Journal of Psychosocial Nursing and Mental Health Services

Guest Editorial Free

Reflections on the Use of Restraint and Seclusion: A 10-Year Update

Kevin Ann Huckshorn, PhD, RN, ICADC

The author has disclosed no potential conflicts of interest, financial or otherwise.

It has been 10 years since the Journal of Psychosocial Nursing and Mental Health Services (JPN) first published a special issue on the use of restraint and seclusion (R/S; Huckshorn, 2004). Since that time, JPN has been vigilant in publishing articles that have highlighted new knowledge and promising practices regarding R/S.

The more recent work to reduce the use of R/S in mental health settings began after the Hartford Courant (Weiss, Altimari, Blint, & Megan, 1998) published a multiple article exposé on R/S use in the United States. Those articles were quickly followed by landmark publications by the National Association of State Mental Health Program Directors (NASMHPD; 1999), the National Alliance on Mental Illness Policy Research Institute (2003), and Mental Health America (Steel, 1999), as well as a joint toolkit published by the American Psychiatric Nurses Association, American Psychiatric Association, and American Hospital Association (2003).

Equally important has been the decade-long work by a small but important group of researchers, policy makers, and advocates who questioned the use of R/S and brought it to the forefront. These visionaries include, but are not limited to, Dr. Elaine F. Morrison, Dr. Wanda K. Mohr, Mr. Charles Curie (former Commissioner for Pennsylvania and former Substance Abuse and Mental Health Services Administration Director), and members of the National Association of Consumer/Survivor Mental Health Administrators.

These individuals represent some of the pioneers in the mental health field who realized that the use of R/S was dangerous and traumatizing to clients and staff. They talked about these ideas, published their research, and set the stage so that when the award-winning exposé on the use of R/S in the United States (Weiss et al., 1998) provided national attention and traction (which had been lacking historically) the mental health field had a head start to make change happen.

The mental health field, and nurses in particular, have come a long way since JPN’s initial special issue on R/S use. We now have evidence that better practices exist, as numerous hospitals and other mental health settings have significantly reduced R/S use while providing safer services for children, youth, and adults, as well as individuals in forensic facilities. We now have an evidence-based best practice that can be implemented without adding new resources (National Registry of Evidence-Based Programs and Practices, 2012). We have also seen our international colleagues take on this work and be successful. The articles included in this 10-year anniversary special issue by LeBel et al. (pp. 22–29), Caldwell et al. (pp. 30–38), and Huckshorn (pp. 40–47) serve as testaments to this work.

One of the lessons learned through the effort to reduce R/S use is a better understanding of the power of peer support. Enlightened agencies are embracing this new workforce because when peer support specialists are integrated to work side-by-side with traditional staff, they break new ground and serve as lightning rods for practice change. It is harder for a facility to keep using R/S when it employs individuals with lived experiences.

I want to share a rather poignant reference on the use of R/S that was given to me by my grandmother (also an RN) and is found in a nursing textbook by Steele and Manfreda (1960):

When approaching an “overactive patient” one fact must be constantly borne in mind…. They must never be abruptly approached, spoken to harshly, threatened with punishment, or roughly handled…. It is always better to try and talk to the patient and attempt to discover the reason for their fear and to dispel it.

Overactive patients always remember the details surrounding their periods of excitement. The less unpleasantness these patients have to reflect on, the better their chances for recovery.

Any form of restraint is very frightening and only increases excitement. Restraint produces unfavorable effects on the circulatory system…. Restraint should only be used in an emergency; and even then, it must be cautiously applied and abandoned as soon as more effective treatment can be administered.  (pp. 536-537)

For me, this reference represents an important lesson. It seems the mental health nursing discipline “lost” this knowledge between 1960 and 1998. It seems that our former colleagues knew and understood the dangers of R/S, but this knowledge was not passed on in academic settings or employee orientations. I hope that all who read this special issue will think about embedding this knowledge into their practice competencies and work settings. Successfully reducing R/S use requires a significant organizational culture change. Maintaining the gains we have seen since 1998 will take a village, and in this case, the village needs to be the nursing profession.

I would like to dedicate this special 10-year anniversary JPN issue on the national and international work that has been done to reduce R/S use in mental health settings to Joyce Jorgenson. Joyce was one of the early pioneers of this work and led the development of the first peer-developed curriculum titled, Roadmap to Seclusion and Restraint Free Mental Health Services (Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2005). Joyce is also a founding faculty member of the NASMHPD-developed Six Core Strategies® to Prevent Conflict, Violence and the Use of Seclusion and Restraint. Joyce’s life and career have been dedicated to the meaningful involvement of consumers and families. She spent several years receiving services in an institution, which formed her dedication to community-based services—the most human way to work with individuals in need. Joyce is a wonderful example of recovery in action. For me, Joyce is both a survivor and a hero.

Kevin Ann Huckshorn, PhD, RN, ICADC

Guest Editor

Director

Division of Substance Abuse and Mental

Health

Delaware Department of Health and Social

Sciences

Wilmington, Delaware

References

  • American Psychiatric AssociationAmerican Psychiatric Nurses AssociationNational Association of Psychiatric Health Systemsthe American Hospital Association Section for Psychiatric and Substance Abuse Services. (2003). Learning from each other: Success stories and ideas for reducing restraint/seclusion in behavioral health. Retrieved from http://www.aha.org/advocacy-issues/mentalhealth/caseex/learningfromeachother.shtml
  • Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. (2005). Roadmap to seclusion and restraint free mental health services (DHHS Pub. No. [SMA] 05-4055). Retrieved from https://store.samhsa.gov/shin/content/SMA06-4055/SMA06-4055-A.pdf
  • Huckshorn, K.A. (2004). Reducing seclusion and restraint use in mental health settings: Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services, 42(9), 22–33.
  • National Alliance on Mental Illness Policy Research Institute. (2003). Seclusion and restraints: Task force report. Retrieved from http://www.nami.org/Template.cfm?Section=Policy_Research_Institute&Template=/ContentManagement/ContentDisplay.cfm&ContentID=10979
  • National Association of State Mental Health Program Directors. (1999). Reducing the use of seclusion and restraint: Findings, strategies, and recommendations. Alexandria, VA: Author.
  • National Registry of Evidence-Based Programs and Practices. (2012). Six core strategies to prevent conflict and violence: Reducing the use of seclusion and restraint. Retrieved from http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=278
  • Steel, E. (1999). Seclusion and restraint practice standards: A review and analysis. Alexandria, VA: National Mental Health Association.
  • Steele, K.M. & Manfreda, M.L. (1960). Psychiatric nursing. Philadelphia, PA: F.A. Davis.
  • Weiss, E.M., Altimari, D., Blint, D.F. & Megan, K. (1998, October11). Deadly restraints: A nationwide pattern of death. The Hartford Courant, 1–16.

10.3928/02793695-20140930-01

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