Restraint and seclusion: a review of the literature

Nurses' judgments regarding seclusion and restraint of psychiatric patients: a social judgment analysis

Clinical judgment of psychiatric nurses was investigated using judgment analysis within the framework of social judgment theory. Nine nurses at a short-term psychiatric care facility made recommendations concerning restraint and seclusion for 80 patients described on paper in terms of 17 characteristics (cues). Nurses generally favored close observation of patients over seclusion and restraint, and information about current behavior and functioning had more impact on nurses' judgments than did patient history. Nurses had good insight into the nature of their own judgments. However, individual differences in cue utilization and inconsistency in strategy usage led to disagreement among nurses about specific recommendations for particular patients. No one patient received identical recommendations from all nurses, and nurses agreed with each other on specific recommendations only about a third of the time. The lack of agreement has implications for development of staff training programs and further research on the clinical judgment processes of nurses.

Practice of seclusion: a five-year retrospective review in north Cheshire

This study examines, retrospectively, the trends and factors associated with the use of seclusion over a five-year period in a regional secure unit located within a large psychiatric hospital that serves the population of North Cheshire. Ninety-four patients (15.3% of total admissions to the unit) spent some time in seclusion on 186 occasions. The average time spent in seclusion was 85 minutes (minimum 15 minutes and maximum 10 hours). Sixty-seven per cent of patients were secluded once, 20% secluded twice, and 13% more than three times. Patients with a clinical diagnosis of personality disorder (11.4%) accounted for 44.2% of seclusions whereas those with a defined mental disorder (55%) accounted for 35% of all seclusions. The rate of seclusion, characteristics of secluded patients, reasons, and average duration spent in seclusion, did not vary significantly over the study period, despite the significant reduction of the unit's admission rate from 150 to 63 per year. The consistent and regular occurrence of the practice over a five-year period may suggest that seclusion of some disturbed patients will inevitably continue to be used as an effective intervention and, probably at times, the only acceptable method that may ensure the safety of patients and staff.

Being restrained: a study of power and powerlessness

Previous research about the use of restraints has mainly sought generalizations regarding (a) who is likely to be restrained, (b) the frequency of the use of restraints, and (c) the behavior that precipitates the application of restraining devices. Therefore, there has been a paucity of research that attempts to understand the impact of restraint on the restrained person. The purpose of this study was to understand the meaning of the experience of being restrained for 10 psychiatric patients who had been restrained in leather restraints. Participants were interviewed in unstructured interviews. The taped interviews were transcribed and analyzed by means of a modification of an eight-stage interpretive process, grounded in Heideggerian phenomenology. In this article the theme of power is reported and discussed.

A restraint on restraints: the need to reconsider the use of restrictive interventions

Children with behavior problems are put in units with milieu therapy for the support and guidance of a specialized health care team, supposedly experts in the care of children with these unique and urgent needs. The reality of such units, however, is that those with the most contact with the children are often inadequately prepared, both in terms of knowledge and skills, to manage disruptive behaviors. As a result, the milieu that is supposed to provide support and structure can actually exacerbate the trauma for the vulnerable child. Preliminary data are presented from an ongoing study that is investigating the experiences and memories of formerly hospitalized children. Three types of traumatic experiences are described: vicarious trauma, alienation from staff, and direct trauma. Many of the traumatic events endured by child patients are the result of an inappropriate use by staff of power and force. There was a marked lack of understanding by the children of why given interventions were used. Although coercive interventions are sometimes necessary, ethical, legal, and other professional considerations make it clear that more work is needed. Research to identify the patterns of lack of knowledge and skills, as well as to develop appropriate interventions are recommended.

Aggressive and violent behavior in a population of psychiatric inpatients

The aim of this observational study was to assess the rates of aggressive and violent behavior in patients admitted to an Italian emergency psychiatric unit and to explore possible risk factors for patient violence. In a population of 313 consecutive patients, we considered aggressive or violent behavior, rated according to a hierarchy from no aggressive behavior to serious physical violence. The results confirm that young age, psychotic symptoms, excitement, akathisia, and diagnosis of personality disorder are risk factors for violent behavior. The unique and major finding of the study is the low prevalence of aggressive and violent acts in this sample of patients, possibly related to their cultural background and to the system of psychiatric care. These data provide supportive evidence for the importance of sociocultural factors in the behavior of psychiatric patients and suggest the need to explore new strategies of prevention and treatment of patient aggression and violence. A non-restraint policy could be a critical factor in reducing violence among psychiatric inpatients.

An ethnomethodological analysis of the use of seclusion

The use of seclusion in psychiatric practice is a contentious issue. This paper reports on an ethnomethodological approach to understanding the decision-making process in the use of seclusion. Through first-level and second-level reasoning analysis, three themes emerged which underscored the subjects' rationalization process. These were: (a) mechanistic searching, (b) frame conflict, and (c) asylum status. This research suggests that the decision to use seclusion is based on a complex interplay of cultural and organizational factors rather than due to the presentation of symptoms by the patient.

The use of restraint on patients in Israeli psychiatric hospitals

This first-ever study of the use of restraint on psychiatric patients in Israel sought to determine the dominant motivations in the decision to use restraint, which patients were most likely to be restrained, and whether there was a consistent policy on the matter. A survey of the official records of every instance of restraint during one month in the closed wards of all government psychiatric hospitals, supplemented with interviews, revealed that 14.2% of the study population had undergone restraint. The declared reasons were conventional, i.e. violence, disturbed behaviour, etc. Undeclared was an interaction between patients and staff, both the most professional and the less skilled, which surprised the authors and requires more investigation. Some subgroups, e.g. women and certain immigrant groups, were restrained markedly more frequently than other groups. No consistency of policy was found. Overall, much of the restraint applied is deemed unnecessary and recommendations are made for its reduction.

Nurses' learning experience and expressed opinions regarding seclusion practice within one NHS trust

Brief face-to-face interviews took place with 64 mental health nurses working within one National Health Service Trust about their education and training regarding seclusion practice. Free comments were also recorded as to their opinions about seclusion practice. Seventy-three per cent claimed to have either implemented seclusion or supervised patients in seclusion. Only 28% recalled any training or education regarding seclusion practice with 34% recalling reading articles. Training experiences were perceived to be more appropriate to practice than reading articles. Sixty-six per cent claimed that they would like more information. Seventy-eight per cent disagreed with the statement that seclusion should no longer be used with 52% agreeing that seclusion was a valuable intervention. Brief comments made during interviews were sorted into six thematic categories. Nurses' comments involved issues concerning: (1) keeping safe; (2) seclusion abuse; (3) nurses' role conflict in implementing seclusion; (4) the value of seclusion in 'real world' practice; (5) the learning process; and (6) 'against the wall' decision-making. Nurses were more able to identify difficulties than define proper use of seclusion. Nurses most closely involved with seclusion were more likely to refuse to be interviewed about their experiences reflecting the fact that issues surrounding seclusion continue to be a sensitive area for research.

Evaluating staff use of crisis prevention intervention techniques: a pilot study

The purpose of this pilot study was to evaluate staff use of crisis prevention intervention (CPI) techniques in averting crisis episodes at the various levels (anxiety, defensive, and acting out) of a crisis (resulting in reduction of seclusion and restraint episodes and patient/staff injuries). A descriptive correlational research design was used. Data were collected by nurse observers trained in CPI techniques through observation of patient incidents and staff interventions. A 51-item CPI instrument based on the CPI training program techniques was developed and used for data collection. Data were analyzed using descriptive statistics, Pearson correlation, t tests, ANOVA, and the Scheffe test. One hundred forty-six observations of patient incidents were completed on both day and evening shifts. The results of the study indicate that staff use of CPI training program techniques was effective in resolving crises in 84.2% of the episodes observed and over a wide variety of diagnostic and functional levels.

Staff members' beliefs about seclusion and restraint in child psychiatric hospitals

BACKGROUND

Staff members beliefs about seclusion and restraint are influential in determining how and when these interventions are employed. Yet there are few studies of staff beliefs in individual hospitals and no comparative studies across hospitals.

OBJECTIVE

To measure staff members' beliefs about the rationale for and efficacy of the use of seclusion and restraint with children and adolescents.

METHODS

A survey of staff members (N = 320) from 13 public and private child psychiatric hospitals.

RESULTS

Results indicate a low to moderate level of confidence among all staff groups regarding the efficacy of seclusion and restraint. Staff members from private hospitals were significantly more positive in their assessment of these interventions than were staff members from the public sector.

CONCLUSION

We hypothesize that the persistent use of coercive interventions in which staff have a low level of confidence reflect both the influence of tradition in the management of aggressive behavior and unacknowledged avoidant/coercive staff responses to patents labeled as deviant. Differences between the public and private sectors and between hospitals within each sector imply that the practice of seclusion and restraint may be idiosyncratic to each institution, and suggest the need for a generally accepted standard for their use.