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Use of Restraint and Seclusion in Psychiatric Settings

A Literature Review
Obay A. Al-Maraira, PhD, RN; and Ferial A. Hayajneh, PhD

ABSTRACT straints are “any manual strategy or

The purpose of the current literature review was to critically review studies re- physical or mechanical equipment
that immobilizes or reduces the abil-
lated to the use of restraint and seclusion in psychiatric settings across cultures,
ity of [an individual] to move his or
identify ethical principles regarding restraint and seclusion, and generate a her arms, legs, body, or head freely”
clear view about patients’ perspectives and factors that influence use of these (Negroni, 2017, p. 100). Seclusion is
measures worldwide. Use of restraint and seclusion in daily nursing practice is “a control measure that consists of
confining an individual to a location
controversial. Previous studies have shown variation in the types, frequency, and
for a specific period of time and from
duration of restraint and seclusion across different countries and differences in which the person may not leave free-
the perception of restraint and seclusion between nurses and patients. Where- ly” (Goulet, Larue, & Lemieux, 2018,
as some mental health staff members have positive attitudes toward restraint p. 120).
The traditional justification for
and seclusion, others have negative attitudes. The current analysis found that
using restraint and seclusion among
restraint and seclusion should be used as a last resort measure. [Journal of Psy- psychiatric patients is derived from
chosocial Nursing and Mental Health Services, 57(4), 32-39.] paternalism (O’Brien & Golding,
2003). Beauchamp and Childress
(2001) defined paternalism as “the

R
estraint is defined by the U.S.
Joint Commission on Accredi-
tation of Healthcare Organi-
zation as “any method (chemical or
physical) of restricting an individual’s intentional overriding of one person’s
freedom of movement, physical preferences or actions by another per-
activity, or normal access to the body” son, where the person who overrides
(Negroni, 2017, p. 100). Physical re- justifies the action by the goal of ben-

32 Copyright © SLACK Incorporated

efiting or avoiding harm to the person
whose preferences or actions are over-
ridden” (p. 178). The paternalistic
view justifies the use of restraint and
seclusion to protect patients from their
non-autonomous actions. Sjöstrand
and Helgesson (2008) supported the
paternalistic justification; they stated
that patients with psychiatric disor-
ders are considered incompetent and
cannot make independent decisions.
Hence, others need to make decisions
and intervene for the patient.
Use of restraint and seclusion in
psychiatric settings is a controversial
measure, with some arguing that the
control of patient behavior seems to
be unethical (Välimäki et al., 2017).
Several countries have begun legisla-
tive efforts to control or reduce use
of restraint and seclusion in clinical
psychiatric settings (Gallagher, 2011;
Hughes & Lane, 2016). However,
psychiatric literature has reported
that legislative and policy change is
inadequate in terms of reducing use
of restraint and seclusion (Gallagher,
2011). Because of these findings,
health care providers should be en-
couraged to create or design a treat-
ment culture that emphasizes minimal
use of restraint and seclusion measures
when handling aggressive psychiatric
patients (Keski-Valkama et al., 2010;
Marx & Baker, 2017). Use of restraint
and seclusion should be monitored
closely and ethical questions regard-
ing restraint and seclusion should be
continuously evaluated (Huckshorn,
2012). One systematic review revealed
that limited evidence exists for mental
health researchers to decide whether
use of coercive measures such as re-
straint and seclusion is considered eth-
ical, effective, and safe for short-term
management of aggressive behavior of
psychiatric patients in clinical settings
(Nelstrop et al., 2006).
The purposes of the current litera-
ture review were to critically review
studies related to the use of restraint
and seclusion in psychiatric set-
tings across different cultures, iden-
tify the ethical principles behind using
restraint and seclusion, and generate
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 57, NO. 4, 2019
a clear view about patients’ perspec-
tives and factors that influence use of
restraint and seclusion worldwide.
METHOD
A comprehensive literature review
was conducted using MEDLINE,
CINAHL, PsycINFO, and ProQuest
online databases to answer the ques-
tion: what is known regarding the use
of restraint and seclusion in psychiatric
settings? Keywords used were restraint,
seclusion, coercive measures, control
measures, culture, perspective, attitudes,
and mental health. Identified literature
was discussed based on substantive
topical themes regarding restraint and
seclusion, including reported types,
frequency, and duration; ethical issues;
patients’ perspectives and associated
factors; and staff attitudes. Studies
related to nursing and other health-
related disciplines and studies reported
in English were included. A date range
was not used, as the process was ex-
ploratory. A total of 62 articles were
included in the review.
RESULTS
Study Description
Identified studies on restraint and
seclusion were mostly quantitative and
descriptive, with only one experimen-
tal design. Most studies were conducted
in acute psychiatric inpatient units in
the United States and Europe.
Reported Types, Frequency, and
Duration of Restraint and Seclusion
The results showed variations in
the types, frequency, and duration of
restraint and seclusion across different
countries. In the United Kingdom,
seclusion is rarely used and is substituted
by physical restraint. Furthermore,
mechanical restraints are avoided in
the United Kingdom (Jarrett, Bowers,
& Simpson, 2008). Countries such as
Austria, Germany, Japan, and Norway
used mechanical restraint more of-
ten than seclusion, whereas seclu-
sion was used more often in Finland,
the Netherlands, New Zealand, and
Switzerland. In Iceland, mechanical
restraint and seclusion were outlawed
and physical restraint was used instead
(Steinert et al., 2010).
Reported levels of restraint and se-
clusion in the literature vary. Use of
seclusion varied between less than 1%
of admissions in Norway and Wales
(Keski-Valkama, 2010) and 15.6% of
admissions in New Zealand (El-Badri
& Mellsop, 2002). Use of physical
restraint varied between 1.2% of ad-
missions in the Netherlands (Abma,
Widdershoven, & Lendemeijer,
2005) and 8% in Germany (Steinert,
Bergbauer, Schmid, & Gebhardt, 2007).
Furthermore, use of physical restraint
varied between 2.5% of admissions in
several European countries and 7.5% in
the United Kingdom (Keski-Valkama,
2010). Eastern countries seem to fall in
the average range in preliminary inter-
national statistics on implementation
of restraint and seclusion. The World
Health Organization (WHO) in col-
laboration with the Jordanian Ministry
of Health (MOH) collected informa-
tion on the mental health system in
Jordan to improve the system and pro-
vide a baseline for monitoring change.
They reported that 10% of psychiatric
patients admitted to Jordanian MOH
hospitals were restrained or secluded at
least once in the past 1 year (WHO &
Jordanian MOH, 2011).
The mean duration of seclusion was
3 hours in Norway and 294 hours in
the Netherlands. The mean duration
of mechanical restraint was 7.9 hours
in Norway and 1,182 hours in the
Netherlands (Abma et al., 2005; Keski-
Valkama, 2010).
Ethical Issues Regarding Use of Restraint
and Seclusion
Nursing practice has several dimen-
sions of care, of which ethical issues
are an essential part. For health care
professionals to arrive at thoughtful
and balanced decisions concerning
their patients, health care professionals
should reflect on the ethical aspects of
the decision, as well as their attitude to-
ward their patients (Goethals, Dierckx
de Casterlé, & Gastmans, 2012).
Coercive measures are widely used
among psychiatric health care providers
33
as means of preventing suicidal behav-
iors and helping patients regain control
over their psychiatric symptoms. More-
over, these measures are used in situ-
ations in which a patient’s aggressive
behavior threatens the safety of self
or others (Vieta et al., 2017). Despite
longstanding traditions of using re-
straint and seclusion in psychiatric care,
use of these measures is a controversial
area of practice (Välimäki et al., 2017).
Although nurses considered restraint and
seclusion effective techniques to calm patients’
agitation and prevent harm, patients considered
these measures to be punishment.
Use of restraint and seclusion to main-
tain patients’ safety may undermine
patient autonomy and violate human
rights. As a result, use of restraint and
seclusion has been increasingly chal-
lenged (Hui, 2015). On the contrary,
Hui (2015) and Prinsen and Van
Delden (2009) argue that respecting
autonomy and human dignity are not
sufficient reasons to reduce or elimi-
nate use of restraint and seclusion. Due
to these varying viewpoints, nurses may
experience difficulty balancing their
responsibilities of protecting patients’
rights and preventing harm to patients
and staff. Coercive interventions such
as restraint and seclusion are common
psychiatric practices that create ethical
dilemmas for nurses (Keski-Valkama et
al., 2010).
Keski-Valkama et al. (2010) found
that policymakers, the public, and
mental health care providers were con-
cerned about the ethical treatment of
mental health patients and legal de-
bates over the use of restraint and se-
clusion. The researchers recommended
avoiding use of restraint and seclusion
as control interventions in routine
care and using them as last-resort mea-
34
sures. Furthermore, they did not view
restraint and seclusion as treatment
options, even in dangerous or emer-
gency situations (Keski-Valkama et al.,
2010). Hence, more evidence is needed
to support the development of clinical
alternatives that will reduce the use of
restraint and seclusion and improve
personalized care plans (Canadian
Institute for Health Information, 2011;
Keski-Valkama et al., 2010).
Patients’ Perceptions of Restraint and
Seclusion
As previously mentioned, restraint
and seclusion in psychiatric units are
used to protect patients from hurting
themselves or to protect staff mem-
bers or other patients from being hurt.
Restraint and seclusion have been
used worldwide to ensure safety when
patient behaviors are difficult to man-
age or control (Presley & Robinson,
2002). Previous research has found that
decreasing use of restraint and seclusion
results in increasing incidences of as-
sault on staff members and other
patients (Khadivi, Patel, Atkinson, &
Levine, 2004).
However, negative outcomes
regarding the use of restraint and se-
clusion have been found. One study
reported that restraint and seclusion
that take place in contained environ-
ments result in delayed development
of life skills necessary outside of these
environments (Donat, 2005). Patients
often view restraint and seclusion
as bullying and traumatic (Sheline
& Nelson, 1993; Walsh & Randell,
1995). In addition, some patients
reported that restraint and seclusion
evoked memories of previous traumatic
events (Wynn, 2004). Moreover, in
one qualitative study, patients noted
that restraint and seclusion during
treatment boosted their feelings of stig-
matization, thus increasing recovery
time (Robins, Sauvageot, Cusack,
Suffoletta-Maierle, & Frueh, 2005). In
addition, restraint and seclusion caused
patients to feel angry, lonely, rejected,
and abandoned (Bonner, Lowe,
Rawcliffe, & Wellman, 2002; Gaskin,
Elsom, & Happell, 2007).
Although nurses considered restraint
and seclusion effective techniques to
calm patients’ agitation and prevent
harm, patients considered these mea-
sures to be punishment. Keski-Valkama
et al. (2010) discovered that 66.3% of
patients viewed restraint and seclusion
as punitive measures that limited their
autonomy. In addition, Keski-Valkama
et al. (2010) showed that forensic psy-
chiatric patients are more likely to
view seclusion as a punitive measure.
In contrast, one study indicated that
some patients viewed restraint and se-
clusion as helpful techniques (Larue et
al., 2013).
Multiple factors contribute to use
of restraint and seclusion. According
to Kong and Evans (2012), psychiatric
mental health nurses reported using
restraint and seclusion for various
reasons, including “being too busy,
lack of resources, beliefs and con-
cerns, lack of education, differences
and inconsistencies, and relationship
issues” (p. 176). Furthermore, Knox
and Holloman (2012) found that
use of restraint and seclusion among
nurses in acute and emergency wards
is significantly higher than in chronic
care wards, as patients who are chroni-
cally ill may develop a rapport with
staff over a period of time.
In addition, patient characteristics
influence use of restraint and seclusion.
One patient characteristic that affects
the use of restraint and seclusion is
migration status. Use of restraint and
seclusion is related to cultural tradi-
tions, norms, and issues (Knutzen,
Sandvik, Hauff, Opjordsmoen, & Friis,
2007). One study showed that patients
Copyright © SLACK Incorporated
who are immigrants have higher inci-
dence of restraint (21.6%) than na-
tive patients (12.9%) (Knutzen et al.,
2007). Another study demonstrated
that immigrants were less likely to be
voluntarily admitted due to the higher
likelihood of restraint and seclusion
(Berg & Johnsen, 2004). Two addi-
tional studies conducted in psychiat-
ric emergency care settings indicated
that patients’ cultural background
significantly contributed to their like-
lihood of being restrained or secluded
(Telintelo, Kuhlman, & Winget, 1983;
Zun, 2003).
Moreover, patients’ clinical back-
ground was found to affect the duration
of restraint and seclusion (Noda et al.,
2013). Patients with brief psychotic
episodes are less likely to have long
durations of restraint and seclusion
(Noda et al., 2013). Thus, patients
with complicated or prolonged psychi-
atric conditions, such as schizophrenia
or bipolar disorder, would have longer
durations of restraint and seclusion.
Another patient characteristic that
influences restraint and seclusion is
gender. Previous studies have found
that male patients are more likely to
be restrained or secluded (Zun, 2003).
In addition, male patients have signifi-
cantly longer durations of restraint and
seclusion than female patients (Noda
et al., 2013). However, one study re-
vealed that there was no difference
between male and female patients re-
garding the incidence and duration of
restraint and seclusion (Knutzen et al.,
2007).
Furthermore, patient age was a
significant factor affecting the inci-
dence and duration of restraint and
seclusion. A study conducted by Zun
(2003) showed that most patients
who were restrained were between
ages 31 and 40, whereas only a few
were older adults (Zun, 2003). Anoth-
er study supported this finding, indi-
cating that patients ages 18 to 29 were
more vulnerable to restraint and seclu-
sion (Knutzen et al., 2007). Moreover,
younger patients were more likely to
have longer durations of restraint and
seclusion (Noda et al., 2013). In addi-
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 57, NO. 4, 2019
tion, patients with low socioeconomic
status are more likely to be restrained
or secluded (Khandelwal, Deb, &
Krishnan, 2015).
Staff Members’ Attitudes Toward
Restraint and Seclusion
Restraint and seclusion are associated
with several negative consequences
for patients and staff members. Due to
nurses’ direct role in using restraint and
seclusion, it is important to understand
their attitudes toward restraint and se-
clusion to reduce the use of these mea-
sures (Happell & Harrow, 2010).
van Doeselaar, Sleegers, and
Hutschemaekers (2008) conducted a
prospective study using the Profession-
al Attitudes Toward Seclusion Ques-
tionnaire (PATS-Q) with a sample
of 540 Dutch professionals in mental
health care who had previously used se-
clusion to determine their attitudes re-
garding use of seclusion. Results showed
that professionals’ attitudes fell into
three major categories: transformers,
maintainers, or doubters. Transformers
included professionals who had little
faith in seclusion, were strongly in favor
of alternative strategies, and wanted to
change seclusion practices. Maintainers
considered safety to be more important
than their personal beliefs about seclu-
sion, believed alternatives were less
effective than seclusion, and did not
believe they needed to reduce seclu-
sion rates, despite their ethical objec-
tions. Unlike transformers and main-
tainers, doubters comprised individuals
who believed that seclusion was valu-
able as an intervention despite ethi-
cal considerations; however, they were
also interested in alternative options.
Furthermore, Husum (2011) investi-
gated the attitudes of Norwegian staff
members toward restraint and seclu-
sion and found similar results, includ-
ing staff members who desire and work
toward reducing use of restraint and se-
clusion, staff members who do not have
clear opinions regarding restraint and
seclusion, and those who oppose alter-
natives to restraint and seclusion.
An experimental study by Mann-
Poll, Smit, van Doeselaar, and
Hutschemaekers (2013) used the
PATS-Q to determine whether profes-
sionals from four acute admission wards
in an adult mental health institute
changed their attitudes toward seclu-
sion after implementation of a seclu-
sion reduction program. Professionals’
attitudes toward seclusion were assessed
at the start (2004) and end (2008) of
the program. The main elements of
the program included development of
multidisciplinary teams, on-the-job
training on topics such as risk taxa-
tion and proactive working, weekly
meetings with an external supervisor,
monitoring and feedback for seclusion
rates, and participating in national and
international conferences. Findings
indicated that after implementation of
the program, during which professionals
reflected on ethical questions about the
necessity and desirability of the use of
seclusion, they were significantly more
knowledgeable about ethical issues
and benefits of using alternatives to
seclusion. Results also indicated an in-
crease in criticism of seclusion, and an
increased willingness to change their se-
clusion practices, thus allowing them to
be categorized as transformers. Findings
indicated that participation in similar
training reduction programs may be in-
fluential on attitudes of mental health
workers (Mann-Poll et al., 2013).
However, as individual participants in
the four wards changed over time due
to regulatory rotations, it would not
have been beneficial for researchers to
analyze attitude changes on individual
levels. Therefore, conclusions were
drawn on a group level. According to
Ramadan (2007), there is a need to use
less restrictive or alternative measures
before using restraint and seclusion.
These measures may include environ-
mental manipulation and de-escalation
techniques. Environmental manipu-
lation involves minimizing environ-
mental stimuli after assessing patients’
triggers. For example, environmental
manipulation may include improving
patients’ comfort, training staff about
emergency psychiatric care and crises
management, and giving respect and
sufficient time to patients.
35
 Happell et al. (2012) investigated
the relationship between attitudes
toward seclusion and levels of burn-
out, staff satisfaction, and therapeu-
tic optimism. The sample comprised
54 staff members recruited using conve-
nience sampling from one adult health
service inpatient unit. Findings indi-
cated that nurses played a large role in
deciding whether to seclude patients;
72% of participants indicated that the
decision to seclude a patient was made
by a nurse. Only 6% of participants
reported that seclusion should never be
used. Happell et al. (2012) found that
nurses experienced feelings of satisfac-
tion when a patient was punished by
seclusion. However, in cases in which
individuals asked to use the seclusion
room, nurses did not perceive seclusion
as an accomplishment, as it was not
their decision, indicating that nurses’
attempts to create a therapeutic envi-
ronment were unsuccessful. Further-
more, when staff members were asked
about when seclusion should be used,
they provided various responses, raising
doubts about whether seclusion is used
only as a last resort. However, results
of this study cannot be generalized, as
the sample was a convenience sample
recruited from only one unit.
In Kuwait, Elgamal (2006)
conducted a study to explore the
effect of gender, educational level, and
years of experience on the attitudes of
62 nurses toward restraint. This study
is significant as it reflects attitudes
of nurses within Arabic and Islamic
cultures. Data analysis revealed that
nurses displayed aggressive attitudes
and admitted that force is typical on
the unit. Use of continuous restraint is
more frequent among male nurses and
nurses working on male wards. Regard-
ing level of education, nurses with less
education or less experience preferred
to use restraint and were more likely to
display aggressive attitudes. In contrast,
nurses with higher levels of education
or more experience were significantly
more likely to report conservative atti-
tudes toward constraint, preferred short
restraint times, and disagreed with the
use of restraint for hyperactive patients.
36
Results also indicated that nursing
staff members with less education and
experience should be targeted for future
educational programs on alternatives to
restraint and seclusion.
DISCUSSION
In the review process, the current
authors found numerous limitations to
definitions of seclusion and restraint.
In particular, there was discrepancy
in the definition of types of restraint,
with physical and mechanical re-
straint often used inconsistently and
interchangeably. Most studies did not
specify or define which type of restraint
and seclusion they had targeted, and
numerous studies combined different
types of restraint and seclusion in out-
come reporting, making it difficult to
compare and amalgamate findings.
The current study indicated that
preferences, frequency, and duration of
restraint and seclusion varied among
countries studied. These differences
may reflect the different cultural beliefs
and values within which a psychiatric
system is situated (Bowers et al., 2007).
In other words, there is a discrepancy in
the literature between those who agree
and disagree with the use of restraint
and seclusion (Dean, Duke, George,
& Scott, 2007). Therefore, the use of
these practices in nursing is controver-
sial. Individuals supporting use of re-
straint and seclusion do so to maintain
the safety of patients and others (Vieta
et al., 2017). However, restrained or
secluded patients might be exposed to
injuries, disabilities, and even death.
Thus, use of restraint and seclusion
might be associated with legal and ethi-
cal dilemmas (Abdeljawad & Mrayyan,
2016). For example, involuntary chem-
ical restraint in Dutch mental health
settings is considered more invasive
and a more serious violation of pa-
tients’ integrity than use of other types
of restraint and seclusion (Steinert &
Lepping, 2009). Consequently, the
international literature indicated that
the Netherlands appears to have the
highest rate of inpatient violence in
Europe, as well as a relatively high
incidence of mechanical restraint
and seclusion (Nijman, Palmstierna,
Almvik, & Stolker, 2005). However,
these findings from the Netherlands
might be at least partly explained by
its negative attitude toward chemi-
cal restraint. On the contrary, in the
United Kingdom, mechanical restraint
in prohibited and seclusion is rarely
used. It has been found that involun-
tary chemical restraint is more likely to
be used in the United Kingdom than in
other European countries (Jarrett et al.,
2008). All other European countries, as
well as the United States, fall between
these two extremes, with most using
mechanical restraint (Steinert et al.,
2010).
The current review indicates that
the literature lacks studies on the types
and duration of restraint and seclusion
used in Arabic countries, which repre-
sent a different culture than those of
Western countries. Only one published
Jordanian report (WHO & Jordanian
MOH, 2011) stated that the level of
restraint and seclusion use in Jordan
was parallel to levels found in studies in
New Zealand and Germany (El-Badri
& Mellsop, 2002; Steinert et al., 2007).
Based on findings of the current re-
view, feelings of abandonment, anger,
loneliness, and rejection, as well as
perceptions of restraint and seclusion
as punishment, are all common patient
perspectives regarding use of restraint
and seclusion. However, nurses per-
ceive restraint and seclusion as effec-
tive ways to control patient aggression
and prevent harm, demonstrating that
nurses and patients perceive restraint
and seclusion differently. Consider-
ing the varying perspectives of nurses
and patients, negative perception of
restraint and seclusion among pa-
tients is likely to be a result of nurses’
practices. One possible cause is lack of
therapeutic communication between
nurses and patients. The literature
indicates that negative feelings of pa-
tients are a result of absence of proper
interaction with nurses before, dur-
ing, and after the use of restraint and
seclusion (Keski-Valkama et al., 2010;
Nijman et al., 2005). Many studies re-
port that patients did not receive infor-
Copyright © SLACK Incorporated
mation regarding restraint and seclu-
sion; thus, they did not understand why
they were restrained or secluded, which
led to them perceiving these measures
as punishment (Donat, 2005; Holmes,
Kennedy, & Perron, 2004; Meehan,
Bergen, & Fjeldsoe, 2004; Mohr, Petti,
& Mohr, 2003). In addition, patients
conveyed that their basic needs (e.g.,
eating, drinking, excretion, security)
were ignored and not met during use
of restraint and seclusion (Holmes et
al., 2004; Okanli, Yilmaz, & Kavak,
2016). A study conducted in a psychi-
atric hospital in Turkey revealed that
training for patients on skills to man-
age challenges related to mental illness
decreases the incidence and duration of
restraint and seclusion among 23.9%
of patients and improves the recovery
process (Donat, 2005).
Thus, to decrease the gap in percep-
tions of restraint and seclusion between
nurses and patients, nurses should
increase proper therapeutic interaction
with patients before, during, and after
use of restraint and seclusion. Before
use of these measures, nurses should ex-
plain the procedure and why it is nec-
essary. This explanation may decrease
patients’ uncertainty regarding the rea-
sons for restraint and seclusion. Dur-
ing restraint and seclusion, interaction
should include regular checkups for pa-
tients’ basic needs. These checkups will
help avoid malpractice and prevent
further harm. After restraint and seclu-
sion, interaction should include train-
ing regarding daily life skills, which
may promote recovery and prevent fu-
ture use of restraint and seclusion.
Another cultural issue that should
be considered is patients’ migration
status. Previous studies have revealed
that immigrants are more likely to be
restrained or secluded (Knutzen et al.,
2007; Zun, 2003). This could be due
to differences in ethical beliefs, race,
ethnicity, and language barriers be-
tween nurses and patients (Knutzen
et al., 2007). These differences could
increase communication problems
and decrease trust between nurses and
patients. Furthermore, forced migra-
tion is considered a severe traumatic
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 57, NO. 4, 2019
experience (Lavik, Hauff, Skrondal, &
Solberg, 1996). Therefore, nurses may
interpret symptoms following such ex-
periences (e.g., fear, agitation, pacing,
aggression) as harmful and requiring
use of restraint and seclusion. In ad-
dition, immigrants are more likely to
develop posttraumatic stress disorder
(PTSD) due to the distressing events
they experienced. One clinical study
confirmed that patients with PTSD are
more susceptible to stress factors that
initiate agitation and consequently
aggressive behaviors (Hummelvoll &
Severinsson, 2001).
It is important to note that refugee
psychiatric patients are individuals
with different and special needs com-
pared to native psychiatric patients.
For better care and maximum benefits,
nurses must carefully examine the
needs and problems of this population.
In addition, nurses should be aware of
the effects of forced migration on refu-
gee psychiatric patients; this awareness
may help nurses identify aggressive be-
havior due to these experiences and
decide on an appropriate treatment
technique. Moreover, nurses’ aware-
ness about issues facing refugee psy-
chiatric patients outside clinical areas
is vital to ensure that these patients
feel understood. Involving patients
and their families in the treatment and
decision-making processes leads to
best results. Thus, nurses working with
such patients need more patience, bet-
ter communication skills, and the abil-
ity to build therapeutic relationships
with these patients.
Previous research on nurses’ at-
titudes toward restraint and seclu-
sion indicated that although nurses
have negative feelings toward use of
such measures, they believe they are
necessary (Möhler & Meyer, 2014).
However, lack of knowledge or un-
derstanding of alternatives to restraint
and seclusion among nurses has been
identified as a barrier to reducing or
eliminating their use (De Bellis et al.,
2013). Based on scientific evidence,
researchers (Mann-Poll et al., 2013;
Ramadan, 2007) reported that suitable
training for mental health staff, an
assessment of the risk of disturbed be-
haviors, and adequate alternative mea-
sures are essential factors for enhancing
staff attitudes toward reducing use of
restraint and seclusion. The findings of
these studies are encouraging in terms
of reducing restraint and seclusion, as
well as the effectiveness of alternative
measures.
LIMITATIONS
The current results are preliminary.
Definitions of restraint and seclusion
are different across studies; however,
standard definitions have recently been
recognized by consensus and could
be used in future studies (Steinert &
Lepping, 2009). For example, data on
the use of mechanical restraint in some
studies include an unknown proportion
of physical restraint.
CONCLUSION
Much research has been conducted
to investigate the use of restraint and
seclusion among mental health staff
members. Use of restraint and seclusion
is a controversial measure in psychiatric
settings. However, psychiatric pa-
tients have the right to be cared for in
a respectful, safe, and non-restrictive
environment. Mental health profession-
als may differ on ethical issues related to
use of restraint and seclusion, yet all seek
to maximize benefits and minimize risks
to their patients (Dean et al., 2007).
One argument in favor of restraint and
seclusion is that these measures are
needed to ensure a safe environment.
The literature revealed that although
safety must be a driving concern, a pa-
tient’s autonomy and rights might be
violated when using restraint and seclu-
sion (Hui, 2015). Thus, use of restraint
and seclusion may be considered un-
ethical, as alternative measures exist.
However, empirical research indicates
that preferences regarding restraint and
seclusion and frequency and duration of
restraint and seclusion vary significantly
across cultures.
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Dr. Al-Maraira is Lecturer, Al-Farabi Private
College, Jeddah, Saudi Arabia; and Dr. Hayajneh
is Professor, Adult Nursing, School of Nursing,
University of Jordan, Amman, Jordan.
The authors have disclosed no potential
conflicts of interest, financial or otherwise.
Address correspondence to Obay A.
Al-Maraira, PhD, RN, Lecturer, Al-Farabi Private
College, Al Rahmaniyah District, Jeddah 23643,
Saudi Arabia; e-mail: dr.obayalmaraira@gmail.com.
Received: July 2, 2018
Accepted: August 29, 2018
doi:10.3928/02793695-20181022-01
39
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