Seclusion & Restraint Workgroup Report
Danielle Bertram, Kristen Kichefski, Samantha Paradis, Charmaine Platon
Advisors: Diane Allen, David Sharp
In 2007, the APNA posted a Position Statement on the Use of Seclusion and Restraint, declaring that “APNA supports a sustained commitment to the reduction and ultimate elimination of seclusion and restraint and advocates for continued research to support evidence-based practice for the prevention and management of behavioral emergencies.”
The position paper described ethical dilemmas inherent in the use of seclusion and restraint, and reviewed research that suggested ways to reduce the use of restrictive interventions and prevent violence. Fundamental principles to guide future action on the issue of seclusion and restraint were articulated. Since 2007, nurses have been working toward eliminating the use of seclusion and restraint, while becoming more focused on recovery and more informed about the effects of trauma. While some have been able to drastically reduce and even eliminate the use of seclusion and restraint, others have, as yet, been unable to achieve this goal.
Concerns about the continued use of seclusion and restraint are well justified. Current literature continues to describe the physical and emotional damage that seclusion and restraint use can inflict upon patients, as well as nurses (Kontio et.al, 2010; Pollard & Rogers, 2007). Seclusion and restraint use is an emotionally stressful process that may hinder the therapeutic nurse-patient relationship and increase patient aggression in the unit (Ashcraft & Anthony, 2008; Moran, Cocoman, Scott, Matthews, Staniuliene, & Valimake, et.al, 2009). Nurses and stakeholders are beginning to understand the need for trauma-informed care. The experience of these events has the potential for negative long-term effects that can impede the recovery process (Ryan & Happell, 2009).
Ethically, it is a nurse's responsibility to maintain patient autonomy and dignity (Kontio et al., 2010); however, seclusion and restraint determines the extent of "patient autonomy", thereby diminishing patient integrity. Nurses must balance the responsibility for safeguarding patient rights with the duty to protect patients from harming themselves or others in situations that have escalated to the point of danger (Barton, Johnson, & Price, 2009).
Joint Commission standards (2009) have helped to reinforce the principle that "people have the right to be free from restraint or seclusion as a means of coercion, discipline, convenience, or retaliation." Nurses have been taught that seclusion and restraint are interventions that may be used only as a last resort, after all other intervention attempts have been made (Moran et. al, 2009).
Attitudes, emotions, demographics and experience of the nursing population have been found to influence the use of seclusion and restraint. Nurses who score high in therapeutic optimism and lower in emotional exhaustion are less likely to use seclusion. More experienced nurses are less likely to justify the use of seclusion in care (Happell, & Koehn, 2011). The expression of anger and aggression among team members is a predictor of increased use of seclusion and restraint (De Benedictis et al. 2011). Female nurses are more likely to report feelings of anxiety, frustration, and low morale related to the use of restraint (Happell, & Harrow, 2010).
Currently, research shows that inpatient psychiatric units are implementing educational programs in an effort to reduce seclusion and restraint use (Johnson, 2011). Two types of programs are identifiable: traditional educational programs and multi-faceted programs (Johnson, 2011; Scanlan, 2010). Traditional educational programs primarily train staff about de-escalation techniques (Scanlan, 2010, E-Morris, 2010). Multi-faceted programs, on the other hand, not only educate staff, but also incorporate environmental, managerial, and regulatory unit changes, such as: leadership involvement, organizational and cultural change, policy change, debriefing, consumer/family involvement, and trauma-informed care (Johnson, 2010; Scanlan, 2010; E-Morris, 2010; Borckardt et al., 2011; Pollard, 2007; Gaskin et al, 2009). Study findings cited in systematic reviews are difficult to generalize to other inpatient psychiatric settings, due to the lack of comparison groups, lack of replication studies, small sample sizes, and individualization of organizational programs (Pollard, 2007; Johnson, 2010; Scanlan, 2010). As such, a randomized controlled trial may be nearly impossible to implement among the vast variety of differentiating factors present in inpatient psychiatric settings (Gaskin et al., 2007; Scanlan, 2010). However, utilization of a multi-faceted approach, in addition to staff training, has been generally effective in reducing seclusion and restraint use (Bowers, 2010; Scanlan, 2010; Borckardt, 2011; E-Morris, 2010).).
Stakeholder Needs and Wants
Literature regarding seclusion and restraint reduction describes the needs of nurses to feel that the last resort use of seclusion and restraints remains an option in unsafe situations that are unable to be resolved by other methods (Barton, Johnson, & Price, 2009). Safety is usually cited as the primary reason for the use of seclusion and restraint. Violence towards self, others and staff, damage to property, and ‘out of control’ behavior are main factors nurses consider in the decision to seclude a patient (Happell, & Harrow, 2010). Hospital leaders need and want compassionate nurses who promote individualized care to recognize cues and help individuals de-escalate before an event occurs (Recupero, Price, Garvey, Daly, & Xavier, 2011). Nurses and stakeholders need adequate staffing to allow time for nurses to focus on the use of non-restrictive interventions to calm patients, prior to an event requiring restraint and seclusion (Recupero, Price, Garvey, Daly, & Xavier, 2011). Consumers of mental health care need and want compassionate care that allows them to be a part of the debriefing process and to reflect on seclusion and restraint events to assist in their recovery process (Ryan & Happell, 2009).
Upon evaluation of the current literature, we present the following recommendations to the APNA Board of Directors toward the use of seclusion and restraint in inpatient psychiatric settings:
Formation of alliances with the following organizations, which have been instrumental in the advocacy of a reduction or elimination of seclusion and restraint use:
American Nurses Association (ANA)
American Psychiatric Association (APA)
Disability Rights Advocates
Consumers (including consumer consultants in the unit)/families
Mental Health America
National Alliance on Mental Illness (NAMI)
National Association of State Mental Health Program Directors (NASMHPD)
Substance Abuse and Mental Health Services Administration (SAMHSA)
The Joint Commission
Formation of an alliance with nursing education programs across the country to evaluate nursing student education on use of seclusion and restraint and to promote a culture of seclusion and restraint use as a “last resort” among future nurses
Advocacy of policy change toward the reduction and eventual elimination of seclusion and restraint use on a state, federal, or organizational level
Appropriation of funds toward the conduction of research projects, particularly of broader and randomized samples
Continuation of the APNA Seclusion and Restraint Task Force toward the production of the APNA Position Paper and Standards on seclusion and restraint
Implementation of a Seclusion and Restraint section in the APNA Resource Center that is accessible to the public in order to educate all nurses, consumers, health care practitioners, and remaining members of the public on the latest standards of seclusion and restraint practice, to educate consumers on their patient rights in inpatient settings, and to advocate for a culture of reduction/elimination of seclusion and restraint
APNA (2007). Seclusion & Restraint: Position Statement & Standards of Practice. American Psychiatric Nurses Association, Arlington VA. Available at : www.apna.org
Ashcraft, L., & Anthony, W. (2008, October). Eliminating Seclusion and Restraint in Recovery-Oriented Crisis Services. Psychiatric Services, 59(10), 1199-1202.
Barton, S. A., Johnson, M. R., & Price, L. V. (2009). Achieving restraint-free on an inpatient behavioral health unit. Journal of Psychosocial Nursing, 47(1), 35-40.
Borckardt, J.J., Madan, A., Grubaugh, A.L., Danielson, C.K., Pelic, C.G., Hardesty, S.J. Frueh, B.C. (2011). Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital. Psychiatric Services, 62, 477-483.
Bowers, L., Van Der Merwe, M., Nijman, H., Hamilton, B., Noorthorn, E., Stewart, D., & Muir-Cochrane, E. (2010). The practice of seclusion and time-out on English acute psychiatric wards: The City-128 study. Archives of Psychiatric Nursing, 24, 275-286.
Curran, S. (2007). Staff resistance to restraint reduction: identifying and overcoming barriers. Journal Of Psychosocial Nursing & Mental Health Services, 45(5), 45.
De Benedictis, L et al. (2011). Staff perceptions and organizational factors as predictors of seclusion and restraint on psychiatric wards. Psychiatric Services, 62(5), 484-491.
E-Morris, M., Caldwell, B., Mencher, K.J., Grogan, K., Judge-Gorny, M., Christopher, T. McQuaide, T. (2010). Nurse-directed care model in a psychiatric hospital: A model for clinical accountability. Clinical Nurse Specialist, 24, 154-160.
Foster, C. (2007). Aggressive behaviour on acute psychiatric wards: Prevalence, severity and management. Journal of Advanced Nursing, 58, 140-149.
Gaskin, C.J., Elsom, S.J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature. British Journal of Psychiatry, 191, 298-303.
Happell, B., & Harrow, A. (2010). Nurses' attitudes to the use of seclusion: a review of the literature. International Journal Of Mental Health Nursing, 19(3), 162-168.
Happell, B., & Koehn, S. (2011). Seclusion as a necessary intervention: the relationship between burnout, job satisfaction and therapeutic optimism and justification for the use of seclusion. Journal Of Advanced Nursing, 67(6), 1222-1231. doi:10.1111/j.1365-2648.
Johnson, M.E. (2010). Violence and restraint reduction efforts on inpatient psychiatric units. Issues in Mental Health Nursing, 31, 181-197.
Joint Commission. (2009). The 2009 Joint Commission Comprehensive Accreditation Manual for Hospitals, PC.03.05.01.
Kontio, R., Välimäki, M., Putkonen, H., Kuosmanen, L., Scott, A., & Joffe, G. ( 2010). Patient restrictions: Are there ethical alternatives to seclusion and restraint? Nursing Ethics, 17, 65-76.
Moran, A., Cocoman, A., Scott, P., Matthews, A., Staniuliene, V., & Valimake, M. (2009). Restraint and seclusion: a distressing treatment option? Journal of Psychiatric and Mental Health Nursing, 16, 599-605.
Pollard, R., Yanasak, E.V., Rogers, S.A., Tapp, A. (2007). Organizational and unit factors contributing to reduction in the use of seclusion and restraint procedures on an acute psychiatric inpatient unit. Psychiatric Quarterly, 78, 73-81.
Recupero, P. R., Price, M., Garvey, K. A., Daly, B., & Xavier, S. L. (2011). Restraint and Seclusion in Psychiatric Treatment Settings: Regulation, Case Law, and Risk Management. The Journal of the American Academy of Psychiatry and the Law, 39, 465-476.
Ryan, R., & Happell, B. (2009). Learning from experience: Using action research to discover consumer needs in post-seclusion debriefing. International Journal of Mental Health Nursing, 18, 100-107.
Scanlan, J.N. (2010). Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: What we know so far a review of the literature. International Journal of Social Psychiatry, 56, 412-423.