Examination of the definition and use of chemical restraint in acute psychiatric settings Eimear Muir-Cochrane Professor of Nursing Chair of Nursing (Mental Health) Suzanne Dawson Senior Occupational Therapist/PhD Candidate

Working definition in Australia Chemical restraint is the administration of medication in an emergency situation and on an involuntary basis to control the behaviour of a person to prevent them from harming themselves of others. It includes circumstances where sedation is provided to ensure safe transport (National Safety & Quality Partnerships Subcommittee)

Context of restraint in health care Long history of use Physical, Environmental and Chemical Some countries prefer certain types of restraint Ethical, Legal & Humanitarian issues Occurs within recovery framework Risk adverse & zero-tolerance Despite controversy, remains commonplace Physical (or mechanical) restraint- includes use of lap belts or wrist cuffs Environmental- seclusion Chemical- where patients are forced or coerced to take psychotropic medication

Seclusion & Restraint Reduction initiatives 6 core strategies USA Sensory modulation NZ SafeWards UK Reducing one form of restraint can increase another With increasing awareness of the impact of coercive measures the need to reduce or eliminate these practices has been recognised Programs have varied internationally

Context for this research Chemical restraint remains commonplace & is subject to less regulation Chemical restraint is under-explored A clear definition will assist in monitoring & assessing use More work needed on chemical restraint Research has focused on physical & mechanical restraint and seclusion Lack of clarity around the definition of CR A clear definition is needed in order to reliably monitor and assess its use

Aims of the research Explore a broad range of stakeholders perspectives and understandings about chemical restraint in adult acute mental health care & emergency departments Examine their reflections on the draft definition of chemical restraint Expand the evidence base of the use of chemical restraint

Research methods Ethics obtained Interviews, focus groups and online surveys Consumers, carers, peer support workers, nurses, psychiatrists, government and nongovernment officials, advocates, educators, researchers and managers 30 participants; 6 states and territories in Australia 10 months in 2015 Thematic analysis against research questions

Chemical Restraint Process & Definition Risk Assessment Risk Management Last Resort DEFINITION Effects on Patients/Staff The findings are presented against the following framework whereby the participants discussion about CR and its use or misuse are explored against key components of the definition & process of CR

Chemical Restraint Process Risk Assessment Is it an emergency (immediate risk of harm to self/others?) Staff attitudes & behaviour Fear, stigma, education, past experiences, engagement, stress, burnout Ward culture & environment Staffing, resources, handover, past versus current risk, long waiting times, lack of use of safety plans & protocols Transport Is it an emergency? Discrepancy between consumer & staff interpretation e.g. bahavour such as throwing a cup of tea against the wall’ ‘nonchantly’ but seen as aggression Reasons for use: went beyond the ‘emergency situation’ Control behaviour Reduce agitation Reduce distressing symptoms Resolve psychosis Ensure safety to all Prevent/reduce aggression and violence Risk Ax influenced by Staff attitudes & behaviour e.g. engaging in timely and respectful manner- both reported to increase incidence (if lack of) as well as improve consumer experience of having CR (if present) Environmental issues Overcrowding in ED Lack of beds Lack of appropriate resources Lack of knowledge of the person Safety plan not followed

“Emergency department staff work to a different set of parameters with regard to acceptable/manageable behaviour then mental health staff…mental health methods of management can often be viewed as “airy fairy” in EDs where the focus is on “doing”. Doing is usually giving drugs or intervening physically in some way” (Nursing Director)

Chemical Restraint Process Risk Management Have other less restrictive measures been tried? Chemical restraint in the context of Therapeutic relationship & Person-centred care Punishment/fear/environmental management/managing mental state Lack of knowledge of the person Safety plan not followed

“[There is the risk of the person seeing themselves as] being bad instead of mad, and you see in hospital punishments instead of something that’s helpful. That’s not where we want to be, people aren’t going to go there for help when they see it as punishment. ” (Peer Worker)

Chemical Restraint Process A last resort (involving force & coercion) Participants with lived experience considered any medication given under coercion to be CR (PRN) Questions as to whether alternative options had been trialled- early engagement, quiet area, SM

Chemical Restraint Process Effects on patients/staff The need for debriefing Experience of chemical restraint Side effects Emotional effects “misuse & overuse” Experiences of CR: Lack of collaboration Not used as a last resort Physical and emotional assault Risk management is not care Punishment Misuse included not being used as ‘last resort’ Some participants with a lived experience spoke about CR positively

“[CR results in] a sense of loss of control over the rights of your body…[and]…vulnerable and at risk of this occurring in future events.” (Peer Worker)

Chemical Restraint Definition What is Chemical Restraint? Medication under force/coercion Why should it be used? Risk of harm When should it be used? Emergency, last resort How should it be used? ?intramuscular, PRN What follow up should be provided? Debriefing to patient, staff & carers The findings are presented in the following framework whereby the participants discussion about CR and its use or misuse inform the definition

Where to from here? Involvement of consumer carer groups in ongoing debates about restraint Individualised care planning required Coordinated response between services (ED. Ambulance Psych units) ‘Acute injectables’ Use of clinical guidelines about medication protocols Need for further research…

“Wherever possible do what you can in between before using any kind of restraint- physical or chemical.” “[Ensure] chemical restraint is used with restraint.” (Peer Workers)

Contact Professor Eimear Muir-Cochrane School of Nursing and Midwifery Flinders University Adelaide, South Australia Eimear.muircochrane@flinders.edu.au www.flinders.edu.au/nursing/mhc