Joy Duxbury

Restraint and the Question of Validity

Restraint as an intervention in the management of acute mental distress has a long history that predates the existence of psychiatry. However, it remains a source of controversy with an ongoing debate as to its role. This article critically explores what to date has seemingly been only implicit in the debate surrounding the role of restraint: how should the concept of validity be interpreted when applied to restraint as an intervention? The practice of restraint in mental health is critically examined using two post-positivist constructions of validity, the pragmatic and the psychopolitical, by means of a critical examination of the literature. The current literature provides only weak support for the pragmatic validity of restraint as an intervention and no support to date for its psychopolitical validity. Judgements regarding the validity of any intervention that is coercive must include reference to the psychopolitical dimensions of both practice and policy.

Classroom-based and distance learning education and training courses in end-of-life care for health and social care staff: A systematic review

Background: Staff from a range of health and social care professions report deficits in their knowledge and skills when providing end-of-life and palliative care, and education and training has been advocated at a range of levels. Aims: To review the literature related to classroom-based and distance learning education and training initiatives for health and social care staff in end-of-life and palliative care, in terms of their target audience, extent, modes of delivery, content and teaching and learning strategies, and to identify the most effective educational strategies for enhancing care. Design: A systematic review of the literature evaluating classroom-based and distance learning education and training courses for health and social care staff in end-of-life and palliative care. Data sources: Online databases CINAHL, MEDLINE, EMBASE and PSYCHINFO between January 2000 and July 2010. Studies were selected that discussed specific education and training initiatives and included pre-and post-test evaluation of participants’ learning. Results: 30 studies met eligibility criteria. The majority reported successful outcomes, though there were some exceptions. Level of prior experience and availability of practice reinforcement influenced learning. Participative and interactive learning strategies were predominantly used along with discussion of case scenarios. Multi-professional learning was infrequently reported and service user and carer input to curriculum development and delivery was reported in only one study. Conclusions: Classroom-based education and training is useful for enhancing professionals’ skills and perceived preparedness for delivering end-of-life care but should be reinforced by actual practice experience.

A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings

Aggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale-Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.

Aggression in a high secure hospital: Staff and patient attitudes

Responding to aggressive behaviour is a key activity for nurses and other care staff in high secure hospitals. The attitudes and beliefs of staff regarding patient aggression will influence the management strategies they adopt. Patients will also hold attitudes regarding the causes of and best ways to respond to aggressive behaviour. This study measured the attitudes towards aggression of staff (n= 109) and patients (n= 27) in a high secure hospital in the UK using the Management of Aggression and Violence Attitude Scale (MAVAS). There was considerable concordance of views, staff and patients disagreeing on only two items on the MAVAS. Aggression was felt to have a range of causes, embracing factors internal to the person, factors in the external environment and situational or interactional factors. Interpersonal means of managing aggression were supported, but both staff and patients also advocated the use of controlling management strategies such as medication, seclusion and restraint. The implications of these findings for aggression management in high secure settings are discussed in the light of best practice guidelines that promote interpersonal approaches over controlling strategies.

The use of physical restraint in mental health nursing: An examination of principles, practice and implications for training

Tackling the problem of aggression and violence in health care is high on the agenda for healthcare professionals. In an endeavour to protect both patients and staff alike when managing aggressive behaviour, the use of physical restraint is under scrutiny, particularly as a result of the reported deaths of a number of patients whilst being restrained. The challenges of employing this type of intervention, implications for safe and effective practices and the need for the suitable training of staff are explored in this paper.

It's the talk: a study of involvement initiatives in secure mental health settings

A study of involvement initiatives within secure mental health services across one UK region, where these have been organized to reflect alliances between staff and service users. There is little previous relevant international research, but constraints upon effective involvement have been noted.

A qualitative study into the attitudes of patients and staff towards violence and aggression in a high security hospital

This paper provides a brief overview of research conducted within a high security hospital to ascertain staff and patient views on how aggression and violence are managed and their subsequent impact on all parties. Both the National Institute for Mental Health in England (NIMHE, 2004) and the National Institute of Clinical Excellence (NICE, 2005) have emphasized the need to take account of contextual factors when considering the cause and management of aggression. While patient variables (internal) are important within psychiatry, the environment or setting (including culture), relational issues (including gender) and staff attitude are equally important (Jansen et al. 2006). Duxbury & Whittington (2005) found that poor communication contributed to the development of patient aggression, whereby restrictions and environmental factors are fundamental to relational issues. There is currently very little research conducted in high secure services (HSS) that focuses on the management of violence and aggression (MVA) in this context. Uppal & McMurran (2009) report on the frequency and nature of incidents of violence, selfharm and security and Ireland (2006) consider bullying within this context. However, these studies do not focus specifically on the attitudes of staff and patients to violence and aggression. McKeown & Stowell-Smith (2006) speak about the construction of ‘difference’ between staff and patients, who exist in conditions of high security; they suggest that we separate ourselves from those with psychopathic personalities to cope with the work, but acknowledge that this creates its own difficulties within the establishment of the therapeutic relationship. More recently, Canadian authors Jacob et al. (2009) stated that ‘Forensic psychiatric nurses work with individuals who may evoke feelings of empathy as well as feelings of disgust, repulsion, and fear.’ (p. 153). They attribute these emotions to the fear of caring for individuals who are viewed as ‘monsters’ (Jacob et al. 2009). This view resonates with that of McKeown & Stowell-Smith (2006), who suggest that in the face of abjection, staff create a context that constructs a sense of difference and ‘otherness’ between themselves and the patients. They suggest that developing greater understanding, and thus a better attitude towards the client group, would benefit forensic mental health nurses. This in turn, would enable them to engage in a reflective process regarding their professional practice, and, as a result, improve the provision of nursing care. Such commentary is valuable, but is based upon observation and experience rather than research.

Deaths in custody: the role of restraint

Purpose – The practice of restraint is controversial as deaths in care or custody have been a consequence of restraint. The purpose of this paper is to clarify research from national and international literature to ascertain any common findings in order to provide guidance for staff on safe and effective restraint techniques where there is no other resort in the management of violent and aggressive individuals.Design/methodology/approach – The researchers undertook a review of the literature on the medical theories relating to restraint‐related deaths and an analysis of deaths in custody in the UK for the time period 1 Jan 1999 to 1 Jan 2010.Findings – Findings showed that certain groups are particularly vulnerable to risks while being restrained. There are also biophysiological mechanisms which staff need to be aware of when restraining an aggressive or violent individual.Originality/value – It is evident that those in vulnerable groups when restrained in a prone position, or in a basket hold, for a prol...

The Eileen Skellern Lecture 2014: physical restraint: in defence of the indefensible?

Accessible summary What is known on the subject: The physical and psychological trauma that can occur as a result of physical restraint is increasingly highlighted in the media and literature across the globe. Despite this, the use of physical restraint continues without a strong evdience base for its value or efficacy. What this paper adds to existing knowledge: A number of common defences for the use of physical restraint are outlined and considered in light of existing research in this area. The potential for adopting restrictive intervention minimization programmes of work is highlighted as a way forward. What are the implications for practice: The implementation of approaches to prevent and reduce physical restraint is required. A combination of factors including the use of advance planning tools, recognition of potential injury and death, and the importance of trauma informed care is necessary. Patients can be severely traumatized by the use of restraint, and there is an increasing drive to examine, reflect upon, and to reduce the use and impact of these. Abstract Aggression is reported to be prevalent in psychiatric inpatient care and its frequency towards healthcare professionals is well documented. While aggression may not be entirely avoidable, its incidence can be reduced through prevention and the minimization of restrictive practices such as physical restraint. This paper aims to explore three common ‘defences’ to account for the use of physical restraint; to challenge each defence with regard to the evidence base; and to identify how services are responding to the challenge of reducing the use of restrictive interventions. Following a number of investigations to highlight serious problems with the use of physical restraint, it seems timely to examine its efficacy in light of the evidence base. A combination of interventions to minimize the use of restraint including advance planning tools, and recognition of potential trauma is necessary at an organizational and individual level. Patients can be traumatized by the use of restrictive practices and there is a growing momentum to promote models that incorporate trauma informed care (TIC) and person centredness.

A cross‐sectional observational study of healthcare professional views of factors affecting teenage adherence with antipsychotic medication

Delays in effective treatment of a first episode psychosis can result in more severe symptoms, a longer time to achieve symptom control and a poorer quality of life; yet around 40% do not take antipsychotic medication as prescribed. There is evidence that patients and staff have different perceptions of what affects adherence with medication. Research in adults suggests healthcare professionals and patients understand the importance of good insight in promoting adherence with medication for schizophrenia; however, healthcare staff may overestimate the impact of side effects and underestimate the importance of medication effectiveness. There is also some evidence to suggest that motivations to take prescribed medication may differ in first and multi-episode psychosis. This research therefore sought views of staff working with adolescents diagnosed with first episode psychosis about what factors affected adherence with antipsychotic medication. Staff responding to the survey felt that young people were more likely to take medication if they felt it would make them better, prevent relapse and if they had a positive rapport with staff. As in an adult population, side effects, particularly weight gain, sedation and muscular side effects, were expressed as a common reason for poor adherence. Doctors and nurses assigned differing importance to parameters such as family views of medication, fear of admission and a preference for cannabis over medication suggesting that views may differ between professional groups Views of young people will be obtained in the next phase of the research study to enable comparison with staff views and consideration of staff interventions to better promote medication adherence. Antipsychotic medication is an effective treatment for first episode psychosis; yet 40% of patients do not take medication as prescribed. Previous research in adults with schizophrenia comparing healthcare professional and patient views suggests that while healthcare professionals recognize the importance of insight in promoting medication adherence, they underestimate the importance of medication efficacy and overestimate the impact of side effects. It was hypothesized that staff in this study would also recognize the importance of insight and positive medication attitudes in teenagers with psychosis, but overestimate the impact of side effects on medication adherence. This cross-sectional observational study sought staff views about factors affecting antipsychotic medication adherence in those aged between 14 and 18 years. An online survey was distributed and 60 responses were subsequently returned. Staff felt that good medication insight as well as positive relationships with staff were important determinants of good medication adherence. The most important influences of poor adherence were poor insight, side effects of medication and a wish to exert personal control around medication decisions. The results therefore confirmed the initial hypothesis. Published literature also provides support for some, but not all, of the staff views expressed in survey responses.Accessible summary Delays in effective treatment of a first episode psychosis can result in more severe symptoms, a longer time to achieve symptom control and a poorer quality of life; yet around 40% do not take antipsychotic medication as prescribed. There is evidence that patients and staff have different perceptions of what affects adherence with medication. Research in adults suggests healthcare professionals and patients understand the importance of good insight in promoting adherence with medication for schizophrenia; however, healthcare staff may overestimate the impact of side effects and underestimate the importance of medication effectiveness. There is also some evidence to suggest that motivations to take prescribed medication may differ in first and multi-episode psychosis. This research therefore sought views of staff working with adolescents diagnosed with first episode psychosis about what factors affected adherence with antipsychotic medication. Staff responding to the survey felt that young people were more likely to take medication if they felt it would make them better, prevent relapse and if they had a positive rapport with staff. As in an adult population, side effects, particularly weight gain, sedation and muscular side effects, were expressed as a common reason for poor adherence. Doctors and nurses assigned differing importance to parameters such as family views of medication, fear of admission and a preference for cannabis over medication suggesting that views may differ between professional groups Views of young people will be obtained in the next phase of the research study to enable comparison with staff views and consideration of staff interventions to better promote medication adherence. Abstract Antipsychotic medication is an effective treatment for first episode psychosis; yet 40% of patients do not take medication as prescribed. Previous research in adults with schizophrenia comparing healthcare professional and patient views suggests that while healthcare professionals recognize the importance of insight in promoting medication adherence, they underestimate the importance of medication efficacy and overestimate the impact of side effects. It was hypothesized that staff in this study would also recognize the importance of insight and positive medication attitudes in teenagers with psychosis, but overestimate the impact of side effects on medication adherence. This cross-sectional observational study sought staff views about factors affecting antipsychotic medication adherence in those aged between 14 and 18 years. An online survey was distributed and 60 responses were subsequently returned. Staff felt that good medication insight as well as positive relationships with staff were important determinants of good medication adherence. The most important influences of poor adherence were poor insight, side effects of medication and a wish to exert personal control around medication decisions. The results therefore confirmed the initial hypothesis. Published literature also provides support for some, but not all, of the staff views expressed in survey responses.