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Abstract

Restraint use in the treatment of mental illness has Instead of reducing restraint use, it was decided to
long been a controversial practice. Regulatory agen- eliminate restraint use. Vision guided, the team de-
cies, licensing organizations, and professional and veloped an action plan. Culture change focused on
advocacy groups have called for reduction of re- the Mental Health Recovery Model and principles of
straint use. Responding to this call for action, the trauma-informed care. Emphasizing person-centered
leadership team of a behavioral health unit in a pri- care, this unit has now been restraint free for nearly
vate, nonprofit community hospital evaluated re- 2 years. A surprise finding was that restraint elimina-
2008 Sandra A. Barton, BSN, RN, BC

ducing restraint use. Following training through the tion accompanied a decrease in use of as needed
National Executive Training Institute of the National sedative-hypnotic medications. Person-centered care
Association of State Mental Health Program Direc- delivered by frontline staff led to culture change, a
tors, a restraint-reduction project team was formed. restraint-free environment, and less medication.

34 JPNonline.com
Earn

4.0 Contact
Hours

U
se of restraint in the chairs to cold wet sheet packs, before 1990, when the Pennsyl-
treatment of mental ill- patients behaviors were restrict- vania seclusion and restraint ini-
ness has long been con- ed. Seclusion was one physicians tiative began, Pennsylvania has
troversial. Regulatory agencies alternative to restraint use and been a leader among states in re-
and licensing organizations, as was deemed a more humane al- ducing seclusion and restraint use.
well as professional and advocacy ternative. Even so, seclusion was The process for accomplishing
groups, have called for restraint considered controversial. this reduction was discussed by
use reduction. Responding to this, Back when alienist was the Smith et al. (2005). They noted
the leadership team of a behavioral term for psychiatrist, ethical con- that while the rate and duration
health unit in a private, nonprofit cerns seem to have been as much of time spent in restraint and se-
community hospital evaluated re- an issue as they are today. Brit- clusion decreased, there was not
ducing restraint use. However, in- ish alienists were more critical of a noticeable increase in staff inju-
stead of reducing use, the team restraint and seclusion use than ries related to patient assaults.
decided to eliminate restraint their American colleagues. Al- In 1998, the Hartford Courant
use. Using trauma-informed though antipsychotic drugs had began a series of articles reporting
care principles and apply- not yet been developed, opiates, deaths that occurred while people
ing the Mental Health bromides, and alcohol were avail- were being restrained or were in
Recovery Model, the able. These agents made patients seclusion (Weiss, Altimari, Blint,
goal of restraint-free was sleep, but sleep was considered & Megan, 1998). This series
achieved. This article therapeutic. Excessive use of these prompted increased advocacy for
outlines how a restraint- agents was recognized as chemical seclusion and restraint reduction.
free vision became reality. restraint (Colaizzi, 2005). Colaizzi In 2002, the National Association
(2005) concluded: of State Mental Health Program
Background From the beginning of psy- Directors (NASMHPD) created
Colaizzi (2005) reviewed chiatric care, founded by the a national call to action. A na-
and summarized a brief his- Quakers, the use of mechanical tional action plan was developed
tory of restraint and the well- devices and drugs to control vio- and over the next several years,
intentioned initiation of restraint lent behavior has been viewed as incentives were developed at the
use. As she noted, Dorothea Dix inimical to the ethical principles national level to bring all states
is credited with the rise of state of benevolence and nonmalfea- on board.
asylums for the insane. This wide- sance. It is not always possible Trauma theory became wide-
spread growth took place through- to translate philosophical ideals ly understood during this
out the 1800s. The new asylums into practical realities and both same time. Trauma-
were barely built before problems of these absolutes contain an ele- informed care, as
with overcrowding were encoun- ment of truth. (p. 37) described by Hodas
tered. By the 1840s, asylums had (2004), became the
already become so overcrowded Restraint-Reduction base for care reform.
that behavior control had become Perspectives Pennsylvania re-
a central concern (Colaizzi, Restraint reduction has been mains at the fore-
2005, p. 33). a major concern of the Penn- front as a leader in
Mechanical methods for be- sylvania Department of Health, trauma-informed
havior control were believed to the Office of Mental Health and care initiatives and
be necessary. A variety of me- Substance Abuse Services of the humane treatment
chanical restraining devices were Commonwealth of Pennsylvania, models for individu-
introduced. From tranquilizer and The Joint Commission. Since als with mental illness.

Journal of Psychosocial Nursing Vol. 47, No. 1, 2009 35


Initial Training Program
To respond fully to the call to
20 19 action to reduce restraint use, a
18 clearly defined plan was needed.
More material, resources, and
16 direction were needed in how
Total Number of Patients

14 to achieve the goal of restraint


reduction. In March 2005, two
12 team members attended the Na-
10
Restraint elimination tional Executive Training Insti-
9 project initiated
8 tute (NETI) (2005) program for
8 the reduction of seclusion and
restraint. Although this program
6 5 was for the public mental health
4
4 3 sector, the team members were
welcomed into the group.
2 The program provided the
0
0 direction needed to guide efforts
02 03 04 05 06 07 08 to effect change. NETI gener-
-20 -20 -20 -20 -20 -20 -20
01 02 03 04 05 06 07 ously provided volumes of edu-
20 20 20 20 20 20 20
cational and how-to materi-
Fiscal Year als. The 3 days of presentations,
many interactive, were filled
Figure 1. Number of patients restrained on this behavioral health unit fiscal year with excellent examples of how
2001-2002 through 2007-2008. to proceed. A manual including
every PowerPoint presentation
Since recognition of trauma events The unit is in an older hospi- was provided on the first day. A
and trauma-informed care, consid- tal structure and is configured in DVD containing all of the Pow-
erable energy has gone toward re- a T shape. The central wing is an erPoint presentations was avail-
ducing the use of restraints in the intensive care psychiatric unit able as well.
care of people with mental illness (ICU) where more acutely ill in- Every presentation was rich
(Huckshorn, 2004). dividuals are held until they are with ideas and suggestions. The
ready to move to the less acute workshop opened with a film
Achieving a Restraint- areas. This ICU wing is locked showing, one after another, chil-
Free Environment as well. Elevators open into the dren and adolescents who had
Description of the Unit center of the unit, although these died during or in the process of
The leadership team of a 26- are restricted in use to certain restraint or seclusion. Included
bed behavioral health inpatient hospital employees with badge- were the offenses of the in-
unit within a private, nonprofit activated access. dividual who required restraint
248-bed community hospital Cameras monitor all public or seclusion. The presentation
had been focusing on decreas- areas and hallways, with a tele- effectively communicated the
ing restraint use. This unit is vision monitor located at both risksboth physical and emo-
locked and is licensed to provide nursing station areas. There is a tionalof restraint use.
care for clients age 14 and older. main nursing station on the less Trauma theory was pre-
Eighty percent of admissions are acute wing and a smaller, satellite sented next, and with it came
processed through the hospital nursing station on the ICU wing. many aha moments for those
emergency department. All di- The average daily census is 17, who had no previous training
agnostic categories are accepted, and the average length of stay is in trauma theory. Further pre-
and admissions are voluntary and currently 5 to 7 days. Much lon- sentations provided more exact
involuntary. The top three diag- ger stays of 4 to 6 weeks or more directions regarding what has
nostic categories are severe recur- occur when patients are awaiting worked for others and what to
rent depression, bipolar disorder, placement in longer term treat- expect as movement is made
and schizoaffective disorder. ment centers. toward restraint reduction. For

36 JPNonline.com
example, staff reactions to pro- From mid-2005, organization
posals to reduce or eliminate of the project became a prior- Table
restraint use can be unpredict- ity. A project chairperson was
able. Many staff react with fear, appointed. Highest level man- Comparison of rates of five
voicing concern for their safety, agement support was obtained. sedative-hypnotic agentsa the
as well as patient safety. These The organizations senior leaders year prior to initiation of the
concerns must be addressed. supported restraint elimination restraint elimination project
100%. They provided additional to the first full year with
Steps to Goal Achievement guidance, access to specialty in-
zero restraints
After completion of the pro- formation service resources, and
gram and the decision to un- visible leadership support. A Year
dertake this project to reduce Project Charter and Statement Variable 2004 2007
restraint use, the project team of Work was developed. A time
Number of patient days 4,919 4,715
established an action plan and line and action plan was created,
time line. The first task was sort- and a project implementation Number of total dosages 4,271 3,208
ing the volumes of material into team was formed. The team in- of the five agents
manageable, bite-size imple- cluded risk management person- Dosage rate per patient 0.87 0.68
mentation pieces. The time line nel, middle and top leaders, and day
proposed by the workshop lead- frontline nursing staff. Including
ers was 18 months. frontline nursing staff was criti- a
The five agents are lorazepam (Ativan),
Restraint events were highly cal for goal success. They were haloperidol (Haldol), fluphenazine (Prolixin),
traumatic for both patients and the day-to-day champions of re- chlorpromazine (Thorazine), and olanzapine
staff on the unit. Physical injury, straint avoidance. (Zyprexa).
even death, was always a possibil-
ity. Knowing death was a possible Vision
outcome, the staff were chal- The original goal was restraint a major and occasionally over-
lenged to reach beyond the goal reduction, but after only approxi- whelming task. Presentations to
of restraint reduction. The vision mately 2 weeks, the Director of staff were developed from these
became restraint elimination. Patient Services for Behavioral conference materials and deliv-
Much of the information Health began calling it restraint ered during an 18-month period.
provided was essential for the elimination and challenged ev- The first presentation, Child-
culture change. Learning about eryone to think in that direction. hood Trauma: Prevalence and
trauma theory was a major eye- The direction was Reach for the Effects, laid the groundwork.
opener. According to Psychiatric- stars; you just might succeed. Staff learned about trauma theo-
Mental Health Nursing: Scope and The restraint elimination vi- ry. Statistics of trauma cases, ex-
Standards of Practice (American sion had to be kept constantly pected to be dull subject matter,
Psychiatric Nurses Association, in the forefront. As a key com- were too compelling to be dull.
2007), The psychiatric-mental ponent in achieving culture This statistical portion now ap-
health nurse provides, structures change, restraint elimination pears to have been a pivotal
and maintains a safe and thera- was constantly addressed, alluded point in realizing culture change
peutic environment in collabora- to, promoted, and talked up in on the unit. Staff could relate to
tion with patients, families and staff meetings and impromptu these numbers. In many cases,
other healthcare clinicians (p. gatherings. Staff safety concerns staff had personal experience
39). Restraining was retrauma- were discussed repeatedly. with trauma. It was necessary to
tizing people. Many nurses saw recognize and address staff be-
restraining as a violation of this Curriculum Development haviors and pain as they became
standard; knowing about retrau- and Staff Training aware of their own trauma his-
matization was even more dis- The materials provided by tories. Support and opportuni-
turbing to staff. Restraint use was NETI were invaluable. Sorting ties to debrief and acknowledge
viewed as treatment failure. Staff and condensing the PowerPoint these feelings were essential.
wanted and needed more infor- presentations and content book, Neurobiological Effects of
mation on alternative ways to along with the DVD, provided Trauma was the second subject
help agitated individuals. at the training conference was for discussion. Observable brain

Journal of Psychosocial Nursing Vol. 47, No. 1, 2009 37


The comfort room is painted pale
peach in color, with the ceiling
2,500 painted as a blue sky with soft
2004
clouds. Occupants can choose
2007
2,113 from selections of soothing na-
2,000 ture sounds or classical music
that is piped in through ceiling
Number of Dosages

speakers. A Comfort Box was


1,500 created, from which people may
1,325 select items to help them relax.
1,173 Items include a soft, washable,
handmade blanket; stress balls;
1,000 928
stuffed animals; and journaling
materials. Sensory approaches,
630
such as lavender hand lotion or
500 589 vanilla oil, are also available. A
248
235 sign is posted on the Comfort
9 229 Room door. Quoting from the
0 l Substance Abuse and Mental
am do ine ine ine
z ep n ) p eri ol ) n az n )
i m
az e ) z ap a ) Health Services Administration
ra a lo ld e ro in an x
Lo (Ativ Ha (Ha ph olix rp oraz Ol ypre (2005, p. 25), the sign reads:
Flu (Pr l o h Z
Ch (T ( The Comfort Room
A special place where you
Drug may spend some time alone. You
may ask any staff member to use
Figure 2. Comparison of sedative-hypnotic agent use for years 2004 and 2007. this room. There are items that
you can sign-out to help you calm
down and relax (stuffed animals,
changes (differences) was new ted patients was a critical compo- soft blanket, music, magazines,
information for staff. The visual nent in being able to de-escalate and more). Persons who wish to
evidence of actual brain chang- hazardous situations. Occasion- use the room will be asked to first
es resulting from emotional or ally, immediate relationship de- sign their names in the sign-in
physical trauma (visible on a velopment would be necessary. book and talk to a staff member
positron emission tomography Additional topics for staff edu- before entering.
scan) made the trauma damage cation involved summary reviews
visible and real. of previous material with added Culture Change
The third presentation, topics concerning intervention From the beginning of this
Changing a Culture, looked at skills and techniques. project, the leaders had been
the words used in conjunction warned that culture change
with patients and families. Re- Comfort Room would be the most difficult to
minders to see patients as people, The seclusion room, which accomplish. This was not true
not disease processes, reframed had never been used, was con- in this situation. At the very be-
staff members orientation. Pa- verted into a Comfort Room. The ginning of the project, some staff
tients were Mary or Joe, not that comfort room is a preventive tool members questioned the safety of
borderline or the schizophren- used to help reduce anxiety and eliminating restraint use. Con-
ic. Patients were recognized agitation. It is well established cerns were discussed repeatedly.
and acknowledged as mothers, that environment significantly The possibility to use restraints
fathers, sisters, brothers, sons, affects mood and behavior. The was always left open if the situa-
and daughters. Personalization of comfort room provides sanctu- tion truly warranted such action.
patients, or person-first, became ary from stress, and it can be a At first, restraints were used on
a priority and a way of thinking place for individuals to experi- occasion, but rarely. Finally, the
and behaving. Development of ence feelings within acceptable unit was down to no-restraint use
relationships with newly admit- boundaries (Bluebird, 2007). and achieved 1 restraint-free year

38 JPNonline.com
as of January 2008. To this date,
the unit remains restraint free. KEY P OINTS
Below are some staff quotes
reflective of attitude and culture 1. Restraint use is always a treatment failure.
change. Pseudonyms have been
used to protect their anonymity. 2. Person-centered care focuses on maintaining the dignity of the individual.
l Jennifer, RN: Restraints
3. Restraint elimination is possible in a recovery-oriented service system. Recovery
now seem barbaricsort of like is not about implementing a new model of care but doing differently what we
the days when insulin-shock do every day.
therapy was used, or cold-wet
packs. 4. A comfort room is a prevention tool that can help people maintain their dignity
l Beth, RN: I just tell pa- and assume responsibility for controlling their behaviors.
tients up frontwe do not re-
strain hereit sets the expecta- Do you agree with this article? Disagree? Have a comment or questions?
tions from the beginning. Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.
Were waiting to hear from you!
l Katie, nursing assistant: I

dont like it [restraint use]. I dont


like seeing it.
l Jesse, nursing assistant: hypnotic agents? or Are you recovery-oriented, and trauma-
There were endless opportunities substituting chemical restraint informed care principles by
for restraints, but we understood for physical restraint? This frontline staff makes a restraint-
more about difficult patients. We question has been asked, and free environment possible. It also
were better able to intervene and the answer is a resounding no. appears to reduce the need for
help people de-escalate. In fact, use of sedative-hypnotic sedative-hypnotic medication to
l Vida, RN: Restraints are agents decreased. control behavior.
inhumane and can cause harm or Comparison of administration Although restraint elimina-
even death to a patient. rates for sedative-hypnotic drugs tion was the term used to de-
l Ricardo, nursing assistant: per patient day declined by 22% scribe the goal, nursing staff of-
Our mission should always be from 2004 (the year prior to initi- ten expressed concern for safety.
to be therapeutic with patients; ation of the restraint elimination Leaving the possibility open to
restraints seem like more of a project) to 2007 (the first full year use restraints as a last resort in
punishment. with zero restraints). The mean unsafe situations allayed fears.
dosage rate per patient day in 2004 In early stages of the project, re-
Project Outcomes was 0.9 as compared with a rate of straints were used occasionally,
For trending purposes, the re- 0.7 per patient day in 2007. but as time passed, it became ap-
straint elimination project team The study included the fol- parent that few, if any, situations
gathered data regarding the inci- lowing five agents of choice by required restraint use.
dence of restraint use beginning our providers to treat agitation, Ironically, these staff mem-
with fiscal year (FY) 2001-2002. anxiety, and psychotic symp- bers are now very inexperienced
Rate of restraint use varied prior toms: lorazepam (Ativan), hal- in restraint use. Some staff
to the initiation of the project, operidol (Haldol), fluphenazine members have never cared for
ranging from a high of 19 in FY (Prolixin), chlorpromazine a patient in restraints. Skills are
2001-2002 to 9 for FY 2004- (Thorazine), and olanzapine kept current by conducting skills
2005. As the project unfolded, (Zyprexa). Comparison of rates laboratories on restraint applica-
the incidence of restraint use of use for these sedative-hypnotic tion and face-to-face assessment,
declined. The last restraint ap- agents is found in the Table and but the truth remains that few
plication occurred early in Janu- Figure 2. staff members have participated
ary 2007. There have been no in a restraining process.
restraint applications during FY Conclusion and A new set of keyless, ease-of-
2007-2008 (Figure 1). Implications for use restraints had been purchased
The first logical questions Practice midway through the project.
are, Did you get to no-restraint The evidence is compelling. These restraints remain brand
use by increasing use of sedative- Application of person-centered, new. They have never been used.

Journal of Psychosocial Nursing Vol. 47, No. 1, 2009 39


References (2005). Training curriculum for reduction Ms. Barton and Ms. Johnson are Clini-
American Psychiatric Nurses Associa- of seclusion and restraint. Alexandria, cal Managers, Behavioral Health Unit,
tion. (2007). Psychiatric-mental health VA: National Association of State Chambersburg Hospital, and Ms. Price is
nursing: Scope and standards of practice. Mental Health Program Directors, Na- Clinical Nurse Specialist in Adult Psychi-
Silver Spring, MD: American Nurses tional Technical Assistance Center for atric and Mental Health and Director of
Association. State Mental Health Planning. Patient Services and Behavioral Health,
Bluebird, G. (2007). Bluebird Consultants: Smith, G.M., Davis, R.H., Bixler, E.O., Lin, Summit Health/Chambersburg Hospital,
Using comfort, communication and the H.M., Altenor, A., Altenor, R.J., et al. Chambersburg, Pennsylvania.
arts to minimize use of restraint and seclu- (2005). Pennsylvania state hospital The authors disclose that they have
sion. Retrieved March 14, 2007, from systems seclusion and restraint reduc- no significant financial interests in any
http://www.bluebirdconsultants.com/ tion program. Psychiatric Services, 56, product or class of products discussed
Colaizzi, J. (2005). Seclusion and restraint: 1115-1122. directly or indirectly in this activity,
A historical perspective. Journal of Psy- Substance Abuse and Mental Health Ser- including research support.
chosocial Nursing and Mental Health Ser- vices Administration. (2005). Mod- The authors thank the Behavioral
vices, 43(2), 31-37. ule 5: Strategies to prevent seclusion Health Unit staff for their courageous
Hodas, G.R. (2004). Understanding and and restraint. In Roadmap to seclusion undertaking, implementation, and
responding to childhood trauma: Creating and restraint free mental health services ongoing dedication to this vision and
trauma informed care. Harrisburg: Penn- (DHHS Publication No. SMA 05- change. The authors also thank Dr.
sylvania Office of Mental Health and 4055). Retrieved March 14, 2007, Rajnikant Lad, Child and Adolescent
Substance Abuse Services. from http://download.ncadi.samhsa. Psychiatrist, for initial direction and
Huckshorn, K.A. (2004). Reducing seclu- gov/ken/pdf/SMA06-4055/Manual_ support of the change project.
sion and restraint use in mental health Module5.pdf Address correspondence to Sandra A.
settings: Core strategies for prevention. Weiss, E.M., Altimari, D., Blint, D.F., & Barton, BSN, RN, BC, Clinical Manager,
Journal of Psychosocial Nursing and Men- Megan, K. (1998, October 11). Deadly Behavioral Health Unit, Chambersburg
tal Health Services, 42(9), 22-33. restraint: A nationwide pattern of Hospital, 112 North Seventh Street,
National Executive Training Institute. death. The Hartford Courant. Chambersburg, PA 17201; e-mail:
sbarton@summithealth.org.
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