Analysis of Restrictive and Coercive Measures in Mental Health Care

This report examines the use of restrictive and coercive measures in mental health care, focusing on their impacts on both patients and nurses. It explores the controversies surrounding these measures, including ethical concerns related to patient rights and the side effects of psychotropic medications. The report highlights the benefits, such as a safer working environment for nurses and patient comfort, while also acknowledging the negative consequences, such as damaged therapeutic relationships. It advocates for the adoption of recovery-oriented mental health services as a potential alternative to mitigate the negative effects of coercive measures. The report discusses the challenges faced by nurses in implementing recovery-oriented care, including violence, understaffing, and ethical dilemmas. Ultimately, the report emphasizes the need for a balanced approach that prioritizes patient well-being, ethical considerations, and the development of more humane and effective mental health care practices.

Running Head: Mental Health 1
Restrictive and Coercive Measures in Mental Health Care.
Name
Course
Institution
Date

Mental Health 2
Introduction
Adoption of appropriate measures to manage mentally ill patients by countries is
essential to reduce the burden of the illnesses. A national health mental report showed that
psychiatric disorders might vary from eating disorders which are a mild condition to severe
diseases such as Psychotic disorders such as Schizophrenia (DoHA, 2013). The Mental
Health Services in Australia (MHSA) (2020), has estimated that almost half of the
Australians aged above 16 years may experience at least one mental disorder in their lifetime.
On a global scale, the burden of mental illnesses is on a rising trend (Vos et al., 2017).
Mental disorders are characterized distortion of fundamental thinking, distorted perceptions
and emotional responses (Morgan et al., 2011). Effects of these disorders may make the
patients aggressive and violent, which may hinder the administration of health care.
Therefore, health staff may opt to use coercive or restrictive measures to manage the patients.
These measures have impacts to both the patients and the nurses as discussed in in this paper.
One way through which the staff apply coercive measures is by inducing sleep in the
patients through the use of sedatives (Latha, 2010). The use of restrictive measures gives the
nurses an easy time while applying the treatment procedure. This is because the patients
might present with aggressive and violent behaviour such as kicking and punching that may
cause injury to the parties involved (Parker, 2015). Safe delivery of medication is one
positive impact of coercive measures. According to Roberts, (2019), psychotropics act on the
Central Nervous System (CNS) which helps reduce anxiety and violence behaviour.
Negative impacts of coercive measures may arise from the use of the psychotropics
such as sedatives. According to Ferreira (2017), long term usage of such medications has side
effects, including sexual dysfunction and extrapyramidal effects. Other impacts include
damaging therapeutic relationship and breach of ethical principles (Stephenson et al., 2013).
The use of more appropriate procedures such as the recovery-oriented mental health services

Mental Health 3
as outlined by the Australian Health Ministers' Advisory Council (AHMAC) (2013), may be
key to overcoming the negative impacts and controversies surrounding restrictive measures.
Recovery-Oriented Mental Health Service Delivery
In mental health care, recovery is a unique process and personal experience defined
by each mentally-ill patient (Davidson et al., 2008). Recovery-oriented mental health care is
essential in replacing overcoming the negative impacts of coercive measures in mental health
care. According to the Victoria Department of Health (2011), the framework for this
approach encompasses a number of domains that guide mental health specialists. The
approach offers self-determination and autonomy, focuses on the strengths of the patient,
promotes a culture of hope, and holistic, personalized care, among others. Recovery-oriented
mental care leads nurses to make treatment decisions based on a patient's needs, values,
circumstances and resources. The collaborative relationships offered by this approach fosters
the understanding of the client's concerns, goals, needs and preferences, thus challenging
stigma in mental services and the larger community. Recovery-oriented mental health care
also fosters therapeutic relationships between the patient and staff because it reduces the
demarcation that would have otherwise resulted from restrictive measures (AHMAC, 2013).
Waldemar and her colleagues (2016) have shown the need to do more research on recovery-
oriented practice not only in Australia but also in other countries such as the United
Kingdom, Canada, U.S.A and Ireland. The approach is essential in stabilizing patients and
relieving symptoms.
Controversy Surrounding Coercive Measures in Mental Care
There have been calls to eliminate restrictive measures around the globe. Involuntary
hospitalization, according to Hotzy and colleagues (2018), has serious implications to
Switzerland and United States citizens’ liberty as outlined in their laws. As in the
international arena, the controversies regarding coercive measures have also emerged in

Mental Health 4
Australia with claims that the measures breach the ethical principles guiding health care. The
rights of patients are governed by the principles such as autonomy which the measures
breaches. Patients are supposed to have a say in the type of treatment they desire. The effects
of psychotropics used are also a source of controversy in mental health care. The use of
sedatives has side effects that can be life-threatening. The side effects include acute dystonia,
sexual dysfunction and myocarditis agranulocytosis (Stroup & Gray, 2018). Luty (2017),
outlines controversial treatments that are widely used in mental health care. Therefore,
overcoming the negative impacts of restrictive measures through recovery-oriented mental
service delivery may be crucial in addressing the controversies.
Impacts of Coercive measures
Restrictive measures are used in mental health care to overcome the non-adherence
that may be shown by some mentally ill patients (Latha, 2019). Coercive measures especially
used include seclusion, restraining patients to beds; and medication that may be administered
forcefully or without the knowledge of the patient. Several national and international studies
have shown the negative and positive impacts of these measures. According to Fiorillo et al.,
(2011), the measures should be sought to as the last option due to their negative effects. The
Department of Health and Ageing in Victoria, Australia, has outlined some of the negative
consequences of coercive measures (DoHA, 2013). Amidst the negative impacts, nurses have
shown their positive attitude toward the use of these measures.
Creation of a safe working environment while attending to psychiatric patients is a
positive impact of restrictive and coercive means. The use of restrictive measures ensures the
safety and comfort of the patients themselves. Nurses in Australia and other countries have
reported that restrictive measures give them an easy time to administer their services. Some
patients might present with violent behaviour that may include abuses which can demoralize
the nurses. Every time coercive measures are used, the nurses are able to protect their own

Mental Health 5
safety and that of other patients. For instance, nurses in Queensland, Australia, adopted
continuous door locking in mental health hospitals to maintain safety (Grotto et al., 2015).
Patient comfort is also achieved through coercive measures. Sedatives help the patients to
relax by minimizing their anxiety (Malamed, 2017). Restraining patients to, for example,
beds reduces their mobility and thus, the damage that may arise from their aggressive
behaviour. Nurses turnover is also reduced when restrictive measures are applied. The reason
being that nurses experience less violence and abuses that raises their working morale (Niu et
al., 2019). The advantages of restrictive measures, most of the time, shrouded with the
negative impacts because most activists are concerned with the rights of the patients than
staff.
Restrictive measures damage the therapeutic relationships that exist between
psychiatric nurses and patients. According to Luciano and others (2014), therapeutic
relationships between the nurses and patients in Italy were damaged when coercive measures
were used in the course of treatment. In Australia, absconding rates among mental patients
rose due to poor therapeutic relationships that existed with the staff (Mulder, 2011). The use
of restraint to limit the movements of the patients have deleterious physiological and physical
consequences (Chieze et al., 2019). These consequences then destroy the relationships
between nurses and patients. Therapeutic relationships are essential to effective and
meaningful treatment. Therapeutic relationships as a vital component of mental health
treatment, centres around empathy, listening and spending time having direct interactions
with the client (McAndrew et al., 2014). Therefore, restrictive measures damage the pillars of
recovery-oriented mental health care that are promoted by therapeutic relationships.
Coercion conflicts the vital moral values of modern health care provision and
specifically the right to liberty. The use of restrictive measures has been implicated as
unethical. In a study carried by Zheng and colleagues (2020), showed that seclusion in mental

Mental Health 6
health in China caused a myriad of negative effects on nurses and patients due to ethical
dilemmas involved. Coercive measures have a negative impact on Australia’s mental
patients’ and nurses’ ethical values (Hem et al., 2018). Various ethical challenges are related
to coercive measures. The challenges include, hinders the promotion of a patient's well-being,
undermines patient's autonomy, and causes moral distress among the psychiatric health
workers (Hem et al., 2018). Treatment procedures must adhere to the ethical principles of
autonomy, beneficence, justice and non-maleficence. Improving the therapeutic environment
in psychiatry health care is imperative to coping with ethical dilemmas associated with
restrictive measures.
The use of psychotropic medications such as sedatives to restrict patients is referred to
as chemical restraint. It is also called pharmaceutical restraint or rapid tranquilization.
According to the European Journal of Psychiatry, chemical restraint of psychiatric patients is
not a standard treatment for the patient's condition (Negroni, 2017). Chemical restraint does
not follow doses according to disorder diagnosis. Therefore, a wrong dose can be
administered unintentionally thus causing dangerous side effects. Tranquillizers can
intoxicate a patient, lead to breathing problems and, may cause death. When administered
without the knowledge of the patient, for instance, mixing sedatives with drinks, chemical
restraint violates the basic rights of autonomy. Recovery-oriented Mental Health Care
involves upholding patients’ values. Therefore, involuntary impacts the approach negatively.
Challenges faced by Nurses in Recovery-Oriented Mental Health Care
Psychiatric nurses face a number of challenges that may hinder effective delivery of
recovery-oriented care. While administering psychotropic medication, nurses re usually
exposed to high levels of violence and aggression. A study to determine the challenges
experienced by psychiatric nurses in South Africa showed that 88%of responding nurses
reported exposure to the aggressive behaviour of their patients (Joubert and Bhagwan, 2018).

Mental Health 7
Psychiatric nurses in Australia have also reported violent episodes from the patient (Crowther
and Ragusa, 2011). According to the NHS Business Services Authority (2015), in England,
68,683 NHS staff reported cases of assault from mental patients. Nurses and other health
workers are always exposed to verbal and physical violence from their patients. Such
behaviour hinders the quality of service that they can give and therefore, hinder recovery-
oriented mental care (Badnapurkar et al., 2017).
Nurses face challenges while administering psychotropics because of underdeveloped
mental healthcare systems. According to Sabella (2013), the systems means include
insufficient resources to cater for large number of psychiatry patients. Under staffing causes a
lot of pressure to the available nurses. Understaffing may lead to mental health services being
offered by non-mental professionals thus reducing the quality of services. This means that the
available nurses are overwork in order to satisfy the needs of the patients. Under such
circumstances, registered may not offer quality care as expected. To achieve efficient
recovery-oriented mental health care necessary resources such as adequate staffing should be
in place.
While administering psychotropics nurses are always faced with ethical dilemmas.
Psychiatric patients are sometimes non-adherent and nurses may be forced to used chemical
restrain to manage the clients. Such a practice interferes with their moral obligation (Hem et
al., 2018). Having to deal with such instances and constant aggression from patients, may
distress. The nurses will therefore experience depression and thus, psychological and
psychosocial issues as shown by a study carried out on Iranian Psychiatry nurses (Zarea et al.,
2018). Registered nurses in psychiatry practice also face discrimination from the wider
community due to their nature of work. Such instances affect them psychologically and may
hinder quality service and extent to which they can apply recovery-oriented health care.

Mental Health 8
Conclusion
Coercion always conflicts the moral obligation of people. Different coercive measures
such as chemical restraining using psychotropics has long term side effects on psychiatry
patients. Restrictive measures have been used for a long period in most countries despite calls
for their elimination. The reluctancy to abolishing such measures despite their impacts can be
attributed to lack of a better means to control and manage the patients. Recovery-Oriented
mental health care can play a significant role to replace coercive measures. Therefore,
Recovery-Oriented Mental Service Delivery should be highly encouraged.

Mental Health 9
References.
Australian Health Ministers’ Advisory Council. AHMAC. (2013). A national framework for
recovery-orientated mental health services: a guide for practitioners and providers. A
national framework for recovery-oriented mental health services: guide for
practitioners and providers.
Badnapurkar, A., Nelson, D., Gray, R., Thomas, D., & Hassanein, E. (2017, October). Is the
physical health of consumers with mental illness important for nurses practicing in a
developing country?. In INTERNATIONAL JOURNAL OF MENTAL HEALTH
NURSING (Vol. 26, pp. 3-3). 111 RIVER ST, HOBOKEN 07030-5774, NJ USA:
WILEY.
Chieze, M., Hurst, S., Sentissi, O., & Kaiser, S. (2019). Effects of Seclusion and Restraint in
Adult Psychiatry: A Systematic Review. Frontiers in psychiatry, 10, 491.
Davidson, L., Rowe, M., Tondora, J., O'Connell, M. J., & Lawless, M. S. (2008). A practical
guide to recovery-oriented practice: Tools for transforming mental health care.
Oxford University Press.
Department of Health and Ageing, (DoHA). (2013). National Mental Health Report 2013:
tracking progress of mental health reform in Australia 1993 – 2011. Canberra:
Commonwealth of Australia.

Mental Health 10
Ferreira, A. C. Z., Brusamarello, T., Capistrano, F. C., Marin, M. J. S., & Maftum, M. A.
(2017). The experience of mental disorder patients using psychotropic medication
under the perspective of complex thinking. Texto Contexto Enferm, 26(3), e1000016.
Fiorillo, A., De Rosa, C., Del Vecchio, V., Jurjanz, L., Schnall, K., Onchev, G., ... &
Georgiadou, E. (2011). How to improve clinical practice on involuntary hospital
admissions of psychiatric patients: suggestions from the EUNOMIA study. European
Psychiatry, 26(4), 201-207.
Grotto, J., Gerace, A., O’Kane, D., Simpson, A., Oster, C., & Muir-Cochrane, E. (2014). Risk
assessment and absconding: Perceptions, understand-ings, and responses of mental
health nurses. Journal of Clinical Nursing, 24, 855–865
Hem, M. H., Gjerberg, E., Husum, T. L., & Pedersen, R. (2018). Ethical challenges when
using coercion in mental healthcare: a systematic literature review. Nursing Ethics,
25(1), 92-110.
Hotzy, F., Kerner, J., Maatz, A., Jaeger, M., & Schneeberger, A. R. (2018). Cross-cultural
notions of risk and liberty: a comparison of Involuntary Psychiatric Hospitalization
and Outpatient Treatment in New York, United States and Zurich, Switzerland.
Frontiers in psychiatry, 9, 267.
John Crowther, A., & Theresa Ragusa, A. (2011). Realities of mental health nursing practice
in rural Australia. Issues in mental health nursing, 32(8), 512-518.
Joubert, P. D., & Bhagwan, R. (2018). An empirical study of the challenging roles of
psychiatric nurses at in-patient psychiatric facilities and its implications for nursing
education. International journal of Africa nursing sciences, 9, 49-56.
Latha, K. S. (2019). The noncompliant patient in psychiatry: The case for and against
covert/surreptitious medication. Mens sana monographs, 8(1), 96.

Mental Health 11
Luciano, M., Sampogna, G., Del Vecchio, V., Pingani, L., Palumbo, C., De Rosa, C., ... &
Fiorillo, A. (2014). Use of coercive measures in mental health practice and its impact
on outcome: a critical review. Expert review of neurotherapeutics, 14(2), 131-141.
Luty, J. (2017). Controversial treatments in psychiatry. BJPsych Advances, 23(3), 169-178.
Malamed, S. F. (2017). Sedation-E-Book: A Guide to Patient Management. Elsevier Health
Sciences.
Mental Health Services in Australia (MHSA). (2020). Retrieved from:
https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-
australia/report-contents/summary/prevalence-and-policies
Morgan VA, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V, et al. (2011).
People living with psychotic illness 2010. Canberra:Australian Government
Department of Health and Ageing.
Mulder, R. (2011). Problems with suicide risk assessment. Australian and New Zealand
Journal of Psychiatry, 45, 605–607.
N. H. S. Protect, (2013). Meeting needs and reducing distress. Guidance on the Prevention
and Management of Clinically Related Challenging Behaviour in NHS Settings.
tinyurl. com/ptces8t (Last accessed: September 2 2015.).
Negroni, A. A. (2017). On the concept of restraint in psychiatry. The European Journal of
Psychiatry, 31(3), 99-104.
NHS Business Services Authority (NHSBSA). (2015). Number of reported physical assaults
on NHS staff in2013/14. London.
Niu, S. F., Kuo, S. F., Tsai, H. T., Kao, C. C., Traynor, V., & Chou, K. R. (2019). Prevalence
of workplace violent episodes experienced by nurses in acute psychiatric settings.
PloS one, 14(1).

Mental Health 12
Parker, C. (2015). Tranquilisation of Patients with Aggressive or Challenging Behaviour.
Pharm J, 294(7868), 9.
Roberts, M. (2019). Psychiatric drugs: reconsidering their mode of action and the
implications for service user involvement. Mental Health Review Journal.
Sabella, D. (2013). Whereʼs the ‘Health’ in mental health? AJN, American Journal of
Nursing, 113(4), 62-65.
Stephenson, C. P., Karanges, E., & McGregor, I. S. (2013). Trends in the utilization of
psychotropic medications in Australia from 2000 to 2011. Australian & New Zealand
Journal of Psychiatry, 47(1), 74-87.
Stroup, T. S., & Gray, N. (2018). Management of common adverse effects of antipsychotic
medications. World Psychiatry, 17(3), 341-356.
Vos, T., Abajobir, A. A., Abate, K. H., Abbafati, C., Abbas, K. M., Abd-Allah, F., ... &
Aboyans, V. (2017). Global, regional, and national incidence, prevalence, and years
lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a
systematic analysis for the Global Burden of Disease Study 2016. The Lancet,
390(10100), 1211-1259.
Waldemar, A. K., Arnfred, S. M., Petersen, L., & Korsbek, L. (2016). Recovery-oriented
practice in mental health inpatient settings: A literature review. Psychiatric Services,
67(6), 596-602.
Zarea, K., Fereidooni-Moghadam, M., Baraz, S., & Tahery, N. (2018). Challenges
encountered by nurses working in acute psychiatric wards: A qualitative study in Iran.
Issues in mental health nursing, 39(3), 244-250.

Mental Health 13