Nursing Practice Keywords: Physical restraint/Violence/

Aggression/Mental health
Discussion
●This article has been double-blind
Restraint peer reviewed

Despite guidelines recommending less coercive methods, physical and pharmacological

Should nurses
restraint is still commonly used in many UK mental health settings

restrain violent
and aggressive
patients?
ures to manage violent behaviour, as well
In this article... as employing strict guidelines to govern
The use of physical restraint in mental health settings the use of physical restraint, which
remains common in UK inpatient mental
The effect of physical restraint on the nurse-patient health settings (Richter and Whittington,
therapeutic relationship 2006).
Using medication to manage aggressive behaviour
Violence and aggression
Using less coercive methods to manage violence Violent and aggressive behaviour in
patients can be influenced by environ-
mental and contextual factors (Duxbury,

Authors Joy Duxbury is reader in mental
health; Karen Wright is divisional leader for
mental health; both at the School of Health,
University of Central Lancashire
Abstract Duxbury J, Wright K (2011)
Should nurses restrain violent and
aggressive patients? Nursing Times; 107:
9, 22-25.
Violent and aggressive behaviour towards
nurses is common, especially in mental
health settings.
This article explores the value and safety
of existing approaches to dealing with
violence and aggression, including the use
of physical restraint and medication.
It highlights the need for greater
preventive and participatory measures, and
the use of less reactive strategies, such as
advance directives.
P
2002).
atient aggression in healthcare Unclear policy and guidelines, over-
settings continues to be of con- crowding, poor ward design, inexperi-
cern, raising questions over the enced staff, poor staff retention and a lack
safety of both patients and staff of information sharing all contribute to
caring for them. violent or aggressive behaviour (Health-
In 2005, the then Healthcare Commis- care Commission, 2005; NICE, 2005).
sion published a national audit of violence Studies have also shown a link between
based on 265 mental health and learning staff characteristics and the development
disability units in the UK. The audit found of aggression and violence in mental
that violence against nursing staff was health patients. These include negative
“consistently high”, with up to 86% of interactional styles, provocative and
nurses affected (Healthcare Commission, authoritarian behaviour, and poor com-
2005). munication skills (Duxbury and Whit-
The National Institute for Mental tington, 2005; Glover, 2005).
Health in England (2004) and the National Reservations about using physical
Institute for Health and Clinical Excellence restraint to manage violent and aggressive
(2005) have published guidelines on the behaviour are backed by a growing body of
prevention and management of violence in evidence suggesting that restraint is asso-
healthcare, highlighting safety priorities ciated with a number of adverse events,
in mental health. including death (Evans et
The guidance empha- For more articles al, 2002).
sises the importance of on restraint go to National guidance also
nursingtimes.net/restraint
using preventive meas- identifies a number of fac-

22 Nursing Times 08.03.11 / Vol 107 No 9 / www.nursingtimes.net

 For a Nursing Times Learning unit
on psychiatric crisis response, go
to nursingtimes.net/crisis

5 key
Huckshorn (2005) set out to eliminate
physical restraint in an American mental
points health settings using the Six Core Strate-
gies framework (Box 1); this reduced the

1 A national audit
of violence in
mental health units
use of seclusion and restraint by 60-70%
(LeBel and Goldstein, 2005).
Both the NIMH (2004) and NICE (2005)
found 73-86% of have identified restraint as one of four pri-
nurses have orities requiring immediate national
experienced violent attention.
and aggressive
behaviour Preserving the therapeutic relationship

2 Physical
restraint is still
common in UK
Balancing the protection of staff and
patients with the preservation of the thera-
peutic relationship can be a dilemma for
mental health nurses.
settings despite Arguments for the continued use of
evidence restraint are based on concerns about
recommending less safety and order, yet patients often enter
coercive measures services in acute distress and previous
to manage experience of restraint can make them
behaviour fearful of admission (Bonner et al, 2002).

Many nurses experience violent and aggressive behaviour 3 Physical

box 1. reducing
restraint
The Six Core Strategies framework for
reducing physical restraint:
● Leadership toward organisational
change;
● Using data to inform practice;
● Workforce development;
● Using prevention tools;
● Service user involvement;
● Post-incident debriefing and review.
Source: Huckshorn (2005)
tors that contribute to the use of physical
restraint, including a lack of agreed stand-
ards, variations in practice, and a lack of
staff knowledge and skills to prevent its
use or identify alternatives (NICE, 2005).
Physical intervention
NICE (2005) defines physical intervention
as a “hands-on method of restraint
involving trained designated healthcare
professionals [aiming] to prevent individ-
uals from harming themselves, endan-
gering others or seriously compromising
the therapeutic environment”.
Physical restraint should only be used
as a “last resort” to manage unwanted or
harmful behaviours (NICE, 2005). How-
ever, it is used frequently in mental health
services to manage aggression, damage to
property or self-harm (Richter and Whit-
intervention
can cause injuries to
patients and staff
4 Restraint
incidents are
often followed by
more containment
measures, which
patients may see as
coercive
5 Nurses should
use advanced
directives to
negotiate
intervention
strategies with
patients to manage
behaviour
Physical intervention can cause injuries
to patients and staff, and can be highly dis-
tressing for service users who often asso-
ciate it with psychological trauma and loss
of dignity (Chien and Lee, 2005). In
extreme cases, it has resulted in fatalities
(see case study, overleaf ).
A Cochrane review found little evidence
to support the efficacy of physical restraint
as a containment strategy (Sailas and
Fenton, 2000). There is also evidence indi-
cating that it can exacerbate the behaviour
it is designed to control, and worsen the
therapeutic relationship between staff and
patients (Duxbury, 2002).
Although nursing staff may endorse
the use of restraint under certain condi-
tions, many see it as an ethically problem-
atic practice that has an untoward effect
on patients (Paterson and Duxbury, 2007;
The decision to restrain a patient is a
difficult one for nurses, who have to con-
sider risk management, cultural imbal-
ances and the safety of all involved (Dux-
bury and Paterson, 2005).
Attitudes to the use of restraint
vary. Although research examining
patients’ and nurses’ views is relatively
scarce, research has shown that nurses
have mixed feelings about using restric-
tive interventions (Duxbury and Whit-
tington, 2005). It is not uncommon for
patients to perceive these strategies as dis-
tressing or even as punishment (Moran et
al, 2009).
Duxbury (2000) argues that coercive
interventions such as restraint can be used
to deal with patients perceived as “diffi-
cult” in an untherapeutic way. There is
increasing evidence for the effectiveness of
preventing or de-escalating situations
involving acutely aggressive or distressed
patients without the need to use restraint
or rapid tranquilisation (Busch, 2005).
LeBel and Goldstein (2005) demon-
strated that the use of restraint can be sub-
stantially reduced without a corre-
sponding increase in alternative methods
of control, and without jeopardising the
safety of staff or patients.
Chemical restraint
Restraint incidents are often followed by
additional containment measures, such as
seclusion or drug-induced sedation; these
are commonly known as chemical restraint
(Stewart et al, 2009).
It has been argued that administering
medication to control aggressive or
harmful behaviour is in the patient’s best
Alamy

tington, 2006). Duxbury and Whittington, 2005). interests (Olsen, 2001), and means that

www.nursingtimes.net / Vol 107 No 9 / Nursing Times 08.03.11 23

Nursing Practice
Discussion
seclusion and physical restraint can be
avoided (Lind et al, 2004).
However, there are concerns about the
potential physical dangers associated with
forced medication use, which can also be
seen as controlling and coercive by
patients. Nurses who use psychotropic
medication for its sedative effect risk disa-
bling and deskilling their patients,
impairing their ability to find a personal
resolution to conflict (Thapa et al, 2003).
The most common methods of medica-
tion administration are “as required” (prn
– pro re nata) and rapid tranquillisation.
Rapid tranquilisation
The NICE (2005) guideline on the short-
term management of aggression and vio-
lence defines rapid tranquilisation (RT) as:
“The use of medication to calm/lightly
sedate the service user, reduce the risk to
self and/or others and achieve an optimal
reduction in agitation and aggression,
thereby allowing a thorough psychiatric
evaluation to take place, and allowing
comprehension and response to spoken
messages throughout the intervention.”
The guideline says RT should only be
used to manage a high risk of imminent vio-
lence that has not responded to interper-
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sonal interventions, and recommends less
coercive methods, such as verbal de-escala-
tion, as a first-line strategy (NICE, 2005).
Medications used for RT should be fast
acting with few side-effects, and oral prep-
arations should be offered first, followed
by parental preparations, which are usu-
ally given by intramuscular injection
(NICE, 2005).
There is no absolute agreement about
which medications or doses should be used
from the available benzodiazepines and
antipsychotic drugs. Lorazepine is usually
the drug of choice because it has a shorter
half-life than diazepam. This limits accu-
mulation of the drug, which can lead to
oversedation. Antipsychotics are also used,
either alone or in combination with benzo-
diazepines, as the newer atypical antipsy-
chotic formulas are known to cause fewer
extrapyramidal side-effects such as tremor,
slurred speech, anxiety and distress.
As required medication
The use of prn regimens of psychotropic
medication for disturbed behaviour, dis-
24 Nursing Times 08.03.11 / Vol 107 No 9 / www.nursingtimes.net
box 2. case study
The inquiry (Blofield, 2003) into the death
of David “Rocky” Bennett highlighted the
use of physical restraint. The 38-year-old
African-Caribbean man died in 1998 after
being restrained for 25 minutes by staff
while an inpatient in a medium secure unit
in Norfolk.
Mr Bennett, who had schizophrenia,
had received care and treatment for 18
years at the time of his death. After
repeatedly experiencing racial abuse
and being involved in an aggressive
incident, he was moved to a different
ward.
While on this second ward he hit a
nurse and was subsequently restrained.
He was held in the prone position, face
down on the floor, and continued to
struggle until he collapse and died, still in
the restraint position.
An inquiry was held and revealed that
he had been given “heavy doses” of
antipsychotic drugs to contain him.
The inquiry into his death led to 22
recommendations for practice, including
calls for further research and a suggestion
tress or agitation is widespread in psychi-
atric units (Chakrabarti et al, 2010).
According to Donat (2005), nurses are
unnecessarily reliant on the use of prn
medication regimens for behaviour man-
agement. McLaren et al (1990) found 23%
of psychiatric inpatients received at least
one prn dose of psychotropic medication
during their stay, rising to 50% among
those in secure psychiatric care. Addition-
ally, Curtis and Capp (2003) found that
almost 80% of patients received prn psy-
chotropic medication over one month.
The main reason for administration was
agitation and most of the medication
administration was initiated by nurses.
This method of prescribing allows
nurses to administer medication rapidly
in acute situations or at the patient’s
request, but it can also allow the adminis-
tration of high or above recommended
doses.
It can also be seen as punitive or disem-
powering by patients, who already feel
subservient to nursing and medical staff
(Duxbury et al, 2010).
This method of administration can
cause staff to rely too heavily on pharma-
cological treatments, although this may
also be due to the lack of techniques and
that some patients may benefit from a
“drug-free holiday” in hospital.
One of the most significant
recommendations was that the time that
any patient should be held in a prone
position should be reduced; it is always
dangerous and, if it is ever required, then it
should not exceed five minutes.
Furthermore, staff should receive
specialist training in control and restraint
and a resuscitation trolley should be
available.
The use of a second opinion-approved
doctor (SOAD) to review prescriptions
was also recommended as good practice.
Independent Inquiry
into the death of
David Bennett
David ‘Rocky’ Bennett
1960 - 1998
December 2003
strategies available for managing aggres-
sion (Thomas et al, 2006).
Advance directives
NICE (2005) identified advanced directives
as a key priority for the management of
aggression.
An advanced directive is a statement of
a patient’s treatment preferences should
he or she lose the capacity to make treat-
ment decisions in the future (Papageor-
giou et al, 2002).
Intervention strategies for the manage-
ment of disturbed or violent behaviour
should be negotiated with service users on
admission to inpatient facilities, or as soon
as possible thereafter. These strategies
must be documented in the service users
care plan and healthcare records.
Benefits of the successful implementa-
tion of advance directives include a posi-
tive therapeutic alliance, greater commu-
nication between staff and patients,
continuity of care and enhanced care plan-
ning (Papageorgiou et al, 2002).
However, staff may be reluctant to use
advance directives, patients may not
understand them, and they may need to be
overridden in some circumstances.
It may also be inappropriate to use
 “The trust’s policies
should be gathered in one
place as a resource file”
Sara Morgan p41
advance directives with some patients, and
breaking the contract could harm the thera-
peutic relationship between nurse patient.
Also a lack of evidence on the use and
efficacy of advance directives can make
their implementation difficult (NICE,
2005).
Post-incident reviews
The aim of a post-incident review is to
learn lessons, support staff and encourage
the therapeutic relationship between staff
and patients.
NICE (2005) recommends conducting a
review within 72 hours of the incident
ending. The review should address what
happened, including any trigger factors
and each person’s role in the incident, and
what can be done about it.
Mental health service providers should
have systems in place to ensure a range of
post-incident support and review options
are available, and that the review takes
place within a culture of learning with
appropriately trained staff.
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Conclusion
Dealing violence and aggression can be
stressful for nurses, particularly if they
feel inadequately trained to deal with it.
The importance of understanding and
addressing contextual and interpersonal
factors that may contribute to aggressive
behaviour cannot be overestimated, and
most trusts now have policies in place to
help staff deal with violent behaviour.
With regard to the prevention and man-
agement of patients who are or may become
aggressive, there is clearly a dichotomy of
care; practitioners are required to balance
the safety of staff and patients with a thera-
peutic philosophy of care.
In the light of the growing evidence,
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The use of physical restraint continues
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