See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/266951467

Reducing Seclusion and Restraint Use in Inpatient Settings: A Phenomenological

Study of State Psychiatric Hospital Leader and Staff Experiences

Article  in  Journal of Psychosocial Nursing and Mental Health Services · October 2014

DOI: 10.3928/02793695-20141006-01 · Source: PubMed

CITATIONS READS

15 1,911

1 author:

Kevin Ann Huckshorn

State of Delaware
16 PUBLICATIONS   333 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Kevin Ann Huckshorn on 18 December 2014.

The user has requested enhancement of the downloaded file.

 A Phenomenological Study of State Psychiatric
Hospital Leader and Staff Experiences

Kevin Ann Huckshorn, PhD, RN, ICADC

ABSTRACT
The current study explored and described the experiences of individuals who
stock.com/Zyxx

either directed or participated in successfully reducing the use of restraint and

seclusion (R/S) in two inpatient public mental health hospitals. A phenomenological
© 2014 Shutter

methodology was used to capture the lived experiences of 21 study participants, in-
cluding senior leaders, middle managers, and direct care staff, who were interviewed
as key informants. Thirty-two themes were extracted and subsequently synthesized
into five “meaning themes.” The five meaning themes yielded six significant findings:
(a) critical roles of leadership and staff in successful R/S reduction projects; (b) ability
of leaders and staff to change their beliefs and behaviors; (c) ability of leaders
and staff to build a shared vision that was critical to the reduction of R/S use in in-
patient settings; (d) identification and resolution of key challenges staff and leaders
experienced in reduction efforts; (e) use of a solid performance improvement lens to
direct changes in practices; and (f ) important lessons learned. [Journal of Psychoso-
cial Nursing and Mental Health Services, 52(11), 40-47.]

40 Copyright © SLACK Incorporated


C
urrently, a large number of
inpatient mental health set-
tings in the United States
provide services that are still based
on a traditional model of care that is
uninformed by recovery-oriented prin-
ciples, trauma, person-directed care,
or evidence-based practices (National
Association of State Mental Health
Program Directors [NASMHPD],
2014b; Wale, Belkin, & Moon, 2011).
This traditional inpatient culture
of care can be characterized by (a)
paternalistic attitudes; (b) staff-to-
consumer power struggles; (c) one-
size-fits-all treatment practices; (d) a
lack of voice from individuals being
served; (e) indiscriminately applied
rules resulting from attempts to con-
trol behaviors; (f) practices based on
intuition rather than evidence; and
(e) often blatant discrimination ex-
pressed through language, practices,
and policies in inpatient settings
(Anthony, Cohen, Farkas, & Gagne,
2002; Huckshorn, 2004; NASMHPD,
2014b). Traditional mental health
practices include (a) talking or writing
about patients as though they were a
disease (e.g., schizophrenic, borderline);
(b) providing documentation in medi-
cal records that reduces requests for
help to adjectives, such as needy, ma-
nipulative, attention seeking, or intrusive;
(c) enforcing idiosyncratic rules that
expect all patients to go to bed at fixed
times regardless of sleep patterns; (d)
requiring mandatory wake-up times
mostly for staff convenience; and (e)
instilling expectations that individuals
passively accept treatment team rec-
ommendations that they had no role
or voice in developing (NASMHPD,
2014a; Robins, Sauvageot, Cusack,
Suffoletta-Maierle, & Frueh, 2005).
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 52, NO. 11, 2014
Earn
Contact
Hours
Inpatient mental health service
culture can be experienced as patron-
izing, shaming, and disrespectful, and
such an environment can lead to pa-
tients’ distrust, which, in turn, results
in poor clinical care (Bluebird, 2004;
Huckshorn, 2007). Previous research
studies have focused on patient expe-
riences that documented the unneces-
sary use of force, a lack of respect from
staff, feeling punished but not under-
standing why, and feeling not listened
to by or having quality time with staff
(Allen, Carpenter, Sheets, Miccio, &
Ross, 2003; Ray, Myers, & Rappaport,
1996). This research topic is relatively
unstudied, but it is the current au-
thor’s experience that these situations
still widely exist. Therefore, it should
not be surprising that staff practices in
these treatment environments can re-
sult in conflicts, threatened or real vio-
lence, and staff responses that include
the use of restraint and seclusion (R/S)
(Callaghan, Nijman, Palmstierna, &
Oud, 2007).
The use of R/S interventions are
controversial and potentially danger-
ous staff practices that are used in most
inpatient mental health care settings
to control an individual patient’s be-
havior that is deemed to be danger-
ous (American Psychiatric Nurses
Association [APNA], 2014; National
Association of Psychiatric Health
Systems & American Hospital Asso-
ciation, 2003; NASMHPD, 2014b).
Seclusion is defined as the “involuntary
confinement of a person in a room or
an area where the person is physically
prevented from leaving” (U.S. Depart-
ment of Health and Human Services
[USDHHS], 2006, 13[f][1]). A seclu-
sion event begins when the individual
is escorted, usually involuntarily, by
staff to a room that is locked or un-
locked where he or she is isolated from
others and physically prevented from
leaving; the event ends when the in-
dividual is informed that he or she can
leave on his or her own volition.
Restraint is defined as a manual (i.e.,
physical) hold or mechanical device,
material, or equipment attached or
adjacent to an individual’s body that
is not easily removed and restricts the
individual’s freedom or normal access
to one’s body (NASMHPD, 2014a;
USDHHS, 2006). Mechanical re-
straint practices include leather or plas-
tic cuffs for extremity immobilization
to a bed or cot, wrist-to-waist restraints
or ankle hobbles, lap belts, lap trays at-
tached to chairs, restraint chairs, and
Posey vests. Physical or manual holds
are mostly, but not always, used on
children and adolescents (NASMHPD,
2014a; USDHHS, 2006). It has been
noted that only in health care settings
is the human and civil right to free-
dom displaced without oversight by a
law enforcement officer, judge, or jury
(NASMHPD, 2014a).
RESTRAINT AND SECLUSION
PRACTICES
R/S practices have received a much
greater level of interest, oversight,
and regulation by legislators and pol-
icy makers in recent years (APNA,
2014; USDHHS, 2006). In part, this
interest initially emerged in response to
hospitals not reporting serious injuries
and deaths in inpatient mental health
service settings. An exposé in The Hart-
ford Courant (Weiss, Altimari, Blint, &
Megan, 1998) and in other investiga-
tions (U.S. General Accountability
Office [USGAO], 1999), coupled with
subsequent research, have shown that
41
R/S are in and of themselves aggressive
and violent acts and have a palpably
negative effect on the quality of care
provided. In addition, they create un-
safe conditions for both patients and
staff, lower staff morale, and increase
staff turnover (NASMHPD, 2014a).
The use of coercive and invasive prac-
tices in settings expected to be safe
and recovery-oriented interrupts and
negates the necessary trust and treat-
ment alliance that is fundamental to
successful engagement with individuals
in care (NASMHPD, 2014b).
R/S practices are most commonly
initiated by inpatient mental health
staff in response to unique clinical sit-
uations, which are generally described
as dangerous patient behaviors that
are experienced by staff as threaten-
ing (NASMHPD, 2014a; USGAO,
1999; Weiss et al., 1998). Situations in
which R/S are used often have similar
origins: the emergence of a conflict be-
tween an individual patient and staff
member, or between patients them-
selves, that escalates and results in a
staff member deciding that only R/S
can control the situation. Although
regulatory language exists that is in-
tended to limit the use of R/S to situ-
ations that are characterized by im-
minent danger, this language is highly
subjective and leaves decision making
up to individual direct care staff, many
cal knowledge about the culture of care METHOD
that supports the use of R/S, the cur- The current study’s data collec-
rent study used a phenomenological tion began with the selection of
methodology instead of a quantitative two state-operated mental health
method, as this was believed to be the facilities, which were chosen based
best method to capture the lived ex- on the state mental health office’s
periences of leaders and staff who suc- agreement to participate in the cur-
cessfully reduced the use of R/S in their rent research project and because they
hospital work environments. were geographically accessible for the
author. The facilities provide services
RESEARCH QUESTIONS to different populations: one facility
The research questions for the cur- provides child, adolescent, and adult
rent study were: services, and the other facility provides
only adult services. The primary key
informants in each hospital included
leadership staff holding executive,
Contemporary and senior, or middle management posi-
tions, in addition to direct care staff.
credible research on The phenomenon of interest and fo-
R/S use unequivocally cus of the current study, common to
all participants, was their personal
concludes that R/S experiences in either directing or par-
cause trauma, result ticipating in an organizational change
process that resulted in a successful re-
in emotional and duction in the use of R/S (i.e., a ≥65%
physical injuries reduction from each hospital’s own
baseline). Participant recruitment was
to patients and based on purposeful sampling, a strat-
staff, and sabotage egy that researchers seeking to under-
stand a specific experience use and one
the therapeutic that only includes participants who
milieu and clinical have first-hand knowledge of the phe-
nomenon under study (Patton, 2002).
relationship on the The interview questions were ini-
ward. tially broad-based and further refined
© 2014 Shutterstock.com

of whom are relatively inexperienced during the research process (Mertens,

and hold 2-year college degrees or
less (NASMHPD, 2014a; USGAO,
1999; Weiss et al., 1998). Overall, the
policy and practice of R/S use is not
supported by credible science-based
evidence, except as a safety measure
of last resort (Institute of Medicine,
2005; NASMHPD, 2014b).
PURPOSE
The principle investigator (K.A.H.)
of the current study explored the de-
scribed experiences of leaders and staff
in mental health inpatient facilities
who had directed or participated in
successfully reducing the use of R/S in
their facilities. Due to a lack of empiri-
1. How did inpatient mental health
hospital leaders and staff describe the
experience of successfully reducing the
use of R/S?
2. How did mental health hospital
leaders and staff change their organiza-
tional culture from one that used R/S
to one that was able to implement new
practices to avoid the use of R/S?
3. What strategies did mental
health hospital leaders and staff use to
implement successful organizational
change, and how did they communi-
cate these strategies to staff?
2005). Thirty-three semistructured,
open-ended questions emerged through
the researcher’s literature review and
experiences. This semistructured in-
terview protocol was field tested with
three chief operating officers (COOs)
and one medical director in other hos-
pitals who significantly reduced the
use of R/S in their respective facilities.
Phenomenological methods require an
active researcher role, beginning with
gathering, audiotaping, and transcrib-
ing interviews; reviewing data from
individuals who have lived the phe-
nomenon of interest; and analyzing
and interpreting these data. This anal-
ysis includes both “dwelling with the

42 Copyright © SLACK Incorporated

data” and bracketing personal beliefs
and biases during the research process
(Patton, 2002; Speziale & Carpenter,
2006).
The researcher, with help from
each hospital’s chief executive offi-
cer (CEO), identified senior leaders,
middle managers, and direct care staff
(N = 21) who had the most indepth
information regarding the focus of the
current research. The senior leaders
identified for inclusion included the
CEO, COO, medical director, chief
nursing officer, director of consumer
affairs, performance improvement di-
rector, and other senior leaders. A vari-
ety of middle managers and direct care
staff were also interviewed. Because fa-
cilities may designate different titles for
these positions, the terms senior leader,
middle manager, and direct care were
used to designate staff levels. Many of
those interviewed held nursing staff
positions or were licensed nurses.
The next step was to locate general
concepts or statements within the par-
ticipant responses that spoke directly
to the lived experience (Patton, 2002).
These key phrases were then studied as
to their meanings from the informed
stance of the researcher. To complete
this step, each participant’s response
was carefully analyzed in regard to
every interview question.
Participant responses to each ques-
tion, also called thematic excerpts, were
analyzed to identify commonalities.
Agreement among at least three of the
21 participants was considered a re-
sponse commonality. Commonalities
that were discovered were then further
analyzed against the original thematic
excerpts from the transcripts. In the
end, 115 initial common themes were
identified.
The researcher engaged the services
of a statistician and used a kappa coef-
ficient statistical process to measure
the level of agreement between two
external raters who were asked to re-
view the work to date. The external
expert raters found 98 common themes
(of the original 115) on which they
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 52, NO. 11, 2014
agreed. The kappa coefficient process is
a conservative statistical measure of
interrater reliability or agreement that
is used to assess qualitative documents
and determine agreement between rat-
ers (Trochim, 2000).
Of the agreed on initial 98 potential
themes, 32 themes that reached at least
fair (i.e., 21% to 60%) agreement were
synthesized into five “meaning theme”
statements, which were used to write
textural, structural, and composite de-
scriptions of the research phenomenon
(Creswell, 2007, p. 62). These three
descriptions are focused on the com-
mon experiences of the interviewed
participants through the development
of the underlying structure of the lived
experience. These descriptions include
three long paragraphs, from which a
reader should walk away feeling, “I un-
derstand better what it is like for some-
one to experience…”(Creswell, 2009,
p. 62).
The last activity of the data analyses
constituted synthesizing the five mean-
ing themes and narrative descriptions
into six significant findings, which rep-
resented the final analysis of what the
participants in the current study expe-
rienced to successfully reduce the use
of R/S. This final step provided a rich
and indepth understanding of the phe-
nomenon under study, as experienced
by several or more key informants
(Creswell, 2007).
RESULTS
The two state hospitals that
provided the inpatient settings for
study are more similar than differ-
ent. Both hospitals serve clients in
civil and forensic settings, are publicly
funded and managed by the state gov-
ernment, hold accreditation from the
Joint Commission, and are certified
by the federal Centers for Medicare &
Medicaid Services (CMS). Both hos-
pitals demonstrate highly similar staff-
ing patterns, types of staff, patient–
staff ratios, lengths of stay (from 6
months to 1 year), and admission and
discharge activity. Differences include
capacity and type of clients. Hospital
B serves a larger number of clients
(N = 192), including adolescents, and
Hospital A has the capacity to serve
169 adults. Both hospitals employ a
similar number of staff (Hospital A,
N = 451; Hospital B, N = 532), given
Hospital B’s slightly larger size.
Meaning Themes
Thirty-two themes were extracted
from the raters’ review of the original
98 identified themes (Appendix A,
available in the online version of the
article). These themes were further
analyzed and reduced to five meaning
themes, including:
(a) State and hospital leaders took
on critical roles in successful R/S re-
duction projects in their respective
hospitals.
(b) Leaders and key hospital staff had
to change their beliefs and behaviors
about the use of R/S throughout the
project.
(c) Leaders and key hospital staff
had to identify and operationalize new
interventions to prevent the use of R/S
throughout the project.
(d) Leaders and key hospital staff
needed to identify and resolve key
challenges to the reduction effort.
(e) Hospital leaders and key staff
were able to report important lessons
learned as a result of this process and
indicate what they would do differently
next time.
Textural Description
A textural description of the phe-
nomenon of interest is a description
of “what the participants in the study
experienced with the phenomenon,”
(Creswell, 2007, p. 159) as reported
to the researcher. This description also
helps answer research Question 1 (i.e.,
“How do inpatient mental health hos-
pital leaders and staff describe the ex-
perience of reducing successfully the
use of R/S?”).
The participants in the current
study described their experiences in
successfully reducing the use of R/S as a
43
 “project that needed to be led by state-
and hospital-level executive leaders
who were able to change the way that
seclusion and restraint were viewed by
staff.” Staff described the change in the
use of R/S from a baseline of being an
“unquestioned, culturally based, prac-
tice norm” to being an “event to be
avoided if at all possible” by reducing
opportunities for staff-to-client con-
flicts resulting from hospital rules and
old beliefs.
Hospital staff in both facilities met
the initial announcement of the goal
to reduce R/S with mixed reactions,
A ranging from negative, to skeptical,
to being welcomed. Over time, most
hospital staff learned new skills to
avoid R/S use and demonstrated new
beliefs, as evidenced by the data that
show that R/S are now rarely used and
only for dangerous behaviors (Figure
1 and Figure 2). Key challenges, such
as a lack of resources, communication
issues, staff uncertainty in practicing
new ways of working, and an initial
negative reaction to change, are com-
mon barriers to implementing organi-
zational changes.

Structural Description
A structural description “reflects
B on the setting and context in which
the phenomenon was experienced”
(Creswell, 2009, p. 161), as reported
by study participants. This statement
also helped answer research Questions
2 and 3 (i.e., “How did mental health
hospital leaders and staff change their
organizational culture from one that
used R/S to one that was able to imple-
ment new practices to avoid the use of
R/S?” and “What strategies did mental
health hospital leaders and staff use to
implement successful organizational
change, and how do they communi-
cate these strategies to staff?”).
At the beginning of the R/S reduc-
tion project, participants characterized
the two hospitals’ organizational cul-
C tures as believing that the use of R/S
Figure 1. Hospital A data for years 2003 to 2008 regarding restraint/seclusion and use of was a normal practice, part of usual
involuntary medicine by (A) patients, (B) hours, and (C) episodes. FY = fiscal year. staff practices, a way to efficiently con-

44 Copyright © SLACK Incorporated

trol clients, a way to keep the units
safe, and the only available option for
staff. The introduction of a new ap-
proach that engendered new thinking
about R/S occurred initially through
specific and credible external training;
this training was seen as a key change
agent. As the project progressed, it be-
came a performance-improvement pro-
cess, in which leaders and staff could
carefully analyze events and learn how
to improve their responses to potential
conflicts. Challenges were identified
during the project, including a lack of
resources, difficulty in communicating
in a timely way with all staff, delayed A
responses to staff concerns, staff uncer-
tainty in trying new approaches with
clients, attempts to include consumers
in the change process, and leaders act-
ing in a way that made staff believe
they were being blamed or criticized.
Success in both hospitals occurred as a
result of the involvement of key lead-
ers at the state and hospital executive
level and direct care staff who led by
example (i.e., core group of staff who
were willing to risk and change their
behaviors and help other staff change
their behaviors). Lessons learned in-
cluded the need to involve clients
sooner and manage staff concerns more
effectively and rapidly. B
Composite Description
A composite description synthesizes
the “textural and structural descrip-
tions and serves to describe the essence
of the phenomenon” (Creswell, 2007,
p. 161).
The successful reduction of the use
of R/S in mental health settings requires
an organizational culture change that
begins with key executive organiza-
tional leadership staff acting as change
agents; the ability of leaders and staff
to change their beliefs and behaviors as
new information is accumulated about
what works; and the ability of leaders
and staff to practice and model success,
resolve challenges, and incorporate les- C
sons learned along the way. Figure 2. Hospital B data for years 2003 to 2008 regarding restraint/seclusion and use of
involuntary medicine by (A) patients, (B) hours, and (C) episodes. FY = fiscal year.

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 52, NO. 11, 2014 45

 apply. These findings support identify-
ing the critical importance of leaders,
KEYPOINTS their significant roles in helping staff
Huckshorn, K.A. (2014). Reducing Seclusion and Restraint Use in Inpatient Settings: A
Phenomenological Study of State Psychiatric Hospital Leader and Staff Experiences. in reducing R/S, and specific strate-
Journal of Psychosocial Nursing and Mental Health Services, 52(11), 40-47. gies that were found to be effective in
successfully reducing the use of R/S.
1. Staff described their participation in reducing the use of restraint and Senior state office leaders, hospi-
seclusion (R/S) as a project that needed to be led by state and hospital
tal senior leaders, and middle man-
executive-level leaders who had the power to change the way R/S were
viewed by direct care staff (i.e., from a practice that was normal and agers assumed critical roles in lead-
unquestioned to an event to be avoided if possible). ing and modeling an organizational
effort to alter staff beliefs about the
2. Staff beliefs about R/S use changed over time. This change seemed to be a use of R/S. The critical role of lead-
result of initial training on how to work to avoid conflicts that lead to violence ership in reducing the use of R/S in
and a performance improvement initiative in which all staff were involved in
mental health settings, including in-
analyzing events and preventing them in the future.
patient hospitals, has been inferred
3. Over time, hospital staff came to believe that R/S can be avoided by reducing or identified as a key component in
opportunities for staff-to-client conflicts through minimizing hospital/ recent literature (Ashcraft, Bloss, &
ward rules, learning new skills, adopting a prevention approach to conflicts, Anthony, 2012; Azeem, Aujla, Ram-
including patients and peers in this work, and finding champions of the merth, Binsfeld, & Jones, 2011; Bar-
project among direct care staff.
ton, Johnson, & Price, 2009; Lewis,
Do you agree with this article? Disagree? Have a comment or questions? Taylor, & Parks, 2009; Sullivan et al.,
Send an e-mail to the Journal at jpn@healio.com. 2005; Wale et al., 2011; Witte, 2008).

IMPLICATIONS FOR NURSING

Significant Findings
Hospital staff members’ beliefs at the
beginning of the project were that (a) R/S
use was a normal practice in the hospital,
(b) R/S use kept the units safe, (c) R/S
use was efficient, and (d) R/S interven-
tions were ones that staff could control.
Hospital staff members’ beliefs
about R/S significantly changed dur-
ing the project time frame and came
to be viewed as “practices that could
be avoided by reducing opportunities
for staff-to-client conflicts by minimiz-
ing hospital rules, learning new skills,
adopting a prevention approach to con-
flict, including patients in the project,
and finding champions among the di-
rect-care staff to help,” as described by
one study participant.
The work to reduce the use of R/S
resulted in a number of challenges, as
reported by hospital leaders and staff
when they implemented change. These
challenges included a reported “lack of
resources, communication issues, resis-
tance from some staff, and leadership
behavior that was interpreted as ‘blam-
ing staff’ for the use of seclusion or re-
straint that were important to manage
in this study,” as detailed by one par-
ticipant.
Approaching the R/S reduc-
tion project through a performance-
improvement lens was helpful, as it
avoided blame and focused on what
worked. The use of data to direct prac-
tice changes was a key component of
performance-improvement work in the
current study.
Lessons learned by hospital leaders
and staff included the following: if they
were to repeat this project, they would
immediately focus on staff development
and training, manage staff concerns
better and faster, involve clients imme-
diately in the project, regularly show
R/S data to direct care staff, and avoid
anything that could be interpreted as
blaming direct care staff.
DISCUSSION
Many mental health hospitals are
still struggling with how to reduce
violence, conflict, and the use of R/S
in their settings. The current study’s
findings are important for mental
health policy makers and clinical and
administrative leaders to process and
The nursing staff workforce is the
key ingredient to develop, maintain,
and monitor inpatient environments
of care for individuals with mental
health conditions who are admitted
to these settings. As such, nursing
staff serve an important and signifi-
cant function in understanding and
assuring the use of research-based
best practices in inpatient settings.
Contemporary and credible research
on R/S use unequivocally concludes
that R/S cause trauma, result in
emotional and physical injuries to
patients and staff, and sabotage the
therapeutic milieu and clinical rela-
tionship on the ward. Nursing staff
have the power to adopt new ways
of addressing potential conflict in
the treatment environment and have
the competencies, if used, to prevent
much of this conflict from occurring.
CONCLUSION
Nursing leadership and staff play
a powerful role in implementing
new evidence-based practices to re-
duce coercion, violence, and events
that lead to the use of R/S in inpa-

46 Copyright © SLACK Incorporated


tient settings. The nursing profession
should adopt and support this work,
assure that these competencies are
addressed in academic settings and
in new hospital orientation train-
ing, and add these competencies to
nursing’s scope of practice and ethics
codes going forward.
REFERENCES
Allen, M.H., Carpenter, D., Sheets, J.L., Miccio,
S., & Ross R. (2003). What do consumers
say they want and need during a psychiatric
emergency? Journal of Psychiatric Practice, 9,
39-58.
American Psychiatric Nurses Association.
(2014). APNA position statement on the
use of seclusion and restraint. Retrieved
from http://www.apna.org/i4a/pages/index.
cfm?pageid=3728
Anthony, W., Cohen, M., Farkas, M., & Gagne,
C. (2002). Psychiatric rehabilitation (2nd ed.).
Boston, MA: Center for Psychiatric Rehabili-
tation, Boston University.
Ashcraft, L., Bloss, M., & Anthony, W.A. (2012).
Best practices: The development and imple-
mentation of “no force first” as a best practice.
Psychiatric Services, 63, 415-417. doi:10.1176/
appi.ps.20120p415
Azeem, M.W., Aujla, A., Rammerth, M., Bins-
feld, G., & Jones, R.B. (2011). Effective-
ness of Six Core Strategies based on trauma
informed care in reducing seclusions and
restraints at a child and adolescent psychi-
atric hospital. Journal of Child and Adolescent
Psychiatric Nursing, 24, 11-15. doi:10.1111/
j.1744-6171.2010.00262.x
Barton, S.A, Johnson, M.R., & Price, L.V.
(2009). Achieving restraint-free on an inpa-
tient behavioral health unit. Journal of Psy-
chosocial Nursing and Mental Health Services,
47(1), 34-40.
Bluebird, G. (2004). Redefining consumer roles:
Changing culture and practice in mental
health settings. Journal of Psychosocial Nursing
and Mental Health Services, 42(9), 46-53.
Callaghan, P., Nijman, H., Palmstierna, T., &
Oud, N. (2007). Proceedings of the 5th Euro-
pean Congress on violence in clinical psychiatry.
Retrieved from http://www.oudconsultancy.
nl/Resources/Proceedings_5th_Violence_in_
Clinical_Psychiatry_2007.pdf
Creswell, J.W. (2007). Qualitative inquiry and re-
search design: Choosing among five approaches
(2nd ed.). Thousand Oaks, CA: Sage.
Creswell, J.W. (2009). Research design: Qualita-
tive, quantitative, and mixed methods approaches
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 52, NO. 11, 2014
(3rd ed.). Thousand Oaks, CA: Sage.
Huckshorn, K.A. (2004). Reducing seclusion
restraint use in mental health settings: Core
strategies for prevention. Journal of Psychiatric
and Mental Health Nursing, 42(9), 22-33.
Huckshorn, K.A. (2007). Building a better
mental health workforce: 8 core elements.
Journal of Psychosocial Nursing and Mental
Health Services, 45(3), 24-34.
Institute of Medicine. (2005). Improving the qual-
ity of health care for mental and substance-use
conditions. Washington, DC: National Acad-
emies Press.
Lewis, M., Taylor, K., & Parks, J. (2009). Crisis
prevention management: A program to re-
duce the use of seclusion and restraint in
an inpatient mental health setting. Issues
in Mental Health Nursing, 30, 159-164.
doi:10.1080/01612840802694171
Mertens, D.M. (2005). Research and evaluation in
education and psychology: Integrative diversity
with quantitative, qualitative, and mixed methods
(2nd ed.). Thousand Oaks, CA: Sage.
National Association of Psychiatric Health
Systems & American Hospital Association.
(2003). Learning from each other: Success sto-
ries and ideas for reducing restraint/seclusion
in behavioral health. Retrieved from https://
www.naphs.org/search/global_results.aspx?c
boSections=All&txtKeyword=Learning%20
from%20each%20other:%20Success%20
stories%20and%20ideas%20for%20
reducing%20restraint/seclusion%20in%20
behavioral%20health
National Association of State Mental Health
Program Directors. (2014a). National Execu-
tive Training Institutes: Training curriculum for
reduction of seclusion and restraint. Draft curric-
ulum manual, revised (12th ed.). Alexandria,
VA: Author.
National Association of State Mental Health
Program Directors. (2014b). The vital role
of state psychiatric hospitals. Retrieved from
http://www.nasmhpd.org/publications/
The%20Vital%20Role%20of%20State%20
Psychiatric%20HospitalsTechnical%20
Report_July_2014.pdf.
Patton, M.Q. (2002). Qualitative research and
evaluation methods (3rd ed.). Thousand Oaks,
CA: Sage.
Ray, N.K., Myers, K.J., & Rappaport, M.E.
(1996). Patient perspectives on restraint and
seclusion experiences: A survey of former pa-
tients of New York State psychiatric facilities.
Psychiatric Rehabilitation Journal, 20, 11-18.
doi:10.1037/h0095407
Robins, C.S., Sauvageot, J.A., Cusack, K.J.,
Suffoletta-Maierle, S., & Frueh, B.C. (2005).
Consumers’ perceptions of negative experi-
ences and “sanctuary harm” in psychiatric
settings. Psychiatric Services, 56, 1134-1138.
Speziale, H.J.S., & Carpenter, D.L. (2006).
Qualitative research in nursing: Advancing the
humanistic perspective (4th ed.). Philadelphia,
PA: Lippincott, Williams, & Wilkins.
Sullivan, A.M., Bezmen, J., Barron, C.T., Rivera,
J., Curley-Casey, L., & Marino, D. (2005).
Reducing restraints: Alternatives to restraints
on an inpatient psychiatric service: Utilizing
safe and effective methods to evaluate and
treat the violent patient. Psychiatric Quar-
terly, 76(1), 51-65.
Trochim, W. (2000). The research methods knowl-
edge base (2nd ed.). Cincinatti, OH: Atomic
Dog Publishing.
U.S. Department of Health and Human Ser-
vices. (2006). 42 CFR Part 482 Medicaid and
Medicare programs; hospital conditions of par-
ticipation: Patients’ rights; final rule. Retrieved
from https://www.cms.gov/Regulations-
and-Guidance/Legislation/CFCsAndCoPs/
downloads/finalpatientrightsrule.pdf
U.S. General Accountability Office. (1999).
Mental health: Improper restraint or seclusion
use places people at risk. Retrieved from http://
www.gao.gov/products/HEHS-99-176
Wale, J.B., Belkin, G.S., & Moon, R. (2011).
Reducing the use of seclusion and restraint
in psychiatric emergency and adult inpatient
services: Improving patient-centered care.
The Permanente Journal, 15(2), 57-62.
Weiss, E.M., Altimari, D., Blint, D.F., & Me-
gan, K. (1998, October 11). Deadly re-
straint: A nationwide pattern of death. The
Hartford Courant. Retrieved from http://
yourchildmychild.com/deadlyrestraint/day1.
htm
Witte, L. (2008, March 31). Reducing the use of
seclusion and restraint. Retrieved from http://
www.behavioral.net/article/reducing-use-
seclusion-and-restraint
Dr. Huckshorn is Director, Division of Sub-
stance Abuse and Mental Health, Delaware
Department of Health and Social Services, New
Castle, Delaware.
The author has disclosed no potential conflicts
of interest, financial or otherwise.
Address correspondence to Kevin Ann
Huckshorn, PhD, RN, ICADC, Director, Division of
Substance Abuse and Mental Health, Delaware
Department of Health and Social Services, 1901
North Dupont Highway, New Castle, DE 19720;
e-mail: Kevin.huckshorn@state.de.us.
Received: July 24, 2014
Accepted: September 5, 2014
Posted: October 15, 2014
doi:10.3928/02793695-20141006-01
47
 APPENDIX A
KAPPA COEFFICIENTS FOR 32 THEMES WITH FAIR TO MODERATE AGREEMENT
Theme Theme Name Kappa Coefficient
1 Department of Mental Health changed seclusion and restraint practices 0.29*
2 National Technical Assistance Center training changed seclusion and restraint practices 0.46**
3 Already working on this 0.31*
4 Welcomed it 0.37*
5 Mixed reaction, skeptical 0.37*
6 Negative reaction, no way 0.45**
8 Staff behavior and culture affect the use of seclusion and restraint 0.36*
9 Use of seclusion and restraint upset me 0.80***
12 Staff controlled with negative attitudes and resistance to change 0.27*
13 Norm, not questioned 0.31*
14 Seclusion and restraint was used for self-harm to keep unit safe 0.39*
15 Seclusion and restraint was part of the staff ’s job and was efficient 0.66***
16 Seclusion and restraint was based on unit culture and staff beliefs 0.21*
19 Leadership at state and executive levels was critical in reducing seclusion and restraint 0.23*
21 Leadership needed to be led by example at all levels 0.30*
24 Hospital middle managers and key hospital staff in informed roles changed seclusion 0.29*
and restraint
28 Lack of resources was a challenge 0.36*
29 Communication issues were a challenge 0.33*
31 Uncertainty in new treatments and methods was a challenge 0.22*
32 Staff reacted with negative emotions 0.42**
37 A shift has occurred in staff ’s philosophy on when to use seclusion and restraint 0.26*
41 Staff have learned new skills and do not immediately resort to seclusion and restraint 0.34*
43 Project was a performance/quality improvement; discretely analyzed current practices 0.50**
to improve future practices
45 Including patients in change was important 0.21*
46 Would focus on staff development and training staff in new skills and practices right away 0.52**
48 Would manage line staff concerns better and faster 0.40*
49 Involve consumers/clients immediately in this project 0.67***
53 Now seclusion and restraint is used only for very dangerous and unremitting behaviors 0.25*
after everything else possible is tried
55 We have worked to reduce opportunities for staff-to-client conflicts over hospital rules 0.50**
and old beliefs
62 Least effective was doing anything that staff interpreted as blaming or criticizing them 0.22*
65 A core group of some of the line staff who were champions for reducing, just willing to 0.21*
help, or to change their behaviors
66 They were key mostly because of their power and their involvement and their values, so 0.23*
they could use these to make change happen
83 Direct care staff responded well to getting data about use of seclusion and restraint and 0.25*
what was effective and not, but there was some push back along the way

Note. Kappa = 0.01 to 0.20, slight agreement; *0.21 to 0.40, fair agreement; **0.41 to 0.60, moderate agreement; ***0.61 to 0.80, substantial
agreement; 0.81 to 1.00, almost perfect agreement.

View publication stats