American Nurses Association Position Paper on Seclusion and Restraint

Karen Daley, PhD, MPH, RN, FAAN
President
American Nurses Association
8515 Georgia Ave, Suite 400
Silver Spring, MD 20910

November 8, 2011

Dear Karen,

The American Psychiatric Nurses Association thanks ANA for their thoughtful consideration of the issues regarding the emergency measures of restraint or seclusion use in patient care.  We support the premise of moving towards restraint free environments in all facilities providing healthcare to patients. We are pleased to note that ANA has acknowledged the considerable work effort in reduction of restraints and seclusion by psychiatric nurses by citing APNA’s Position Statement on the Use of Seclusion and Restraint. We ask that ANA consider the content in APNA’s Standards of Practice for Restraint and Seclusion as they have The Joint Commission’s standards. We believe that APNA’s Standards are the voice of psychiatric-mental health nursing and form a more informed opinion on the matter than the Joint Commission’s standards alone.

A few key points that our members have suggested be included is the emphasis on the need for the Registered Nurse to be at the forefront of any mention of “staff”. We believe the RN is key to both reducing the use of restraints or seclusion as well as providing the safest care when they are necessary.

The APNA has a particular focus on the recovery oriented principles regarding patients and would support the inclusion of language that honors the voice of the individual and sees the individual as having strengths and resources that can be used to limit behavioral emergencies. In addition, we encourage all who are in a position to make decisions regarding restraint and seclusion use to be well educated in the area of trauma informed care.  Both of these principles ensure that our work with patients is proactive, and we believe that education is a key component to achieve this end.

We particularly concur with specifically addressing the growing older population that calls for broad strategies to address restraint use and would like to also consider the vulnerability of persons with mental illness who are known to exhibit chronic medical conditions about 25 years earlier than the broader population.  Conditions such as diabetes, obesity, cardiac and respiratory issues increase their vulnerability to life threatening complications from restraint use.

The APNA has asked our members to submit comments and have received these along with questions some of which relate to content and some to wording.  We would like to share these for your consideration and clarification:

Line 24: “either directly or indirectly”: indirectly isn’t clear, how does one become restrained or secluded indirectly?

27 and 28: “lack of personnel…for monitoring…or less restrictive approaches”. We too have concerns about the lack of personnel and would like to see the unacceptability of this included in the document. The statement should also foster the premise that there must be trained personnel, especially Registered Nurses, who are monitoring and assessing patient behaviors and directing alternative interventions.

30-32: We suggest that these lines be edited to say: “Nurses struggle to balance the responsibility to protect patients’ rights to freedom with the duty to prevent harm to patients and staff. They may face pressure from families and peers to physically intervene and use restraints.” This separates two important and common issues faced by nurses.

37: It is our preference that the term “intervention” regarding restraints or seclusion not be used as we believe this carries the connotation of a therapy or treatment. Instead it is our preference to call it an “emergency measure” or an “emergency strategy”.  We offer these terms as alternatives.

100: “…so that the patient is not abandoned once a decision is made.” This isn’t clear.

118-120: Perhaps instead of not addressing restraint use with criminals and custody arrangements, it would be stronger to say that when persons are involved with the criminal justice system, restraints are sometimes used for public safety rather than clinical purposes.  In those circumstances, when RNs are involved they should still work to promote dignity and physical well-being.

138-151: We are particularly pleased to see this inclusion and support addressing these areas specifically.

169: Trained RNs in addition to LIPs are now conducting the one hour face to face assessment of patients who are restrained or secluded and we support this and would like to see them added.

176 and 209: We are in support that “…sufficient nursing staff ” is necessary but would like to specifically emphasize the inclusion of Registered Nurses as necessary.

194-197: We note that the issue of delirium is critical and when applicable, as perhaps in this paragraph, it too should be included as an example.

In summary we are in general agreement with the ANA publication and we are hopeful that our feedback will be viewed favorably and incorporated into the final document. APNA appreciates the openness of the ANA process and your leadership in advancing the entire nursing profession while still providing specialty organizations a voice in matters that have particular impact on individual nursing specialties.

Sincerely,

Marlene Nadler-Moodie, MSN, APRN, PMHCNS-BC
President
American Psychiatric Nurses Association
1555 Wilson Blvd Suite 530
Arlington, VA 22209