Running head: REVIEW OF THE LITERATURE

Review of the Literature

Elise DAgostino
Professional Capstone Project
Grand Canyon University

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Review of the Literature

This article will analyze the ethics of restraints in the health care setting, primarily mental
health. One of the main reason why restraints and seclusion are used in a psychiatric setting is for
the protection of the patient and/or health care providers. This method is only used after all
medication and verbal therapies are unable to control a potentially dangerous patient. The
restraint of a violent patient provides safety for the health care providers to provide
psychotherapeutic tasks that are ordered to prevent or avoid further escalation. In order to
analyze and discuss this topic fifteen articles were chosen to aid in coming up with a critical
appraisal for this argument. Each article will be dissected to show it purposed view on the ethics
of restraints.
The first article The use of mechanical restraint in mental health: a catalyst for change?
states that using mechanical restraints are thought of as a last resort mechanism. This article
showed examples as to why mechanical restraints may be the last resort in dealing with extreme
behaviors. A womans facility unit was viewed and a patient mentioned in the article as Ms. A
who was diagnosed as Schizophrenia and Personality Disorder and had been a longtime
residence of the institutional setting. Ms. A was described as a very violent patient that had made
many assaults on the health care staff that cared for her. Not only had that continued to self-harm
as well. Chemical and physical restraints proved to be inhumane and ineffective in the care of
Ms. A. The use of mechanical restraints was the only form of restraint that showed a positive
effect and allowed her wounds to heal and avoid further self-harm. This article doesnt state that
mechanical restraints should be frequently used, but more of a last resort to treat extreme unsafe
behaviors.

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The second article Reducing restraint and seclusion in an acute aged persons mental
health unit explains how there would be a reduction of restraint and seclusion if other
therapeutic measures were followed. This article listed four major factors that aided in the
prevention of restraint and seclusion use. They are leadership and support from management,
increased team input, renovations to the inpatient setting, and better collection of patient history.
This article talks about the stress that restraints can have not only on the staff but the patients as
well. It also discusses the use of restraints in the older population of patients and how there is a
greater chance of injury and the use of therapeutic interventions show greater results.
The third article Achieving restraint-free on an inpatient behavioral health unit states
that a reduction in the use of mechanical and chemical restraints proves to be more effective
causing a cultural change among the patients. This article stated that the less restraints that were
used the less they were having to as needed medications. The author S. Barton stated Personcentered care delivered by frontline staff led to culture change, a restraint-free environment, and
less medication. Several facilities were observed and nurses reported that they let the patients
know that they would not be restraining or secluding anyone and that seemed to bring about
peace among the unit. The article states that the use of restraints is considered a treatment failure.
There are few cases that would cause the use of restraints which brings about the reasons why so
many of the health care workers are unexperienced and may need educational training.
The fourth article Crisis Prevention Management: A Program to Reduce the Use of
Seclusion and Restraint in an Inpatient Mental Health Setting is another article that talks about
reducing the use of restraints and seclusions. The article breaks down the different prevention
methods that are effective in prevention management. The first is primary prevention which
focuses on providing a therapeutic environment in caring for high risk individuals. The second

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one is secondary prevention which uses selective interventions that promote a reduction in stress.
Some examples of therapeutic interventions are music therapy, art supplies, aromatherapy, and
journal writing. This article does support the reduction of restraints and does support the use of
other measures to care for a patient.
The fifth article Time for unrestrained Debate is an article about the debate of the use
of restraints. The author argues the fact that the use of restraints brings forth multiple risks. The
author mentions the tragic death of a man in 1998 from the use of physical restraints in a
hospital. This article contributes to the promotion of the prevention of restraints and the risks that
are involved. While restraints are used in violent scenarios there has been a report of restraints
being misused and causing harm or even death for patients.
The sixth article Strategies to prevent restraint-related deaths is an article that discusses
different mechanisms that will aid in the prevention of restraints that could potentially cause
harm even death. Although this article does advocate for the prevention of restraints it does talk
about the need for them. In some cases that may be necessary when a patient becomes violent
and is out of control. This article enforces the need for more clinical education that will educate
the staff on how to deescalate a patient and what therapeutic measures could prevent the use of
restraints and or seclusion. This article also reports incidents where death has been a result in the
improper use of restraints.
The seventh article Perspectives on the experience of being physically restrained: An
integrative review of the qualitative literature uncovers the perspective from the eyes of the
patients that have been restrained. Twelve studies were included in this article. There were four
themes that were discovered were a negative impact, re-traumatization, unethical practices, and a
broken spirit. This article aided in providing a voice for patients and what the repercussions are

REVIEW OF THE LITERATURE

from the use of restraints. It helped open the eyes of health care workers and implemented the
need to use caution and awareness when using restraints and to think about the psychological
impact it may have on the patient and what other interventions could be used first.
The eighth article Letters to the Editor is another article that points out the need to
reduce the use of restraints. This article researched a three year program that provides ways to
prevent the use of restraints. This article is a little different then the others it is more of an
authors opinion but helps add to the positive attributes aiding in the prevention of using restraints
and using other options before restraints are considered.
The ninth article Frequency of assault and severity of injury of psychiatric nurses in
relation to the nurses' decision to restrain is an article that talks about respect, respect for the
patients and using less restrictive interventions. It also mentions the frequency of assaults and
injuries on psychiatric nurses. In this article the author does a study with a sample of 110 nurses
from five institutions, 80% of the nurses were assaulted, 65% had been injured and 26% had
been seriously injured. Some of the Injuries included were fractures, eye injuries and
permanent disability. This article does support the elimination of restraints and shows that nurses
that do decide to restrain are more to be put at risk for injury. The nurse must make a decision on
whether or not to restrain and whether other forms of intervention like music therapy, journal
writing, or reading other forms of coping and deescalating a potential aggressive patient.
The tenth article The mentally ill and social exclusion: a critical examination of the use
of seclusion from the patient's perspective is about the study of seclusion and how it may affect
a patient. Seclusion is almost always the first go to when a patient is out of control or aggressive,
but this study shows that secluding a patient is not beneficial. The patient is already feeling
isolated and rejected and then being put in a locked room with no nurse to patient interactions

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can cause them to get worse. This article states that seclusion should not be used so frequently
and nurses should use all their resources and choose wisely before making the decision to
restrain or seclude in any form.
The eleventh article The health of the staff is as important as the health of the people we
serve talks about all the need to bring patients and nurses together so that nurses are partners
with their patients not their adversaries. In most health care facilities that is not common and this
article speaks about the strong need for unity. While coming together as partners a nurse would
be less likely to need to use restraints having a stronger bond with the patients leads to less use of
restraints.
The twelfth article Survey highlights lack of uniformity in C&R training is about a
professor that argues that there is not enough training for new graduates. He writes how new
graduate nurses are sent off to work in the mental health facility with nearly no training. The
professor spoke about the need to improve C & R training and the need to improve the guidelines
regarding the training. The professor also spoke about the need for pain compliance with patients
and how it can bring about change and prevent the escalation of a patient.
The thirteenth article ISPN Position Statement on the Use of Restraint and Seclusion
does not fully support the elimination of restraints. It discusses the need for restraints and
seclusion and how the nursing staff is put at great risk if there is no intervention in place to
protect the staff. It does speak about It takes a specially trained health care provider to care for
patients in a mental health facility. Staff can be at fault for the escalation of a patient if their
communication skills are used in a provoking style. While restraints are used in violent scenerios
there has been a report of restraints being misused and causing harm or even death for patients.

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This article does not fully support the prevention of restraints but it does state the risks that
nursing staff are faced with.
The fourteenth article The development of a scale to measure staff attitude to coercion
is an article that does not support the wrong use of restraints. The author supports the need for
restraints as a mean of safety for the staff. The author argues without restraints or seclusion the
nursing staff could not efficiently handle an aggressive patient. This article does promote the use
of therapeutic interventions and supports restraints as being the last resort of intervention for the
patients.
The fifteenth article Why Restraint Prevention is the Priority is an article that does
support the prevention of restraint use . This article does mainly discuss the use of restrainsts
with adolescence. There should be more guidelines for restraint use of adolescence. Therapeutic
meaures have been far more effective for children and have caused a better comfort level with
the patient to nurse relationship. More parents would also be more comfortable allowing their
children to receive treatment knowing that they will not be restrained. The use of restraints is
making a huge impact in both positive and negative aspects. The goal that comes from restraints
is not to make a patient fearful but yet keep some order and safety for other patients and staff.
The primary goal of Restraints and Seclusion in an inpatient psychiatry facility is to uphold the
safety of everyone in the treatment environment. The use of restraints and seclusion can be an
effective measure used in the appropriate way but can also cause controversy among the health
care community. In hospitals that still use restraints and seclusion, they must uphold the policies
and training that is involved therefore ensuring patients safety. For the hospitals that refrain from
restraints and seclusion, they must use a therapeutic approach in calming down and deescalating
patient preventing aggressive behavior.

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References
Grand Canyon University Library.(2015) Resources. Retrieved from
http://eds.a.ebscohost.com.library.gcu.edu:2048/eds/search/advanced?sid=5b6d7565-028a-4ae8ac03-410e5e9a4119%40sessionmgr4005&vid=0&hid=4108

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References

Last Name, F. M. (Year). Article Title. Journal Title, Pages From - To.
Last Name, F. M. (Year). Book Title. City Name: Publisher Name.