1. 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

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. “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)

11. 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

12. “[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)

13. 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

14. 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

15. “[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)

16. 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

17. 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…

18. “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)

19. Contact Professor Eimear Muir-Cochrane School of Nursing and Midwifery
Flinders University
Adelaide, South Australia