Behavioral precipitants of restraint in the modern milieu

Organizational and unit factors contributing to reduction in the use of seclusion and restraint procedures on an acute psychiatric inpatient unit

OBJECTIVE

The use of seclusion or restraint (S/R) as an emergency medical intervention to assist patients in regaining behavioral control continues to be an area of interest and concern for the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), consistent with the ongoing concerns in the medical, patient advocate, legislative and legal communities. This study examined unit characteristics and the use of S/R in a VA facility with a secured, acute mental health unit before and after the promulgation of the JCAHO 2000 standards for utilization of S/R for behavioral health reasons.

METHODS

Variables examined include patient acuity, patient census, number of admits, number of discharges, length of stay, number of nursing staff on duty, critical incidents and S/R hours per month.

RESULTS

Results indicated S/R use began showing a notable decrease corresponding to the time that senior unit management began discussions of the new JCAHO standards. These reductions maintained statistical significance even after controlling for changes in unit environmental variables.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

Psychiatric nurses' thoughts and feelings about restraint use: a decision dilemma

Patients continue to be physically restrained in psychiatric in-patient units. Studies concerned with staff-related variables have suggested that the emotional reactions of professionals to violent or potentially violent patients may influence their use of restrictive measures. However, no research existed that described psychiatric nurses' thoughts and feelings while they were involved in restraint situations nor what effects their thoughts and feelings had on their decision to restrain. Therefore, an ethnographic qualitative study was conducted in order to describe systematically nurses' thoughts and feelings toward restraint use in the in-patient psychiatric setting. The conceptual approach guiding the study was Etzioni's (1992) theoretical work on the role of normative-affective factors in decision making. Following ethical approval of the study, ethnographic interviews were conducted with six nurses from an in-patient psychiatric unit who had participated in a situation involving the physical restraint of a patient. The analysis of the nurses' thoughts and feelings revealed that the restraint situation represented a decision dilemma for them. This overall finding was supported by four themes: (1) the framing of the situation: the potential for imminent harm; (2) the unsuccessful search for alternatives to physical restraints; (3) the conflicted nurse; and (4) the contextual conditions of restraint. The results indicated that restraint use is more complex than is currently conveyed in the literature in that normative-affective factors influenced nurses' restraint decisions. The findings advance our understanding of why restraints continue to be used in psychiatric units. Further research is necessary to examine the findings in other settings and with a larger and more diverse population in order to draw definitive conclusions about the continued use of physical restraints in the care of patients on psychiatric units in hospitals.

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.

Geropsychiatric restraint use

OBJECTIVES

To investigate predictors and reasons for restraint use with geropsychiatric patients.

DESIGN

A prospective, correlational study.

SETTING

The geriatric unit of an acute-care psychiatric hospital.

PARTICIPANTS

Twenty-one staff nurses and 131 patients admitted consecutively over a period of 6 months.

MEASUREMENTS

Disruptive behaviors were measured with the Nursing Home Behavior Problem Scale (NHBPS), cognitive function was measured with the Mini-Mental State Examination (MMSE), mobility was measured with a Functional Mobility Screen (FMS), and reasons for restraint use were obtained with a questionnaire completed by nurses.

RESULTS

Patients with a diagnosis of dementia, impaired mobility, or behavioral problems were more likely to be restrained. The most frequent reasons given by staff for restraint use were an unsteady gait and a risk of falling. The incidence of restraint use was 27.1%.

CONCLUSIONS

The use of restraint with geropsychiatric patients may be more common than previously reported and requires further investigation.

Use of physical restraints in a nineteenth-century state hospital

Archival records of physical restraint usage at the St. Louis Insane Asylum (now the St. Louis State Hospital) were examined from January through June 1885. The demographics of restrained patients were determined from archival admission records. In the 6-month (181-day) sample period, 53 patients accounted for the total of 2,537 incidents of night restraint. Sixty percent of the restrained patients were women and 53% were immigrants. By far most (98.5%) of the incidents of restraint were brought on by violent behaviour (fighting, destroying property, injury to self) while most incidents in modern hospitals result from verbal threats or shouting. When these records were combined with day restraint records from the same 6-month period in 1889, an overall incidence rate of 9.7% per month was estimated. This is similar to rates reported from modern psychiatric hospitals. Possible reasons for the discrepancies and similarities in the types of patients restrained and the activities which brought on restraint in the nineteenth and twentieth centuries are discussed.

Physical control of patients on an inpatient setting: forensic vs. civil populations

The current study examines the use of physical control (seclusion and restraint) in a sample of patients hospitalized in a public mental hospital during 1989. A total of 243 patient records involving physical control were examined; of these, 124 had been civilly committed and the remaining 119 were forensic (Incompetent to Stand Trial or Not Guilty by Reason of Insanity). Some 870 physical control events occurred in the sample, a rate that is intermediate when compared with other facilities described in the literature. Seclusion was employed most often (46% of events), with the combination of seclusion and restraint used in 32% of events and the remaining 22% of physical control events being restraint. Seclusion tended to be used more often with civilly committed patients, with restraint more frequently employed with forensic patients. Forensic patients differed from civil subjects in their greater frequency of threats, agitation, and verbal hostility. However, civil patients were more frequently aggressive toward others and destructive of property. These findings are discussed in the context of previous evidence also describing forensic patients as being perceived as more dangerous, but behaving in a fashion no more physically aggressive than civil patients.

Delirium and physical restraint in the hospitalized elderly

Delirium or acute confusion increase the likelihood of physical restraint use and subsequent harmful physical and psychological effects. Assessment for delirium is presented as a conceptual framework to guide researchers, administrators, and clinicians in developing strategies to decrease the use of physical restraint and to support quality of life for hospitalized older adults.

A further exploration of the use of physical restraints in hospitalized patients

Four hundred twenty-one consecutive patients admitted to an acute general medical ward and two acute rehabilitation medical wards were studied to compare the characteristics and outcomes of physically restrained patients and unrestrained patients. Restraints were used in 35 (13%) of the general medical patients and in 49 (34%) of the rehabilitation patients. The restrained general medical patients had higher mortality and morbidity rates than their unrestrained counterparts. Restrained patients had a higher prevalence of a psychiatric diagnosis, and major tranquilizers were used more than in their unrestrained counterparts in both settings. The general medical patients tended to have more than one type of restraint at a time, whereas the rehabilitation patients were restrained for longer proportions of their hospital stay. Thirty-three percent of the restrained patients whom we were able to interview expressed negative perceptions about the presence of the physical restraints. Moreover, it was found that the presence of cognitive and physical impairments were highly predictive of restraint use in both populations.

Emergency department violence in United States teaching hospitals

Violence in the emergency department is a common concern. However, most aspects of this problem remain unstudied because no organization or government agency tracks such data and no regulatory or administrative guidelines adequately address its management. We surveyed 170 US teaching hospital ED medical directors with respect to violence and security issues and received responses from 127 (74.7%). Among other findings, 41 institutions report at least one verbal threat each day, and 23 report at least one threat with a weapon each month. Four-point physical restraint is used by 125 of the 127 facilities. Personnel in 32 of these facilities restrain at least one patient each day. Seventeen institutions report having significantly injured a patient during restraint in the last five years, resulting in one death. Twenty institutions report involvement with litigation with respect to restraint. Only 51 institutions provide ED nurses with formal training in recognition and management of aggression and violence, and only 79 institutions have security personnel present in the ED 24 hours a day. A sizable number of facilities receiving frequent threats and batteries are not among those with 24-hour-a-day security personnel. A preventative, risk-management approach that addresses environmental factors, training policies, restraint, security arrangements, and legal precedents is suggested.

Recovery from schizophrenia in the Third World

Approximately two to four billion dollars were spent on the treatment of schizophrenia in the United States in 1971 (Gunderson and Mosher 1975)--about half of one percent of the gross national product. This amount excludes expenditure on social security support for schizophrenics and such indirect costs as loss of productivity. Such a substantial investment should surely have yielded Americans significantly better rates of recovery than in less affluent parts of the world, for psychiatric care is very low on the list of priorities in developing countries. The evidence, however, points overwhelmingly to much better outcome for schizophrenia in the Third World. I will review the evidence in some detail and then analyze the possible reasons for this surprising finding.

Factors associated with the seclusion of psychiatric patients

Records of adult psychiatric patients in a university hospital revealed 116 patients had been secluded on 263 occasions during one year. Seclusion was more frequent in winter and spring, and during the late night and early morning, but there was no relationship between seclusion and lunar cycle, week day, weather, menstrual cycle, or month of birth. More males than females were secluded, but females had more multiple seclusions. A control group matched for ward, sex, and within ten years of age consisted of 108 patients. The most common diagnoses for both groups were the major affective disorders and schizophrenia.