Rajiv Gandhi Unversity of Health Sciences, Karnataka, Bangalore

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name of the candidate and address (in block letters) / VALERIAN SUDEEP PINTO
I YEAR M.Sc NURSING
FATHER MULLER COLLEGE OF NURSING
MANGALORE-575002
2 / Name of the Institution / FATHER MULLER COLLEGE OF NURSING
KANKANADY
MANGALORE – 575002.
3 / Course of study and subject / M.Sc NURSING
PSYCHIATRIC NURSING
4 / Date of admission to course / 16.05. 2011
5 / Title of the topic:
PSYCHIATRIC INPATIENTS’ PERCEPTION OF PHYSICAL RESTRAINTS.
6
7.
8 / Brief Resume of the Intended Work
6.1 Need for the Study.
According to World Health Organization one in four people develop some kind of mental illness at some point in their lives in the world. Mental illness is one of the most common health conditions worldwide. People suffer twice over - from the illness itself, and because they are shunned by their families, exiled from their communities and isolated by society1.
Mental disorders afflict 5 crore of the Indian population (5%) and need special care. World Health Organization estimates of 2001 indicate a prevalence level of about 22% of individuals developing one or more mental or behavioral disorders in their lifetime in India2.
People with different psychiatric conditions like mood disorders, substance abuse, schizophrenia, organic mental disorders, mental retardation with psychosis, phobias and obsessive disorders and sexual disorders and other mental illness get admitted in the psychiatric hospitals.
Despite advances in the management of acute psychiatric disorders, violent behaviors among psychiatric inpatients remain common and vexing clinical occurrences. Suicidal behaviors, assaults on patients, and attacks on psychiatric staff are often considered separately for reporting purposes but together they represent potentially preventable adverse events that occur on inpatient psychiatric units3.
Physical restraints are any device, material or equipment attached to or near a person's body and which cannot be easily removed by the person and it deliberately prevents a person's free body movement to a position of choice or a person's normal access to their body. Examples of physical restraint include vests, straps/belts, limb ties, wheelchair bars and brakes, chairs that tip backwards, tucking in sheets too tightly, and bedside rails. Physical restraints are the one of the non therapeutic intervention to prevent the complications which is occurring due to violent behaviors. Bruises, decubitus ulcers, respiratory complications, urinary incontinence and constipation, under-nutrition, increased dependence in activities of daily living, impaired muscle strength and balance, decreased cardiovascular endurance, increased agitation are some of the complications due to physical restraints4.
A study was conducted in Lady Hardinge Medical College and associated hospitals, New Delhi. A questionnaire was administered to 278 qualified psychiatrists from all over India-60% of them from government hospitals and rest of them from private setup. It was found that about (80%), psychiatrists use the physical restraints some time or the other. Most of them (70%) took informed consent from the relatives. In most cases maximum period of restraint varied from 8 to 10 hours. Only a few reported little longer than this. The most frequent reasons for physical restraints used, include irrespective of diagnosis, were found to be violent and agitated behavior (81%), patient who were harm to self (31%), and delirium (24%). Among the diagnostic groups, acute manic episodes is the most common reason for using restraint followed by acute transient psychotic disorder and schizoprenia5.
A qualitative study was conducted in Princess Margaret Hospital, Kwai Chung, NT, Hong Kong SAR, China. It explored the experiences and feelings of psychiatric inpatients concerning their first encounter with physical restraint. Thirty psychiatric inpatients’ who had experienced physical restraint in two acute admission wards within the previous two days, were interviewed by the principal researcher. About two-thirds of the participants expressed positive feelings towards staff who had shown concern about their needs and had been willing to help. Positive therapeutic effects, other than physical protection, were largely related to the caring attitudes and behavior demonstrated by the staff. Negative effects were related to the inability of staff to satisfy patients’ needs for: concern, empathy, active listening, and information about restraint during and after its use. The conclusion of the study was that physical restraint could be a therapeutic intervention when health professionals were able to provide psychological and informational support to patients throughout the procedure. A perceived unsatisfactory caring attitude and behavior by the restraint provider would cause negative feelings in the patient and would be more likely to result in the patient struggling physically with the restrainer. Additional physical and psychological harm would also be experienced by patients in these circumstance6.
A study was conducted in Harding Hospital Emergency Services, Ohio, Washington to assess patient perceptions of seclusion. Patient perceptions of seclusion revealed many negative feelings. The quest for the human element, dignity, to understand and to be understood, and to be reassured were the themes which were identified7.
Whatever nurses can do before or during the seclusion process that results in more positive perceptions by patients helps promote more comfortable feelings and more appropriate behavior. Frequent reviews of seclusion policies and procedures are important. It is one of the most important ways that staff can help the patient in diminishing the emotional impact of seclusion. It provides an opportunity to clarify the rationale for the seclusion, offer mutual feedback, and promote the patient’s self-esteem7.
The investigator has come across many restrained patients who expressed varying feelings about restraints. The review of literature also showed varying perception of the patients under restraints. Hence the investigator got motivated to undertake the study.
6.2 Review of literature.
A study was conducted by Holy Names College of Nursing to assess the attitudes and perceptions of patients, family, and staff about restraints and seclusion. Each member’s attitude and perceptiondiffered. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varied, but professionals claimed that they are necessary to prevent/treat violent or unruly behavior. Some believed seclusion/restraint were effective, but there was no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued8.
A study was conducted on people with developmental disabilities to assess the personal experience of emergency intervention. A statistical analysis of 3,767 such incidents, involved 82 clients with developmental disabilities, was presented along with semi-structured interview material.The data reviled that women were involved in a disproportionately high number of incidents. It was found that women had a significantly higher probability of being given rapid tranquilization following a violent incident. In contrast, seclusion was more likely to be used with men. Interviews with women demonstrated a commonly held understanding of interventions as punishment and expressions of intense anger and anxiety, physical pain and discomfort 9.
A study was conducted on in-patients of a Secure Mental Health Service to assess the patients’ experiences of physical restraint procedures. Interview data were subjected to thematic content analysis in accordance with grounded theory methodology.Patients had differential experiences of similar physical procedures. Most reported some negative psychological experience of restraint. Anger and anxiety were two major themes. Some respondents held the perception that restraint was used to punish patients and several suggested that restraint incited further violence and aggression. Some female service users reported that restraint evoked flashbacks of previous sexual trauma.A subset of female respondents gave contrasting accounts of restraint, suggesting that they purposely brought about the restraint to gain a sense of containment or as a way to release feelings10.
A study was conducted in Medium Secure Learning Disability Service in North-West England to assess the staffs and client perspectives on physical interventions. Staffs and clients were asked about incidents which required the use of physical intervention, using unstructured interviews within a participatory research framework. The article explores clients’ and staff accounts of aggressive incidents and the consequences of physical intervention. Clients cited other clients and the ward atmosphere as the main reasons for aggressive behavior. Some clients said that the use of physical intervention made them more frustrated and brought back memories of frightening experiences. Staff reported that incident of aggression and the use of physical intervention were upsetting and traumatic, causing feelings of guilt and self-reproach. Staff said that they always used physical intervention as a last resort, although clients often reported otherwise11.
A nine-month prospective study was conducted on all patientswho were restrained in the acute psychiatric units of two general hospitals. A group of non-restrained controls revealed significant demographic and diagnostic differences between restrained and non-restrained patients. Restraint occurred more often in young, unmarried, seriously ill men with a previous history of violent behavior and previous psychiatric treatment. These characteristics were coupled with inadequate nueroleptic treatment and a perception of inadequate power authority. There was a significantly higher frequency of a history of previous violence in restrained patients compared to non-restrained patients on the same unit12.
A large randomized trial was undertaken to assess factors associated with the use of physical restraints for agitated patientsin three psychiatric emergency rooms at Rio de Janeiro. Principal researcher fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints. Of 301 agitated, aggressive people admitted to emergency rooms, 73 (24%) were restrained during the first two hour of admission. In Rio, younger people (OR=1.03 for each year younger), exhibiting intense (OR=2.53) or extreme agitation (OR=7.71), thought to result from substance misuse (OR=1.75) or diagnoses other than psychosis (OR=1.88) and arriving in the morning (OR=1.64) were at greater risk of physical restraints than older, less severely aggressive or agitated people, arriving at the hospital during the afternoon or night. Hospital, gender, first admission to hospital and medication were not associated with risk of being restrained13.
A study was conducted to assess the psychiatric inpatients' perceptions of the seclusion-room experience. 52 voluntarily admitted adult patients in a State Hospital were interviewed within 3 days of the experience. An 88-item semi-structured interview schedule was used to obtain information on six research questions. Subjects' perceptions of the reasons for their seclusions varied greatly from perceptions of staff members. Findings implied that for some patients seclusion may have been unnecessary, but for others it was beneficial. Subjects who reported out-of-control impulses or pathological intensity of relationships prior to seclusion and who showed positive change in mood, behavior, or thinking toward staff and/or other patients during or after seclusion seem to have benefited from the experience14.
A study was conducted to assess the attitudes of patients and staff members toward seclusion. To make such a comparison, a questionnaire consisting of 24 items was given to adult psychiatric inpatients and staff members of a state mental hospital. The results showed that the two groups differed greatly in their attitudes over a wide range of topics; many staff members did not realize how much and in what ways seclusion affects patients. It was concluded that appropriate training of both groups is needed to make seclusion less traumatic and more efficient15.
A study was conducted to examine the experiences and attitudes of staff to restraint and seclusionin a Norwegian University Psychiatric Hospital at Norway.The data demonstrated that a majority of staff believed the interventions were used correctly. Staff at wards with high usage of restraint and seclusion, and male staff, was most critical to how often the interventions were used. Most staff favored the use of physical restraint, although they believed it was the intervention patients were least favorable to. Highly educated staffs were not more critical to the use of restraint and seclusion than other staff. Despite the fact that a majority of staff believed that using restraint and seclusion made patients calmer and did not cause aggression, anxiety or injuries, about 70% had been assaulted by patients in connection with the interventions. Many staff believed the use of restraint and seclusion violated patients' integrity, could harm the provider-patient alliance and could frighten other patients. Violence, self-harm and threats were given as main reasons for the use of restraint. Increased staffing and more attention by level-of-care staff were cited as the most important strategies for reducing the use of restraint and seclusion. There is a need for informing all staff about the negative effects of restraint and seclusion and for training staff in less restrictive ways in dealing with aggressive and violent patients16.
A study was conducted to assess staff opinions about seclusion and restraint at Atascadero State Hospital, California. AFourty-item questionnaire was distributed to 129 staff members who routinely used these techniques. Of the 109 respondents, 63 percent favored the use of medications over physical procedures, and 65 percent said that they would order seclusion over restraint if medications could not be used. Responses indicated that staff tended to choose to treat patients as they themselves would want to be treated. Staff with more education, including psychologists and social workers, believed that staff other than physicians should have the authority to write seclusion and restraint orders. Female staff believed that patients experienced seclusion or restraint as positive attention, while male staff believed that it was a negative experience. Staff with more education believed that restraints, seclusion, and medication were overused. The findings that gender and level of education affect staff's use of physical procedures with acutely psychotic patients have important implications for staff training17.
6.3 Statement of the Problem
“A DESCRIPTIVE STUDY TO ASSESS THE PSYCHIATRIC INPATIENTS’ PERCEPTION OF PHYSICAL RESTRAINTS IN A SELECTED PSYCHIATRIC HOSPITAL AT MANGALORE.”
6.4 Objectives of the Study
1. To assess the psychiatric inpatients’ perception of physical restraints.
2. To determine the association between psychiatric inpatients’ perception and selected baseline variables of psychiatric inpatients.
6.5 Operational Definitions
Psychiatric inpatients
Psychiatric inpatients’ arethose who admitted in the psychiatric hospital for treatment psychiatric disorders which is diagnosed by registered Psychiatrist as per ICD-10.
Perception
Perception is the awareness or understanding of the physical restraints by the psychiatric inpatients’ which will be measured by structured interview.
Physical restraints
Physical restraints refers to any harmless device like hand cuffs, ropes (gauze and cotton cloth belts), straps attached to a person's body that cannot be easily removed by the person and which deliberately prevent a person's free body movement thus preventing individuals from violent, assaultive and suicidalbehaviors.
6.6 Assumptions

The psychiatric inpatients’ are sometimes restrained in the hospitals, for their violent behavior (out- of- control impulses) and to prevent suicidal risk.
The psychiatric inpatients’ will be having varying perception about physical restraints.
Delimitations.

Only to the psychiatric inpatients’ who are admitted in the psychiatric hospital of Father Muller Medical College Hospital.
6.8 Hypotheses (projected outcome)
All hypotheses will be tested at0.05 level of significance
H1: There will be significant association between the selectedbaseline variablesof psychiatric inpatients’ and their perceptions about physical restraints.
Material and Methods
7.1. Source of data
Hospitalized psychiatric inpatients’whoare admitted in psychiatric hospital ofFather Muller Medical College Hospital for the treatment of mental illness.
7.1.1 Research Design
Descriptive
7.1.2Setting
Study will be conducted in the psychiatric wards of Father Muller Medical College Hospital Mangalore, is a multi specialty hospital with 1250 bed strength and psychiatric units has 193beds, and an annual admission of 2164 inpatients in this hospital. People with different psychiatric illness like mood disorders, substance abuse, schizophrenia, organic mental disorders, mental retardation with psychosis, phobias and obsessive disorders and sexual disorders and other psychiatric disorders are admitted in this hospital.
7.1.3 Population
The psychiatric inpatients’who are admitted in the psychiatric hospital of Father Muller Medical College Hospital Mangalore.
7.2 Methods of Data Collection
7.2.1 Sampling Procedure
Purposive sampling.
7.2.2 Sample Size
100
7.2.3Inclusion Criteria for Sampling

The patients’in the age group of 18 and above.
The patients’ who had undergone physical restraint present and recent admissions.
The patients’ who can speak English, Kannada, Malayalam, Tamil, Konkani and Hindi.
Exclusion Criteria for Sampling

The patients’ who score 23 or below in mini mental status examination.
The patients’ with formal thought and perceptual disorder as per mental status examination.
Instruments intended to be Used

Folstien Mini-mental status examination.
Structured interview schedule.

7.2.6. Data Collection Method
The investigator will obtain permission from concerned authority to conduct the study. Informed consent will be obtained from the subjectswho fulfill the sampling criteria they will be interviewed about the perception of physical restraints.
7.2.7 Data Analysis Plan
Descriptive statistics.
Collected data will be analyzed by descriptive statistics such as mean, standard deviation, frequencies and percentages.
Inferential statistics.

Chi-square testwill be used to find the association between the selected demographic variables.
Collected data will be presented by tables and diagrams.
Does the study require any investigations/interventions to be conducted on

Patients or the human or animals? If so please describe briefly.
Yes. Investigator will be conducting structured interview with psychiatric inpatients.
7.4Has ethical clearance been obtained from your institution in case of 7.3:
Yesethical clearancehas been obtained.
List of References.
1SaxenaS. World mental health atlas,Geneva:[serial online]2011 Oct 19[cited2011 nov 24].Available from:URL:

2Sraddha. Mental health in India. Shraddha Rehabilitation Foundation.2008.[Cited 2011 Nov 12].Availablefrom:URL:
3Khadivi AN, Patel RC, Atkinson AR, Levine JA. Association between Seclusion and Restraints and Patient-Related Violence. J Psychiatric Services 2004 Nov; 55:1311-2.
4Gastmans C, Milisen K. Use of physical restraint in nursing homes: clinical ethical considerations. J Med Ethics 2006March;32(3):148–52. [serial online]2005 may 03[cited 2011 nov 02].Available from:URL:
5Khastigir U, Kala A,Goswami U, Kumar S,Behera D. The nature and extent of use of physical restraint and seclusion in psychiatric practice: report of a survey.I J Psy 2003;45(111):155-7.
6Wai-Tong C, Carmen WHC, Lai-Wah L, Kam CW. Psychiatric inpatients’ perceptions of positive and negative aspects of physical restraint. [Serial online]2004 Nov 19. Available from:URL:
7Norris MK, Kennedy CW. The view from within: how patient perceive the seclusion process.J Psychosoc Nurs Ment Health Serv.1992Mar; 30(3):7-13. [serial online]:[cited 2011 Oct 09]. Available from: URL:
8Bower FL, McCullough CS, Timmons ME.A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update. J Knowl Synth Nurs. 2003 Apr 22;10:1.
9Sequeira H, Halstead S. “Is it meant to hurt, is it?” Management of violence in women with developmental disabilities. In L. Chenoweth, & S. Cook (Eds.), Violence against women with disabilities [Feature issue]. ViolenceAgainstWomen, 2001 April;7(4):462-476.
10Sequeira H, Halstead S. Control and restraint in the UK: service user perspectives. British Journal of Forensic Practice, 2002;(4)9–18. Citied on 14-11-2011. Available from:URL: .
11Fish R, Culshaw E. The last report?staffs and client pesrspectives on physical interventions.Journal of intellectual disability2005;(9)93-107.[Serial online]2005[cited 2011 Sept 05]. Available from:URL:
12Bornstein PE.The use of restraints on a general psychiatric unit. J Clin Psychiatry, May; 46(5):175-8.[serial online]:[cited 2011 Oct 4].Available from:URL:
PMID: 3988716.
13Marcelo NM, Evandro SC, Giselle H, Clive EA, Geraldo MC, Michael HA. Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms.[serial online]2008 April 20[cited 2011 Aug 16]. Available from: URL:

14Richardson BK. Psychiatric inpatients' perception of the seclusion-room experience.NursRes.1987Jul-Aug;36(4):234-8.[serial online]:[cited2011 Sept 09]. Available from:URL:

15Soliday SM. A comparison of patient and staff attitudes toward seclusion.J Nerv Ment Dis1985May;173(5):282-91.[serial online]:[Cited2011 Aug 08] available from:URL:

16Wynn R. Staff's attitudes to the use of restraint and seclusion in a Norwegian university psychiatric hospital.Nord J Psychiatry.2003; 57(6):453-9.
17Kline V. Staff opinions about seclusion and restraint at a state forensic hospital. Hosp Community Psychiatry. 1994 Feb; 45(2):138-41.[serial online]:[cited 2011 Aug 26]. Available from: URL:

9 / Signature of the candidate
10 / Remarks of the guide / Studying the patient’s perceptions on the restraints will be helpful for evaluating the present policies and for providing better care to the patients
11 / Name & Designation of
(in block letters)
11.1 Guide / MRS. AGNES E.J M.SC. (N), PROFESSOR
PSYCHIATRIC NURSING
FATHER MULLER COLLEGE OF NURSING
MANGALORE
11.2 Signature
11.3 Co-guide (if any)
11.4 Signature
12 / 12.1 Head of the Department / MRS. CHANU BHATACHARYA M.SC. (N)
HEAD OF THE DEPARTMENT
PSYCHIATRIC NURSING
FATHER MULLER COLLEGE OF NURSING
MANGALORE
12.2 Signature
13 / 13.1 Remarks of the Chairman and Principal
13.2 Signature