Case Study Whilst on placement in a Psychiatric Intensive

Case Study

Whilst on placement in a Psychiatric Intensive Care Unit. I met Paul who was aged 35. Paul had a known diagnosis of Paranoid Schizophrenia and showed symptoms of auditory hallucinations, and paranoid delusions. For Paul, this must have been a terrifying situation as he had not been admitted to a ward for some time. Unfortunately, Paul had become unwell leading him to believe that he was under threat from people around him, therefore he would uncontrollably lash out at people if they were to approach him in a way in which he would find threatening. On one particular occasion, a member of staff had activated their alarm after entering into Paul’s bedroom. Paul had attacked the member of staff resulting in injury. It was at this point that four other members of staff entered Paul’s bedroom to restrain his arms and legs, as he was continuously kicking and punching out. The restraint continue for approximately 20 minutes with no signs of de-escalation, therefore the team felt they had no other option but to place Paul into seclusion. All patient details have been changed due to the importance of confidentiality.  

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Paul valued his independence, self-determination, and autonomy greatly. Paul later stated that prior to the incident he felt ignored and isolated. Paul believed that he generally was not a violent person and valued the fact that he is respectful and appreciative of others, this left Paul feeling ashamed after the incident.

The team felt it was necessary to restrain Paul and temporarily place him in seclusion. Amidst the team there was different values and beliefs, some felt empathetic towards Paul in the fact that he must have been so upset and frustrated at the time of the incident. Whereas others believed seclusion was the best option for Paul to be able to calm down before returning to the ward. Overall the team felt that securing the ward environment was essential in regards to keeping staff and other patient’s safe, as well as protecting Paul from further distress.  

I was brought up in an environment with zero tolerance to violence, and that there is always an alternative. Seeing both Paul being violent towards staff and then him having to be restrained outbalanced my values leaving me feeling distressed and confused, due to this I needed to reflect on the situation to gain an understanding of what had happened.


The Department of Health DOH (2015a) refer to physical restraint as any direct physical contact with the intension to subdue, prevent, or restrict movement of the body of another person. According to Ryan (2010), the origin of conventional manual restraint techniques may have begun in Canada around 1974. The restraint training programme consisted of self-defence techniques, the use of pressure points and certain restraint techniques (Ryan, 2010). The National Institute for Health Care and Excellence NICE (2015) state that violence and aggression are relatively common and serious occurrences in health and social settings.  Between 2013 and 2014 there were 68,683 assaults reported against NHS staff in England (NICE, 2015). Ryan (2010) suggests that control and restraint are referred to by a variety of different terminologies each perhaps motivated for political correctness rather than evidence-based development. According to Kelley (2015), the nurse has to come to the decision that although possible physical and psychological trauma may occur, restraining or secluding a patient is in the best interest and safety of the patient as well as staff and other patients on the unit. Nurses working in the mental health sector are expected to practice ethically and respectfully and should comply with the Mental Health Act principles, and follow the codes of practice set out (Williamson & Daw, 2013).


Diversity, culture and gender influences

Soininen, Kontio, Joffe, and Putkonen (2016) held a study on patients with schizophrenia within a psychiatric setting, they found that women were more likely to show signs of aggression but with less intensity than that of male equivalents, whilst aggression from males is more severe. Men were more likely to be restrained or secluded, while women were more likely to receive forced medication (Soininen et al., 2016). Knox and Holloman (2012) state that during a patient’s entry into a psychiatric setting they may be at their lowest point of functioning and their sense of reality is grossly impaired, this, therefore, could leave the patient feeling vulnerable and scared within their surroundings.

Values and Values-Based Practice

The Nursing and Midwifery Council NMC (2015) set up “The Code” in which contains professional standards that registered nurses must uphold. The standards within “The Code” are the values and principles that patients and members of the public expect from healthcare professionals (NMC, 2015).

The Department of Health DOH (2015b) state that there are seven key principles that guide the National Health Service NHS in all that it does. The principles are underpinned by core NHS values which were resulting from extensive discussions with patients, the public, and with staff (DOH, 2015b).  Within the DOH (2015b) policy it outlines the NHS 6C’s which are Care, Compassion, Communication, Commitment, Courage, and Competence.

Duncan (2010) claims that all who work within a healthcare setting should possess a fundamental concern with issues of values and ethics. Fulford (2008) states that values embrace much more than just ethics, but also include other values such as preference, expectations, hopes, morals, beliefs, concerns, and needs. Furthermore, it is argued that each patient may have unique and individual values in which they may bring to a clinical encounter, which then must be integrated into a clinical decision if the patient is to be served within their best interests (Fulford, 2008).

Values-Based Practice VBP is a framework developed originally in the domain of mental health and is an approach to support clinical decision making where complex and often conflicting values arise (Adshead, 2009; Petrova, Dale, & Fulford, 2006). Adshead (2009) believes that there is a strong public desire that healthcare professionals should commit themselves to particular principles and values as part of the therapeutic relationship with patients. Furthermore, VBP focuses on individual’s values, this makes it especially important for person-centred care (Morgan, Felton, Fulford, Kalathil, & Stacey, 2015).  

Alternative View

Baillie and Black (2014) state that as nurses, we need to form relationships with patients to develop an understanding of the individual’s world. According to Baillie and Black (2014), some nurses are often unable to share their decision-making powers, generating a power imbalance with the consequence of little patient input. If nurses and patients are to work in partnership, nurses must make additional effort to equalise the power imbalance (Baillie & Black, 2014).

The Safeward model allows for the generation of a number of different interventions in order to reduce the rates of conflict and containment (Bowers, 2014). Bowers (2014) explains the term of conflict being aggression and self-harm and defines the term of containment as seclusion and manual restraint. The Safeward model specifies that there are several conflict-originating factors that may cause certain social and psychological situations, which in turn indicate and proceed to imminent behaviours, in which Bowers (2014) terms as flashpoints. Conflict-originating factors include different domains, such as staff team, physical environment, outside hospital, patient community, patient’s characteristics and regulatory framework. Bowers (2014) states the Safeward model creates a distinction between the originating domains and flashpoints and allows for clearer thinking about what can and cannot be changed by clinical staff working on the ward, therefore, facilitating a generation of ideas that have the potential to reduce conflict and containment. Richmond et al. (2012) report that there are a number of alternative strategies to restraint which includes de-escalation, distraction, reassurance, or sitting with a family member or staff. Furthermore, Robertson, Daffern, Thomas and Martin (2012) state that when dealing with an agitated or violent patient their behaviours occur as progressive and not as sudden or isolated incidents, by understanding this nurses are in a better position to assess the situation and break the progressive cycle before it gets to the point of restraint or seclusion.


Throughout designing this poster my personal values and beliefs were contended. I still feel that the decision to use restraint should not be taken lightly, as there is minimal evidence to suggest many positive effects of physical restraint. Since physical restraint is known as a challenging intervention, training nurses to find an alternative method would be suggested. Reviewing the Safeward model has enlightened me in thinking there are other options for reducing physical restraint on patients. However, I also understand that without restraint and seclusion there could be possible chaos within wards, people could potentially get hurt, and nurses possibly wanting to leave their profession. Respect and communication with patients is essential.