International Journal of Law and Psychiatry 35 (2012) 43–49

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International Journal of Law and Psychiatry

Physical restraint in a therapeutic setting; a necessary evil?

Elizabeth Perkins a,⁎, Helen Prosser b, David Riley c, Richard Whittington a

a Health & Community Care Research Unit, University of Liverpool, UKb Centre for Social Justice Research, University of Salford, UKc Mersey Care NHS Trust, Liverpool, UK

⁎ Corresponding author at: Health & Community CInstitute of Psychology, Health and Society, Universit3GB, UK. Tel.: +44 151 794 5909(direct line), +44 15151 794 5434.

E-mail address: e.perkins@liv.ac.uk (E. Perkins).

0160-2527/$ – see front matter © 2011 Elsevier Ltd. Alldoi:10.1016/j.ijlp.2011.11.008

a b s t r a c t

a r t i c l e i n f o

Available online 16 December 2011

Keywords:Physical interventionRestraintCoercion

Physical restraint of people experiencing mental health problems is a coercive and traumatic procedurewhich is only legally permitted if it is proportionate to the risk presented. This study sought to examinethe decision-making processes used by mental health staff involved in a series of restraint episodes in anacute care setting. Thirty nurses were interviewed either individually or in focus groups to elicit theirviews on restraint and experience in specific incidents. Four factors which influenced the decision to restrainwere identified: contextual demands; lack of alternatives; the escalatory effects of restraint itself; andperceptions of risk. While some of these factors are amenable to change through improvements in practice,training and organisational culture, nurses viewed restraint as a necessary evil, justified on the basis of theunpredictable nature of mental illness and the environment in which they worked.

© 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Physical restraint of people experiencing mental health problemsagainst their will is an intrusive and risky procedure which is onlylegally permitted in very specific circumstances. In most jurisdictions,these circumstances include detention under the relevant mentalhealth legislation. Such detention does not, however, eradicate therequirement for the intervention to be proportionate to any riskperceived by the practitioners (NIMHE, 2004). There is an expectationthat ‘best practice’ means practitioners will strive to de-escalatebehaviour and so avoid restraintwhilstmaintaining a safe environment.If staff have to use restraint it is expected that they will use the leastintrusive method of restraint appropriate in the circumstances. Sincephysical restraint can range from firmly holding the person's armswhilst they remain standing to forcing the person to the floor andpinning all four limbs down (‘takedown’), there is always a choice tobemade about the degree of force even once the decision to implementrestraint has been taken. Notwithstanding the drive to establishconsistent standards of good practice in this area, such judge-ments of proportionality and decisions on when to implementphysical restraint are highly complex and inevitably somewhat

are Research Unit (HaCCRU),y of Liverpool, Liverpool L691 794 5503(office); fax: +44

rights reserved.

subjective. They have been subject to legal challenge in the UKand elsewhere (e.g. R on the Application of AC –v- Secretary ofState for Justice).

Coercive physical interventions (PI) such as restraint have been acontroversial aspect of psychiatric care since the time of Pinel witha consensus which lasted into the 1990s that such interventions arean inevitable, albeit undesirable,means of ensuring safety. The potentialtraumatic effects of PI use are well-established (Chien, Chan, Lam, &Kam, 2005; Cusack, Frueh, Hiers, Suffoletta-Maierle, & Bennett, 2003;Frueh et al., 2005; Hoekstra, Lendemeijer, & Jansen, 2004; Lancaster,Whittington, Lane, Riley, & Meehan, 2008; Meehan, Bergen, & Fjeldsoe,2004; Paterson, Bradley, & Stark, 2003; Robins, Sauvageot, Cusack,Suffoletta-Maierle, & Frueh, 2005; Wynn, 2004). However, it is onlyrecently that a groundswell of opinion has developed in North America,Europe and Australasia over the past decade against the use of PI as apart of everyday mental health care (Huckshorn, 2004). PI, in this new‘zero tolerance’ thinking, is either always illegitimate by definition, orshould be restricted to a very small number of highly risky situations.In the context of a mental health system which espouses core valuesof collaboration and partnership with service users, PI is viewed as aprofessional and systems failure requiring intensive scrutiny andexecutive action. Such a culture shift increases the pressure onpractitioners to reflect on their practice in terms of the proportionalityof response to the perceived risk. In particular, in relation to thisstudy, the choice between standing (‘vertical’) restraint and ‘takedown’to the floor (‘horizontal restraint’) is pertinent and worthy ofexamination.

The study on which this paper is based used a recent physicalrestraint episode as a basis for exploring the attitudes of staff towards

44 E. Perkins et al. / International Journal of Law and Psychiatry 35 (2012) 43–49

restraint and as a way of beginning to unpick some of the influenceson their decision making and behaviour.

2. Methods

Thirty nursing staff working in an acute adult mental healthsetting in the UK were recruited to the study; of whom, fifteen wereinterviewed individually, thirteen took part in focus group interviewsand a further 2 took part in both. The individual interviews wereundertaken in 2007within twoweeks of a restraint episode occurring.They involved a range of nursing staff that included staff nurses andward managers, on both day and night shifts. The individualinterviewees included 9 women and 8 men, who ranged in age from25 to 56. All respondents had worked in an acute mental healthinpatient setting for between 18 months and 25 years. The interviewwas designed to explore the restraint incident retrospectively, usingit also as a basis for discussion of more general views and attitudeson the use of restraint. Both individual interviews and focus groupdiscussions were conducted in a private and confidential locationwithin the mental health trust. All interviews and focus groups wereaudio-recorded and transcribed verbatim after first gaining thewritten consent of participants. All quotes have been anonymised orattributed to a pseudonym.

Interview and focus group transcripts were read and re-read toidentify the main thematic areas. Since the aim of the study was touncover new insights into the factors influencing restraint, theemphasis was on identifying variation in accounts, rather than inquantifying the frequency of particular types of experience. Analysisbegan by organising the data into broad domains based on theinterview and topic guides. Consistent with a thematic analyticapproach (Charmaz, 2006), further themes, categories and sub-categories were constructed from the data as analysis proceeded.Categories and themes were explored for consistency and comparedwithin and between transcripts in order to examine variations inresponses. Finally, key concepts were identified by re-reading thecategorised data and searching for links between each concept. Thisprocess also incorporated a search for any anomalous findings, withconceptualisation revised to take account of these. The study wasapproved by an NHS Research Ethics Committee.

3. Findings

In the majority of restraint incidents discussed with staff, theservice user was moved to the floor and restrained in a horizontalposition. In only 2 incidents the service user was restrained in avertical (standing) position and in one of these the staff memberinterviewed stated that a move to the floor would have been preferablehad space permitted. Staff identified aggression or violence, self-harm,absconding and the planned administration of medication as theantecedents leading to restraint. There were a number of factors thatstaff identified which help to explain why restraint is seen as animportant intervention within mental health institutions. Thesewill be explored in more detail starting with the contextualdemands, moving on to the sense of a restricted range of availableoptions, the escalatory effects of restraint itself and finally percep-tions of risk.

3.1. Contextual demands

A recurring perception throughout the interviewswas that organisa-tional demands and ward factors created the climate in which difficultbehaviour developed and escalated. There was recognition that changesin the service user population impacted on the dynamics on the ward.Not just between staff and service users but also between serviceusers. Staff were more cautious in their dealings with individualswho they did not know very well. One staff member succinctly

described the attempted balancing and weighing of risks when talkingabout one new service user who had been making threats of physicalassault.

He has got no history of aggression … but I think his bark is worsethan his bite, but I don't know, I have never nursed him before, so Idon't know how much he would escalate and when he would backoff, if he would, so I don't know, he is a bit of an unknown quantityreally. (Interview 17)

The sense of knowing an individual, or having built up a relationshipwith someone and recognizing their behavioural pattern and triggershelped inform staff's expectations of an individual's behaviour and, inparticular, the risks posed.

If you know a person's potential, and you know what their strengthsand weaknesses are and whether you can actually talk somebodyround then it's always easier. With somebody who is an unknown,who has a previous recent history of aggression towards family andfriends, then you know that this person is more capable andmore likelyto lash out and hurt somebody, than somebody who has no previouscontact, but hasn't got a history. (Interview 6)

The use of past behaviour as a predictor of future behaviourprovided staff with a frame of reference which in certain circumstancesincreased the likelihood of de-escalation and decreased the use ofrestraint.

I didn't feel that unsafe because I knew there were two staff with me,because I had got quite a good relationship with him… I didn't feelthat threatened. (Interview 16)

So if they trust you and you know them, it makes a difference…but ifyou know someone, you can often spot the triggers, the warningsigns, you know the triggers, you know when they're building up toit. (Interview 9)

While staff reported that knowing an individual provided a basisfor a good relationship and therefore for de-escalation, they felt thatstaffing levels prohibited the amount of time they had to spend withany one individual. So, while de-escalation was seen as important, stafffelt that it was not always possible within the context of their currentstaffing levels to develop the relationships which made it possible.

You would have to spend an awful lot of time talking with them,which is probably time that… while you are spending so muchtime trying to de-escalate you are actually taking your timeaway from other patients who probably need your help morethan the actual other person. (Interview 10)

Ironically, while recognising that preventing a situation fromescalating took time, it was also recognised that restraint episodeswere also labour intensive, often requiring higher staffing levels anddrawing staff from other wards.

We had three incidents last night, one was a restraint, one wasdiffused and one a meds issue, but there was only four staff on theward so we had to use six additional staff from other wards, whichof course leaves them short. (Interview 8)

Interestingly, although staff were familiar with de-escalationstrategies which focused on neutralising behaviour, (e.g. reducingexternal stimuli; removing other service users from the area; movingthe service user to a safer, or more quiet and private environment;calming the service user by showing signs of listening and acknowl-edgement of their concerns), in everyday use de-escalation focused

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on communicating with the service user and often directing theservice user to modify and contain their behaviour. Paradoxically,communicative de-escalation techniques were deemed to be of leastvalue where a service user was suffering from acute and uncontrollablepsychiatric symptomatology.

Usually we try and de-escalate it by talking to the patient… but some-times because they are so unwell, and at the time it could be throughhearing voices, or through their illness, could be alcohol or drugabuse, then no amount of talking can actually stop the patient or theservice user. (Interview 3)

In the context of a changing service user population and what staffperceived to be low staffing levels, it was not surprising that tworespondents reported the inconsistent management of service userbehaviour as a contributory factor to behaviours leading to restraint.These staff felt that a more objective and consistent approach shouldbe adopted in defining the behaviours to be tolerated, and the stepsthat should be taken to intervene earlier in managing disruptiveand agitated behaviours:

I think though that some situations could be avoided, or the potentialfor situations could be avoided. It's important that the clients knowwhat the boundaries are and that these boundaries should apply toeveryone, everyone has to be treated the same. … If some clientsare treated differently then that creates tension between staff andclients and it can lead to resentment, frustrations, so behaviourscan get difficult. (Interview 8)

Therewas also the sense that the threat of restraintwas occasionallyused as an alternative to de-escalation but with a view to deterring ormodifying behaviour. Again, it was recognised that this in itself mightbe seen as provocative and have the opposite effect from that intended.

I have heardmembers of staff say, “well don't do that, if you do that, theconsequence will be….”, well that, that's provocative to me, that isprovocative, that is going to anger a person. (Interview 1)

Restraint is used as a means of controlling a difficult patient indifficult circumstances. I think sometimes, and this is justmy perception,that sometimes, in reality, it is used as a threat rather than ameans of…it's used proactively, rather than reactively I think, that's the best way Ican put it. (Interview 14)

3.2. Lack of alternatives

While the majority of staff acknowledged the existence of aprogressive approach to restraining an individual; with horizontalrestraint being the last resort, the reality was that the majority ofincidents resulted in horizontal restraint without any interveningpositions being tried. In only a small number of incidents was verticalrestraint reported to have been used as an initial procedure in aprogressive step-wise process. If staff felt that they could control theservice user's behaviour and the service user was calming down andbecoming compliant with staff directions, then a move to horizontalrestraint was seen as unnecessary. In the majority of incidents theservice user was reported as either physically assaulting or attemptingto assault others physically, or was threatening physical violenceagainst others. If the service user resisted attempts to be restrainedand staff felt they were unable to reduce the targeted behaviour invertical or sitting restraint, then restraint was reinforced by movingthe service user to the floor.

Well, I know in the C&R (training) you are encouraged not to bring theperson down to the floor right away as a matter of course, if you feel

you don't have to, you can restrain somebody on their feet, or evenjust sort of half way which is on their knees, most restraints are stillbrought down to the floor. (Interview 1).

Initially he was standing up, as I say we had his arms, trying to gethis arms down his side, just to stop him from lashing out and hittingus, that was proving unsuccessful because of his fitness and theexcitement of the patient himself, he was quite threatened by thisand I think that made him a lot more hostile to us initially. And itfinished up we just had to pull him on the floor just to make surethat his legs weren't a problem because of his height. (Interview 6)

Acts of actual violent assault or the threat of assault were usuallyreported to be involved where staff proceeded immediately tohorizontal restraint.

He was punching me in the head mostly and then he was kicking meas well in the ribs, in the side, my chest and that, and then I fellbackwards to the floor, and as I fell backwards to the floor he was…, still punching me and kicking me while I was down on the floor,and I managed, he stumbled a bit, and as he stumbled I just managedto jump up, and while I was waiting for the rest of the staff to come tomy assistance, I had to get his head in a head lock and like pull himhalf way down to the floor and then the rest of the staff respondedand he had to be restrained then. (Interview 12)

When describing incidents involving a rapid move to the floor,respondents' accounts often suggested that explicit decision-makingwas overtaken by an instinctive or intuitive response.

He just ran right at me and he was, I was sort of like by the doorstanding up, with my back against the wall, he just ran at me, sortof like with his head down and his arms out, to go to punch me. Soinstinct really I just protected myself and as he got closer, I grabbedhis head and brought his head down, because the lower you bring aperson, the more difficult it is for them to punch you. (Interview 4)

The notion of protecting the self and others from physical harm orintent was used by the staff as justification for using horizontalrestraint. However, it also became clear that within staff accountsthere was a sense in which particular triggers elicited standardizedresponses. For instance, as described above and below, physicalassault was likely to trigger a decision to use horizontal restraint inself-defence.

I mean personally I don't think any of that training, the C&R, equipsyou for it, does it? It just helps you after you have got them on thefloor to keep them down in a safe way. But before that it's just, thatis just, it's them or you isn't it. (Interview 13)

The overriding concern when faced with violence and aggressionor a perceived intent to harm, was the need to act quickly. Thissense of urgency often seemed to result in an unsystematic restraintepisode, rather than a graduated, progressive sequence.

Describe the way we did it? Well really on restraining and takingsomeone down, we wouldn't know how it happens because ithappens that quick, that you just, it's just a scrap to be quite honest.It is a scrap. I mean you get taught all these methods …It doesn'twork. To be quite honest, it's dog eat dog. (Interview 13)

There's no training that can ever really portray what it's like to gohands on, and I think the course is really good, but when you actually,when you're in a situation when you're about to restrain someonevery seriously,… everyone's adrenalin is going and everyone can justsort of jump in really without there being that control. (Interview 15)

46 E. Perkins et al. / International Journal of Law and Psychiatry 35 (2012) 43–49

In these circumstances, the ability to make clear decisions aboutrestraint was over ridden in the eyes of the staff by the need tocontrol the service user's behaviour.

We had to use restraint, there was no other option of controlling him.(Interview 12)

Throughout the interviews, staff, while recognising the notion ofrestraint as a means of last resort, viewed it as a ‘necessary evil’, thatis a necessary strategy in controlling behaviour and reducing therisk of violence and harm even though the majority of staff talkedwith dislike about its application.

You need it because it's for your safety and other people's safety.Because, you just need it there because if you didn't have it, peoplecould get hurt. I mean I know it's not the nicest thing, and it is un-comfortable, but you have got to look at it, at the safety aspects ofwhat could happen if we don't use restraints. (Interview 2)

For the majority of the respondents there was a clear associationbetween mental illness and the service user's inability to controltheir own behaviour which created the context in which the needfor restraint was almost normalised.

I just think because of the type of people you are dealingwith… I thinkit's a natural progression, that some people will become aggressivebecause of their state of mind. (Interview 17)

It's driven by mental illness, and basically they are not so much awareof what they are doing, they are not really responsible for what theyare doing, and because of their mental illness I think you don't knowhow far they would go, so they are really dangerous,… some patientsyou will get, and they are that mentally ill, that psychotic they areconstantly hearing voices, telling them to harm people, and so theyare the ones who are really unpredictable who I think could, youknow, go as far as killing people. (Interview 17)

But I think it happens too often as well on our ward anywaylately....we restrain on a daily basis sometimes. (Focus group3;P1)

The nursing staff in this study judged that all of the incidents ofrestraint discussed in the interview had been used appropriately,and, on reflection, considered that little could have been done differ-ently to prevent the incident from occurring. Very few staff reportedfeelings of disquiet over their own practice in handling the incidentafter it had finished or after their shift had ended. There was onlyone respondent who reported that the process itself could havebeen executed better, but none felt that restraint had been usedinappropriately.

References to ‘taking control’ formed a central feature in staff'srationalisations of the use of horizontal restraint. This related to oneof two conceptualizations: a) restraint as a technique to directlysuppress aggressive and violent behaviour; and b) restraint as amanagement strategy to maintain order and stability within theorganisational setting.

We had to move her onto the floor because we just couldn't controlher on the bed, we were all moving, so the only way we couldcontrol her, she was lying face down and there was one on eitherarm, one on the head, and two on the legs because she was strong,and we had to talk her round for about 45 minutes, she was on thefloor. (Interview 2)

Actually I have never used the vertical restraint. … you have morecontrol when you take people down to the floor. (Interview 4)

As the above examples demonstrate, horizontal restraint isconsidered the most expedient and effective means in disempoweringthe service user and rapidly subduing the targeted behaviour. At thesame time, staff rationalised the use of restraint in terms of acting tominimise harm and keep individuals safe. Significantly, however, staffemphasised that whether an individual was restrained horizontally orvertically, or on their front or back was rarely a matter of choice. Moreoften it resulted from a lack of other options. Two situational factorsinfluencing restraint position were cited: space and immediacy.Limitations of physical space and the physical positioning of theservice user contributed to the restraint position used.

The second dimension to taking control concerned threats to theestablished order and stability of the ward. The importance ofmaintaining control over service user's behaviour on the ward wasevident in a number of accounts. Threats to the functioning andstability of the ward were important factors in deciding to userestraint, not least because it was recognised by staff that the intensi-fication of agitated and disturbed behaviour could spread acrossindividuals.

I mean when you are working on a ward like this, I am always wellaware that shouting, screaming, commotions on a ward affects allthe other patients on the ward and there is a lot of people here withlike anxiety problems and things, so I felt I needed … to calm thesituation down. (Interview 17)

While the overall safety of the ward environment may be at theheart of such rationalisations, there is an evident tension betweenmaintaining the therapeutic environment and the best interests ofthe individual service user.

3.3. The escalatory effects of restraint

Once restraint is implemented it seems that the end goal is simplyan attempt to reduce the undesirable behaviour (crisis intervention),with the specific causes or antecedents to it becoming inconsequentialin the effort to take control. However, all staff reported that the physicalintervention itself becomes the battleground for control between staffand the service user with each seeking to gain the upper hand.

The minute you lay hands on, the incident that originally got you to thatpoint, is lost, it then becomes a situation ofwell you know, get offme, Iwillcalm down when you get off me, and then the retort from the staff side iswell no, when you have calmed down, and the service user then says wellI will calm downwhen you get offme, and it then becomes a stalemate…a service-user, might calm down quicker if the restraint wasn't so long,instead of being forced, as it were, into submission, sort of like we willtake hands-off when we feel you have calmed down. (Interview 1)

Indeed, while staff reported making efforts to explain the purposeof the restraint to the service user, at the same time, they were highlydirective and demanding of the service user. Staff generally consideredcontrol of the situation to have been established when the service userexhibited signs of submission and co-operation.

She looked at me, she said ‘I fucking hate you, I really hate you’, and thevenom in her face was like unbelievable and that's when we kept herdown. You know for a factwhen they have calmed down. (Interview13)

You know every time you loosen your hold or take any pressureaway, if he is trying to get up and fight you then you say, ‘no, justlie still, we don't like to do this anymore than you do, erm, just relax.’(Interview 6)

Respondents acknowledged that service users were not routinelygiven the opportunity to discuss their experiences following an

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incident of restraint or given a clear explanation of the decision to userestraint. Staff reported that this was generally left to the discretion ofstaff and was dependent upon an assessment of the service user'smental state and capacity to comprehend.

I have never really asked them, I have never actually gone backand said, ‘well ok how do you feel about it?’ Perhaps we shoulddo. (Interview 10)

Interestingly the staff also reported the need for debriefing andsupport following restraint incidents.

When a restraint happens…, we don't talk about the restraint, wedon't talk about what happens, what we done well, we don't learnabout the restraint, we just sort of fuddle on, back onto our jobs,and do what we do again and then a restraint comes again and wedo the same thing, we don't learn. (Focus group 1; P 4)

3.4. Perceptions of risk

In trying to understand the way in which restraint was used in thissecure forensic setting, perceptions of risk emerged as a crucial driver.Risk was regarded as a part of everyday mental health care for themembers of staff involved in this study. How risk is played out in thissetting is complex. While staff adopted a discourse of risk assessmentand progressive de-escalation in their interviews, they also describedhow perceptions of risky behaviour in practice often triggered a reflexrestraint response. Perceptions of risk, however, appear to be formedquickly and intuitively based on responses to actual or attemptedphysical violence and were also linked to particular situational contexts.One staffmember described howa judgement about the use of horizontalrestraint was made instinctively after being assaulted in the face.

It was almost a reflex action in the sense that you make all thesejudgements very quickly and the safest thing to do seemed to be to takehim straight onto the floor. (Interview 14)

When you hear that noise you just drop everything and go and youhave got to, because it could be your colleagues in danger, it couldbe a client in danger, you just, you have got that instinct to just goand see what it is. (Interview 2)

Behaviours that are regarded as having high probability of causingsignificant and immediate harm are instinctively constituted asexposing staff to high risk. This was also clearly the case for behav-iours that were seen to erupt without any warning signs. As notedpreviously, horizontal restraint is seen as a situational necessity inorder to minimise the risk of harm and to exert control.

If … you were planning that you were going to have to go andrestrain someone because, I don't know, they were smashing up thedining room or something, then in those circumstances you wouldbe planning to go in as a team to take them straight to the floor,…because if they were already actually being aggressive and violent,you probably wouldn't take the risk of standing and it demobilisesthem quicker. (Interview 16)

As the above quote suggests, the challenges for staff arise fromassessing the risk in various situations, and predicting the outcomeand consequences of a situation. An assessment of the concurrentlevel of threat, the attribution of intent and the interpretation of agiven behaviour are critical mediators in making this calculation.

I was asking him would he come sit with the Dr, he wasn't having anyof it, as I say he started spitting at us and lashing out. And there comes

a point where you feel that any second now instead of being stoodagainst the wall and lashing out with a distance between you, he isgoing to come at us, and at that point we said like, and that iswhen we actually put hands on. (Interview 6)

Although staff report that they assess escalating situations withinthe context of safety to self and others, not all escalating situationswere deemed to be dangerous. Another further element that appearsto have an influence on decision-making is individual staff's toleranceof risk and uncertainty. Several respondents recognised that restraintwas sometimes used too quickly.

Sometimes some people go in too hastily I think, instead of just standingback and talking, you know de-escalate, a lot of people think a patientraises their voice, and their arm comes up and get on top of themand I don't think there is any need for that. I mean, sometimesthere is a need for it, but I don't think there is a need for it half thetime. (Interview 10)

Differing degrees of risk tolerance may help explain the variationin restraint procedure that some respondents acknowledged betweenindividuals. Staff surmised that those who they saw as intervening‘too hastily’, were perhaps fearful and thus overly-cautious, inresponding to risk.

I mean you know it might be fear of getting smacked, let's just get itover with now and cut down the possibility of getting smacked.(Interview 10)

Some staff I feel because of lack of confidence will go in sooner ratherthan later, because they don't want the situation to escalate, ratherthan give it time to de-escalate. They would say they are being morepro-active because they feel that the risk was there, that's theirassessment. (Interview 6)

Clearly, the staff interviewed recognised different perceptions ofrisk and danger and perhaps more importantly read situations indifferent ways. There was uncertainty about reliably predicting howevents would unfold leading some staff into a physical interventionalmost as a pre-emptive strike. Of course this risked creating thesituation that staff were keen to prevent — a physical struggle.

I don't think you can take the chance to think well maybe they won'tstrike out again. I don't think you can wait to be hit. I think you justautomatically…when someone is actually aggressive towards you,putting hands on keeps everyone safe. (Interview 17)

Keeping everyone safe was very much informed by knowledge ofa person's behavioural or restraint history. There was little acknowl-edgement, however, that this view could perpetuate the use ofphysical intervention as a first line strategy for particular serviceusers who appeared to have a history of violence and aggression.

The previous night he'd actually attacked another member of staffand punched him three times in the head, so I was already onalert… We had to take him down to the floor. (Interview 8)

As already reported above, there was a common perception thatthere were clear differences between staff in the way theyapproached restraint. Personal qualities and individual tolerancelevels of aggression and violence were forwarded as explanations ofthis difference.

There are some people who always seem to be involved in C&R and Iwonder why that is. The same staff, the names keep cropping up inC&R incidents and I wonder if they're too quick to go hands on rather

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than to continue to try de-escalation and to try other tactics. (Inter-view 15)

There are different staff attitudes and some staff can be aggressive,which doesn't help the situation. If you're highly charged and you'vegot a member of staff who comes in bluntly, saying ‘calm down’, itcan have the opposite effect. Some staff are better at dealing withpatients than others, it's their attitude, some people just know howto calm people down better than others. (Interview 9)

4. Discussion

The research literature on the use of restraint is quite extensivenow but given the difficulties of researching emergency situations isbedevilled by methodological limitations. Although Exworthy,Mohan, Hindley, and Basson (2001) report a role for restraint in theprevention and reduction of disturbed behaviour in a therapeuticsetting, a Cochrane Review (Sailas & Fenton, 2000) found nocontrolled studies that evaluated the effect of restraint or seclusionon those with serious mental illness. Notwithstanding this thereappears to be a consensus that the use of physical restraint in psychi-atric settings is pervasive. In a recent survey of 307 PICUs and Lowsecure units in the UK Pereira, Dawson, and Sarsam (2006) reportedthat the majority used control and restraint as core interventions tomanage disturbed behaviour. There is also extensive nationalguidance in the UK based on the assumption that restraint is anunfortunate but inevitable part of mental health care.

This study explored how restraint is viewed and used by staffworking in an acute mental health setting. Successful de-escalationand the less intrusive forms of restraint, such as holding the personwhilst standing, were less evident in the interviews but had theybeen present, might have given insight into the successful use ofminimal force. Given the small scale nature of this study and itsfocus on staff in one institution it is perhaps not surprising thatthere was little discernible difference in the views of staff takinginto account their age, gender and clinical experience.

Four groups of factors were identified by staff to have influencedthe use of restraint; contextual demands; lack of alternatives; theescalatory effect of restraint itself; and; perceptions of risk. The studyhighlights the complex and sometimes contradictory interaction ofvariables which were perceived by staff to influence their decision touse restraint. At the same time as talking about the importance ofbuilding relationships and trust between staff and service users, stafftalked about policy changeswhich brought new and demanding serviceusers onto the wards leaving them little time to develop relationshipsand mutual trust. Staff identified a range of techniques forde-escalation but almost exclusively relied upon communicativestrategies which they recognised as likely to be the least effectivestrategy given the service user's mental state. They talked aboutmaximising time with the service user to get to know him/her beforecrises developed but recognised that the resource-intensive nature ofrestraint drew staff away from interacting with other service users notinvolved in the restraint episode. In addition, staff recognised theinconsistencies which existed in the use of restraint with staff holdingdifferent thresholds for intervention depending on their perception ofthe risk posed at the time. They reported situations in which formalrisk assessments are overridden by intuition and the need to managea crisis raising perceptions of personal threat and in so doing triggeringrestraint. Importantly, staff identified the inherent tensions that exist inacute mental health care provision today as a justification for thecontinued need for restraint as an intervention. Not surprisinglytherefore, whether used as a threat to prevent escalation or as an actualintervention to manage a situation, restraint was viewed as a necessaryevil. Other studies also report that nurses see restraint as a necessarypart of their job but one that they would like to minimise (Bigwood &

Crowe, 2008). A postal questionnaire survey of 269 nurses in regionalsecure and psychiatric intensive care units in England and Waleswhich examined nurses' last experience of using control and restraint(Lee et al., 2003) reported that most nurses (96%) reported positiveoutcomes of the restraint. However a quarter of respondents alsoexpressed concern about the impact on patients and some found theexperience of restraint demeaning and stressful.

It is possible that restraint may provide staff with a strategy forresolving the risk ambiguities inherent in working with potentiallyviolent and aggressive individuals. In this study staff reportedviolence and aggression as major precursors to a restraint episode.This association between the use of restraint and patient violence isreflected in much of the psychiatric literature. However, a study ofpost-incident manual restraint forms analysed by Ryan and Bowers(2006) found that violence was rarely mentioned as a cause forrestraint. The most common reasons related to more general disruptiveand challenging behaviours. Stewart, Bowers, Simpson, and Tziggili(2009) suggest that there is a distinction between the causes enteredon incident forms and the factors which determine the managementof an incident. Whilst this is a possible explanation of the difference itdoes raise questions about the factors which influence the way inwhich restraint episodes get recorded and why disruptive andchallenging behaviours result in restraint.

The most recent National Audit of Violence within Working AgeAdult (Psychiatric) Services (Healthcare Commission, 2008) reportedan increase in the nature, level and severity of violence on wards. Theauthors also stated that the ‘effectiveness with which staff teamsprevent and manage incidents has also increased’, with ‘clearevidence that the majority of services are now adopting proactiveand preventive strategies to tackle violence in inpatient services’.The staff interviewed in this study had been trained to use PhysicalIntervention and saw it as a way of preventing individuals from“harming themselves, endangering others or seriously compromisingthe therapeutic environment” (National Institute for Health & ClinicalExcellence, 2005:9). What is not clear from the study is how andindeed whether, this training had an impact on the proportionalityof the restraint imposed in relation to its antecedents and on thefrequency with which staff use this form of intervention.

Given the complex nature of the use of restraint it cannot beassumed that improved training on its own will reduce the incidenceof restraint. Health services in the United States have been activelyworking on reducing and preventing restraint, driven, according toLeBel (2011), by a number of largely unreported deaths arising fromboth restraint and seclusion. Widespread adoption of the Six CoreStrategies model appears to offer the opportunity for a more holisticorganisational alternative to the reliance on coercive interventionsthan does the implementation alone of training programmes forindividual members of staff and care teams. The six elements are;(i) leadership towards organisational change (ii) using data to informpractice (iii) workforce development (iv) use of seclusion/restraintprevention tools (v) consumer roles in inpatient settings and(vi) debriefing. Nine years after the first implementation of the SixCore Strategies model, LeBel, Huckshorn, and Caldwell (2010) havereported a number of success stories. Not only has the number ofrestraint/seclusion episodes decreased in a number of services inwhich it has been implemented but also a range of other benefitshave been reported. Most notably these include a reduction in staffturnover, staff injuries, absenteeism and retraining costs (LeBel,2011). These six elements appear to offer staff and patients supportin creating and sustaining a therapeutic environment on an ongoingbasis. It does however require substantial commitment from all levelsof the organisation based on a recognition from the top down of thesystemic nature of the problems which underpin the frequency withwhich restraint is used.

Contrary to the rhetoric of partnership working in which serviceusers are active participants in their own treatment and nurses have

49E. Perkins et al. / International Journal of Law and Psychiatry 35 (2012) 43–49

a clear therapeutic role, the nurses in this study expressed a resignedacceptance of the conditions and limited options which they felt gaverise to the need for physical intervention. This may reflect broaderproblems in terms of the purpose and success of both acutein-patient services in general (Warner, 2005) and mental healthnursing in particular. Numerous reports have identified the therapeuticpoverty of many acute wards and the attendant problems of boredomand frustration (Care Quality Commission, 2009; Department ofHealth, 2002). Hopton and Glenister (1996) reported an ongoing crisisof legitimacy in the work of mental health nurses. They suggested thatdespite educational changes over the last two decades there wasevidence that service users have difficulty getting time to speak withnurses and that nursing interventionswere largely empty of therapeuticcontent. Interestingly, Bowers, Van Der Merwe, Paterson, and Stewart(2011) suggest that attempts to lessen usage of manual restraint andforce could usefully focus on increasing the availability of medical staffto patients, reducing reliance on security guards and establishing agood ward structure.

This study suggests that the crisis has not yet been resolved.Restraint and typically restraint of the service user on the floor wereembedded within routine mental health practice as a legitimateintervention to deal with a situation exacerbated by organisationalconstraints and the failure to develop a therapeutic relationshipwith service users. This study suggests a sense of inevitability aboutits recurring use in future practice, unless a stronger organisationalapproach is taken to its reduction.

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