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Restraining patients is a practice that dates back at least three centuries. In recent years, there has been a mandate and advocacy in various countries for organizations to shift towards the minimization of restraint, whereby its use is only as a 'last resort'. There is growing evidence internationally indicating the negative impact of the use of restraint. However, to date there is no research specifically focusing on trying to understand the concept of 'last resort'. Further insights to explore this concept among mental health nurses are therefore warranted. The empirical research comprised a hermeneutic phenomenological study. By recruiting and interviewing thirteen mental health nurses from across Canada who had experiences of restraint use, the research aimed to generate a deeper understanding of the meanings and lived experiences of the concept of 'last resort'. Data were collected through fifteen in-depth interviews. Data analysis was undertaken through a hermeneutic phenomenological framework based on van Manen's approach and Heideggerian philosophy. Five Heideggerian concepts were used to illuminate 'last resort' in restraint use by mental health nurses - temporality, inauthenticity, thrownness, leaping in and leaping ahead, and mood (fear). Key findings highlight the influence of nurses' past experiences, how nursing staff adopt a collective (rather than individual) approach, and the dependency on knowledge and skills of others in using restraint as a 'last resort'. Overall, the lived experience of 'last resort' is comprised of many elements. This study provides insights and an initial understanding, which is hoped to advance the field of restraint minimization., (© 2020 Australian College of Mental Health Nurses Inc.)

WHAT IS KNOWN ON THE SUBJECT?: Mental health nursing in the UK and other countries faces an acute workforce crisis. Safe staffing levels are called for, and in some jurisdictions have been legislated for. The evidence base linking staffing levels and patient outcomes is limited. Staffing levels are implicated in adverse experiences of service users and staff within mental health ward settings, and they might contribute to levels of violence and aggression and the application of restrictive practices, such as physical restraint but there is limited research evidence to support this. Programmes such as Safewards, No Force First, the Engagement Model and the Six Core Strategies can reduce the use of restrictive practices. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Staffing levels on acute mental health wards appeared crucial in the implementation of a restraint minimization project. Both staff and service users implicate insufficient staffing for deficiencies in the relational elements of care, such as lack of face-to-face contact between nurses and service users. Similarly, staffing levels are associated with perceived problems in the cause of violence and aggression and responses to it. Despite successes in minimizing restrictive practices in this project, difficulties implementing alternative forms of practice that would reduce use of physical restraint, such as de-escalation, were also attributed to staffing levels. There is an irony that a project concerned with safety itself provoked concern over safe staffing levels. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Efforts to reduce restrictive practices will be hampered without adequate staffing levels. Restrictive practices may justifyably be framed as an employment relations matter. Organisations and policy makers ought to address environmental, contextual and resourcing factors, rather than identify problems exclusively in terms of perceived aberrant behaviour of staff or service users. ABSTRACT: Introduction Safe staffing and coercive practices are of pressing concern for mental health services. These are inter-dependent, and the relationship is under-researched. Aim To explore views on staffing levels in a context of attempting to minimize physical restraint practices on mental health wards. Findings emerged from a wider data set with the broader aim of exploring experiences of a restraint reduction initiative. Methods Thematic analysis of semi-structured interviews with staff (n = 130) and service users (n = 32). Results Five themes were identified regarding how staffing levels impact experiences and complicate efforts to minimize physical restraint. We titled the themes-"insufficient staff to do the job"; "detriment to staff and service users"; "a paperwork exercise: the burden of non-clinical tasks"; "false economies"; and, "you can't do these interventions." Discussion Tendencies detracting from relational aspects of care are not independent of insufficiencies in staffing. The relational, communicative and organizational developments that would enable reductions in use of restraint are labour intensive and vulnerable to derailment by insufficient and poorly skilled staff. Implications for practice Restrictive practices are unlikely to be minimized unless wards are adequately staffed. Inadequate staffing is not independent of restrictive practices and reduces access to alternative interventions for reducing individuals' distress., (© 2019 John Wiley & Sons Ltd.)

Unlabelled: WHAT IS KNOWN ON THE SUBJECT?: There is emerging evidence highlighting the counter therapeutic impact of the use of restraint and promoting the minimization of this practice in mental health care. Mental health nurses are often the professional group using restraint and understanding factors influencing their decision-making becomes critical. To date, there are no other published papers that have undertaken a similar broad search to review this topic. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Eight emerging themes are identified as factors influencing mental health nurses decisions-making in the use of restraint. The themes are: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. 'Last resort' appears to be the mantra of acceptable restraint use, although, to date, there are no studies that specifically consider what this concept actually is. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These findings should be considered in the evaluation of the use of restraint in mental health settings and appropriate strategies placed to support shifting towards restraint minimization. As the concept of 'last resort' is mentioned in many policies and guidelines internationally with no published understanding of what this means, research should prioritize this as a critical next step in restraint minimization efforts., Introduction: While mechanical and manual restraint as an institutional method of control within mental health settings may be perceived to seem necessary at times, there is emergent literature highlighting the potential counter-therapeutic impact of this practice for patients as well as staff. Nurses are the professional group who are most likely to use mechanical and manual restraint methods within mental health settings. In-depth insights to understand what factors influence nurses' decision-making related to restraint use are therefore warranted., Aim: To explore what influences mental health nurses' decision-making in the use of restraint., Method: An integrative review using Cooper's framework was undertaken., Results: Eight emerging themes were identified: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. These themes highlight how mental health nurses' decision-making is influenced by ethical and safety responsibilities, as well as, interpersonal and staff-related factors., Conclusion: Research to further understand the experience and actualization of 'last resort' in the use of restraint and to provide strategies to prevent restraint use in mental health settings are needed., (© 2016 John Wiley & Sons Ltd.)

Aggression is reported to be prevalent in psychiatric inpatient care and its frequency towards healthcare professionals is well documented. While aggression may not be entirely avoidable, its incidence can be reduced through prevention and the minimization of restrictive practices such as physical restraint. The study aims to explore three common 'defences' to account for the use of physical restraint; to challenge each defence with regard to the evidence base; and to identify how services are responding to the challenge of reducing the use of restrictive interventions. Following a number of investigations to highlight serious problems with the use of physical restraint, it seems timely to examine its efficacy in light of the evidence base. In order to do this, three key defences for its use will be challenged using the literature. A combination of interventions to minimize the use of restraint including advance planning tools, and recognition of potential trauma is necessary at an organizational and individual level. Patients can be severely traumatized by the use of restrictive practices and there is a drive to examine, and reduce the use and impact of using these models that incorporate trauma informed care (TIC) and person centredness., (© 2015 John Wiley & Sons Ltd.)

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.

Aim: This paper is a report of a study to determine the transferability of the Management of Aggression and Violence Attitude Scale to European mental health inpatient settings., Background: Incidents of patient aggression and violence are common in psychiatric in-patient facilities, and nurses' attitudes may play a part in how they are managed., Methods: Nursing staff from acute psychiatric in-patient units in Switzerland and the United Kingdom completed the Management of Aggression and Violence Attitude Scale. Data were collected in the UK in 2001 and Switzerland in 2003. The Swiss sample comprised 75 respondents: 45 female, mean age 36.24, mean experience 7.35 years, 60 Registered Nurses. The United Kingdom sample was 75 respondents: 58 female, mean age 32, mean experience 5.25 years, 48 Registered Nurses. T-tests identified differences between the groups in their responses to each Management of Aggression and Violence Attitude Scale statement., Results: There was 66% concordance of views between the groups. Swiss nurses were, however, more likely to regard factors internal to the patient as contributory to aggression while United Kingdom nurses perceived environmental factors to be more important. Both groups endorsed physical means of aggression management, Swiss nurses more so., Conclusion: There are both commonalities and differences between the attitudes of Swiss and United Kingdom nursing staff regarding patient aggression. Differences may relate to rates of aggression, variations in management approaches, training and policy. The Management of Aggression and Violence Attitude Scale is a potentially effective tool for making comparisons about perspectives on patient aggression.

Restraint as an intervention in the management of acute mental distress has a long history that predates the existence of psychiatry. However, it remains a source of controversy with an ongoing debate as to its role. This article critically explores what to date has seemingly been only implicit in the debate surrounding the role of restraint: how should the concept of validity be interpreted when applied to restraint as an intervention? The practice of restraint in mental health is critically examined using two post-positivist constructions of validity, the pragmatic and the psychopolitical, by means of a critical examination of the literature. The current literature provides only weak support for the pragmatic validity of restraint as an intervention and no support to date for its psychopolitical validity. Judgements regarding the validity of any intervention that is coercive must include reference to the psychopolitical dimensions of both practice and policy.

This paper considers the phenomenon of aggressive behaviour perpetrated by people with dementia in residential care settings. Aggressive behaviour is defined in the context of people with dementia, and the problem of ascertaining the incidence of aggression among people with dementia is discussed. The emotional impact of assaults on nurses and other professionals is highlighted, and differing perspectives on the causation of aggressive behaviour are considered. Management strategies derived from the physical/pharmacological; environment management; behaviour modification and person-centred approaches are reviewed. Our conclusion is that while certain strategies appear to reflect good and common sense practice, in particular those deriving from the person-centred approach, there is no clear research evidence for the general effectiveness of any one management approach, and each has drawbacks of a practical or ethical nature. There is also little empirical information about how professional carers actually manage aggressive behaviour in practice.

Aggression in healthcare systems poses a major problem for nurses because they are the most susceptible to suffer violence. Studies demonstrate that attitudes of nurses influence their behaviour regarding aggression and violence. Training programmes can positively change nurses' attitudes. This quasi-experimental study aimed to examine the effects of a systematic training course in aggression management on mental health nurses' attitudes about the reasons for patients' aggression and on its management. Sixty-three nurses (29 in the intervention and 34 in the control group) participated in this quasi-experimental pre-test and post-test study. The attitude of the participants of a training course was recorded by the German version of the Management of Aggression and Violence Attitude Scale (MAVAS). No significant attitude changes occurred in the intervention group at post-test. It is concluded that trainings intending to influence attitudes regarding the reason for patient aggression should consider the impact of the pedagogical quality of the training course, organizational support, and the user's perception. Moreover, it remains questionable to what extent a single instrument of measurement can record attitude changes.

Aim: This paper reports a study of staff and patient perspectives on the causes of patient aggression and the way it is managed., Background: The incidence of aggression in healthcare is reportedly on the increase, and concerns about the management of this problem are growing., Method: A convenience sample of 80 patients and 82 nurses from three inpatient mental healthcare wards were surveyed using The Management of Aggression and Violence Attitude Scale. A further five patients and five nurses from the same sample participated in a number of follow-up interviews., Results: Patients perceived environmental conditions and poor communication to be a significant precursor of aggressive behaviour. Nurses, in comparison, viewed the patients' mental illnesses to be the main reason for aggression, although the negative impact of the inpatient environment was recognized. From interview responses, it was evident that both sets of respondents were dissatisfied with a restrictive and under-resourced provision that leads to interpersonal tensions., Conclusion: There are differences between the views of staff and patients about reasons for aggression and its management. Future approaches therefore need to be developed that address these opposing views. For example, training in the use of fundamental therapeutic communication skills was advocated by patients, whilst the need for greater attention to organizational deficits was advocated by nurses. A move away from reliance on the use of medication was also felt to be necessary. Evaluation of local needs and practices must be an integral part of this process.

The use of medication in acute mental health is common practice however, there is a lack of research into all aspects of pharmacology within inpatient settings. This paper explores the specific use of benzodiazepines and areas of potential mismanagement. A number of priorities for investigation are raised and implications for nursing roles and responsibilities discussed.

Until relatively recently, aggression and violence in nursing has been an area of little discussion (Poster & Ryan 1993). Today, concerns are rising about escalating levels of violence towards nurses (Wykes 1994, Whittington 1997). In response, this paper explores registered nurses' experiences of patient aggression encountered in the acute inpatient general and mental health settings. Critical incidents from registered nurses in both areas are examined and analyzed in relation to existing literature. The aim of the research is to ascertain if differences exist or similarities prevail. Findings reveal that the two areas have similar problems in terms of types of aggression. Verbal and 'minor' types of aggression are the most problematic. Also, the 'biomedical model' of care is evident in both settings and possibly underpins chosen approaches to aggression management. The repeated use of chemical and physical restraint is apparent. The main comparison identified between the two groups relates to nursing control over situations involving violent patients. Mental health nurses seem to consistently take control of aggressive situations whilst general nurses tend to rely more heavily upon the input of others (medical staff, mental health teams and the police) when intervening. These two nursing specialties therefore have much to learn from each other in terms of nursing experience and possible future approaches to the management of aggressive patients.

The recent report of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People (the Boyd report) compiled for the government, and the imminent publication of the Mental Health Patient's Charter, highlight national concern over the provision of care for this group of people. This article examines some of the dilemmas facing mental health nurses when caring for patients under detention orders and evaluates guidelines and recommendations which can aid the nurse in providing appropriate care.

Following an initial springboard study, a further more extensive piece of research was conducted to identify and evaluate approaches used to manage patient aggression and violence on three acute mental health wards. Data were gathered using an incident form, a questionnaire and interviews. The views of patients (n = 80), nurses (n = 72) and medical staff (n = 10) were explored. Findings revealed a clear distinction between the way staff and patients view both the problem and the response. Patients' view present staff approaches as 'controlling' and believe that environmental and poor communication factors underpin aggressive behaviour. Staff, conversely, attribute aggressive behaviour to internal patient and external factors, which may explain the reason for approaches used. A strong correlation was found between type of patient aggression and response (r = 0.36, P < 0.000) and a high percentage of incidents reported were of an aggressive, as opposed to violent, nature. For example 70% of incidents involved verbal abuse or threat. Despite this, 47% (n = 103) of approaches incorporated the use of medication, restraint or seclusion. These are commonly referred to as traditional methods. Patients clearly view this controlling style as a part of the problem and an emphasis upon control and symptom reduction may be inappropriate given the type of aggression encountered. Key issues were further analysed using an internal, external and situational model, each of which endeavour to explain reasons for patient aggression from different perspectives. It is this emphasis upon sole perspectives that may both contribute to and result in the use of a limited number of management approaches adopted in practice. The integration of all three models to examine the complex nature of patient aggression and violence from a variety of perspectives may be the way forward. As a result, approaches to deal with this problem could be more meaningful and subsequently effective. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented which discusses topics within the issue including mental health, substance abuse and relationship between social climate and levels of aggression.