Nearly a quarter of mental heath patients in Ontario are restrained through straps, medication or seclusion, according to the largest ever study of its kind in Ontario.
Patients unable to make themselves understood — because of illnesses like dementia or schizophrenia — were more than twice as likely to be restrained. And patients in general hospital were two and a half times as likely to be restrained by jackets or straps as those in psychiatric hospitals.
The Canadian Institute for Heath Information collected data from 30,000 mental health patients in both general and psychiatric hospitals between 2006 and 2010 to examine what caused restraints to be used.
“That is a very high number, much higher than at CAMH,” said Dr. Rani Srivastava. She is the chief of nursing practice and professional services at the Centre for Addiction and Mental Health. Restraints are used on less than six per cent of patients at CAMH and they are also cutting down on the time spent in restraints, she said.
“The biggest shift has happened over how people view restraints. [Before] for psychiatric populations it was thought to be one of those necessary evils. But now we’re challenging our thinking. If someone goes into a restraint… What did we miss? What could we have done to prevent this?” she said.
The study includes four categories of restraints. Acute control medication, including administering psychotropic drugs which can alter behaviour, was used 59 per cent of the time. Use of both mechanical restraints, including straitjackets, straps and bed restraints as well as physical restraints, including being held by staff to restrict movement, was at 21 per cent. Seclusion, where the patient is confined to a room was used 20 per cent of the time.
General hospitals — which provide 80 per cent of inpatient mental health medical services — were more likely to use restraints than psychiatric hospitals in similar cases, the study found. Patients were two and a half times more likely to be restrained using methods like bed restraints and straps.
Within the last two or three years, I was visiting in one of our general hospitals in the "psyche" ward, when I discovered the use of patient restraints. When I probed, I learned that, in Ontario there are two categories of psychiatric patients, "voluntary" and "non-voluntary". The first category must give permission for the administration of any medication, the second category have already relinquished their consent and can be administered whatever medication, or restraints the hospital staff deems necessary.
If a patient is unable to communicate his or her needs adequately, or is agitated, it would seem that the first line of "defence" is medical restraints. In order to administer such restraints, the hospital needs to reclassify any "voluntary" patient to a "non-voluntary" patient.
In order to make that reclassification, a form (in Canada we have a form for everything) is required and patient advocates or family are notified of the change in status of the patient. So, a patient who was originally admitted as a "voluntary" patient is often reclassified, when nursing staff considers that patient unco-operative, or more seriously, "as a threat to others or to him/herself" using the wording on the form.
Naturally, when the form is challenged by the patient advocate, or family member, there must be a conference, this time including the psychiatrist supervising the case. If the challenge is to proceed further, to have the reclassification removed, and the patient's status confirmed as "voluntary" there must be a panel or a "hearing" to which no medical staff, especially the psychiatrist, wishes to have to attend. So what happens upon a challenge by a patient advocate or family member is that the staff verbally agree to a reclassification from "involuntary" to "voluntary" to placate the advocate or family member, and then, if they consider restraints necessary, they administer them anyway.
Upon further investigation, I learned from a separate hospital department, through casual conversation, that the chief of psychiatry, newly appointed, had instituted a policy of "zero tolerance" of patient acting out, and a policy of strict "security" for the staff.
In other words, the security of the staff, which concept includes patient compliance with their rules, with their instructions and with their definition of the patient classification, in order to do their jobs, is a higher priority than patient care.
Most of the non-psychiatrist staff, nurses, orderlies etc. are not fully trained in psychiatric care; they have moved to that department from various other departments in the hospital. The psychiatrists themselves are vastly overburdened with the number and severity of their caseload. And patient control and their own "safety and security" trump their version of patient care.
Even when a family member or patient advocate is called to calm a patient, after an especially stressful incident, the nursing staff acknowledges little hope or expectation that such a visit will be effective. The reason: they simply have not gotten to know the patient, to encounter the patient, to interact with the patient, except on an extremely formal and objective and usually disdaining manner.
Only this week, in another conversation with a medical worker in a busy emergency department, I learned that psychiatric patients, after hours, are admitted through "emerg" and that staff are frequently beaten by unco-operative patients and have to call security to restrain them.
There are multiple issues in play in this issue:
- the need for more professionally trained psychiatric nurses, orderlies and patient advocates
- the need for more recognition of the growing need for additional psychiatric care in both public hospitals and in psychiatric hospitals
- the need for enhanced public education about the needs of psychiatric patients, and their illnesses
- and the need for the gradual reduction of public fear of psychiatric patients and their illness generally