A Hermeneutic Phenomenological Exploration of ‘Last Resort’ in the Use of Restraint

Abstract

Restraining patients (i.e. physically confining their movement or using devices to restrict their movement) is a practice that dates back at least three centuries. In more recent years, there has been a mandate and advocacy in countries such as Canada, USA and UK, for organisations to shift towards the minimisation of restraint, whereby its use is only as a ‘last resort’ when all other alternative interventions have been exhausted. There is growing evidence internationally indicating the negative impact of the use of restraint. However, to date there is no research describing the concept of ‘last resort’. Further insights to explore how this concept is enacted within practice amongst mental health nurses are therefore warranted.

I undertook an integrative review to synthesise existing knowledge of mental health nurses decision-making into the use of restraint. The empirical research comprised a hermeneutic phenomenological study. By recruiting and interviewing mental health nurses 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’. A total of thirteen mental health nurses were recruited from various provinces in Canada. Data was collected through fifteen in-depth interviews. Data analysis was undertaken through a hermeneutic phenomenological framework based on van Manen’s approach and Heideggerian hermeneutics. 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 fear. Key highlights emerging from these concepts are that nurses past experiences influence when they use restraint as a ‘last resort’. Moreover, nurses demonstrated a collective view in relation to their lived experience, the patients and the care provided. Lastly, there appears to be a dependency on the knowledge and skills of others that impact nurses determining restraint to be used as a ‘last resort’.

Theorisation of the findings from within the broader literature also revealed a number of concepts that further offer an understanding of ‘last resort’. The concepts are dehumanisation, collective identity, groupthink, fear-based approach, and trauma. With this initial insight into ‘last resort’, a number of practice recommendations, such as debriefing, recovery-oriented care, de-escalation techniques and mitigation of groupthink, have been discussed in support of restraint minimisation.

In conclusion, the lived experience of ‘last resort’ is comprised of many elements. This study provides insights and an initial understanding, which is hoped to pave the way in the advancement of our knowledge in the field of restraint minimisation.