Can mental health nursing ever give up the option of restraint?

Restraint techniques have long been used on psychiatric patients
when they become uncontrollably violent, but last year’s inquiry
into the death of David “Rocky” Bennett raised serious questions
about their safety.
Bennett, a schizophrenic, suffocated while being restrained for 25
minutes by four to five nurses at the Norvic Clinic, Norwich, in
1998. They held him down after he had hit a nurse in the face.

A key recommendation of the inquiry was that a patient should
not be restrained in the “prone” position on the floor for longer
than three minutes at a time. The Prison Service already limits
physical restraint to five minutes.

The case caused an outcry as much for its racial dimensions –
Bennett was African-Caribbean – as for the question of whether the
nurses used excessive force.

But it is not unique. The Mental Health Act Commission says that
between 1997 and 2000 two mental health patients died while under
restraint, four died within 24 hours of being held down and 22 died
within a week.
It is likely that these figures are underestimates, says pressure
group Inquest, as hospitals are not obliged to summon the police or
order a postmortem examination.

When Kurt Howard died while under restraint at a Swansea
psychiatric hospital in 2002, the on-duty doctor recorded death as
“natural causes”. Only when a hospital pathologist questioned this
did the police investigate.

The Department of Health, however, rejected the inquiry’s calls
for an interim three-minute limit on restraint. Draft guidelines
from the National Institute for Clinical Excellence (Nice), which
are due to be finalised in February, emphasise that restraint
should be used for the “minimum possible” period only.

Dr Richard Stone, a former GP who sat on the Bennett inquiry,
argues that the three-minute time limit was its most important
recommendation.

“There’s no doubt in my mind that restraining someone on the
floor is an incredibly dangerous procedure – you feel you are being
suffocated and killed,” he says.

“If someone is pinned for a limit of three minutes face down on
the floor, then at least he has time to catch his breath for a
minute, even if you have to put him down again.”

The draft guidance sets national standards for training in
restraint and alternative techniques for managing violence. It also
emphasises that restraint and other physical techniques for
managing violence, such as seclusion and sedation, should be used
only after all other attempts to defuse the situation have
failed.
However, the current code of practice, written in 1983, already
says the technique should be one of “last resort”.

Stone says: “The reality is that when people are given a power
as a last resort it quickly becomes the power of first resort. Our
view was that, as soon as you say it can be used in exceptional
circumstances, you have no limit on restraint. There’s no
definition of what exceptional circumstances are. The result is
that more people are going to die.”

Neither the Mental Health Nurses Association nor the Royal
College of Nursing explicitly backs the idea of a time limit. Both
organisations are more concerned to ensure that nurses are better
trained in de-escalation techniques and safety in the use of
restraint.

The RCN’s mental health adviser, Ian Hulatt, says: “We need an
agreed national standard for a safe way to use the last resort and
a better understanding of the first resorts. Issues like
maintaining a good airway are essential.”

Errol Francis, of the Sainsbury Centre for Mental Health, says:
“A time limit would be difficult to enforce.”
A more profound question is whether mental health nursing can
abandon restraint techniques altogether. “Control and restraint is
not part of the technique in other specialties. Why is it part of
the range of interventions that are taught?” asks Francis.

“In mental health it’s institutionalised. Scenarios are
rehearsed, and that’s the problem. If someone becomes violent it
should be an issue for law enforcement, not for nurses.”

This would entail a massive cultural shift. Francis says: “It’s
such a tradition, and has been part of the regime since the birth
of psychiatry. People are not ready to abandon it.”

One issue is to consider why the nurse-patient relationship can
deteriorate so far that restraint is deemed necessary, says
Francis.

The inquiry report is clear that Bennett had suffered
“cumulatively” from 18 years of racial abuse by fellow patients
that in most cases went unchallenged by staff. He became involved
in a fight with a patient who had racially abused him in the past,
but it was Bennett who was transferred to another ward, not the
white patient. So a feeling of injustice triggered his attack on
the nurse.

Stone says the nursing staff, who were not racist, cited
patients’ vulnerability as the reason for not challenging their
racism. Yet the inquiry team had noticed that smoking rules were
strictly enforced.

It is a question of priorities. Because restraint techniques are
used disproportionately on black patients, tackling racism in
in-patient care may hold one answer to reducing reliance on a
dangerous technique.

Advance directives, in which patients specify how they would
prefer to be dealt with should they lose control, could be another
solution. They are included in the draft guidelines, but are
omitted from the draft Mental Health Bill.

Another client group with experience of restraint techniques in
institutional care prefers this option.

A report by England’s children’s rights director, Dr Roger
Morgan, gives the views of children in residential care homes. The
children say the method should only be used as a last resort to
prevent injuries or serious damage. It should not be a punishment –
as it was for one child who merely threw a newspaper.

Staff also need to be mindful – and here there are parallels to
sensitivities over race in mental health – that children who have
been abused do not like being touched, says the report.

Morgan wants the government to produce guidelines and improve
training in using restraint in children’s homes. Each child’s
placement plan should also describe how to deal with them if they
lose control.

Everyone agrees there is a dearth of evidence on how effective
restraint techniques are compared with non-physical alternatives.
Nor has their safety been studied, although a large body of
evidence points to the risks.

Figures on deaths under restraint in secure hospitals are not
routinely collected, nor is the number of times that restraint is
used, although a voluntary reporting system is being
established.

In the meantime, restraint remains the nuclear option in mental
health services. For now, nobody is prepared to give up the
deterrent.

DRAFT GUIDELINES

• When using restraint the level of force applied must be
  justifiable, appropriate, reasonable and proportionate and should
  be applied for the minimum possible time.
• Rapid tranquillisation, physical interventions and seclusion
  should only be considered once de-escalation and other strategies
  have failed to calm the service user. They should never be used as
  punishment. 
• During physical restraint one team member must be responsible
  for protecting and supporting the head and neck at all times, for
  ensuring that the airway and breathing are not compromised and that
  vital signs are monitored.
• Where possible (in the form of an advance directive)
  intervention strategies for the management of disturbed or violent
  behaviour should be negotiated with all service users, and be
  documented in the care plan and records.
• All those involved with rapid tranquillisation, physical
  interventions or seclusion must receive training to a minimum of
  intermediate life support.
• The crash bag must be available within three minutes in health
  care settings where rapid tranquillisation, physical interventions
  and seclusion might be used.
• Staff must receive training to recognise anger, potential
  aggression, antecedents and risk factors of violence and to monitor
  their own verbal and non-verbal behaviour. It should include
  methods of anticipating, de-escalating or coping with violent
  behaviour. 
• Techniques that rely on the deliberate application of pain are
  permitted in exceptional circumstances only, when other techniques
  have been tried and proved unsuccessful.