Seclusion & Restraint

APNA Position on the Use of Seclusion and Restraint

The newly updated Position Statement on the Use of Seclusion and Restraint was approved by the Board of Directors on March 13, 2018. Accompanying this position paper are the Seclusion and Restraint Standards of Practice. A continuing education session, Seclusion and Restraint: Keys to Assessing and Mitigating Risks and 2018 Competency Based Training for Conducting the One Hour Face-to-Face Assessment for Patients in Restraints or Seclusion are also available to supplement these two resources.


APNA Position Statement on the Use of Seclusion and Restraint 
(Original, 2000; Revised, 2007; Revised, 2014; Revised, 2018)

Contents


Introduction

Psychiatric-mental health nursing has a 100 year history of caring for persons in psychiatric facilities. Currently, nurses serve as direct care providers as well as unit-based and executive level administrators in virtually every organization providing inpatient psychiatric treatment. Therefore, as the professional organization for psychiatric-mental health nurses, the American Psychiatric Nurses Association (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.

Thus, 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. Furthermore, we recognize the need for and are committed to working together with physicians, clients and families, advocacy groups, other health providers, and our nursing colleagues in order to achieve the reality of eliminating the use of seclusion and restraint.


Back to Top

Background

In the mid-1800s, proponents of “moral treatment” of psychiatric patients advocated for the elimination of the practice of restraining patients. Despite the relative success of this movement in England and Europe, psychiatrists in the United States concluded that restraints could never be eliminated in the United States (Fisher, 1994). Belief in the necessity for continuing the practice of secluding and restraining patients as a way to prevent injury and reduce agitation persisted until the beginning of the 21st century. Nurses then concluded that this practice was not grounded in research that supported its therapeutic efficacy, but upon the observation that these measures interrupted and controlled the patient’s behavior (Sailas & Fenton 2000; Paterson & Duxbury, 2007; Steinert et al. 2010; Scanlan 2010). Regulatory changes and increased study led to recognition that seclusion and restraint are not grounded in research and are not therapeutic (World Health Organization, 2017).

Reports of patient injuries and deaths (Berzlanovich, Schöpfer & Keil, 2012; Cecchi et al. 2012; Rakhmatullina, Taub and Jacob, 2013; Duxbury, 2015) and studies of patients’ experiences in restraint and seclusion (Kontio, 2011; Steinert et al. 2013; Soininen et al., 2013; Ling, 2015; Okanli, 2016) have prompted psychiatric-mental health nurses to give serious consideration to the ethical conflict inherent in the use of seclusion and restraint: between the nurse’s responsibility to prevent harm and the patient’s right to autonomy (Cleary, Hunt and Walter 2010; Mohr, 2010; APNA Janssen Scholars, 2012; Ezeobele, 2013). However, violence cannot always be predicted, and since the nursing staff are held responsible for maintaining the safety of all patients, they sometimes see seclusion and restraint as the only way to maintain that safety (Duxbury, 2015). Therefore, studies of the impact of assault on those who care for patients must be taken into consideration when developing standards for practice and when addressing organizational strategies to assure equal commitment to workers, as well as patient safety (Flannery et al., 2011; Happell & Koehn, 2011). Research has highlighted the influence of unit philosophy and culture, treatment philosophy, staff attitudes, staff availability, staff training, ratios of patients to staff and location in the United States on either the disparity in the incidence of seclusion and restraint or the perpetuation of the practice of secluding and restraining psychiatric patients ( Happell & Koehn, 2011; Azeem et al., 2011; Chandler, 2012; Ashcraft, Bloss & Anthony, 2012; Chang et al., 2013). In 2012, NASMHPD’s Six Core Strategies to Reduce Seclusion and Restraint Use program (2008) was recognized by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices, based on the results of a five-year, eight-state research project. This multi-modal approach has been implemented widely by organizations striving to decrease seclusion and restraint use (Delacy et al., 2003; Masters, 2017).

“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.”

 From the research, it appears that the key to seclusion and restraint reduction is prevention of aggression by (a) maintaining a presence on the unit and noticing early changes in the patient and the milieu (Johnson & Delaney, 2007; Ward et al., 2011; Taylor et al., 2012), (b) 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 (Bak et al., 2012; Sivak, 2012; Bostwick & Hallman, 2012; Chalmers et al., 2012; Bowers et al., 2012) and (c) changing aspects of the unit to promote a culture of structure, calmness, negotiation and collaboration, rather than control (Kontio et al., 2012; Bowen, Privitera, and Bowie, 2011; Jones, 2012). The Safewards Program (Bowers, 2014; Hamilton, 2016) has helped caregivers in the United Kingdom to reduce the use of containment procedures by avoiding flashpoints that precede aggression. The Scottish Patient Safety Programme (2016) achieved reduction in the rate of restraint by promoting the idea that when people are and feel safe, staff are and feel safe. Recent evidence has shown that use of a standardized tool to improve time to first medication has been a factor in a successful restraint reduction effort in an emergency department (Winokur, Loucks and Rapp, 2018). Another important factor seems to be adequate staffing skill mix (Staggs, Olds, Kramer & Shorr, 2017).  

There is evidence that changes in a unit’s treatment philosophy can lead to changes in patient behavior that will ultimately impact the incidence of the use of seclusion and/or restraints (Delaney and Johnson, 2012; Goetz and Taylor-Trujillo, 2012). There is also growing awareness that inpatient treatment must be shaped by the principles of trauma-informed care and the recovery movement and that these philosophies will create a collaborative spirit that is essential to restraint reduction and elimination efforts (Hammer et al., 2011; Hardy & Patel, 2011; Subica, Claypoole & Wylie, 2012; Bowen, Privitera & Bowie, 2011; Azeem et al., 2011; SAMHSA, 2018).

Despite the best efforts at preventing the use of seclusion and restraint, there may be times that these measures are used. Thus, it is important to be cognizant of the vulnerability of individuals who are secluded or restrained and the risks involved in using these measures (Nadler-Moodie, 2009; Huf & Adams, 2012; Hollins & Stubbs, 2011; Mohr & Nunno, 2011; Georgieva et. al, 2012). Moreover, 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. Therefore, 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.

Back to Top

Position Statement

APNA believes that psychiatric-mental health nurses play a critical role in the provision of care to persons in psychiatric settings. This role requires that nurses provide effective treatment and milieu leadership to maximize the individual’s ability to effectively manage potentially dangerous behaviors. To that end, we strive to assist the individual in minimizing the circumstances that give rise to seclusion and restraint use. Therefore:

  • We advocate for policies at the federal, state, and other organizational levels that will protect individuals from needless trauma associated with seclusion and restraint use, while supporting both individual and staff safety.
  • We take responsibility for providing ongoing opportunities for professional growth and learning for the psychiatric-mental health nurse whose treatment approach promotes individual safety, as well as autonomy and a sense of personal control.
  • We promulgate professional standards that apply to all populations and in all settings where behavioral emergencies occur and that provide the framework for quality care for all individuals whose behaviors constitute a risk for safety to themselves or others.
  • We advocate and support evidence-based practice through research directed toward examining the variables associated with the prevention of and safe management of behavioral emergencies.
  • We recognize that organizational characteristics have substantial influence on individual safety and call for shared ownership among leaders to create a work culture that supports minimal seclusion and restraint use and that will enable the vision of elimination to be realized.
  • We articulate the following fundamental principles to guide action on the issue of seclusion and restraint:
    • Individuals have the right to be treated with respect and dignity and in a safe, humane, culturally sensitive and developmentally appropriate manner that respects individual choice and maximizes self-determination.
    • Seclusion or restraint must never be used for staff convenience or to punish or coerce individuals.
    • Seclusion or restraint must be used for the minimal amount of time necessary and only to ensure the physical safety of the individual, other patients or staff members and when less restrictive measures have proven ineffective.
    • Individuals who are restrained mechanically must be afforded maximum freedom of movement while assuring the physical safety of the individual and others. The least number of restraint points must be utilized and the individual must be continuously observed.
    • “We promulgate professional standards that apply to all populations and in all settings where behavioral emergencies occur and that provide the framework for quality care for all individuals whose behaviors constitute a risk for safety to themselves or others.”
      Seclusion and restraint reduction and elimination requires preventative interventions at both the individual and milieu management levels using evidence based practice.
    • Seclusion and restraint use is influenced by the organizational culture that develops norms for how persons are treated. Seclusion and restraint reduction and elimination efforts must include a focus on necessary culture change.
    • Effective administrative and clinical structures and processes must be in place to prevent behavioral emergencies and to support the implementation of alternatives.
    • Hospital and behavioral healthcare organizations and their nursing leadership groups must make commitments of adequate professional staffing levels, staff time and resources to assure that staff are adequately trained and currently competent to perform treatment processes, milieu management, de-escalation techniques and seclusion or restraint.
    • Oversight of seclusion and restraint must be an integral part of an organization’s performance improvement effort and these data must be open for inspection by internal and external regulatory agencies. Reporting requirements must be based on a common definition of seclusion and restraint. Specific data requirements must be consistent across regulatory agencies.
    • 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.


Approved by the APNA Board of Directors March 13, 2018.

Back to Top

Acknowledgements:

2018 APNA Council for Safe Environments Workgroup for Seclusion and Restraint Position Paper: Diane Allen, Marlene Nadler-Moodie.

2014 APNA Institute for Safe Environments Workgroup for Seclusion & Restraint Position Paper: Catherine Batscha, Catherine O’Reilly, Diane Allen.

2007 APNA Seclusion and Restraint Steering Committee: Lynn DeLacy (Chair), Amy Rushton (Co-Chair), Diane Allen, Hyman Beshansky, Laura Curtis, Kathleen Delaney, Germaine Edinger, Carole Farley-Toombs, Kathryn Fritsche, Susan Griffin, Lyons Hardy, Mary E. Johnson, William Koehler, Georganne Kuberski, Lee Liles. Kathleen McCann, Marlene Nadler- Moodie, Pamela Nold, Douglas Olsen, Kathleen Regan, , Theodora Sirota, Joan van der Bijl, Karen Vergano, Theresa Warfield.

2000 APNA Seclusion and Restraint Task Force: Lynn DeLacy (Chair), Terri Chapman, Sue Ciarmiello, Kathleen Delaney, Germaine Edinger, Carole Farley-Toombs, Mary Johnson, Lyn Marshall, Marlene Nadler- Moodie, Marilyn Nendza, Pamela Nold, Linda Ovitt, Brenda Shostrom, Mary Thomas, Linda Wolff.

Back to Top

References

American Psychiatric Nurses Association. (2012). Janssen Scholars Seclusion & Restraint Workgroup Report. Available at: http://www.apna.org/i4a/pages/index.cfm?pageid=4950

Ashcraft, L.,Bloss, M. & Anthony, W.A. (2012). "Best Practices: The Development and Implementation of “No Force First” as a Best Practice." Psychiatric Services, 63 (5):415-417.

Azeem, M. W., Akashdeep, A., Rammerth, M., Binsfeld,G., & Jones, R.B. (2011). "Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital." Journal of Child and Adolescent Psychiatric Nursing, 24(1):11-15.

Bak, J., Brandt-Christensen, M., Sestoft,D.M., & Zoffmann, V. (2012). "Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review." Perspectives in Psychiatric Care, 48 (2):83-94.

Berzlanovich, A.M., Schöpfer, J. & Keil, W. (2012). "Deaths due to physical restraint." Deutsches Ärzteblatt International, 109 (3):27.

Bostwick, J.R, Hallman, I.S.(2012). "Agitation management strategies: overview of non-pharmacologic and pharmacologic interventions." Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses 22 (5):303-7, 318.

Bowen, B., Privitera, M.R. & Bowie, V. (2011). "Reducing workplace violence by creating healthy workplace environments." Journal of Aggression, Conflict and Peace Research, 3(4):185-198.

Bowers, L., Ross,J., Owiti,J., Baker, J., Adams,C., & Stewart, D. (2012). "Event sequencing of forced intramuscular medication in England." Journal of Psychiatric and Mental Health Nursing no. 19 (9):799-806.

Bowers, L. (2014). Safewards: a new model of conflict and containment on psychiatric wards.
           Journal of Psychiatric and Mental Health Nursing, 21(6), 499–508.

            https://doi.org/10.1111/jpm.12129

Cecchi, R., Lazzaro,A., Catanese,M., Mandarelli, G., & Stefano Ferracuti, S. (2012). "Fatal thromboembolism following physical restraint in a patient with schizophrenia." International Journal of Legal Medicine no. 126 (3):477-482. doi: 10.1007/s00414-012-0670-1.

Chalmers, A., Harrison,S., Mollison,K., Molloy,N. & Gray, K. (2012). "Establishing sensory-based approaches in mental health inpatient care: a multidisciplinary approach." Australasian Psychiatry, 20 (1):35-39.

Chandler, G.E. (2012). "Reducing Use of Restraints and Seclusion to Create a Culture of Safety." Journal of psychosocial nursing and mental health services.50 (10): 29-36. doi: 10.3928/02793695-20120906-97

Chang, N.A., Grant,P.M., Luther,L. & Beck, A.T. (2013). "Effects of a Recovery-Oriented Cognitive Therapy Training Program on Inpatient Staff Attitudes and Incidents of Seclusion and Restraint." Community Mental Health Journal:1-7. doi: 10.1007/s10597-013-9675-6.

Cleary, M., Hunt, G.E., Walter, G. (2010). "Seclusion and its context in acute inpatient psychiatric care." Journal of Medical Ethics, 36(8):459-462.

Code of Federal Regulations, Ch. IV. (2010). Centers for Medicare & Medicaid Services,

Conditions of Participation: Patient rights. HHS § 482.13(e)(1).Definitions: (i) restraint, (ii) seclusion. Accessed at: http://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol5/pdf/CFR- 2010-title42-vol5-sec482-13.pdf

DeLacy L, Edner B, Hart C, et al. (2003). Learning from Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health. American Psychiatric Association, American Psychiatric Nurses Association, National Association of Psychiatric Health Systems, and American Hospital Association Section for Psychiatric and Substance Abuse Services; 2003. [19 January 2015]. http://c?.ymcdn.com/sites/www.copaa.org/resource?/collection/662B1866-952D-41FA-B7F3-D3CF68639918?/Learning?_from_each_other?_-reducing_restraint.pdf.

Delaney, K.R., Johnson, M.E. (2012). "Safety and Inpatient Psychiatric Treatment Moving the Science Forward." Journal of the American Psychiatric Nurses Association, 18 (2):79-80.

Duxbury, J. (2015). Minimising the use of coercive practices in mental health: the perfect storm. Journal of Psychiatric and Mental Health Nursing 22 89-91. https://doi.org/10.1111/jpm.12206

Ezeobele, I. E., Malecha, A.T., Mock, A. Mackey-Godine, A., & Hughes, A. (2013). "Patients' lived seclusion experience in acute psychiatric hospital in the United States: a qualitative study." J Psychiatr Ment Health Nurs. doi: 10.1111/jpm.12097.

Fisher, W. A. (1994). Restraint and seclusion: a review of the literature. The American Journal of Psychiatry, 151(11), 1584–1591. https://doi.org/10.1176/ajp.151.11.1584

Flannery, R. B., Jr., LeVitre,V., Rego, S., & Walker, A.P. (2011). "Characteristics of staff victims of psychiatric patient assaults: 20-year analysis of the Assaulted Staff Action Program." Psychiatr Q, 82(1):11-21. doi: 10.1007/s11126-010-9153-z.

Georgieva, I., Mulder,C.L., & Whittington, R. (2012). "Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions." BMC psychiatry,12 (1):54.

Goetz, S.B., Taylor-Trujillo, A.  (2012). "A Change in Culture Violence Prevention in an Acute Behavioral Health Setting." Journal of the American Psychiatric Nurses Association, 18 (2):96-103.

Hamilton B, Fletcher J, Sands N, Roper C, Elsom S (2016) Safewards Victorian Trial Final Evaluation Report. Report to Chief Mental Health Nurse, Department of Health and Human Services. Melbourne: Centre for Psychiatric Nursing, University of Melbourne.

Hammer, J.H., Springer, J., Beck,N.C., Menditto, A. & Coleman, J. (2011). "The relationship between seclusion and restraint use and childhood abuse among psychiatric inpatients." Journal of interpersonal violence, 26 (3):567-579.

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.

Hardy, D. W., Patel, M. (2011). "Reduce inpatient violence: 6 strategies: active, unwavering, and visible commitment of hospital leadership is key to reducing violence and restraints." Current Psychiatry, 10(5).

Hollins, L.P, Stubbs, B. (2011). "The shoulder: Taking the strain during restraint." Journal of Psychiatric and Mental Health Nursing, 18(2):177-184.

Huf, G., Adams, C.E. (2012). "Physical restraints versus seclusion room for management of people with acute aggression or agitation due to psychotic illness (TREC-SAVE): a randomized trial." Psychological medicine, 42(11):2265-2273.

Johnson, M. E., & Delaney, K. R. (2007). Keeping the Unit Safe: The Anatomy of Escalation. Journal of the American Psychiatric Nurses Association, 13(1), 42–52. https://doi.org/10.1177/1078390307301736

Jones, B. (2012). "A culture of recovery requires program redesign." Health progress (Saint Louis, Mo.), 94(2):20-24.

Kontio, R. (2011). "Patient seclusion and restraint practices in psychiatric hospitals-towards evidence based clinical nursing."

Kontio, R., Joffe,G., Putkonen, H., Kuosmanen, L., Hane, K., Holi,M.,& Välimäki, M. (2012). "Seclusion and Restraint in Psychiatry: Patients' Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives." Perspectives in psychiatric care, 48(1):16-24.

Ling, S., Cleverley, K., & Perivolaris, A. (2015). Understanding Mental Health Service User Experiences of Restraint Through Debriefing: A Qualitative Analysis. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 60(9), 386–392.Masters, K. (2007). Pulse oximetry use during physical and mechanical restraints. J Emerg Med 33:289.

Masters, K. (2009). RISK MANAGEMENT: PART 1 SECLUSION AND RESTRAINT From Navigating the Maze of Malpractice Risks: Let Risk Management Lead the Way, presented by Professional Risk Management Services, Inc.  Auto Digest Psychiatry, Vol 38 Issue 6. February. Available at: http://www.cme-ce-summaries.com/psychiatry/ps3806.html, Accessed May 14, 2013.

Masters, K. J. (2017). Physical Restraint: A Historical Review and Current Practice. Psychiatric Annals, 47(1), 52–55. https://doi.org/10.3928/00485713-20161129-01

Mohr, W. (2006). There’s No Such Thing as a Safe Restraint. Nurse.com. New Jersey Nursing News.mht.  Accessed at: http://news.nurse.com/apps/pbcs.dll/article?AID=/20080310/NJ02/80305005

Mohr, W. K. (2010). "Restraints and the code of ethics: An uneasy fit." Archives of psychiatric nursing,24 (1):3-14.

Mohr, W. K., Nunno, M.A. (2011). "Black boxing restraints: the need for full disclosure and consent." Journal of Child and Family Studies, 20(1):38-47.

Morphet, J., Griffiths, D., Plummer, V., Innes, K., Fairhall, R., & Beattie, J. (2014). At the crossroads of violence and aggression in the emergency department: perspectives of Australian emergency nurses. Australian Health Review: A Publication of the Australian Hospital Association, 38(2), 194–201. https://doi.org/10.1071/AH13189

Muir-Cochrane E, Duxbury JA (2017) Violence and aggression in mental health-care settings.

        International Journal of Mental Health Nursing 26 421-422.

NASMHPD. (2008). National Association of State Mental Health Program Directors. Six Core Strategies for Reducing Seclusion and Restraint Use. Accessed February 10, 2018: https://www.nasmhpd.org/content/six-core-strategies-reduce-seclusion-and-restraint-use

Nadler-Moodie, Marlene. (2009). Clinical Practice Guideline: 1 hour face-to-face assessment of a patient in a mechanical restraint. Journal of Psychosocial Nursing 47(6), 37-43.

Okanli, A., Yilmaz, E., & Kavak, F. (2016). Patients’ Perspectives on and Nurses’ Attitudes toward the Use of Restraint/Seclusion in a Turkish Population. International Journal of Caring Sciences, 9(3), 932.

Paterson, B., Duxbury, J. (2007). "Restraint and the question of validity." Nurse Ethics, 14 (4):535-45. doi: 10.1177/0969733007077888.

Putkonen, A., Kuivalainen, S., Louheranta, O., Repo-Tiihonen, E., Ryynänen, O.-P., Kautiainen, H., & Tiihonen, J. (2013). Cluster-randomized controlled trial of reducing seclusion and restraint in secured care of men with schizophrenia. Psychiatric Services (Washington, D.C.), 64(9), 850–855. https://doi.org/10.1176/appi.ps.201200393Rakhmatullina, M.,Taub,A., &  Jacob, T. (2013). "Morbidity and Mortality Associated with the Utilization of Restraints." Psychiatric Quarterly:1-14.

Sailas EES, Fenton M (2000) Seclusion and restraint for people with serious mental illness. Cochrane Database of Systematic Reviews. Issue 1. Art. No.: CD001163. http:// onlinelibrary.wiley.com/doi/10.1002/14651858.CD001163/ pdf (accessed 29 November 2017)

SAMHSA. (2018). US DHHS Substance Abuse and Mental Health Services Administration. National Center for Trauma Informed Care. Available at: https://www.samhsa.gov/trauma-violence/seclusion. Accessed February 23, 2018.

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(4):412-423.

Scottish Patient Safety Programme. (2016). http://ihub.scot/spsp/mental-health/

Sivak, K. (2012). "Implementation of Comfort Rooms to Reduce Seclusion, Restraint Use, and Acting-Out Behaviors." Journal of psychosocial nursing and mental health services, 50(2):24-34.

Soininen, P., Valimaki,M., Noda, T., Puukka, P., Korkeila, J.,  Joffe, G., & Putkonen, H. (2013). "Secluded and restrained patients' perceptions of their treatment." Int J Ment Health Nurs, 22(1):47-55. doi: 10.1111/j.1447-0349.2012.00838.x.

Staggs, V. S., Olds, D. M., Cramer, E., & Shorr, R. I. (2017). Nursing Skill Mix, Nurse Staffing Level, and Physical Restraint Use in US Hospitals: a Longitudinal Study. Journal of General Internal Medicine, 32(1), 35–41. https://doi.org/10.1007/s11606-016-3830-z

Steinert, T., Birk, M., Flammer, E. & Bergk, J. (2013). "Subjective Distress After Seclusion or Mechanical Restraint: One-Year Follow-Up of a Randomized Controlled Study." Psychiatric Services, 64(10):1012-7. doi: 10.1176/appi.ps.201200315

Steinert, T., Lepping, P., Bernhardsgrütter,R., Conca, A., Hatling, T., Janssen, W., Keski-Valkama, A., Mayoral, F. & Whittington, R.(2010). "Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends." Social Psychiatry and Psychiatric Epidemiology, 45(9):889-897.

Subica, A.M. ,Claypoole, K.H., & Wylie, A.M. (2012). "PTSD'S mediation of the relationships between trauma, depression, substance abuse, mental health, and physical health in individuals with severe mental illness: Evaluating a comprehensive model." Schizophrenia research, 136(1):104-109.

Taylor, K.,Mammen, K., Barnett,S, Hayat, M. & Gross, D. (2012). "Characteristics of Patients With Histories of Multiple Seclusion and Restraint Events During a Single Psychiatric Hospitalization." Journal of the American Psychiatric Nurses Association, 18(3):159-165.

Ward, A., Keeley, S., & Warr, J. (2011). "Physical interventions training and organisational management in mental health: an integrated approach to promote patient safety." Journal of Psychiatric Intensive Care, 8(1):25.

Winokur, E., Loucks, J., Raup, G. (2018) Use of a Standardized Procedure to Improve Behavioral Health Patients' Care: A Quality Improvement Initiative. Journal of Emergency Nursing. 44(1):26-32, 2018 Jan. [Journal Article] UI: 28802869

World Health Organization, Department of Mental Health and Substance Abuse (2017) Strategies to end the use of seclusion, restraint and other coercive practices – WHO Quality Rights training to act, unite and empower for mental health (pilot version). Geneva: World Health Organization.

AMERICAN PSYCHIATRIC NURSES ASSOCIATION and APNA-Logoare registered in the U.S. Patent and Trademark Office as trademarks of the American Psychiatric Nurses Association.
The American Psychiatric Nurses Association is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.