Seclusion and Restraint – Nurses Must Take the Lead for Safety

You regularly monitor seclusion and restraint use as a psychiatric-mental health nurse committed to safety for staff and patients. Your knowledge base positions you to take a leadership role in ensuring that best practices are being followed regarding seclusion and restraint. Thankfully, you have an ally in this work. The APNA Council for Safe Environments keeps apprised of the latest in research so that you can stay informed and provide appropriate guidance: “APNA recognizes that the ultimate responsibility for maintaining the safety of both individuals and staff in the treatment environment and for maintaining standards of care in the day-to-day treatment of individuals rests with nursing and the organizational leadership that supports care settings” (APNA Position Statement On the Use of Seclusion and Restraint).

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 Council for Safe Environments’ work to stay on top of this issue over time is crucial to maintaining safe and effective standards of care. Council chair Diane Allen sees opportunity for improvement regarding this practice, “While progress has been made over the past two decades in the effort to eliminate the use of seclusion and restraint, these emergency measures continue to be used as a last resort in many healthcare settings.”

The Council for Safe Environments recently made updates to APNA’s Position Statement On the Use of Seclusion and Restraint. These revisions ensure that the wealth of information contained in the statement is both current and comprehensive. A thorough literature review was conducted resulting in the updates made earlier this year. Though the evidence sourced previously was still the most current, additional information and resources are now cited to support recommendations. 

“Changes to the background section of the position paper highlighted some of the important work being done in other countries, such as the Safewards Program in the United Kingdom and the Scottish Safety Programme,” says Allen. “We also recognized recent work being done in the United States, such as studies of the impact of nurse staffing (Staggs, Olds, Kramer & Shorr, 2017) and timely emergency room treatment (WInokur, Loucks and Rapp, 2018) on the use of restraint.”

“Skilled assessments of individuals who are restrained or secluded will not only ensure the safety of individuals in these vulnerable conditions, but also will ensure that the measures are discontinued as soon as the individual is able to be safely released.”  - APNA Position Statement On the Use of Seclusion and Restraint

A key factor in mitigating the use of seclusion and restraint is the application of skilled assessments. According to the APNA Position Statement on the Use of Seclusion and Restraint, “assessing the patient and intervening early with less restrictive measures, such as verbal and non-verbal communication, reduced stimulation, active listening, diversionary techniques, limit setting and medication,” contributes to a reduction in use of those measures. 

Detailed information on how to conduct these assessments is available in the APNA eLearning Center, including the 2018 Competency Based Training for Conducting the One Hour Face to Face Assessment of a Patient in a Restraint or Seclusion. During the session, key components of the one hour face to face assessment of a patient in a restraint or seclusion are discussed. Another valuable resource is Seclusion and Restraint: Assessment and Risk Mitigation, which outlines the potential dangers associated with the use of restraint or seclusion and the importance of assessment.

The significance of such evaluations is underscored further in the position statement, “Skilled assessments of individuals who are restrained or secluded will not only ensure the safety of individuals in these vulnerable conditions, but also will ensure that the measures are discontinued as soon as the individual is able to be safely released.”

The reality is that seclusion and restraint methods are still used in some situations despite efforts to stop their use. Therefore, awareness of vulnerable individuals is essential. “The dangers inherent in the use of seclusion and restraint include the possibility that the person’s behavior is a manifestation of an organic or physiological problem that requires medical intervention and may, therefore, predispose the person to increased physiological risk during the time the individual is secluded or restrained.” (APNA Position Statement On the Use of Seclusion and Restraint.)

Allen draws attention to the final point of the position statement which shows the path forward, “Movement toward future elimination of seclusion and restraint requires instituting and supporting less intrusive, preventative, and evidence-based interventions in behavioral emergencies that aid in minimizing aggression while promoting safety.”

 

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