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Restraint in hospital settings
Restraint refers to involuntary mobility restrictions imposed on hospitalized patients to facilitate treatment compliance or to prevent self-inflicted harm or harm to care providers or fellow inpatients. Except for rare exceptions, restraint is practiced almost exclusively for hospitalized psychiatric hospitals. Indeed, it may be the only feasible option for instituting treatment in patients such cases. (Eren, et al. 2014) Due to ethical concerns and the potential repercussions for patient well being and autonomy, it is desirable to evaluate the different modalities of restraint; the objective being the achievement of best possible treatment outcomes with the least restrictive practices. This work employs a PICOT approach to evaluate and compare two commonly used restraint modalities, i.e., physical restraint using mechanical means and use of psychotropic drugs. The objective is to evaluate their comparative efficacy in terms of treatment outcomes and respective advantages and disadvantages.
Restraining patients has always been a contentious issue. Several alternative methods are in vogue depending upon the context and morbid considerations. Physical and chemical methods (psychotropic drug administration) are most commonly employed restraining methods in addition to isolation of patients in solitary confinement. Instances of unwarranted or unjustified restraint in mental health institutions are well documented.
Justification for this review
PICOT format has been used for delineating the parameters of this analytic study. The framework and key modalities of this literature review are outlined below:
Study population: Adult patients (both male/female) admitted in psychiatric wards in middle- to large-sized hospitals (especially, patients with schizophrenia, mania, dementia and those with cognitive and behavioral disorders)
Intervention: Physical and pharmacological methods for patient restraint. Triangulation of data available data from recent peer reviewed studies will be conducted as part of this analytic study.
Comparison: Respective indications, outcome indicators, comparative efficacy and ethical concerns pertaining to the two types of restraint practices
Outcome: Identification of evidence-based restraint practices based on their respective merit and applicability in a particular context, e.g., indicators like duration of incarceration (hospitalization), discharge rates, length of hospital stay and patient satisfaction.
Data on restraining practices are not routinely documented in many settings. (Larue, et al. 2013) Literature review revealed considerable variance in study elements like methodology, data variables and indicators used. Moreover there are differences in restraint policies between different countries that prevent any valid or meaningful quantitative comparison. Indeed, many researchers have acknowledged this limitation. Therefore, inferences drawn using quantitative methods are liable to significant bias. (Dumais, et al. 2011) (Bilanakis, et al. 2011)
The objective of this analytic study is to evaluate comparative applicability of physical and pharmacological restraining methods in order to prevent abuse, minimize harm and address the ethical issues concerning psychiatric treatment. Due to the limitations, a purposeful sampling of qualitative studies was done in order to draw best possible inferences and identify future thematic areas of research. Despite the paucity of robust data, some helpful pointers have emerged from some of the studies that have managed to adequately capture the phenomenon of interest, i.e., future research priorities for comparing physical restraint with pharmacologic methods. The overarching objective is to minimize harm, allay ethical concerns and adopt the least harmful restraining practices for the least possible duration of time. (Borckardt, et al. 2011) (Dumais, et al. 2011) These are briefly listed below:
Long term, prospective randomized controlled or cohort studies using standard elements like procedures, methodology and pre defined indicators need to be conducted. Other key considerations include use of standard inclusion criteria, comparable time horizon of the studies, and accounting for variables like differences in policies, institutional capacities, catchment population composition and morbidity profile.
Institutional mechanisms for safeguarding patient welfare are not uniformly implemented. Appropriate methods for mainstreaming these mechanisms need to be researched along with evaluation of different models of psychiatric treatment. (Eren 2014) (Borckardt, et al. 2011) (Larue, et al. 2013)
Evidence suggests that given adequate staff training it is often possible to reduce the need for restraining patients. By factoring ergonomic considerations in building design, use of safety equipment and behavioral interventions, it may be possible to minimize restraint and adopt a more humane treatment approach. Optimal staff planning in terms of skill mix and competencies is another key research imperative identified in this review. (Borckardt, et al. 2011) (Dumais, et al. 2011) (Larue, et al. 2013)
Restraining patients by different means is often required in patients with psychiatric disorders. However, several ethical issues need to be considered since the practice may be unjustified or in violation of the patient rights. (Eren 2014) Used with due discretion such a practice if often valuable in many circumstances, and, indeed, beneficial for patients. However, by its very nature there is much potential for abuse, especially in resource constrained settings. (Borckardt, et al. 2011)
Whatever the indication for resorting to patient restraint, due diligence should be exercised and all possible alternatives to restraint considered. Owing to a lack of standardization of studies, valid comparison of physical and pharmacological methods of restraint was not possible to address the research question in its entirety. Future directions for research on this subject have been identified drawing qualitative inferences. Ongoing evaluation of institutional practices, models of care and ethical considerations using standardized methodologies is a major research imperative. Available studies suggest that given adequate controls and institutional support system, more humane methods can be more commonly used than is the current practice. Alternative methods that have shown promise include behavioral interventions, ergonomic building design, safety equipment, and, mentoring and capacity building of nursing staff. Studies have suggested that least possible use of restrictive practices is often possible without incurring much additional costs.
Scheepmans, K, Dierckx, de Casterlé B, Paquay, L, Van Gansbeke, H, Boonen, S & Milisen, K (2014). Restraint use in home care: a qualitative study from a nursing perspective. BMC Geriatrics; 14:17. doi: 10.1186/1471-2318-14-17.
Eren, N (2014). Nurses' attitudes toward ethical issues in psychiatric inpatient settings. Nursing Ethics: 21(3):359-73. doi: 10.1177/0969733013500161.
Borckardt, J J, Madan, A, Grubaugh, A L, Danielson, CK, Pelic, C G, Hardesty, S J, Hanson, R, Herbert, J, Cooney, H, Benson, A & Frueh, BC (2011). Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital. Psychiatric Services (Washington); 62 (5): pp 477-83.
Ishida, T, Katagiri, T, Uchida, H, Takeuchi, H, Sakurai, H, Watanabe, K & Mimura M (2014). Incidence of deep vein thrombosis in restrained psychiatric patients. Psychosomatics; 55(1):69-75.
Larue C, Dumais A, Boyer R, Goulet MH, Bonin JP, Baba N (2013). The experience of seclusion and restraint in psychiatric settings: Perspectives of patients. Issues in Mental Health Nursing; 34 (5): pp 317-24.
Bilanakis N, Papamichael G, Peritogiannis V (2011). Chemical restraint in routine clinical practice: A report from a general hospital psychiatric ward in Greece. Annals of General Psychiatry;10:4.
Dumais A1, Larue C, Drapeau A, Ménard G, Giguère Allard M (2011). Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: a 2-year retrospective audit. Journal of Psychiatric and Mental Health nursing; 18 (5): pp 394-402.
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