Implications of mechanical restraints for the nursing team
Mechanical restraint is a technique still used in various healthcare settings, despite the adverse physical (pain, bruising, edema, dislocations, ulcers, etc.) and emotional effects it causes. People who have been restrained describe it as a traumatic experience , which often prevents them from returning to the service or seeking help from the mental health system for fear of experiencing it again (Chinchilla et al., 2011; Megías et al., 2016; Sastre & Campaña, 2014; Stucchi et al., 2014). Furthermore, it is not considered an effective technique on its own, as it is used in conjunction with others, such as pharmacological restraint. Therefore, taking this into account, along with its adverse effects, the goal for everyone (institutions, hospitals, professionals, and patients) is to eliminate its use and achieve zero restraint .
In addition to the impact on the people being treated, this intervention also affects the professionals who have to practice it, who often feel guilt and frustration , as indicated by a study prepared by the Parc Sanitari Sant Joan de Déu Barcelona (Manzano et al., 2022), focused on the impact of mechanical restraints on the nursing team.
Interventions towards zero mechanical containment
How it can affect the nursing team
In the current healthcare system, and specifically in mental health, this technique is prescribed by psychiatrists, but it is the nursing team that carries it out . In mental health units, nurses are present 24 hours a day and are the most accessible to the patients. Typically, it is the nursing team that initiates the interventions prior to mechanical restraint and, sometimes, that must make the decision to use restraint.
As nurses, our role is to care for the people in our care, ensuring their maximum emotional and physical well-being and fostering their autonomy. Our professional values are conflicted when the decision is made to restrict a person's movements. Articles such as those by Keser et al. (2015), Korkeila et al. (2016), Okanli et al. (2016), Muir-Cochrane et al. (2017), Sobhy-Mahmoud (2017), Giacchero-Vedana et al. (2018), and Laukkannen et al. (2019) agree that the nursing team, when performing a technique that prioritizes safety over autonomy , feels:
- Worry
- Anxiety
- Sadness
- Emotional pain
- Blame
- Frustration
- Failure
In the reviewed articles (Cocho et al., 2018; Dahan et al., 2017; Riahi et al., 2016), nursing staff explained this decision to themselves as "the lesser of two evils." The dissonance caused by acting in a way that contradicts one's own values generates these kinds of self-explanations to alleviate anxiety or guilt, but in the long run, this is merely a defense mechanism that can harm the relationship with the person being cared for.
As we have already seen, it is a potentially harmful intervention, both physically and psychologically, for the people being treated, and an intervention that generates guilt and frustration in the professionals , so it is reasonable to consider eliminating it.
Mechanical restraint harms the person who suffers it physically and emotionally, and generates feelings of guilt, anxiety and frustration in the person who practices it.
It is necessary to foster a zero-restraint culture within units, as it has been observed that attitudes toward coercive measures can be modulated and influenced by those of team members, creating what Keser et al. (2015) refer to as Ward culture . This occurs when a person joins a team and adapts their own values, beliefs, and emotions to those of the other members, homogenizing both interventions and attitudes, either to reduce the use of mechanical restraints or to legitimize them (Korkeila et al., 2016; Jalil et al., 2017; Salzmann-Erikson, 2018).
Foster a culture of service based on human rights
What are the keys to eliminating the use of mechanical restraints?
Back in 2010, Scanlan proposed seven structured interventions to reduce the need for mechanical restraints in mental health units, and several of them involve the nursing team.
- Leadership policy: senior officials must commit to policies that reduce coercive interventions, because if they do not, subsequent interventions cannot be carried out.
- External review: committees external to the hospital review situations that have precipitated a restraint to prevent the interventions from being repeated.
- Data collection: its importance lies in its role in evaluating the effectiveness of other interventions. Data collection and reporting can also foster healthy competition between units or hospitals.
- Training for mental health professionals, both in conflict de-escalation skills and in sensitivity training.
- Involvement of the person being cared for and the family: the active participation of both the person being cared for and the family is proposed in the planning of the treatment and in the review of cases that have required the use of coercive measures.
- Adjustment of staff ratio: the increase in staff-person-person interactions is related to the lower use of coercive measures.
- Structural changes to the units: to reduce environmental stress and promote closer relationships between those being cared for and staff.
The future of care lies in abandoning restrictive measures
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