Jen HillPlease note, the following contains descriptions of physical restraint in a healthcare setting. Patient identifiable information has been removed or changed.
Beneath the droning light of the clinic room, I laid out my equipment in a tray: nasogastric tube, pH testing strips, lubricant. I was prepping for one of my patient’s twice-daily NG feeds. Naomi, aged seventeen, had a diagnosis of Anorexia Nervosa, and would restrict her caloric intake so drastically that to not deliver nutrition via a tube would swiftly lead to her becoming incredibly unwell, or worse. Naomi was a Looked After Child, with a history of being groomed and sexually exploited by adult men. Her experiences resulted in psychological trauma manifesting through a kaleidoscope of harmful coping strategies beyond that of an eating disorder, including self-harm and suicidal behaviour.
Naomi did not consent to nasogastric feeding. Sectioned under The Mental Health Act (MHA), we could lawfully administer this treatment against her will. To safely deliver nutrition, staff would have to use service-approved, hands-on restraint techniques to keep control of her long enough for me to insert the tube and deliver the feed. Without secure holds, if Naomi fought us, we risked life-preserving nutrition failing to be delivered, Naomi or staff becoming injured during her resistance or God forbid, the tube becoming displaced and potentially delivering medical feed into her lungs.
In the context of her trauma, to say that such an intervention was extremely distressing for Naomi is an understatement. For mental health nurses on wards that perform NG feeding under the MHA, delivering treatment under conditions of restraint can be tragically common. It is often an extraordinarily unpleasant procedure for any young person. But in the case of patients like Naomi, when the bare mechanics of such procedures can risk mirroring traumatic experiences – firm physical touch by staff of both genders, a physically invasive act against her will – the potential for retraumatization is evident.
And so the question must be asked: in such a scenario when informed consent cannot be gained despite thorough engagement with the young person and you, the clinician, are lawfully sanctioned to deliver treatment, how does one coordinate and deliver a feed in a manner that is trauma-informed at its core?
Clinicians should abide by the principles of least restrictive practice. This intervention is a last resort, not an option chosen for the sake of expedience or routine. Have staff truly exhausted all efforts to engage the young person beforehand? Have they taken the time to patiently explain and seek consent, or better, support the young person to attempt to eat, even when such efforts may have failed the day prior? If the child must be fed under holds, have staff taken steps to preserve their dignity, to clear the area of unnecessary eyes? Do staff take the time to offer emotional support after the event, to acknowledge the potential trauma, to act therapeutically? In the context of the procedure’s potentially traumatic nature, staff have a duty to communicate with the young person before, during and after such procedures, to help them to understand why it is medically necessary and to provide support for any distress that results from treatment.
I delivered those feeds confident in my knowledge that as Naomi’s nurse, I was duty-bound both morally and ethically to treat her. Anorexia Nervosa carries the highest mortality rate of any psychiatric disorder amongst adolescents. But as a clinician, the dilemma posed by the risk of retraumatization by my actions, right though they were, is one that clings to me, just as it did as I uncurled that tube below the droning light of the clinic room then. The question of how to perform such an intervention in a trauma-informed manner is not one that I claim to have the answer to. The question is one put to all of us. As clinicians, we must strive towards putting trauma-informed care at the heart of our interactions with survivors, and in the wake of a healthcare system still getting to grips with that principle, we have a responsibility to examine our existing practices with an unflinching stare.