Eight years after the Hartford Courant published its investigative report, "Deadly Restraint,"[1] the Centers for Medicare and Medicaid Services (CMS) released final revised standards regarding restraint and seclusion for the management of violent or self-destructive behavior.[2] In the intervening time period, psychiatric and mental health professional organizations, including the American Psychiatric Nurses Association (APNA), have formulated position statements and standards of practice for the use of seclusion and restraint in mental health settings. These standards articulate the vision of eliminating seclusion and restraint, emphasizing prevention and reduction of the use of these restrictive measures and their safe application only in behavioral emergencies that pose an immediate risk of harm.[3] In 2007, the APNA will again update their position paper and standards to reflect the latest recommendations of the CMS and emerging evidence-based and best practices.



Medscape readers have asked a number of tough clinical questions about how they can reduce the use of seclusion and restraint in mental healthcare settings, environments often challenged by short staffing and elevated risk of violence. We posed these questions to 2 psychiatric-mental health nurse experts: Lynn DeLacy, PhD, RN, CNAA, Director of the Northern Virginia Mental Health Institute in Falls Church, Virginia, and Chair of the APNA Seclusion and Restraint Task Force; and Marlene Nadler-Moodie, MSN, APRN-BC, Clinical Nurse Specialist at Scripps Mercy Hospital in San Diego and member of the Board of Directors of APNA.
Which Situations Call for the Use of Seclusion Rather Than Restraint?

Restraint and seclusion are 2 very different emergency protective measures. In 2006, the CMS adopted the following definitions of restraint and seclusion:

Restraint. Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.[2]

Restraints do not include devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, other methods that involve the physical holding of a patient for the purpose of conducting routine physical examination or tests, to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm.[2]

Seclusion. Involuntary confinement of the patient alone in a room or an area where the patient is physically prevented from leaving; a situation where a patient is restricted to a room or area alone and staff physically intervenes to prevent the patient from leaving is also considered seclusion.[2]

Seclusion can only be used for the management of violent behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.[2] Seclusion should not be used for punishment, coercion, or threat. Seclusion is generally considered less restrictive than restraint, unless the patient expresses a preference for restraint, in which instance that preference should be considered.

Seclusion is used in circumstances when a patient is temporarily unable to control impulses or surges of emotion leading to behavior that might harm someone else. Seclusion is not safe for patients who might harm themselves (for example, patients who bang their heads). A locked seclusion room should also be avoided if the patient has medical problems because of the difficulty observing subtle signs of cardiac and respiratory compromise. The weight gain associated with some psychiatric medications, along with the increasing prevalence of comorbid medical conditions, exacerbates these risks.

Seclusion might be used for the patient whose behavior endangers others, who needs to be alone for the protection of others, or who must be removed from situations that may trigger harmful and escalating behaviors. This temporary and brief time alone offers the opportunity for the patient to use positive coping strategies to calm and quiet him or herself. If a patient expresses a preference for seclusion in situations where other alternatives have not worked, that preference should be honored. In these or other instances, the least restrictive means to accomplish the separation of a person from others is to encourage the person to use his or her room, positioning a staff person at the door to help the patient use the quiet time effectively.

Mechanical restraint may be preferred when the person would benefit from continued verbal interventions by staff that may safely remain near to them to assist with calming strategies, allowing restraints to be removed at the earliest possible time. Mechanical restraint should be avoided with persons who have a history of sexual abuse and trauma. Physical restraint may also be contraindicated for these persons and must be used very cautiously in all instances owing to the risk of positional asphyxia or sudden cardiac collapse.

Occasionally, either seclusion or restraint would equally accomplish the necessary emergent protections. A patient may express a preference for one safety measure over another, and staff may consider this request if there are no contraindications. Since use of seclusion or restraint can disrupt the therapeutic alliance, honoring advance directives or preferences is important.

Practices associated with chemical restraint seem to vary widely. It is important to remember that some "as-needed" or stat medications can actually help the individual to safely manage him or herself. Those medications that are designed to put a person to sleep, and not treat the underlying condition, are considered chemical restraint.
What Alternative Approaches Can Nurses Use to Avoid the Use of Seclusion and Restraint?

A reader asks, "What do you do when a 220-pound violent patient is throwing furniture or has already assaulted a staff member?" The first thing you should do is clear the area of others, and then remain quietly available at a safe distance until the peak of the crisis has passed. The risk of injury to both patients and staff is high when a direct verbal or physical intervention is attempted at the peak of a crisis. If a staff member has been assaulted, the staff member should be removed from the area and other staff must take the lead in intervening. A patient should not automatically be secluded or restrained following a staff assault, a response often born of fear or the conviction that the person needs "consequences." Seclusion or restraint should never be used to introduce consequences; instead, other approaches to supporting behavior change may be instituted once the crisis has passed.

Early identification of the problem and appropriate assessment of the situation are essential because different situations must be dealt with differently. Anger, fear, and frustration can all lead to violent behavior, and each calls for a specific approach. "Meet the patient where the patient is at" is a phrase commonly used to convey the need to match the approach to the patient's emotional state and to what has triggered that state.

An often overlooked but very simple crisis communication technique is to ask the patient "What would help you right now, at this moment?" It is surprising that this is a question we don't think of asking, yet it often yields a very specific and helpful response. A patient might just need clarification of a misunderstanding, some personal space, or might need to walk. Engaging the patient in the decision of how best to intervene can help them get through the situation without resorting to seclusion or restraint.

Delaney, Pitula, and Perraud[4] developed the Four S Model as a way of reducing the use of seclusion and restraint. The 4 S's are safety, support, structure, and symptom management. In brief:

* Safety means assuring the individual's physical and emotional well-being via interventions such as modifying the environment to reduce stimuli and induce a calming ambiance.

* Support involves listening and talking in a supportive way, offering comfort measures or whatever is needed according to the individual, and using verbal de-escalation.

* Structure techniques, like limit setting, convey behavioral expectations and aid in constructive problem solving.

* Symptom management is aimed at specific symptoms including stress and relaxation measures, diversionary activities, or medication.

The scenario described above (the 220-pound patient throwing furniture) is already an out-of-control situation. The question must be asked, what happened before this patient started throwing furniture or assaulted the staff member? At that point, engaging this patient might have led to a different outcome. When the patient is at the point of throwing furniture, the only option may be to clear the area and have everyone get out of the way until the patient winds down. This can be difficult and scary for staff to do, but it is likely to result in less injury than trying to physically contain the patient and apply restraints. When the patient is calmer, staff can proceed with crisis communication techniques that involve the patient, and the use of seclusion or restraints has been avoided.

Prevention is always easier and more effective than reacting to episodes of violent behavior. Careful patient assessments can identify risk factors for violence including triggers, previous restraint and seclusion history, and trauma and abuse history. At the same time, effective coping strategies previously used by the individual to safely manage behavior, as well as specific directions for what staff can do to help, should be elicited and documented in the treatment plan. Patients can be involved in developing their own de-escalation or safety and support plans (including psychiatric advance directives). Gathering this information at the point of admission provides a foundation for effective partnership when circumstances present that could give rise to a behavioral emergency. "I remember you saying...." is an opening statement that sets the stage for working together.
How Do You Convince Your Staff That They Must Reduce Use of Seclusion and Restraint?

Start with the premise that seclusion and restraint use is not therapeutic, represents a failure in treatment, and causes physical and psychological harm to patients. Research shows that these measures are traumatic for both staff and patients. Staff must be encouraged to question their beliefs that if seclusion and restraint are not used, staff injuries will follow. In contrast, research confirms that environments characterized by control and coercive interactions are more likely to result in staff injuries.

The challenge for leaders, who must simultaneously assure both patient and staff safety, is to guide staff through the transition from controlling patients as a way to achieve safety to partnering with patients to ensure safety.[5] Once staff understand that we are not asking them to choose between their safety and reduced use of seclusion and restraint, but that both can be accomplished, they will be more open to seeking alternatives, discussing best practices, and sharing experiences about what works and what doesn't. Staff members need to realize that they themselves are therapeutic tools, the main intervention that will help individuals with mental illness get better. This realization is an important part of a culture change in how patients are treated, moving away from custodial care and toward true patient-centered care.[5]

Leaders must be present, available, and start from where staff members currently are, supporting them to consider different ways of thinking. Leaders must believe and communicate that staff and patients have the answers that will reduce seclusion and restraint. Leaders must not only pay attention to the use of restraint and seclusion but notice and reward the big and little things that effectively minimize restraint and seclusion. Leaders play an important role in helping staff to see and claim their successes -- often staff will say it was just "luck" that an intervention worked, when it really was their superb efforts. Helping staff see this outcome creates cycles of confidence that they can build upon.

What shouldn't leaders do? They should not simply inform staff they must not use restraint or seclusion anymore, without giving them any other options. Staff members need training, resources, and support to develop and implement strategies to replace restraint and seclusion while maintaining safety in the workplace.[5]
How Can Nurses Avoid the Use of Seclusion and Restraint When They Are Chronically Short Staffed?

It is true that improving staffing ratios tends to lessen the reliance on restraint and seclusion.[6] The organization must certainly provide enough staff to sustain a safe working environment. That said, the number of staff on duty is not the whole answer. It is also important to have the right mix of professional staff who are properly trained in therapeutic communication and behavioral techniques. The research consistently shows that hospital characteristics have a greater influence on seclusion and restraint use than patient characteristics.[7] Nursing staffing is one of the chief characteristics that distinguishes one hospital from another.

Both the numbers and the skill mix of nursing staff can greatly influence seclusion and restraint use. Sufficient staff must be present to make timely observations and implement alternatives very early in a situation that could become a behavioral emergency. Short staffing can contribute to greater use of restraint and seclusion -- not just because of the numbers, but because the way we tend to behave when we are short staffed can intensify a conflict. When we are short-staffed, we feel stressed and pressured and become more directive (eg, issue commands and orders, use confrontational limit setting), which can lead to greater use of restraints or seclusion to more quickly resolve a crisis.

In light of significant nursing shortages, if improved staffing ratios are not possible, nurses and other nursing staff must be relieved of nonnursing duties. Educate nurses to be aware of their interactions with patients, particularly when tensions are running high due to short staffing. Teach nurses to mitigate their interactions so that they are less directive and more engaging. And, importantly, managers should carefully screen nurses who are hired to work in behavioral health settings; applicants should have a sincere desire to work in the behavioral health arena and be prepared to use both the art and science of psychiatric mental health nursing.
Could You Provide Examples of How to De-Escalate a Person in Crisis?

De-escalation is a valuable therapeutic intervention that can be used by nurses to help counter the growing problems of aggression and violence in mental healthcare settings.[8] It is, however, not necessarily an intuitive skill, and most nurses will benefit from formal training and practice in using de-escalation strategies.

The immediate priorities of the nurse faced with an angry and potentially violent individual are to maintain safety while preventing the behavior from escalating into violence.[9] The recommended approach is to maintain caring and concern, a nonauthoritarian, therapeutic manner that helps to defuse anger, while at the same time setting limits.

Here is a partial list of de-escalation techniques that experienced mental health nurses find to be helpful in a crisis:

* Assess the situation promptly. If you see signs and symptoms of a person entering into crisis, intervene early.

* Maintain a calm demeanor and voice.

* Use problem solving with the individual -- ask "What will help now?"

* Be empathetic.

* Reassure individual that no harm will come to him or to others.

* Avoid an argumentative stance.

* Offer to help.

* Engage the individual.

* Use stress management or relaxation techniques such as breathing exercises.

* Don't crowd the individual; give him or her space.

* Be aware of yourself -- your look, your tone.

* Offer choices.

* Use open-ended questions.

* Give the individual time to think.

* Decrease the tension with relaxation techniques.

* Ignore challenges; redirect challenging questions.

* Tell them what you can do to help them.

* Allow venting.

* Allow pacing.

* Don't say "you must."

* Avoid power struggles.

* Set limits and tell them what the expectation is.

* Be careful with your nonverbal behaviors.

* Be aware of the individual's nonverbal behaviors.

* Be clear; use simple language.

* Language -- follow the rule of 5 (no more than 5 words in sentence, 5 letters in a word -- eg, "Would you like a chair?")

* Use reflective technique -- "Am I hearing you?"

* Agree to disagree.

* Be willing to break the rules.

* Consider using sensory modalities such as weighted blankets or calming rooms with stress reduction tools.

Guidelines to maintain safety of both yourself and others during situations of potential violence include[9]:

* Take a position just outside the individual's personal reach (out of arm's reach) on the nondominant side.

* Maintain an open posture.

* Keep the individual in visual range.

* Make certain the room's door is readily accessible; avoid letting the individual get between you and the door.

* Summon help if the individual's aggression escalates to violence.

* If other patients are in the vicinity, ask them to leave the room to decrease distractions and protect the person's dignity.

What Is the Role of Medication in Managing Behavioral Emergencies?

Medication can be a tremendous therapeutic ally, but the right medication needs to be given for the right reason. Medications are treatments for target behaviors in behavioral emergencies, not for the purposes of chemical restraint.[10] The definition of chemical restraint is, "a medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition." A chemical restraint, for example, would put a patient to sleep, rendering them unable to function as a result of the medication. On the other hand, a therapeutic agent is used to treat behavioral symptoms.[10] Given during a crisis, a therapeutic agent might calm agitation, help the patient concentrate, and make him or her more accessible to interpersonal intervention. Regardless of indication, medication administration must be preceded by an appropriate clinical assessment.

Medications most commonly used for behavioral symptoms include the atypical antipsychotics (olanzapine, quetiapine, risperidone, and ziprasidone). Other, older antipsychotics such as haloperidol are still used. As an adjunct, for its calming effect, a benzodiazepine such as lorazepam may be offered.[11]
Are Nurses More Likely to Become Injured Because of Increased Patient-to-Nurse Ratios?

Yes, this outcome is possible if nurses deal with short staffing by being overly directive. Keep in mind that contrary to what many individuals believe, decreasing the rate and duration of seclusion and mechanical restraint use in psychiatric hospitals does not lead to more staff injury; in fact, it may actually reduce staff injuries.[12] When the use of seclusion and restraint is high, injuries tend to be high because the act of applying restraints is itself physically dangerous to staff members and because the coercive nature of the measure tends to elicit a more aggressive response.

The practice of restraining patients puts both patients and staff at risk of injury. Restraint and seclusion can be violent, stressful, and humiliating events, both for patients and the staff members imposing these measures.[13] The use of restraint and seclusion can also traumatize patients and staff members, damage therapeutic relationships, and impede patient recovery.[13] Furthermore, staff member disagreement about the use or non-use of restraint or seclusion in specific situations can create tension between staff members, harming their working relationships. Therefore, leaders must assure there is a system in place to support staff "defusing" and debriefings. If critical incidents are not debriefed, staff may carry their feelings about one event into the next situation in a way that reduces the likelihood that the next behavioral emergency can be averted.

The risk of physical injury increases when inexperienced nurses are left on a unit with acutely ill patients. Experienced nurses must be present. At no time should one nursing staff member ever be alone on a unit. Regardless of the number of patients present, at least 2 staff members should be present, including during break times. Staffing levels should take into account patient acuity, the staff skill mix and level of experience, and the physical environment of the unit.
What Training Should Staff Have to Help Them Learn to Prevent Violence and Implement Alternatives to Seclusion and Restraint?

One premise is that all staff and other individuals who might be around during an emergency should be included in some version of training. In settings where there are ambulatory patients, clerical and janitorial staff might also participate in some form of training. Training should be extended to whoever might be in a position to be around and interact with patients because the overall tone of the unit must create an environment for recovery.

Professional staff who provide care must be trained during orientation and on an ongoing basis. Training includes communication skills, building therapeutic relationships, cultural and generational diversity, personal professionalism, and self-awareness. Specific training for coping with behavioral emergencies includes the aggression cycle, crisis communication, and de-escalation techniques.

Training should also address the causes of aggression and violence, such as the influence of trauma and abuse history, comorbid medical conditions, and coercive or controlling interactions within rule-bound environments. Appropriate medical assessment prior to using restraint and seclusion is extremely important to prevent serious adverse consequences related to the use of restraints.

The final CMS rule, effective in January of 2007, states that "all clinical staff that have direct patient contact must have ongoing education and training in the proper and safe use of seclusion and restraint application and techniques and alternative methods for handling behavior, symptoms, and situations that traditionally have been treated through the use of restraints or seclusion." Requirements for staff training focus on demonstrated competencies and building a skill set for working with patients. Staff must be trained and able to demonstrate competency prior to applying restraints, implementing seclusion, performing associated monitoring and assessment, or performing care of a patient in restraint or seclusion.[2]
What Can Be Done to Assure Staff Safety in Forensic Settings, if Restraint and Seclusion Are Not Used?

It is beyond the scope of this article to address all aspects of forensic settings. However, there are some key points that might help nurses conceptualize alternatives to seclusion and restraint when they are working with people who have a mental illness and are involved in the judicial system. Assessing and differentiating risk factors in a systematic way is the most important way to open a path to effective alternatives. For example, some risk factors are static, meaning they will never change. These include dispositional risk factors like age, gender, and psychopathy. Other static risk factors are historical, like the nature of the crime, relationship instability, or history of sexual abuse. These too will never change. The irony is that these are the factors we tend to focus on, and they tend to make us feel helpless and frightened.

However, there is another set of risk factors that empowers both staff and patients to develop and use alternatives. These are the clinical risk factors that include psychiatric symptoms, substance use, and personality disorder. Treatment that is well focused can address these factors and reduce their influence. The therapeutic milieu that nursing can influence, along with the nature of the psychiatric-mental health nursing interventions, are powerful tools within forensic settings. To maximize their effectiveness, in addition to treatment, nurses must assess, use, and strengthen the individual's protective factors, thereby reducing risk. Protective factors include positive, stable social relationships; positive self esteem; treatment adherence; and, most importantly, shared vigilance with the caregiver. The latter is the same concept used in behavioral health settings when we involve the person in discussing triggers and alternatives and how staff might help.

Laura Stokowski, RN, MS