Mechanical restraints are one of the most controversial aspects of psychiatric care. The aversion to using them no doubt dates back to the popularity of films like One Flew Over the Cuckoo's Nest, which portrays the psychiatric institutions and medical authorities using restraints to constrain the free spirits of sane, but noncompliant patients. The reality of the use of restraints is far more complex and some defend the use of these devices to promote patient safety. According to the review article "Mechanical restraint -- which interventions prevent episodes of mechanical restraint? -- A systematic review" by Bak (2011), "in some countries, mechanical restraint is performed according to the law when psychiatric inpatients pose a risk to themselves or to others." But other countries do not allow the use of mechanical restraints: for example, in the United Kingdom, only the use of seclusion and holding (physical restraint) is allowed (except in exceptional circumstances in special hospital environments)" (Bak 2011).
The consensus as to what constitutes the ethically-acceptable use of mechanical restraints is thus still in doubt. This article from Perspectives in Psychiatric Care attempts to establish greater clarity about how to avoid the use of this controversial technique whenever possible. The use of mechanical restraints can have grave physical as well as psychological consequences for an already vulnerable psychiatric population. Even when available to use as a method of last resort, it is desirable to find other means to treat the patient population and promote safety.
What were the author's objective(s) for the systematic review?
The objectives of the authors were to provide greater clarity about how to avoid the use of mechanical restraints. "In order to provide a basis for choosing and developing nursing interventions, under which the number of mechanical restraint episodes are decreased, the following will be reviewed: Which conditions in nursing and which nursing interventions have been shown to reduce the frequency of mechanical restraint episodes?" (Bak 2011). The presumption of the authors is that not all uses of mechanical restraints are invalid, although some countries, such as the United Kingdom, have entirely banned their use. The presumption is that it is preferable not to use such a technique when another is available. A review of existing literature will enable clinicians to better understand why certain nursing interventions are more successful in doing so and others are not. The format of the review encompassed both qualitative and quantitative research.
Describe the author's search process and the criteria used to include the studies in the review
The authors encountered major problems related to the paucity of research on the subject. It "was recognized very early during the process that only very few randomized clinical trials existed, and no meta-analyses were found (Muralidharan & Fenton, 2006). Therefore, searches were not limited to these study designs. Also, many of the areas under investigation could not be covered from quantitative papers solely. Therefore, we developed a way to combine quantitative and qualitative papers into ranked recommendations in order to deduce maximum information from the available papers" (Bak 2011).
On one hand, this technique has an advantage in terms of comprehensiveness. It also ensures that more personalized and experiential evidence that may give greater voice to nurses' and even patient's personal perspectives may be deployed in the form of qualitative analysis. The downside to this approach is that interventions that use different research techniques were compared in a manner that might be a form of 'apples vs. oranges' comparison. Comparing even similar quantitative studies even presents features of difficulty given that the patient populations may be different; as well as the clinical setting, experience level of nurses, etcetera. The authors were also forced to combine different elements of ethical standards and guides for the review process. "The combination of principles from the mentioned sources has been necessary because no one in itself covered both quantitative and qualitative research quantification" (Bak 2011). As chronicled in Table 1 in the article, one of these steps involved "Grading the recommendations for the quantitative and qualitative evidence separately" (Bak 2011).
However, despite the desire to include a wide variety of studies and patients, there were clear criteria in selecting the cases. Only "original peer-reviewed papers, covering the care of adult psychiatric inpatients who have been physically restrained, were included in the review" alone were included (Bak 2011). Children and patients not identified as psychiatric patients were omitted. The use of restraints in learning disability settings, nursing homes, and prisons were excluded, and no study was included more than once in the statistical tabulations. The emphasis was on current studies, only including papers published after 1998 and the review and selection process spanned August and November 2008 and was updated in April 2009 (Bak 2011).
The studies were written in English, Danish, Norwegian, and Swedish and all had available English abstracts. Key words were used in different combinations and included such words as restraint, active, adolescent, elder, music, talk-down, and various other terms associated with intervention therapies. The researchers used 32 different databases that housed peer-reviewed articles (Bak 2011).
The search technique included "an overarching strategy for conditions and interventions across selected databases;" a "search to identify guidance and reports…not indexed in the major databases; followed by "a topic-specific search strategy on PubMed" (Bak 2011). Then, "for each condition or intervention, evidence of effectiveness or harm was sought" (Bak 2011). The authors also conducted manual searching for studies that were not electronically indexed and they used reference lists to find other relevant papers.
Once the papers were amassed, the quantitative studies were graded based upon the levels of evidence provided and the qualitative studies were graded based upon levels of complexity in the evidence. Finally, the researchers synthesized their finding to come to a consensus upon the quality of the work. The search process involved considerably whittling down of the original search findings of 2,885 papers. These were reduced to 358 based upon abstract and title review, and the full papers after being read were reduced in number to 268. Final quality checking yielded 59 papers (48 were quantitative and 11 were qualitative papers) (Bak 2011).
Describe the overall effectiveness of the interventions reviewed along with their statistical significance
Once the authors had found studies that satisfied their criteria, they listed the different interventions in the studies and rated them on an effect scale of 1 to 5, with one being the most effective and 5 being the least. The most effective intervention included "implementation of cognitive milieu therapy….through patient involvement and empowerment" (Bak 2011). In other words, encouraging patients to become involved participants in their treatment had the most salutary effect on behavior and was most effective in reducing the need for mechanical restraints. Almost as effective were "combined intervention programs" also using "patient participation, patient education, staff education, programmatic changes, high-level administrative endorsement, cultural changes, data analysis" and "implementation of patient-centered care with a higher degree of patients' positive involvement in their own care" (Bak 2011).
Other forms of intervention were far less effective. Some of the least effective interventions were trying to change the nurses' focus: "from considering the patient as deviant to being a resource in his/her own treatment;" using music interventions to soothe patients; separating patients in solitary confinement; early administration of evening medications; "debriefing, defusing, and crisis intervention minimize the number of mechanical restraint episodes" amongst the staff; improving the education or experience level of the staff; trying to explain the rationale for rules to patients; higher staff ratios; and better video surveillance systems (Bak 2011).
It should be noted that all of the studies did find that these improvements still had a positive effect. But by comparing all of the studies and the quality of the studies, the authors found that the studies which stressed patient empowerment and participation were more effective, relatively speaking, than those which tended to focus upon staff members exclusively or upon the physical aspects of the mental health facility. "The recommendation grade describes the intervention's ability to exert an effect on reducing the number of mechanical restraints in the clinical setting, not the degree of how much it would reduce the number of mechanical restraints, but if it would" (Bak 2011). The most effective reduction was found in the use of cognitive milieu therapy (CMT) which involved an 87% reduction in the use of mechanical restraints through the implementation of an "active, structured, problem-orientated, psycho-educational, and dynamic treatment form" (Bak 2011). The second and third most effective interventions, statistically speaking, involved changing the culture of the organization to allow for more patient input along with better staff education and the third most effective intervention involved shifting the focus to more patient-centered care.
Discuss the similarities and differences of the effects the authors found between the studies
The authors noted that "no interventions reached the highest degree of recommendation combined with the highest effect, and to create strong evidence-based practice in this area" and stated that more high-quality research was needed…
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