Relationship between nurses' use of verbal de‐escalation and mechanical restraint in acute inpatient mental health care: a retrospective study

The scientific literature repeatedly points to the need to find alternatives to the use of restraints in mental health hospital settings because of the negative impact on both patients and nurses (Aguilera-Serrano et al. 2018; Jury et al. 2019; McKeown et al. 2019; Thomann et al. 2021). Numerous studies report negative experiences related to these practices and provide the scientific community with alternatives to the use of these measures (Fernández-Costa et al. 2020; Guzman-Parra et al. 2020). Thus, verbal de-escalation has been highlighted as the main strategy for the control of pre-agitation states due to its high patient acceptance and its positive impact on the feelings of health professionals, patients, and health institutions (Kuivalainen et al. 2017; Price et al. 2018). In addition, risks arising from other interventions that may require the use of force are minimized (Jury et al. 2019) which facilitates the establishment of a good therapeutic relationship (Garriga et al. 2016).

Background

Mechanical restraint is a common restraint measure currently permitted for use in mental health. It is defined as an intentional limitation of the patient to control their freedom of movement as part of a treatment. It can affect a part of the body or the whole (Mahmoud 2017; Vedana et al. 2018). Thus, mechanical restraint is an intervention used to limit a patient's movements to prevent destructive behaviours and preserve the safety and integrity of the patient and others (Mahmoud 2017; Vedana et al. 2018; Wilson et al. 2018). It is important to distinguish mechanical restraint from physical restraint; the latter is defined as the immobilization of a patient by bodily force by holding the person on the floor or on a bed, with the help of several people (Lepping et al. 2016; Steinert & Lepping 2009). Typically in inpatient units, the profile of patients includes those with diagnoses of schizophrenia or psychosis, bipolar disorder, personality disorder, substance abuse, and risk of violence (Garriga et al. 2016).

The use of mechanical restraint has been shown to be a traumatic experience for patients and nurses and may present an ethical dilemma for staff, while encouraging regressive behaviour and patient dependence on institutions (Di Lorenzo et al. 2014). Both patients and staff verbalize feelings of distress, fear, anger, anxiety, and frustration (Kinner et al. 2017; Wilson et al. 2017). In fact, many direct and indirect physical injuries, such as lung disease, lacerations, asphyxiation, and even sudden death, have been reported (Di Lorenzo et al. 2014; Kuivalainen et al. 2017). In addition, the use of mechanical restraint compromises the therapeutic relationship and the establishment of trust between nurses and patients experiencing these restrictive practices (McKeown et al. 2020).

In recent years, there has been a shift in international policy to reduce restrictive interventions (Cusack et al. 2018; McKenna 2016). Reduction towards the elimination of mechanical restraint is a constant orientation for mental health services (Al-Maraira & Hayajneh 2019; McKeown et al. 2020). In fact, many European countries are aligned with the USA and Australia in the interest of creating a legal framework to tend to reduce or even eliminate the use of mechanical restraint in mental health units (McKeown et al. 2020; Pérez-Revuelta et al. 2021). Legislative changes and new regulations have started to emerge to prevent its use or restrict it to very extreme situations (Guzman-Parra et al. 2016). In Europe, mechanical restraint is not allowed in England, Wales, Scotland, Ireland, Netherlands, and Iceland. The case of Iceland is the most extreme, where no type of restraint measure is allowed for controlling the patient in case of violence or agitation (Steinert & Lepping 2009). In the UK, Australia, and New Zealand, work is underway on seclusion reduction guided by the ‘Six core strategies for reducing seclusion and restraint use’ (Jury et al. 2019). In the USA, various initiatives have been taken in many states to end the use of the most restrictive measures in mental health settings (Steinert et al. 2010). Despite support for the reduction and elimination of mechanical restraints, and evidence that a reduction in the use of restrictive practices does not lead to an increase in assaults (Kuivalainen et al. 2017; McKenna et al. 2017; Muir-Cochrane et al. 2018), these practices continue to be used in mental health care (Bullock et al. 2014; Muir-Cochrane et al. 2018; Price et al. 2018). Restraint rates from four European countries with similar social and health structures are remarkably similar regarding patients affected by restraint. However, large differences exist concerning the type and length of coercive measures used (Lepping et al. 2016).

In order to reduce or eliminate the use of mechanical restraint, nurses use interventions aimed at addressing the patient in a state of agitation such as environmental or spatial restraint, pharmacological restraint, and verbal restraint or de-escalation (Pérez-Revuelta et al. 2021). Of these, verbal de-escalation is the intervention that generates the most confidence, and thus it is considered the first psychomotor agitation control strategy (Hallett & Dickens 2017; Lavelle et al. 2016). De-escalation techniques consist of a variety of psychosocial techniques aimed at reducing violent and/or disruptive behaviour. They are intended to reduce/eliminate the risk of violence during the escalation phase, through the use of verbal and non-verbal communication skills (Lavelle et al. 2016; Price & Baker 2012). Verbal de-escalation techniques have the potential to decrease agitation and reduce the potential for associated violence, in the emergency setting (Richmond et al. 2012). Nurses use verbal de-escalation to help patients manage violent behaviour and redirect them to calm down without confrontation or provocation (Berring et al. 2016) and favour a better relationship between the staff and the patient, together with a solidification of the therapeutic alliance (Fernández-Costa et al. 2020; Mavandadi et al. 2016). Numerous studies have demonstrated the benefits of managing violent situations or agitated patients by means of verbal de-escalation techniques (Berring et al. 2016; Cusack et al. 2016; Fernández-Costa et al. 2020; Garriga et al. 2016; Hallett & Dickens 2015, 2017; Jury et al. 2019; Kuivalainen et al. 2017; Lavelle et al. 2016; Mavandadi et al. 2016; McKeown et al. 2019; Price et al. 2015, 2018; Richmond et al. 2012). In addition to the reduced intervention time, other authors have described the following benefits: (i) avoiding violence and preventing harm without having to resort to mechanical restraint or isolation (Fernández-Costa et al. 2020; Jury et al. 2019), (ii) verbal de-escalation helps nurses develop better relationships with their patients (Garriga et al. 2016), increasing self-esteem, and job satisfaction (Cowin et al. 2004; De Berardis et al. 2020; Price et al. 2018), (iii) verbal de-escalation is less time-consuming than the process of mechanical restraint and involuntary medication (Richmond et al. 2012).

Although the most common characteristics of patients who require mechanical restraint have been extensively studied (Bowers et al. 2015; Bullock et al. 2014; Cusack et al. 2016; Hotzy et al. 2018; Keski-Valkama et al. 2010; Knutzen et al. 2013; McKenna et al. 2017; McLaughlin et al. 2016) and there are known effective alternatives for the management of agitation such as verbal de-escalation (Garriga et al. 2016; Hallett & Dickens 2017) to avoid the use of mechanical restraint (Gaynes et al. 2017; Hallett & Dickens 2017; Price et al. 2015; Richmond et al. 2012), no studies have been found that deepen the knowledge on the use of verbal de-escalation and the patients who have required the use of mechanical restraint. Examining this relationship could help deepen our knowledge regarding the factors that condition the use of de-escalation by nurses during clinical practice in mental health inpatient units and thus establish strategies for improvement to reduce or eliminate the use of mechanical restraint. The aim of this study was, therefore, to examine the relationship between the use of verbal de-escalation among nurses and the clinical profile of patients who ultimately receive mechanical restraint at an acute mental health unit.

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