraint and seclusion in out-come reporting, making it difficult to compare and amalgamate findings.
The current study indicated that preferences, frequency, and duration of restraint and seclusion varied among countries studied. These differences may reflect the different cultural beliefs and values within which a psychiatric system is situated (Bowers et al., 2007). In other words, there is a discrepancy in the literature between those who agree and disagree with the use of restraint and seclusion (Dean, Duke, George, & Scott, 2007). Therefore, the use of these practices in nursing is controversial. Individuals supporting use of restraint and seclusion do so to maintain the safety of patients and others (Vieta et al., 2017). However, restrained or secluded patients might be exposed to injuries, disabilities, and even death. Thus, use of restraint and seclusion might be associated with legal and ethical dilemmas (Abdeljawad & Mrayyan, 2016). For example, involuntary chemical restraint in Dutch mental health settings is considered more invasive and a more serious violation of patients' integrity than use of other types of restraint and seclusion (Steinert & Lepping, 2009). Consequently, the international literature indicated that the Netherlands appears to have the highest rate of inpatient violence in Europe, as well as a relatively high incidence of mechanical restraint and seclusion (Nijman, Palmstierna, Almvik, & Stolker, 2005). However, these findings from the Netherlands might be at least partly explained by its negative attitude toward chemical restraint. On the contrary, in the United Kingdom, mechanical restraint in prohibited and seclusion is rarely used. It has been found that involuntary chemical restraint is more likely to be used in the United Kingdom than in other European countries (Jarrett et al., 2008). All other European countries, as well as the United States, fall between these two extremes, with most using mechanical restraint (Steinert et al., 2010).
The current review indicates that the literature lacks studies on the types and duration of restraint and seclusion used in Arabic countries, which represent a different culture than those of Western countries. Only one published Jordanian report (WHO & Jordanian MOH, 2011) stated that the level of restraint and seclusion use in Jordan was parallel to levels found in studies in New Zealand and Germany (El-Badri & Mellsop, 2002; Steinert et al., 2007).
Based on findings of the current review, feelings of abandonment, anger, loneliness, and rejection, as well as perceptions of restraint and seclusion as punishment, are all common patient perspectives regarding use of restraint and seclusion. However, nurses perceive restraint and seclusion as effective ways to control patient aggression and prevent harm, demonstrating that nurses and patients perceive restraint and seclusion differently. Considering the varying perspectives of nurses and patients, negative perception of restraint and seclusion among patients is likely to be a result of nurses' practices. One possible cause is lack of therapeutic communication between nurses and patients. The literature indicates that negative feelings of patients are a result of absence of proper interaction with nurses before, during, and after the use of restraint and seclusion (Keski-Valkama et al., 2010; Nijman et al., 2005). Many studies report that patients did not receive information regarding restraint and seclusion; thus, they did not understand why they were restrained or secluded, which led to them perceiving these measures as punishment (Donat, 2005; Holmes, Kennedy, & Perron, 2004; Meehan, Bergen, & Fjeldsoe, 2004; Mohr, Petti, & Mohr, 2003). In addition, patients conveyed that their basic needs (e.g., eating, drinking, excretion, security) were ignored and not met during use of restraint and seclusion (Holmes et al., 2004; Okanli, Yilmaz, & Kavak, 2016). A study conducted in a psychiatric hospital in Turkey revealed that training for patients on skills to manage challenges related to mental illness decreases the incidence and duration of restraint and seclusion among 23.9% of patients and improves the recovery process (Donat, 2005).
Thus, to decrease the gap in perceptions of restraint and seclusion between nurses and patients, nurses should increase proper therapeutic interaction with patients before, during, and after use of restraint and seclusion. Before use of these measures, nurses should explain the procedure and why it is necessary. This explanation may decrease patients' uncertainty regarding the reasons for restraint and seclusion. During restraint and seclusion, interaction should include regular checkups for patients' basic needs. These checkups will help avoid malpractice and prevent further harm. After restraint and seclusion, interaction should include training regarding daily life skills, which may promote recovery and prevent future use of restraint and seclusion.
Another cultural issue that should be considered is patients' migration status. Previous studies have revealed that immigrants are more likely to be restrained or secluded (Knutzen et al., 2007; Zun, 2003). This could be due to differences in ethical beliefs, race, ethnicity, and language barriers between nurses and patients (Knutzen et al., 2007). These differences could increase communication problems and decrease trust between nurses and patients. Furthermore, forced migration is considered a severe traumatic experience (Lavik, Hauff, Skrondal, & Solberg, 1996). Therefore, nurses may interpret symptoms following such experiences (e.g., fear, agitation, pacing, aggression) as harmful and requiring use of restraint and seclusion. In addition, immigrants are more likely to develop posttraumatic stress disorder (PTSD) due to the distressing events they experienced. One clinical study confirmed that patients with PTSD are more susceptible to stress factors that initiate agitation and consequently aggressive behaviors (Hummelvoll & Severinsson, 2001).
It is important to note that refugee psychiatric patients are individuals with different and special needs compared to native psychiatric patients. For better care and maximum benefits, nurses must carefully examine the needs and problems of this population. In addition, nurses should be aware of the effects of forced migration on refugee psychiatric patients; this awareness may help nurses identify aggressive behavior due to these experiences and decide on an appropriate treatment technique. Moreover, nurses' awareness about issues facing refugee psychiatric patients outside clinical areas is vital to ensure that these patients feel understood. Involving patients and their families in the treatment and decision-making processes leads to best results. Thus, nurses working with such patients need more patience, better communication skills, and the ability to build therapeutic relationships with these patients.
Previous research on nurses' attitudes toward restraint and seclusion indicated that although nurses have negative feelings toward use of such measures, they believe they are necessary (Möhler & Meyer, 2014). However, lack of knowledge or understanding of alternatives to restraint and seclusion among nurses has been identified as a barrier to reducing or eliminating their use (De Bellis et al., 2013). Based on scientific evidence, researchers (Mann-Poll et al., 2013; Ramadan, 2007) reported that suitable training for mental health staff, an assessment of the risk of disturbed behaviors, and adequate alternative measures are essential factors for enhancing staff attitudes toward reducing use of restraint and seclusion. The findings of these studies are encouraging in terms of reducing restraint and seclusion, as well as the effectiveness of alternative measures.
The current results are preliminary. Definitions of restraint and seclusion are different across studies; however, standard definitions have recently been recognized by consensus and could be used in future studies (Steinert & Lepping, 2009). For example, data on the use of mechanical restraint in some studies include an unknown proportion of physical restraint.
Much research has been conducted to investigate the use of restraint and seclusion among mental health staff members. Use of restraint and seclusion is a controversial measure in psychiatric settings. However, psychiatric patients have the right to be cared for in a respectful, safe, and non-restrictive environment. Mental health professionals may differ on ethical issues related to use of restraint and seclusion, yet all seek to maximize benefits and minimize risks to their patients (Dean et al., 2007). One argument in favor of restraint and seclusion is that these measures are needed to ensure a safe environment. The literature revealed that although safety must be a driving concern, a patient's autonomy and rights might be violated when using restraint and seclusion (Hui, 2015). Thus, use of restraint and seclusion may be considered unethical, as alternative measures exist. However, empirical research indicates that preferences regarding restraint and seclusion and frequency and duration of restraint and seclusion vary significantly across cultures.
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