Restraints and Seclusion in the Psychiatric setting

Seclusion is defined differently by different institutions.  Therefore, it is hard to compare the frequency of its use across different institutions. It can be defined as the containment of an emergency situation by placing and keeping a patient in a bare room with a locked door.  Seclusion of patients is used because of aggression of patients and prevents harm to the patients and to others in the environment.

In contrast, physical restraints confine patient movements. They are used because of an emotional or behavioral disorder and to prevent harm to the patient or others.

Griffiths (2001) describes chemical restraints as high doses of antipsychotic or tranquilizers to sedate patients against their will. They can be compared to seclusion as patients cannot leave their room or be in control of the situation. The Joint Commission on Accreditation of Healthcare Organization (JCAHO) defines chemical restraint as “the inappropriate use of a sedating or psychotropic drug to control or manage behavior. “

A review of the literature revealed that researchers have come to different conclusions when evaluating situations that predispose to patient aggression and violence.

 In a literature review by Duxbury (2002), we learn that internal, external, and situational variables can contribute. Some internal factors are patient age, sex, gender, and diagnosis. Diagnoses such as mania and psychosis are at times linked to aggression, as is intoxication. On medical units, older patients who have dementia, and are at risk of falling are sometimes restrained.  External factors are those environmental ones such as limited space, decreased privacy, overcrowding, and change of shift situations. Gender, experience, training, and level or grade of staff can also be external factors. Situational factors occur with the interaction of internal and external ones. Griffiths (2001) reported that stressed, overworked staff can also result in an increase in seclusion.

The literature reviewed by Bower, Mc McCullough, and Timmons (2003) revealed restraint use was positively correlated with the age of the patient, with impaired cognition and dementia, severe illness, immobility, and physical dependence.  In critical care units those with disruptive behavior, those who interfered with treatments or devices, those at a risk of falls or who wandered, were confused or agitated were more likely to be restrained.

Staff reported turning to restraints to avoid legal liability.  Those staff that used restraints were more likely to be poorly educated regarding alternatives and about the risks and benefits of restraints.  Situations with inadequate number of staff also resulted in more restraint use.  Environmental factors such as the distance of the patient’s room from the nurse’s station or the height of the bed were also linked to restraint use.

Restraint and seclusion should only be considered when less restrictive methods to protect the patient or others have been ineffective.  These interventions can be thought of as occurring on a continuum (Kozub & Skidmore, 2001) with interaction and redirection being the least restrictive response, then time out and setting limits.  Restraints and seclusion are at the most restrictive end of the continuum.  Different institutions do not rank the least restrictive interventions in the same way.

Before listing these alternatives the authors stress that the first step in preventing or delaying restraints and seclusion is staff training.  This training must be part of orientation for new staff and then repeated as needed and at least yearly.  Proper use of restraints can be included in crisis intervention or management of disruptive behavior inservices.

Examples of least restrictive alternatives include, but are not limited to:

• Interaction on 1:1 basis with staff (Kozub & Skidmore 2001)
• Redirection
• PRNrn medication with patient consent
• Staff or patient initiated time out in a quiet room with door unlocked. It should be presented as a way for patient to regain control, not as a threat.
• Staff presentation of limits where consequences are presented for patient to choose
• Removal of stimuli from the patient or vice versa
• Relaxation exercises
• Calming music

Well trained staff will be aware of escalating behavior, conversation, and non-verbal cues in patients. Staff in these situations can help de-escalation by: (Doerr & Boyko, 2004)

• Remaining calm
• Speaking quietly in a normal tone
• Encourage patients to verbalize their problems
• Offering choices when possible
• Reinforce patients ability to maintain control
• Provide adequate personal space
• Decrease environmental distractions or move patient to a safer place with decreased stimuli
• Provide adequate distance from patient
• Assess need for additional staff.
• Stay prepared to step back and or to block blows
• Avoid aggressive verbal or body language

 Some behaviors of staff that can increase the aggressive behavior of patients include aggressive tone of voice and body stance, close proximity, unconsented touch, disrespectful comments or tone, comments that decrease a patient’s sense of control and self- esteem, and threats.  Remember that restraints and seclusion should not be presented to the patient as a form of retaliation or punishment.

A review of the literature done by Bower et al (2003) reported on how patients felt about seclusion.  Patients usually report uniformly negative responses. They felt angry, helpless, trapped, sad, powerless, punished, frustrated, embarrassed and robbed of their privacy. After being secluded, patients usually state they would have preferred medication.  Families as well usually have a negative response to restraints and seclusion.  It is important to explain unit policies to patients and families, ideally before the situation presents itself where one or the other is needed.

On the other hand, when queried, staff had more conflicted responses ranging from anger to sympathy; from regret to beliefs that restraints and seclusion benefit all patients. Staff also believed that restraints and seclusion would prevent them from legal liability.

According to JCAHO (2004), the following factors must be included in patient assessment prior to any decision for restraints or seclusion:

• Determination of a history of sexual abuse or , the authors believe,  of post traumatic stress disorder
• Health history including ascertaining if there are any physical conditions that would put the patient at risk for falls since falls increase the risk of restraints.
• Nutritional status since malnutrition can alter cognitive status which increases risk of restraints
• Physical strength. Perhaps a program that helps the patient sit better may decrease need for restraints.
• Pain management needs.
• Toileting needs
• Medication usage

Assessment of patients after restraints or seclusion have been implemented

• If patient in restraints, continuous observation is required
• Vital Signs every hour
• Airway and respiratory checks ongoing
• Assess hydration and offer fluids offered at least every two hours
• Toileting offered every two hours
• Nutrition at mealtimes as safety permits
• Check circulation and range of motion every fifteen minutes
• Check for injury associated with the application of restraint or seclusion
• Assess psychological status including readiness for discontinuation of restraint or seclusion
• Documentation of all activities

Although staff often cite fear of legal action as the reason they chose restraints or seclusion, it should be stressed that using these options can lead to their own problematic outcomes.   Restraints can contribute to decreased muscle strength, decubiti, incontinence, strangulation, psychological distress, and even death.

Signs of physical distress related to restraints and seclusion:

• Extremely elevated pulse/respirations
• Extremely slowed pulse/respirations
• Skin color changes
• Swelling of hands/feet
• Respiratory distress
• Apparent injuries needing treatment

Restraints/seclusion should be interventions of last resort and never done with force or to humiliate the patients. 

Patients should be released when they are no longer a danger to themselves or others.  Signs that a patient is no longer a danger to themselves or others and may be ready for discontinuation of restraint and seclusion includes the following:

• The patient is no longer making verbal threats of harm
• Is able to verbalize ability to control behavior
• Contracts verbally with staff to abstain from behavior that precipitated restraint/seclusion
• There as been at least a fifteen minute period of calm behavior

Now that seclusion and restraints have been defined, least restrictive alternatives noted, discussed patients and staff attitudes/perceptions and addressed characteristics of patients requiring seclusion or restraint; the focus will shift to the legal and ethical aspects. This area will also include the required documentation and ideas on reducing usage of seclusion and restraint as well as suggestions to improve staff education.

According to Bower, McCullough and Timmons (2003), their review of literature reports there have been no studies conducted to examine the legal use of restraint and seclusions yet there are studies of nurses that questioned them about the use of seclusion and how they determined the least restrictive intervention. The least restrictive alternative concept is ensuring one’s personal freedom be limited to the minimum necessary to achieve the purpose of the intervention. In behavioral health treatment, the law is that one must use the least restrictive alternative but it does not specify which intervention is least restrictive. Just as an example, the authors of this article have a differing view on which is the least restrictive between seclusion and restraint. Bower et al (2003) stated in their review of the literature that some authors question the appropriateness of the least restrictive alternative as a generalizable concept.

There are two regulatory agencies that affect the legal requirements of seclusion and restraint. Title 42 of the Code of Federal Regulations Chapter IV Part 482.13 (Patients rights) and JCAHO standards clearly mandate what requirements the organizations must meet.  Title 42 requires that a hospital protect and promote patients’ rights. The critical piece of this regulation is that it states the patient has the right to be free from seclusion and physical or chemical restraints except to ensure the patient’s physical safety in emergent situations. The only exception occurs after the least restrictive alternative has been used and was not effective.

JCAHO has well defined standards. Staten (2003) reports that planning, using new or allocated resources, thoughtful education and performance improvement will result in an organizational approach to restraints that will protect the patient’s safety and preserve his or her dignity, rights and well-being. She reports that grasping the new standards allows for customers to understand about seclusion and restraints.  Standards PC.12.10 through PC.12.190 apply to all behavioral health care settings while selected standards (PC.11.10 through PC11:100) apply to non-behavioral healthcare settings staff must also follow the organizations policy. Bleak, Keys, Maynard, Provost & , Senator (2004) provide a concise summary table that lists the legal requirements as well as interpretive guidelines for patients in seclusion or restraints. The summary iterates the patient’s rights to be free unless other means are not effective, only a licensed independent practitioner may order seclusion or restraints (please note in teaching hospitals the first year residents can not give an order), the initial order for seclusion or restraint must be written within one hour of restraints being applied, order must be renewed every 4 hours for adult, 2 hours for patients ages 9-17 and every hour for anyone less than 9 years of age and under NO circumstances can seclusion or restraint be ordered as PRN. It is also important to note that ordering restraints or seclusion for staff convenience, as punishment, or as a retaliatory measure is specifically prohibited. The one way to ensure meeting these requirements as well as making sure staff feels safe is through proper documentation.

According to JCAHO standards each episode of seclusion or restraint use is to be documented. The documentation needs to include; the circumstances that led to seclusion or restraint, consideration or failure of non-physical interventions, rational for intervention used, if appropriate – notification of family, written order in chart, behavior criteria for discontinuation as well as informing the patient of the behavior criteria, each in person evaluation and re-evaluation, 15 minute assessments, any assistance provided to the patient, continuous monitoring, debriefing of patient with staff and any injuries (to patient and/or staff) that are sustained and treatment received. It may seem difficult to meet all these requirements yet it is the only way to demonstrate quality patient care.

It is imperative for staff to remain proficient and competent in seclusion and restraint therefore the educational training for staff is critical. The JCAHO benchmark article in 2000 stated “with restraint and seclusion reduced so significantly, the challenge is to remain good at something you do infrequently to maintain your success rate.” This quote was made by the senior medical director of a 40 bed psychiatric and chemical dependence treatment center in Montana. At this facility in Montana, a nurse supervisor was sent to a systematic training program designed to de-escalate crisis situations and manage people by using a combination of skills. The program was a week long. After the program the supervisor developed and implemented an educational program for all the staff. Recognizing that the goal is to continue to reduce use of seclusion and restraint, one part of the education program was to ensure ongoing training. This facility has chosen to do a monthly review which is documented and kept in the employee’s competency folder. Other pieces of the program they use are to discuss the topic of restraint and seclusion at staff meetings and do quarterly mock interventions to practice skills and techniques of safe and therapeutic interventions. JCAHO also clearly states a standard for performance improvement, incorporating these or similar ideas should be an expectation of all facilities where seclusion and restraints are utilized.

The major dilemma in the use of restraints and seclusion is related to violating the patient’s right to autonomy and to refuse treatment. Bower, et al (2003) noted that in review of the literature that nurses know they are violating ones right yet feel they need to protect the integrity of the group and/or promote patients’ self control. The nurses shared they often feel quietly, frustrated and sad while having to restrict one’s freedom. They further noted that when nurses believe there is a potential benefit from using seclusion or restraint that the moral conflict is increased because the nurse’s wants to provide good and avoid harm yet must violate one’s freedom to accomplish it.  Nurse’s views vary from empathizing with the patient to others whose utilitarian view reflects that the greater good is found in protecting others from any harm.

Another ethical consideration is the question if seclusion or restraint is a valid therapeutic intervention or merely a method of containment. In this author’s experience, some hospitals use seclusion and restraints while others see no use in seclusion so only use restraints for emergent situations. In addition, most patients will openly share their negative feelings about seclusion and restraint. Patients often view these interventions as punishment, not a form of treatment.

As Bower, et al (2003) noted there needs to be more research done in regards to ethical issues. An area that needs attention is finding appropriate and effective alternative ways to protect patients and continue behavior while ensuring patient’s rights. Those who have evidence based knowledge need to quickly share their successes so everyone can move towards a more humane practice.  The alternatives have to be proven effective to ensure that everyone’s safety remains the primary focus.

Last but certainly not least is the aspect that falls under both ethical and legal consideration.  Safety is the aspect and it is all inclusive.  One needs to look at safety from the point of patients who are suicidal/homicidal, other patients as well as staff.  The question often asked is should staff put themselves and other patients at risk due to fear of liability.  Research suggests that many staff do fear litigation from restricting a patient’s freedom.  It is also noted that when a patient is severely agitated, threatening and seen as imminent danger to self or others that there is no conflict for staff to make the right decision.  The authors have seen a major shift in this area from when they started psychiatric nursing to the present.  In the past, it was common practice to use seclusion and restraints without looking at least restrictive alternatives.  The rights movement of the 1960’s and 70’s helped bring attention to this issue yet only since the 1990’s has there been documented decrease in use of seclusion and restraints. 

Another point to be aware of is the need for continuous monitoring when using seclusion or restraints.  Many times these interventions are used to prevent to prevent one from harming themselves or others yet it is important to note that even when using these interventions the patient may attempt to harm themselves.   According to JCAHO, when using seclusion the patient must have face to face contact the first hour and then can be visually and audio monitored.  When using restraints the patient must be observed face to face the entire time they remain in restraints.   Continuous monitoring incorporates monitoring several aspects of care and may vary slightly from institution to institution so staff must adhere to both JCAHO standards as well as hospital policy.   Although it may seem time consuming it is the one way to ensure safety for all parties involved and that the intervention is terminated as soon as appropriate.

Seclusion and restraints have been defined, nurses and patients attitudes discussed, least restrictive alternatives reviewed, and legal and ethical ramifications were addressed.  As noted before it is important to remember that patients almost always have a negative attitude whereas staff have mixed feelings about the use of seclusion and restraints.  Most importantly is the need for research to be done so alternative interventions can be based on sound rationale.  The next time that you may need to seclude or restrain a patient just remember what you have learned and make the best informed decision.

Our goal is to help someone who is angry and having problems controlling themselves to gain control using less restrictive alternative!