Policy on Restraints and Person Centred Nursing Care in Mental Health Services

Practice Based Evidence and Evidence Based Practice

In this assignment I will be looking at a national policy on restraints and the implications of the policy to person centred nursing care in relation to mental health services. The policy I have chosen to look at is for the purpose of this assignment is ‘Restraint/Restrictive Practices Policy’, the rational for this is due to having the opportunity to attending a PICU unit to attend a planned intervention to carry out nasogastric tube bolus feed which involved restraining a young person who refused to nutritional intake. A study in a recent issue had noted that 53% of the patients receiving nasal tube feedings had physical restraints used to prevent those patients from pulling out their feeding tubes (Uhs.nhs.uk, 2014). Which then has developed an interested to me on the subject of restraint and why it is needed, the UK law allows health care professionals to restrain patient with eating disorders in order to replace the tubes and feed them (Tewv.nhs.uk, 2018). Literature on the impact physical restraint on children and young people is limited therefore I decided to look at the ‘Restraint/Restrictive Practices Policy’. The policy I am looking at for this assignment also helps to prevent interference or obstruction with medical treatments such as self-extubation and intubation as well as to protect medical devices such as intravenous lines which has a linked to the planned intervention I was observed (Restraint ‘Physical and Mechanical’, 2015). The importance of the policy ‘Restraint/Restrictive Practices Policy’ is it guides healthcare professional with the challenge of intervention that require restraint when a patient is a risk to themselves or others (Restraint ‘Physical and Mechanical’, 2015). Restraint is only to be used as a last resort, when prevention and de-escalation have not worked in the efforts to de-escalate and prevent further risk of harm (Cowin et al., 2003). It is stated when used with a compassionate and humanistic approach restraint can achieve a therapeutic outcome for the patient while protecting the safety of others (Moylan, 2009). The rational and of this policy is to provide guidance for health care professional in the situation where restraint may be required. It also guides health care professionals on the approved methods of restraint and how these methods can be used safely and effectively. The policy also aims to ensure actions taken are consistent with all legal and professional requirements (Mid Essex Hospital Services NHS Trust, 2014). The nature of this policy is to enabling health professionals to taking action with the intention of restraining a person who lacks capacity the however the following two conditions must both be met in order to restrain, the health professional taking action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity, and the amount or type of restraint used and the amount of time it lasts must be a proportionate response to the likelihood and seriousness of harm. As long as these two conditions are met you will be acting within the legal framework of the Mental Capacity Act and you will therefore be protected against liability (Mental Capacity Act 2005).

Evidence based practice (EBP) is evidently used throughout nursing care as it provides nurses with scientifically proven evidence for delivering quality health care to a specific population alongside providing a method to use critically assesse health care to improve nursing care. EBP is designed to help healthcare professionals stay up to date with the best available evidence as it is published in nursing care (Schultz, 2009). Evidence based practice requires decisions about nursing care to be based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care and informed by the explicit and implicit knowledge of those providing care as well as within the context of available resources (De Brún, 2013). Which suggest that EBP requires the combination of best research evidence as well as individual clinical expertise in addition to patient choice. In health care there are three types of knowledge that is used for EBP, which involve the consideration of 3 equally weighted factors, the patient values, clinical expertise and relevant research (Howlett, Rogo and Shelton, 2013). The raise of EBP requires a healthcare organisation dedicated to supporting organisations to deliver EBP and an education system efficient in supporting healthcare professionals in attaining evidence based practice competencies (Melnyk and Fineout-Overholt, 2015). Evidence based practice is seen as any practice that has been established as effective through scientific research according to a clear set of explicit criteria (Drake et al., 2001). However EBP has done much to advance the field, with its insistence that assessment and intervention methods be based on the best available evidence and that the opinions of experts are just that opinions rather than proven facts as EBP cannot in itself answer all of the questions that arise in policy and practice. In evidence informed policy, few would discount the role of public opinion, political expediency and ideology as shaping even the most rational use of research evidence (Grayson and Gomersall, 2003). A careful review of classification of criticisms of evidence based medicine which apply equally well to applications in other evidence based practice fields Straus and McAlister grouped the criticisms as addressing either limitations or misperceptions of evidence based medicine. Two types of limitations were identified that applied to health practice in general, shortage of coherent and consistent scientific evidence as well as difficulties in applying evidence to the care of individual patients and barriers to the practice of high-quality (Gambrill, 2002). In the United Kingdom social care EBP has been described as ‘the conscientious, explicit and judicious use of current best evidence in making decisions regarding the welfare of service-users and carers’ (Sheldon, 2003). Evidence based practice, is based on the belief that what we do as professionals should be based on the best available evidence. Generally, the best evidence comes from well-designed and -executed randomized controlled trials or better yet meta-analyses of a number of randomized controlled (Schultz, 2009). The query that surfaces proponents of evidence based practice is whether there is enough high quality studies so that evidence based decisions can be made. Unexpectedly for a field that places a high quality on research, few studies have examined this (Sackett, 2002). Concern have been expressed about how evidence based policy is possible when so many opposing factors enter into policymaking, such as public opinion, resource limitations and ideology (Grayson & Gomersall, 2003). There are multiple barriers to EBP within community mental health settings. First, limited knowledge of EBP is one of the biggest barriers to use and is associated with decreased use, acceptance and favourability (Southam-Gerow, Hourigan and Allin, 2009).Nevertheless there have been reports of substantial improvement in health outcome for patients who are treated through evidence based practices as EBP has greatly changed the landscape of healthcare provision (Drake et al., 2001). It has made it possible for health care providers to use the best practices that have been greatly research in details while handling their patients. Evidence based practice puts the client value at the centre of the health care practices making sure that clients have a contribution to their healthcare. This is in the intelligence that EBP ensuring that patient values and practices are considered while providing health care (Melnyk and Fineout-Overholt, 2015).

For the purpose of this assignment the paper I have chosen to critique for this assignment is ‘Physical restraint and the therapeutic relationship’ from the NICE guidance reference list due to being unable to find an appropriate paper to critique from the policy reference list for this assignment due to lack of appropriate references for me to critique. I will be using the Critical Appraisals Skills Programme (CASP) tool to critique the policy I have chosen CASP as it aims to help individuals develop skills to find and make sense of research evidence, helping them to apply evidence in practice (Brice et al., 2019). The Critical Appraisals Skills Programme tool has over 25 years of significant and incomparable expertise in the delivery of training to healthcare professionals (Critical Appraisal Skills Programme, 2018). I will be using the CASP tool to critique the paper ‘Physical restraint in mental health nursing’ the research method used in this paper is a qualitative study in mental health services on physical restraint. The study was conducted in a forensic medium secure psychiatric service in the UK which is designed to fulfil a therapeutic function in addition to those of security and custodianship (Mason, King and Dulson, 2009). The abstract in the study stated it studied the impact of physical restraint on the nursing staff and patient therapeutic relationship which clearly specified the objective of the study also went to acknowledged how physical restraint may be used in forensic services as part of routine care, but concerns have been raised about how restraint fits with ethical practice. It was thought the subject matter is important as the literature stated that physical restraint is a security element of the role which may have an impact on their ability to work therapeutically with patients (Mohr, 2010). The study was undertaken in a medium secure service in the north of England however if the same research was carried out in a different part of England would the results be the same or would they be different. A high proportion of patients in the service have committed offences this could be a factor to the outcome of this study as the patients detained are thought to present a significant risk to others, in addition to their mental health difficulties (Gelkopf, et al. 2009). The type of qualitative research methods that was used for this study was a semi structured interview for each participant, this method typically consists of a conversation between researcher and participant guided by a flexible interview protocol and to add an extra element by follow up questions, probes and comments. The method allows the researcher to collect open ended data to explore participant thoughts, feelings and beliefs about a particular topic and to explore deeply into personal and sometimes sensitive issues. The researcher did state the limitation to this study of not having had the opportunity to build up a relationship or trust with the participants prior to the interview therefore it appeared that some participants had some concerns about talking openly due to a fear of potential consequences as result of it (DeJonckheere and Vaughn, 2019). The literature does not go into great detail in regards to the semi structure interviewer or who the interviewer was which indicates that the interview my not necessary have the required skills to conduct the semi structured interview as the layout requires some skill on the part of the interviewer, as the interviewer must be able to establish rapport with the interviewee and allow enough room to explore related ideas while still keeping on track. It is also stated that “data from semi structured interviews is also typically harder to organise and analyse than data from a structured interview might be” (Jamshed, 2014). The study stated it felt a sample size of 8 participants was sufficient enough to answer the research questions 1 out of the 8 was female the remaining 7 were male and were aged between 27 to 51 with all participant being described as “white British” could ethnicity alter the quality of the study. The researcher also did acknowledge there was only one female participant and it would be useful if further research could be undertaken to see if there are any gender differences in results of the study. Choosing a suitable sample size in qualitative research is an area of theoretical debate and practical uncertainty that sample size ideologies, guidelines and tools have been developed to enable researchers to agree and justify the acceptability of their sample size is an indication that the subject matter establishes an important marker of the quality of qualitative research. Nevertheless research shows that sample size sufficiency reporting is often poor if not absent across a range of disciplinary fields (SAGA Research Methods, 2019). However the study did not go on to clarified why the participants they selected were the most appropriate to provide access to the type of knowledge required for the study but did go on to clarify how they were selected for the study as the participants “opted in” by completing a slip and placing it in a sealed letter box on the ward area. 16 patients expressed an interest, 1 patient was felt unsuitable for the research due to communication difficulties and 7 patients were “opted out” by the care teams due to not meeting the inclusion criteria. 8 participants were selected using the following inclusion criteria of having been physically restrained at least once whilst being within the current medium secure service and being detained within the service for at least two also being able to take part in the interview process. The sample size of the study was small “although adequate for thematic analysis” the study stated, the research was undertaken in one setting, thus limiting the generalisability of the results. Potentially a more robust conclusion could be accomplished by including different sites to eliminate site specific factors in the analysis, although none were evident to the researcher (Robinson, 2013). The study did not indication of how interviews were conducted or of the use a topic guide was used however did go on to say the interviews were held in a ward meeting or therapy room away from other staff and patients briefly indicated qualitative research was the best fit for this study however did not elaborate on this. The study recorded the interviews lasting for “about 45 minutes” they were also conducted, recoded and transcribed by “the first author”. Though transcription is seen to assist learning, it also rationalises the research process as it can help you ensure your notes and data are both accessible and accurate. Sound quality, multiple speakers, accents, people talking over each other, and audience interaction can significantly slow down the transcription process causing frustration and reducing productivity all need to be considerate factors to the quality of the analysis for the study (Davidson, 2009). It was unclear if video material, tape recording and notes were used for the form of data for this study. There is also no indication of how the researcher carefully measured the relationship between the participants and the researcher however did express thematic analysis of the data was undertaken.  Patients were excluded from participating in the study as the care team felt that participation in the research could have a negative impact on the mental health of the patient or if there were concerns about the quality and reliability of the data they would provide however did not go on to say if the care team was involved in the care of the patients as well as the research. The relation between researcher and participants has been a recurring concern in the methodology literature as it inherent power inequity between the parties and the ethical concerns concerning to this inequity are commonly dwelled upon, with particular attention to the predetermined the absence of a violation roles between the researcher and the participants (Pitts and Miller-Day, 2007). The researcher did include in the study appropriate ethical approval was gained however the study did not go on to show in the study if research was explained to participants or whether ethical standards were maintained. Thematic analysis of the data was undertaken as it was viewed as the most appropriate methodical technique due to the complexity of the data and diversity of the participants and flexibility of the approach (Braun and Clarke, 2006). The data in the study were then analysed at an informative level focussing upon the underlying assumptions, concept and ideologies of the data in the study. The analysis began by reading and gaining familiarity with the data and identifying initial codes in the data. Codes were then connected across the transcripts from the study which were then used to generate themes. The themes in the study were reviewed and refined and quotes and descriptions are used to illustrate each theme in the results (Gildberg, Elverdam and Hounsgaard, 2010). The finding of the study showed patients could sometimes understand the need for restraint to be employed which supports the national policy ‘Restraint/Restrictive Practices Policy’ as it ensures restraint is only used in exceptional circumstance when all alternatives have been explored and they were able to give examples of when they felt that they had been justifiably restrained though they referred restraint as having a potential traumatic impact for them (Duxbury, 2002). The policy as acknowledges restraint is an imposition on an individual’s rights and dignity and should only be used in exceptional circumstances when considered there is a significant risk of injury/harm to the individual or others however participants in the study voiced they felt the motive of the healthcare professional was they enjoy the power and inflicting pain on patients and expressed feeling of helplessness and powerlessness throughout the restraint experience which goes against the rational of the policy. The aim of the policy is to reduce and make services a restraint free environment, which from this study shows there is a gap between practice and the policy (Bigwood and Crowe, 2008).

Conclusion

In conclusion the research paper was not a highly respectable study though it stated the purpose of the study clearly and the importance of the study however did have gaps in the study though the researcher acknowledges this as limitation. There was little amount of clarification on a number of subjects in the study such as why the research method and why it was felt appropriate for this particular study does not have considerable amount of strength in the study. The researcher did explain how the participants were selected however did not elaborate enough to exclude bias from the selection of the participants. The researcher stated the data was collected through a semi structured interview as most appropriate for this type of study but did not elaborate any further. There was no indication of consideration of the relation between the participants and researcher though ethical approval was gained for this study. The data analysis did go into detail as it did state thematic analysis was used for the study and was clear how the themes were derived from the data obtained by the study however the researcher did identify the limitation to the study and need for generalisability due to the lack of the strength in the study.

References

• Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology. 3, pp.77-101.
• Brice, R., Brice, R., Brice, R., Brice, R., Brice, R. and Brice, R. (2019). Home - CASP - Critical Appraisal Skills Programme. [online] CASP - Critical Appraisal Skills Programme. Available at: https://casp-uk.net/ [Accessed 3 Dec. 2019].
• Critical Appraisal Skills Programme. (2018). CASP (Qualitative) Checklist. [online] Available at: https://casp-uk.net/wp-content/uploads/2018/03/CASP-Qualitative-Checklist-2018_fillable_form.pdf [Accessed: 14 Dec. 2019]
• Cowin, L., Davies, R., Estall, G., Berlin, T., Fitzgerald, M. and Hoot, S. (2003). De-escalating aggression and violence in the mental health setting. International Journal of Mental Health Nursing, 12(1), pp.64-73.
• Davidson, C. (2009). Transcription: Imperatives for Qualitative Research. International Journal of Qualitative Methods, 8(2), pp.35-52.
• De Brún, C. (2013). Finding the Evidence. [online] England.nhs.uk. Available at: https://www.england.nhs.uk/wp-content/uploads/2017/02/tis-guide-finding-the-evidence-07nov.pdf [Accessed 3 Dec. 2019].
• DeJonckheere, M. and Vaughn, L. (2019). Semistructured interviewing in primary care research: a balance of relationship and rigour. [online] Family Medicine and Community Health. Available at: https://fmch.bmj.com/content/7/2/e000057 [Accessed 14 Dec. 2019].
• Department of Health (2005). Mental Capacity Act. London. HMSO. Available at: https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice [Accessed 14/12/2019].
• Drake, R. E., Goldman, H., Leff, H. S., Lehman, A. F., Dixon, L., Mueser, K. T., et al. (2001). Implementing evidence-based practices in routine mental health service settings.
• Gambrill, E. (2002). Evidence-based practice: An alternative to authority-based practice. Families in Society: The Journal of Contemporary Human Services.
• Gelkopf, M., Roffe, Z., Behrbalk, P., Melamed, Y., Werbloff, N., & Bleich, A. (2009). Attitudes, opinions, behaviors, and emotions of the nursing staff toward patient restraint. Issues in Mental Health Nursing. 30, pp.758-763.
• Gildberg, F. A., Elverdam, B., & Hounsgaard, L. (2010). Forensic psychiatric nursing: A literature review and thematic analysis of staff–patient interaction. Journal of Psychiatric and Mental Health Nursing. 17, pp.359-368.
• Grayson, L., & Gomersall, A. (2003). A difficult business: Finding the evidence for social science reviews. ESRC [Economic and Social Research Council] UK Centre for Evidence Based Policy and Practice, London.
• Howlett, B., Rogo, E. and Shelton, T. (2013). Evidence based practice for health professionals.
• Jamshed, Shazia. (2014). Qualitative research method-interviewing and observation. Journal of Basic and Clinical Pharmacy. 5 (4), pp.87-88.
• Mason, T., King, L., & Dulson, J. (2009). Binary construct analysis of forensic psychiatric nursing in the UK: High, medium, and low security services. International Journal of Mental Health Nursing. 18, pp.216-224.
• Melnyk, B. and Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare.
• Mid Essex Hospital Services NHS Trust. (2014). 1st ed. Adult Patient Safer Restraint.
• Mohr, W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing. 24, pp.3-14.
• Moylan, L. (2009). Physical Restraint in Acute Care Psychiatry. Journal of Psychosocial Nursing and Mental Health Services.
• Pitts, M. and Miller-Day, M. (2007). Upward turning points and positive rapport-development across time in researcher—participant relationships. Qualitative Research, 7(2), pp.177-201.
• Restraint (Physical and Mechanical). (2015). [ebook] Care Quality Commission. Available at: https://www.cqc.org.uk/sites/default/files/20160422_briefguide-Restraint_physical_mechanical.pdf.pdf [Accessed 3 Dec. 2019].
• Robinson, O. (2013). Sampling in Interview-Based Qualitative Research: A Theoretical and Practical Guide. Qualitative Research in Psychology, 11(1), pp.25-41.
• Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). New York: Churchill Livingstone.
• SAGA Research Methods. (2019). Sampling in Qualitative Research. [online] Available at: https://methods.sagepub.com/book/collecting-qualitative-data/i269.xml [Accessed 14 Dec. 2019].
• Sheldon, B. (2003). Brief summary of the ideas behind the Centre for Evidence-Based Social Services. Available at: http://www.ex.ac.uk/cebss/introduction.html [Accessed 11 Oct. 2019].
• Schultz, A. (2009). Evidence-based practice. Philadelphia, PA: Saunders.
• Southam-Gerow, M. A., Hourigan, S. E., & Allin, R. B., Jr. (2009). Adapting evidence-based mental health treatments in community settings: Preliminary results from a partnership approach. Behavior Modification.
• Tewv.nhs.uk. (2018). [online] Available at: https://www.tewv.nhs.uk/content/uploads/2018/09/Nasogastric-Insertion-and-Management-Procedure.pdf [Accessed 13 Dec. 2019].
• Uhs.nhs.uk. (2014). Nasogastric tubes: a narrow dispute. [online] Available at: https://www.uhs.nhs.uk/HealthProfessionals/Clinical-law-updates/Nasogastric-tubes-a-narrow-dispute.aspx [Accessed 13 Dec. 2019].