Trend To Decrease Use Of Seclusion And Restraint

Specialties Psychiatric

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:rolleyes: Hello fellow Psychiatric RNs,

I am interested to know how the new trend by NAMI,JCAHO,PTS Rights

to radically decrease use of seclusion and restraints has affected your psych nursing practice??Here in Nevada they take it very seriously,we 've only had 6 restraints in 6 months!!But it affects limit setting and how we approach patients when they are intrusive or inappropriate in their behavior.It affects the whole miliieu.I belive in using S&R as a last resort,but severe agitation to me should be curtailed by time out,seclusion,injections and sometimes restraint.

Here they feel use of seclusion or restraint is a "failure of treatment"

Have you dealt w this?Any suggestions ?Thanks a lot.

Marylyn

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:rolleyes: Hello fellow Psychiatric RNs,

I am interested to know how the new trend by NAMI,JCAHO,PTS Rights

to radically decrease use of seclusion and restraints has affected your psych nursing practice??Here in Nevada they take it very seriously,we 've only had 6 restraints in 6 months!!But it affects limit setting and how we approach patients when they are intrusive or inappropriate in their behavior.It affects the whole miliieu.I belive in using S&R as a last resort,but severe agitation to me should be curtailed by time out,seclusion,injections and sometimes restraint.

Here they feel use of seclusion or restraint is a "failure of treatment"

Have you dealt w this?Any suggestions ?Thanks a lot.

Marylyn

My understanding of NAMI positiion is that it is only to be used if the safety of patient is at sake. It cannot be used as punishment or just for the convience of the staff.

So in the case you mentioned about severe agitation, it actually can be used if the agitation is going to affect the patient's safety (not just the patient who is agitated, but potentially other patient).

The only thing that sort of bother me is that it requires a written order. I mean if a patient suddenly goes psychotic and is causing a danger to him/herself or others, how in the world is one going to wait for a written order before the staff take action? Or is there a pre-written order ahead of time?

Another thing is that NAMI also has the position that the facility is to be ADEQUATE staffed AND all the staff are TRAINED in the use of R/S AND its alternatives. The key here is enough resources and appropriate training.

My understanding is base on the following link:

http://www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.cfm&ContentID=7801

My question is - what are the alternatives and how effective are they?

-Dan

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:rolleyes: Hello fellow Psychiatric RNs,

I am interested to know how the new trend by NAMI,JCAHO,PTS Rights

to radically decrease use of seclusion and restraints has affected your psych nursing practice??Here in Nevada they take it very seriously,we 've only had 6 restraints in 6 months!!But it affects limit setting and how we approach patients when they are intrusive or inappropriate in their behavior.It affects the whole miliieu.I belive in using S&R as a last resort,but severe agitation to me should be curtailed by time out,seclusion,injections and sometimes restraint.

Here they feel use of seclusion or restraint is a "failure of treatment"

Have you dealt w this?Any suggestions ?Thanks a lot.

Marylyn

I have not heard of this! Of course restraints is a last resort but safety is first. We have a relatively low rate of restraint use but no one hesitates to use restraints when needed. I can't imagine having to add the "threat" of JACHO to the mix when trying to ensure unit/patient safety! Some of our patients are so internally stimulated, limit setting, attempts to reason and offering meds are not the solution. Forcing meds often leads to restraints. Patients don't have a right to harm others. Unfortunately, restraints must be used in these circumstances.

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I'm a student nurse doing my psych rotation right now...seriously considering going into psych nursing :)

My wife is a mental health worker in a psych hospital. She says there, they used to restain patients when they would go off or have a fit...now, unless they're a threat to themselve or the client, they're just supposed to get all the other patients out of the area, and let the one patient go on until he/she settles down.

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I'm a student nurse doing my psych rotation right now...seriously considering going into psych nursing :)

My wife is a mental health worker in a psych hospital. She says there, they used to restain patients when they would go off or have a fit...now, unless they're a threat to themselve or the client, they're just supposed to get all the other patients out of the area, and let the one patient go on until he/she settles d

own.[/quote/

That sounds like my hospital-any other tips?

We have a room called Comfort room-its a transformed time out room-With comfy chair,and pictures on walls and soft pillows.If A person is anxious but not too destructive they go in there for 20mins.That and letting them vent is all we do.Does your wife have furhter suggestions?Thanks

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How did the trend of radically decreasing the use of seclusion and restraints affect my psych nursing practice? It made me leave psych nursing for good because I no longer felt safe. It's all about patients rights. Nobody cares if the nurses are permanently disabled and hurt by the mentally ill. :angryfire

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I'm a student nurse doing my psych rotation right now...seriously considering going into psych nursing :)

My wife is a mental health worker in a psych hospital. She says there, they used to restain patients when they would go off or have a fit...now, unless they're a threat to themselve or the client, they're just supposed to get all the other patients out of the area, and let the one patient go on until he/she settles d

own.[/quote/

That sounds like my hospital-any other tips?

We have a room called Comfort room-its a transformed time out room-With comfy chair,and pictures on walls and soft pillows.If A person is anxious but not too destructive they go in there for 20mins.That and letting them vent is all we do.Does your wife have furhter suggestions?Thanks

Both of these situations sound unsafe. Obviously clearing the area is a good idea but from what I've seen, once patients start to "go off" they are looking to engage with someone and they don't particularly care who it is. I can't imagine working in either of these places. I'd be afraid of getting hurt and beyond that afraid of getting sued. If I didn't intervene on a potentially violent situation and a patient was hurt there goes my license and my house. I don't know how you deal with this!

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Hi, I work in an acute inpatient psychiatric hospital. I'm a travel nurse and took this as a 13 week assignment. Where I work there are clear protocols for managing escalating patient behavior in appropriate ways. Everyone is trained in CPI, which is a system of nonviolent intervention with a goal of safety for not only the patient who's having difficulty, but also the other patients and staff. We work as a team and if a situation arises, there are basic types of response based on the patient behavior in that moment. The interventions run the gamut of empathetic listening, clear directives, limited choice (either this or that), show of support(several staff showing up at once), physical holding if necessary, and restraints only as a very last resort. It's very helpful to have had the training, I feel I have a much clearer idea of when to set limits and give directives which help keep things from escalating so easily. We do need orders but there are usually two psychiatrists working whenever I'm on, so it's not difficult to get. Since we know different roles as a team in this kind of situation, we know what to do. I do think that it's very traumatic for patients and staff when things get to the point of needing physical intervention to keep everyone safe. I'm taking a research class on-line right now and researching the use of seclusion and restraints, the effects of their use (on patients and staff) and alternatives, in the acute psychiatric inpatient hospital setting. Also, we do have security that will respond if needed so we do call them as back-up. I think some of the problem is that we have patients with every possible mental illness diagnosis and symptomology. Very different needs. If we could somehow cluster similar or seperate differing needs to create a more individually supportive environment there might be less need for intervention at the extreme end of the spectrum. Bye for now.

Annerose, Psych Nurse

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Specializes in Critical Care.

Ok this may not pertain to your topic but I have some questions that I can not find on the internet and being a nurse for 12 years I have not dealt with. My brother was admitted to a local facility asking for help he admitted to suicidal thoughts with a plan, homicidal thoughts to anyone that gets in the way and was also drunk. The facility placed him on the unit where his soon to be ex-wife works and when I got there and asked why he did not have a 72-hour detention order is when they implemented it. The hospital in NW indiana then explains that he has to be restrained. I disagreed with them and said it wasn't going to happen. unfortunately he overheard a nurse talking about his wife cheating with a physician and he got very aggresive and then they did restrain him. What my question is what are forensic restraints? I complained to the VP of nursing because they did not release the restraints or check on him every two hours( I have photographic proof of an empty nursing station) they did not offer him water ROM and when I asked if the physician came into renew the restraint order I was told that he was in forenic restraints and that they don't have to be release just checked on every two hours. I documented everything that happened while I was there visiting and only twice within an approximate 8 hour period did the nurse check his skin integrity. In all my years of nursing and inservices on restraints have I ever heard of forensic restraints. So I am a little confused and whether this magnet facility is trying to cover up a screw up. Any help is appreciatged

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The only thing that sort of bother me is that it requires a written order. I mean if a patient suddenly goes psychotic and is causing a danger to him/herself or others, how in the world is one going to wait for a written order before the staff take action? Or is there a pre-written order ahead of time?

In emergent situations, an RN can initiate seclusion or restraint if necessary and THEN contact the physician for the order asap after the client is safe. "Pre-written" orders would be, effectively, PRN orders for restraint and are strictly forbidden.

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DOrothy,

The place to check the law in Indiana regarding restraints is through The Department of Developmenatal Disabilities. At least that's what it's called in Illinois. There are specific laws which may vary from state to state which provide the law regarding the use of restraints, ROM, toileting and hydration. In Illinois, the physician is required to see and document at the beginning of the restaint and every eight hours. There also must be a restriction of rights completed every 4 hours. In this restriction, a copy which must be provided to the patient, the nurse must state the reason for the restraint. In addition, in Illinois, the nurse must document every 15 minutes the behavior of the patient. If the patient is sleeping, he is no longer a danger and the restraint must be removed. In addition, the patient must be monitored one to one by staff. Meaning a staff memeber must be present at all times. In Illinois, complaints are filed with guardian and advocacy. I'm sure Indiana has a similar agency. On the back of the restriction of rights, in Illinois, the location and phone numbers of the offices are listed. I have never heard of "forensic restraints". Hope this helps.

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Specializes in Critical Care.

It does help a lot and thanks for your help!

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