Trend To Decrease Use Of Seclusion And Restraint

[marylyn_91604]

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

[aura_of_laura]

Pennsylvania has some of the toughest restraint laws in the US, after several people died in prone restraints. Every new change brings cries of outrage from healthcare workers...

At my facility, we do not use any object restraints (like leather ties, mittens, chairs, etc) - every restraint requires three people trained in therapeutic crisis intervention, plus a nurse to document every five minutes, and it can't last more than one hour. You can bet a lot more thought goes in to preventing restraints when it takes so much manpower and time to complete one! Not to mention the pages and pages of paperwork following the restraint...

Have our rates gone down? Yes and no. Usually one or two patients will make up 75% of the restraints and seclusions for the month, and there is genuinely nothing we can do to prevent them. But we are certainly past the days of tying a patient to their bed for hours at a time - can't even imagine working in a place where I could tie up a patient!

[Orca, ADN, ASN, RN]

The quality of training given to the staff has a lot to do with the number of restraint situations. I was the first swing shift charge nurse on a new hospital mental health unit, and despite the nurse manager's best efforts to anticipate everything, we still ran into a lot of situations we had not trained for and had no written policies for. Restraint situations were done the best way we could, and they were often awkward. Then our staff was trained in the Mandt system, which not only showed us how to safely restrain people, but also how to avoid those situations altogether. Our restraint situations dropped considerably after everyone was trained, and the ones we did have were properly handled. Staff was confident, and the patients also seemed to respond to our new-found calmness. I found it much better to have a feeling of control when these situations happened rather than the adrenaline rush and the "Oh, crap, what do we do now?" feeling.

Usually one or two patients will make up 75% of the restraints and seclusions for the month, and there is genuinely nothing we can do to prevent them.

Reminds me of a patient I had on a geropsych unit several years ago. This man was a sociopath, and his actions were calculated. For instance, the first thing he would do before acting out was to reach over the desk and pull the phone cord out of the wall, so that we couldn't call for backup. He deliberately injured at least three staff members. Restraint situations were pretty much a daily occurrence. This man should have been arrested for assault.

[Meraki]

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

I was the exact opposite. The efforts to decrease seclusion and restraint are what kept me in psych nursing. I hated being part of restraints that were about behavior management, unit management, power struggles between staff and patients, ultimatums, and convenience.

Our unit went seclusion and restraint 'free'* about 5 years ago and really it has been wonderful for all - staff and patients. The unit is a much nicer and safer place to work and feels less punitive for the patients. So many psych patients have histories of trauma that knowing they aren't going to be restrained makes them feel much safer. And we have far fewer back / muslce injuries that staff used to get trying to move / restrain combative patients.

What we did was...

Do a lot of staff training on what underlies externalized behaviour (trauma and stress reactions, attachment, poor executive functioning, poor coping skills, concrete thinking, poor receptive / expressive language skills, learned patterns of acting / reacting etc as well as situations such as boredom, threat, feeling ignored, feeling restricted, bravado, control...). We learned about trauma informed care, worked hard on deescalation skills and nonviolent crisis management skills.

• We now have a schedule that keeps patients busy and engaged in meaningful activities
  
• We watch carefully for any cues of agitation, distress and immediately approach the patient to problem solve
  
• We provide attention and validate the emotions /thoughts or give space if needed.
  
• We do a lot of deescalating - showing understanding of what is behind the behavior and focusing on those issues rather than consequencing or punishing the behaviors
  
• We added a workout room to the unit to try and get the patients exercising and to blow off agitated energy
  
• We added locking doors so we can block off sections of the unit so the patient is 'secluded' from other patients but still in their own room comfortable space
  
• We try and provide individualized care rather than milieu care - so unit rules and guidelines need to make sense for that patient and not be enforced just because
  
• We encourage (positive) families and friends to visit often
  
• We provide individualized attention and 1:1 chat times throughout the day to diminish behavior that is attention seeking
  
• We use oral prns more often than we used too - early on before the crisis really gets going to try and help the patient remain in control ( I have mixed feelings about this, I don't like patients being reliant on meds to cope)
  
• We do a lot of skill based group work focused on self expression and coping
  
• Every one is treated with respect, and with the expectation that they are capable of being in control of their behavior with staff support
  
• We are flexible with assignments so that whoever is on shift that the patient has the best rapport with will usually step in and either support or take over the deescalation / crisis management
  
• We are well staffed
  

There may be others. When we changed to this approach a few of the very rigid, boot camp type staff left as they felt we were being too easy on the patients - this was also a good thing! If you are going to change the unit philosophy, you have to have consistency and everyone on board.

*By free I don't mean we never do seclusion / restraint. We have a seclusion room that patients can choose to go to voluntarily to calm (door stays unlocked), and we may strongly encourage them to take themselves there. Maybe a few times a year we will physically escort someone there and they are restrained until they are in the seclusion room then staff gets out. We do not restrain for loud, obnoxious, oppositional behaviour - there has to be an imminent safety risk. Rarely but it happens that we restrain someone who is actively hurting themself - usually only long enough to get the sharp from them. We occasionally physically restrain psychotic patients to give them chemical restraints if their delusions / hallucinations are causing them great distress. It is very much a last, final, nothing else worked option.

[Blackcat99]

You have a whole lot of good ideas. Unfortunately, at the state psychiatric hospital we were extremely short staffed on a regular basis. Staff were getting injured all the time and nothing was done about it. Anyway, I am very happy to not work psych nursing anymore.

[Meraki]

You have a whole lot of good ideas. Unfortunately, at the state psychiatric hospital we were extremely short staffed on a regular basis. Staff were getting injured all the time and nothing was done about it. Anyway, I am very happy to not work psych nursing anymore.

And I am happy that you are happy! I too wouldn't work where I didn't feel safe. I am fortunate that I work on a well staffed unit with management that was prepared to back up policy with training and resources. It makes a world of a difference.