Restraint in mental health services has been a recent national topic of interest by various tabloid papers and current affairs programmes, with reports stating that last year there were over 80,000 restraints by staff on patients in mental health units across the UK.1 So the question at hand “Is it ethical to use restraint when working with patients who have a mental health illness?” is very much so a relevant and contemporary issue of the day.
Staff are expected to intervene when there is a risk of harm to self or another person, and be proactive in reducing that likelihood. Speaking about restraint on Mental Health wards former Health Minister Norman Lamb described the current situation as “endemic” on many units.2 The Care Quality commission (CQC) and Department of Health (DOH) states that there must be “a real possibility of harm to the person or to staff, the public or others” for restraint to be used(Ibid).
When talking about restraint, restraint falls into 3 categories 1) Environmental restraint; is putting procedures in place to strictly limit the movement of people, such as stopping people from going outside, from using the Internet or putting phone restrictions in place. Implementing blanket rules for everyone to follow rather than if there is a specific risk associated with a particular individual. 2) Restrictive Interventions: Which includes observations, seclusion, manual restraint, mechanical restraint is were a patient is physically held in a particular place or position.3 3) Chemical restraints: this is controlling the patient’s behaviour by using a psychoactive drug. To cause sedation, for instance haloperidol, midazolam and olanzapine.4
As a quote taken from the Guardian by an anonymous mental health nurse states; “It takes more than niceness to be here, you have to have a heart as big as the earth and, at the same time, be made of stone”.5 Compassion, attentiveness and dedication are some of the many traits expected from support staff however at the same time being a solid, decisive, tower of strength.
Latest figures taken from 40 mental health trusts in England have shown an increase in physical restraint from it being implemented 46,499 times in 2013-14 to 59,808 times in 2016-176. Dr Sridevi Kalidindi of the Royal College of Psychiatrists says “The increase in the number of restraints recorded is concerning.”7 Since 2013 a number of mental health charities and advocates have been calling for the government and NHS England to put an end to “life-threatening” face down restraint of people with mental health problems in secure units.8
Women and girls’ mental health often is closely linked to experiences in the past of violence and abuse, with more than half of women with mental health issues having experienced some form of abuse. These links are particularly profound for those with a more serious mental health condition.9
Naomi Ball is a former service user from Birmingham, she documented her experiences of being restrained numerous times within a secure setting. When talking to the BBC she said “I felt totally dehumanised and degraded because all control has been taken away from you. You are pinned to the floor face down, you are terrified anyway, and it just makes you feel more scared,” she further went on to say “I don’t know why they felt the need to it,” the 46-year-old from Essex said. “I wasn’t aggressive or throwing things around, I wasn’t being abusive or anything like that”.10
The most important phase of aggression is the behaviour escalating from baseline. However each baseline varies from person to person. If properly utilised This is the stage that will significantly lower the frequency of restraints in patients. If support staff become successful in lowering the patient aggression level in escalation phase then the need of restraints will drastically be decreased in such a user of the service, according to best practice means practitioners will strive to de-escalate behaviour and so avoid restraint.11
In 2016-17 there was a reported 42,000 assaults on mental health staff, that’s an increase of 25% in the last four years.12 The department of health states “its completely unacceptable for staff to be subject to violence and we expect the NHS to work with the police to seek the strongest possible action”.(ibid) Nurses have reported that patients are now arriving on wards in a very “unwell” state, receiving help only when they have reached a breaking point. 42% of responders said they had been victims of violence in the last year according to The Union Unison who have compiled a report called Struggling to Cope which revealed this information.(ibid)
Similarly in the same time frame (2016-17) a reported 9,285 mental health staff took long term leave due to their own mental health an increase from 2012 when it stood at 7,580.13 Dave Munday mental health lead at Union Unite said “Our members tell us workplace stress is increasing and that cuts to staff and services mean they’re working longer hours with fewer resources, Staff themselves are feeling the impact of austerity and there’s a lack of trust in the often repeated but not fulfilled promises of the current government.”(ibid)
This leaves staff under resourced and implementing environmental restraint as to easier manage the staff to patient ratio gap. Which has repercussions with patients feeling constantly controlled and frustrated, in turn leading to aggressive behaviour and a vicious cycle of environmental restraint to physical restraint.
The job of a mental health nurse and support staff can be exceedingly challenging, multi faceted and exhausting but yet inwardly rewarding. Staff can find themselves in the proverbial rock and a hard place scenario, looking out for the best interests of patients but having to use heavy handed techniques in accomplishing that. As the title of the article from the Guardian containing the earlier quote from the anonymous Mental Health nurse sums up with its title “I hate restraining mental health patients but often it’s the only option”.
Verbal communication from staff and benign strategies to de-escalate behaviour is critical, with patients reporting that they felt there were other methods that could have been implemented before they were physically restrained.
Staff training and adequate resources will help combat malpractice, however with 23% of NHS activity taken up by mental illness, mental health trusts have been receiving only about 11% of funding in recent years.14 Leaving staff with limited resources .
Supporting users of the service in the community before they meet their “crisis point”, would significantly improve the rising violence in mental health wards.
The cost of health and safety to service users and staff cannot be measured.