Mechanical Restraints in Psychiatric Care: A Systematic Review

Mechanical restraints are one of the most controversial aspects of psychiatric care. The aversion to using them no doubt dates back in part to the popularity of films like One Flew Over the Cuckoo's Nest, which portrays psychiatric institutions and medical authorities using restraints to constrain the free spirits of sane but noncompliant patients. The reality of restraint use is far more complex, and some practitioners defend these devices as necessary tools for promoting patient safety. According to the systematic review article 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." Other countries, however, do not permit mechanical restraints at all: "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. The review article from Perspectives in Psychiatric Care attempts to establish greater clarity about how to avoid 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 as a method of last resort, it is desirable to find other means to treat patients and promote safety.

The objectives of the authors were to provide greater clarity about how to avoid the use of mechanical restraints. As stated in the review: "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 authors' presumption is that not all uses of mechanical restraints are invalid — though some countries, such as the United Kingdom, have entirely banned their use — but that it is preferable to employ alternative techniques whenever another is available. A review of existing literature would enable clinicians to better understand why certain nursing interventions are more successful than others at reducing restraint use. The review encompassed both qualitative and quantitative research.

The authors encountered major problems related to the scarcity 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).

This combined approach has an advantage in terms of comprehensiveness. It also ensures that more personalized and experiential evidence — including nurses' and patients' personal perspectives — may be incorporated through qualitative analysis. The downside is that interventions using different research techniques were compared in a manner that risks being an "apples vs. oranges" problem. Even comparing similar quantitative studies presents difficulties given that patient populations, clinical settings, and staff experience levels may differ substantially. The authors were also forced to combine different ethical standards and methodological 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 detailed in the article, one of these steps involved "grading the recommendations for the quantitative and qualitative evidence separately" (Bak, 2011).

Despite the desire to include a wide variety of studies and patients, the selection criteria were clear. Only "original peer-reviewed papers, covering the care of adult psychiatric inpatients who have been physically restrained, were included in the review" (Bak, 2011). Children and patients not identified as psychiatric patients were omitted. Studies on restraint use 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 research; only papers published after 1998 were included, and the review and selection process spanned August through 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. Keywords were used in different combinations and included terms such as restraint, active, adolescent, elder, music, talk-down, and various other terms associated with intervention therapies. The researchers searched 32 different databases housing peer-reviewed articles (Bak, 2011).

The search strategy 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). For each condition or intervention, "evidence of effectiveness or harm was sought" (Bak, 2011). The authors also conducted manual searching for studies not electronically indexed and used reference lists to identify additional relevant papers.

Once the papers were assembled, quantitative studies were graded based upon levels of evidence provided, and qualitative studies were graded based upon levels of complexity in the evidence. The researchers then synthesized their findings to reach a consensus on the quality of the work. The search process involved considerably narrowing down the original findings: 2,885 papers were reduced to 358 based on abstract and title review, and after full-text reading, the number was reduced further to 268. Final quality checking yielded 59 papers — 48 quantitative and 11 qualitative (Bak, 2011).

Once the authors had identified studies that satisfied their criteria, they listed the different interventions and rated them on an effect scale of 1 to 5, with 1 being the most effective and 5 being the least. The most effective intervention was "implementation of cognitive milieu therapy through patient involvement and empowerment" (Bak, 2011). In other words, encouraging patients to become active participants in their own treatment had the most beneficial effect on behavior and was most effective in reducing the need for mechanical restraints. Nearly as effective were "combined intervention programs" incorporating "patient participation, patient education, staff education, programmatic changes, high-level administrative endorsement, cultural changes, data analysis," as well as "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. Among the least effective were: attempts to shift nurses' focus "from considering the patient as deviant to being a resource in his/her own treatment"; music interventions to soothe patients; separation of patients in solitary confinement; early administration of evening medications; "debriefing, defusing, and crisis intervention" strategies among staff; improvements in staff education or experience level; attempts to explain the rationale for rules to patients; higher staff-to-patient ratios; and better video surveillance systems (Bak, 2011).