Ms. Barton and Ms. Johnson are Clinical Managers, Behavioral Health Unit, Chambersburg Hospital, and Ms. Price is Clinical Nurse Specialist in Adult Psychiatric and Mental Health and Director of Patient Services and Behavioral Health, Summit Health/Chambersburg Hospital, Chambersburg, Pennsylvania.
The authors thank the Behavioral Health Unit staff for their courageous undertaking, implementation, and ongoing dedication to this vision and change. The authors also thank Dr. Rajnikant Lad, Child and Adolescent Psychiatrist, for initial direction and support of the change project.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Sandra A. Barton, BSN, RN, BC, Clinical Manager, Behavioral Health Unit, Chambersburg Hospital, 112 North Seventh Street, Chambersburg, PA 17201; e-mail: firstname.lastname@example.org.
© 2008 Sandra A. Barton, BSN, RN, BC
Use of restraint in the treatment of mental illness has long been controversial. Regulatory agencies and licensing organizations, as well as professional and advocacy groups, have called for restraint use reduction. Responding to this, the leadership team of a behavioral health unit in a private, nonprofit community hospital evaluated reducing restraint use. However, instead of reducing use, the team decided to eliminate restraint use. Using trauma-informed care principles and applying the Mental Health Recovery Model, the goal of restraint-free was achieved. This article outlines how a restraint-free vision became reality.
Colaizzi (2005) reviewed and summarized a brief history of restraint and the well-intentioned initiation of restraint use. As she noted, Dorothea Dix is credited with the rise of state asylums for the insane. This widespread growth took place throughout the 1800s. The new asylums were barely built before problems with overcrowding were encountered. “By the 1840s, asylums had already become so overcrowded that behavior control had become a central concern” (Colaizzi, 2005, p. 33).
Mechanical methods for behavior control were believed to be necessary. A variety of mechanical restraining devices were introduced. From tranquilizer chairs to cold wet sheet packs, patients’ behaviors were restricted. Seclusion was one physician’s alternative to restraint use and was deemed a more humane alternative. Even so, seclusion was considered controversial.
Back when alienist was the term for psychiatrist, ethical concerns seem to have been as much an issue as they are today. British alienists were more critical of restraint and seclusion use than their American colleagues. Although antipsychotic drugs had not yet been developed, opiates, bromides, and alcohol were available. These agents made patients sleep, but sleep was considered therapeutic. Excessive use of these agents was recognized as chemical restraint (Colaizzi, 2005). Colaizzi (2005) concluded:
From the beginning of psychiatric care, founded by the Quakers, the use of mechanical devices and drugs to control violent behavior has been viewed as inimical to the ethical principles of benevolence and nonmalfeasance…. It is not always possible to translate philosophical ideals into practical realities and both of these absolutes contain an element of truth. (p. 37)
Restraint reduction has been a major concern of the Pennsylvania Department of Health, the Office of Mental Health and Substance Abuse Services of the Commonwealth of Pennsylvania, and The Joint Commission. Since before 1990, when the Pennsylvania seclusion and restraint initiative began, Pennsylvania has been a leader among states in reducing seclusion and restraint use. The process for accomplishing this reduction was discussed by Smith et al. (2005). They noted that while the rate and duration of time spent in restraint and seclusion decreased, there was not a noticeable increase in staff injuries related to patient assaults.
In 1998, the Hartford Courant began a series of articles reporting deaths that occurred while people were being restrained or were in seclusion (Weiss, Altimari, Blint, & Megan, 1998). This series prompted increased advocacy for seclusion and restraint reduction. In 2002, the National Association of State Mental Health Program Directors (NASMHPD) created a national “call to action.” A national action plan was developed and over the next several years, incentives were developed at the national level to bring all states on board.
Trauma theory became widely understood during this same time. Trauma-informed care, as described by Hodas (2004), became the base for care reform. Pennsylvania remains at the forefront as a leader in trauma-informed care initiatives and humane treatment models for individuals with mental illness. Since recognition of trauma events and trauma-informed care, considerable energy has gone toward reducing the use of restraints in the care of people with mental illness (Huckshorn, 2004).
Achieving a Restraint-Free Environment
Description of the Unit
The leadership team of a 26-bed behavioral health inpatient unit within a private, nonprofit 248-bed community hospital had been focusing on decreasing restraint use. This unit is locked and is licensed to provide care for clients age 14 and older. Eighty percent of admissions are processed through the hospital emergency department. All diagnostic categories are accepted, and admissions are voluntary and involuntary. The top three diagnostic categories are severe recurrent depression, bipolar disorder, and schizoaffective disorder.
The unit is in an older hospital structure and is configured in a T shape. The central wing is an intensive care psychiatric unit (ICU) where more acutely ill individuals are held until they are ready to move to the less acute areas. This ICU wing is locked as well. Elevators open into the center of the unit, although these are restricted in use to certain hospital employees with badge-activated access.
Cameras monitor all public areas and hallways, with a television monitor located at both nursing station areas. There is a main nursing station on the less acute wing and a smaller, satellite nursing station on the ICU wing. The average daily census is 17, and the average length of stay is currently 5 to 7 days. Much longer stays of 4 to 6 weeks or more occur when patients are awaiting placement in longer term treatment centers.
Initial Training Program
To respond fully to the call to action to reduce restraint use, a clearly defined plan was needed. More material, resources, and direction were needed in how to achieve the goal of restraint reduction. In March 2005, two team members attended the National Executive Training Institute (NETI) (2005) program for the reduction of seclusion and restraint. Although this program was for the public mental health sector, the team members were welcomed into the group.
The program provided the direction needed to guide efforts to effect change. NETI generously provided volumes of educational and “how-to” materials. The 3 days of presentations, many interactive, were filled with excellent examples of how to proceed. A manual including every PowerPoint® presentation was provided on the first day. A DVD containing all of the PowerPoint presentations was available as well.
Every presentation was rich with ideas and suggestions. The workshop opened with a film showing, one after another, children and adolescents who had died during or in the process of restraint or seclusion. Included were the “offenses” of the individual who required restraint or seclusion. The presentation effectively communicated the risks—both physical and emotional—of restraint use.
Trauma theory was presented next, and with it came many “aha” moments for those who had no previous training in trauma theory. Further presentations provided more exact directions regarding what has worked for others and what to expect as movement is made toward restraint reduction. For example, staff reactions to proposals to reduce or eliminate restraint use can be unpredictable. Many staff react with fear, voicing concern for their safety, as well as patient safety. These concerns must be addressed.
Steps to Goal Achievement
After completion of the program and the decision to undertake this project to reduce restraint use, the project team established an action plan and time line. The first task was sorting the volumes of material into manageable, “bite-size” implementation pieces. The time line proposed by the workshop leaders was 18 months.
Restraint events were highly traumatic for both patients and staff on the unit. Physical injury, even death, was always a possibility. Knowing death was a possible outcome, the staff were challenged to reach beyond the goal of restraint reduction. The vision became restraint elimination.
Much of the information provided was essential for the culture change. Learning about trauma theory was a major eye-opener. According to Psychiatric-Mental Health Nursing: Scope and Standards of Practice (American Psychiatric Nurses Association, 2007), “The psychiatric-mental health nurse provides, structures and maintains a safe and therapeutic environment in collaboration with patients, families and other healthcare clinicians” (p. 39). Restraining was retraumatizing people. Many nurses saw restraining as a violation of this standard; knowing about retraumatization was even more disturbing to staff. Restraint use was viewed as treatment failure. Staff wanted and needed more information on alternative ways to help agitated individuals.
From mid-2005, organization of the project became a priority. A project chairperson was appointed. Highest level management support was obtained. The organization’s senior leaders supported restraint elimination 100%. They provided additional guidance, access to specialty information service resources, and visible leadership support. A “Project Charter and Statement of Work” was developed. A time line and action plan was created, and a project implementation team was formed. The team included risk management personnel, middle and top leaders, and frontline nursing staff. Including frontline nursing staff was critical for goal success. They were the day-to-day champions of restraint avoidance.
The original goal was restraint reduction, but after only approximately 2 weeks, the Director of Patient Services for Behavioral Health began calling it “restraint elimination” and challenged everyone to think in that direction. The direction was “Reach for the stars; you just might succeed.”
The restraint elimination vision had to be kept constantly in the forefront. As a key component in achieving culture change, restraint elimination was constantly addressed, alluded to, promoted, and “talked up” in staff meetings and impromptu gatherings. Staff safety concerns were discussed repeatedly.
Curriculum Development and Staff Training
The materials provided by NETI were invaluable. Sorting and condensing the PowerPoint presentations and content book, along with the DVD, provided at the training conference was a major and occasionally overwhelming task. Presentations to staff were developed from these conference materials and delivered during an 18-month period.
The first presentation, Childhood Trauma: Prevalence and Effects, laid the groundwork. Staff learned about trauma theory. Statistics of trauma cases, expected to be dull subject matter, were too compelling to be dull. This statistical portion now appears to have been a pivotal point in realizing culture change on the unit. Staff could relate to these numbers. In many cases, staff had personal experience with trauma. It was necessary to recognize and address staff behaviors and pain as they became aware of their own trauma histories. Support and opportunities to debrief and acknowledge these feelings were essential.
Neurobiological Effects of Trauma was the second subject for discussion. Observable brain changes (differences) was new information for staff. The visual evidence of actual brain changes resulting from emotional or physical trauma (visible on a positron emission tomography scan) made the trauma damage visible and real.
The third presentation, Changing a Culture, looked at the words used in conjunction with patients and families. Reminders to see patients as people, not disease processes, reframed staff members’ orientation. Patients were Mary or Joe, not “that borderline” or “the schizophrenic.” Patients were recognized and acknowledged as mothers, fathers, sisters, brothers, sons, and daughters. Personalization of patients, or person-first, became a priority and a way of thinking and behaving. Development of relationships with newly admitted patients was a critical component in being able to de-escalate hazardous situations. Occasionally, immediate relationship development would be necessary.
Additional topics for staff education involved summary reviews of previous material with added topics concerning intervention skills and techniques.
The seclusion room, which had never been used, was converted into a Comfort Room. The comfort room is a preventive tool used to help reduce anxiety and agitation. It is well established that environment significantly affects mood and behavior. The comfort room provides sanctuary from stress, and it can be a place for individuals to experience feelings within acceptable boundaries (Bluebird, 2007). The comfort room is painted pale peach in color, with the ceiling painted as a blue sky with soft clouds. Occupants can choose from selections of soothing nature sounds or classical music that is piped in through ceiling speakers. A Comfort Box was created, from which people may select items to help them relax. Items include a soft, washable, handmade blanket; stress balls; stuffed animals; and journaling materials. Sensory approaches, such as lavender hand lotion or vanilla oil, are also available. A sign is posted on the Comfort Room door. Quoting from the Substance Abuse and Mental Health Services Administration (2005, p. 25), the sign reads:
The Comfort Room
A special place where you may spend some time alone. You may ask any staff member to use this room. There are items that you can sign-out to help you calm down and relax (stuffed animals, soft blanket, music, magazines, and more). Persons who wish to use the room will be asked to first sign their names in the sign-in book and talk to a staff member before entering.
From the beginning of this project, the leaders had been warned that culture change would be the most difficult to accomplish. This was not true in this situation. At the very beginning of the project, some staff members questioned the safety of eliminating restraint use. Concerns were discussed repeatedly. The possibility to use restraints was always left open if the situation truly warranted such action. At first, restraints were used on occasion, but rarely. Finally, the unit was down to no-restraint use and achieved 1 restraint-free year as of January 2008. To this date, the unit remains restraint free.
Below are some staff quotes reflective of attitude and culture change. Pseudonyms have been used to protect their anonymity.
- Jennifer, RN: “Restraints now seem barbaric…sort of like the days when insulin-shock therapy was used, or cold-wet packs.”
- Beth, RN: “I just tell patients up front—we do not restrain here—it sets the expectations from the beginning.”
- Katie, nursing assistant: “I don’t like it [restraint use]. I don’t like seeing it.”
- Jesse, nursing assistant: “There were endless opportunities for restraints, but we understood more about difficult patients. We were better able to intervene and help people de-escalate.”
- Vida, RN: “Restraints are inhumane and can cause harm or even death to a patient.”
- Ricardo, nursing assistant: “Our mission should always be to be therapeutic with patients; restraints seem like more of a punishment.”
For trending purposes, the restraint elimination project team gathered data regarding the incidence of restraint use beginning with fiscal year (FY) 2001–2002. Rate of restraint use varied prior to the initiation of the project, ranging from a high of 19 in FY 2001–2002 to 9 for FY 2004–2005. As the project unfolded, the incidence of restraint use declined. The last restraint application occurred early in January 2007. There have been no restraint applications during FY 2007–2008 (Figure 1).
Figure 1: Number of Patients Restrained on This Behavioral Health Unit Fiscal Year 2001–2002 Through 2007–2008.
The first logical questions are, “Did you get to no-restraint use by increasing use of sedative-hypnotic agents?” or “Are you substituting chemical restraint for physical restraint?” This question has been asked, and the answer is a resounding “no.” In fact, use of sedative-hypnotic agents decreased.
Comparison of administration rates for sedative-hypnotic drugs per patient day declined by 22% from 2004 (the year prior to initiation of the restraint elimination project) to 2007 (the first full year with zero restraints). The mean dosage rate per patient day in 2004 was 0.9 as compared with a rate of 0.7 per patient day in 2007.
The study included the following five agents of choice by our providers to treat agitation, anxiety, and psychotic symptoms: lorazepam (Ativan®), haloperidol (Haldol®), fluphenazine (Prolixin®), chlorpromazine (Thorazine®), and olanzapine (Zyprexa®). Comparison of rates of use for these sedative-hypnotic agents is found in the Table and Figure 2.
Figure 2: Comparison of Sedative-Hypnotic Agent Use for Years 2004 and 2007.
Table: Comparison of Rates of Five Sedative-Hypnotic Agents the Year Prior to Initiation of the Restraint Elimination Project to the First Full Year with Zero Restraints
Conclusion and Implications for Practice
The evidence is compelling. Application of person-centered, recovery-oriented, and trauma-informed care principles by frontline staff makes a restraint-free environment possible. It also appears to reduce the need for sedative-hypnotic medication to control behavior.
Although restraint elimination was the term used to describe the goal, nursing staff often expressed concern for safety. Leaving the possibility open to use restraints as a last resort in unsafe situations allayed fears. In early stages of the project, restraints were used occasionally, but as time passed, it became apparent that few, if any, situations required restraint use.
Ironically, these staff members are now very inexperienced in restraint use. Some staff members have never cared for a patient in restraints. Skills are kept current by conducting skills laboratories on restraint application and face-to-face assessment, but the truth remains that few staff members have participated in a restraining process.
A new set of keyless, ease-of-use restraints had been purchased midway through the project. These restraints remain brand new. They have never been used.
- American Psychiatric Nurses Association. 2007. Psychiatric-mental health nursing: Scope and standards of practice. Silver Spring, MD: American Nurses Association.
- Bluebird, G. 2007. Bluebird Consultants: Using comfort, communication and the arts to minimize use of restraint and seclusion. Retrieved March 14, 2007, from http://www.bluebirdconsultants.com/
- Colaizzi, J2005. Seclusion and restraint: A historical perspective. Journal of Psychosocial Nursing and Mental Health Services, 432, 31–37.
- Hodas, GR2004. Understanding and responding to childhood trauma: Creating trauma informed care. Harrisburg: Pennsylvania Office of Mental Health and Substance Abuse Services.
- Huckshorn, KA2004. Reducing seclusion and restraint use in mental health settings: Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services, 429, 22–33.
- National Executive Training Institute. 2005. Training curriculum for reduction of seclusion and restraint. Alexandria, VA: National Association of State Mental Health Program Directors, National Technical Assistance Center for State Mental Health Planning.
- Smith, GM, Davis, RH, Bixler, EO, Lin, HM, Altenor, A & Altenor, RJ et al. . 2005. Pennsylvania state hospital system’s seclusion and restraint reduction program. Psychiatric Services, 56, 1115–1122. doi:10.1176/appi.ps.56.9.1115 [CrossRef]
- Substance Abuse and Mental Health Services Administration. 2005. Module 5: Strategies to prevent seclusion and restraint. In Roadmap to seclusion and restraint free mental health services (DHHS Publication No. SMA 05-4055). Retrieved March 14, 2007, from http://download.ncadi.samhsa.gov/ken/pdf/SMA06-4055/Manual_Module5.pdf
- Weiss, EM, Altimari, D, Blint, DF & Megan, K. 1998, October11. Deadly restraint: A nationwide pattern of death. The Hartford Courant
Comparison of Rates of Five Sedative-Hypnotic Agentsa the Year Prior to Initiation of the Restraint Elimination Project to the First Full Year with Zero Restraints
|Number of patient days||4,919||4,715|
|Number of total dosages of the five agents||4,271||3,208|
|Dosage rate per patient day||0.87||0.68|