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This research paper was written as a requirement for a mental health clinical. This research paper explores the alternative measures to physical restraints in behavioral health patients.
This research paper was written as a requirement for a mental health clinical. This research paper explores the alternative measures to physical restraints in behavioral health patients.
This research paper was written as a requirement for a mental health clinical. This research paper explores the alternative measures to physical restraints in behavioral health patients.
Running Head: ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS 1
Alternative measures to physical restraints and seclusion in Mental Health units.
Jaclyn Strangie NURS 616C December 4, 2013 Ellen Tucceri
ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
2 The Issue This paper will address the issues associated with using restraints in mental health units. In particular, it will explore alternate measures to using physical restraints when dealing with challenging patients. This is an important issue that has been the center of much debate and research in the last several years. Patients can potentially be put in physical restraints every day in behavioral health units. As a student nurse, working on a mental health unit, this area has become very interesting to me. I am aware that putting someone in physical restraints is a last resort. However, I wanted to learn more about what nurses could do first and what other alternatives and least-restrictive measures existed. I was eager to learn about the variety of measures that nurses could implement before physical restraints were utilized. Many hospitals have different policies regarding the implementation and use of physical restraints in their hospitals. Portsmouth Regional Hospital utilizes physical restraints after the nursing staff and other members of the interdisciplinary team have exhausted all other measures. Certainly, if a patient is deemed unsafe and can harm themselves or a member of the staff, then the patient may be put in physical restraints. In knowing this, I was eager to see if what I had learned about the use of physical restraints was congruent with what the research states when caring for a client displaying aggressive behaviors. Assessing The Research When initially searching this topic, the search words used were alternative measures to physical restraints in mental health units. This search came up with about 1,440 results. In order to limit the number of results, I changed the search criteria to include only adults, the English language, a publish date no later than 2003, a special interest in nursing, and peer-reviewed ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
3 articles. After doing this, I searched alternatives to restraints in behavioral health units into the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. After this search, CINAHL yielded 94 results, which was much more workable. From these 94 I browsed through, making minor changes to my search terms and found the majority of my sources. PSYCHINFO was another database that was used while researching this topic. The same type of advanced search was done using the same key words in the search engine. This database presented with 228 search results. Within these results, there were a lot of studies regarding physical restraints in other types of nursing besides mental health. After determining that these results didnt relate to my research topic, I narrowed down the search more and changed mental health to behavioral health units in the search engine. After refining my search, the results were still at about 225. Eventually, I was able to narrow it down to about 100 and found a few sources that were useful to this paper. CINAHL was a great database to use because it is used more in nursing research and especially nursing care, making it a perfect resource for this paper. PSYCHINFO was also another great resource as it had some results pertaining to mental health and the use of restraints. However, this database is not specifically for nursing. Therefore, doing an advanced search was necessary to achieve the outcome desired. Logical Argument Sivakumaran, George, and Pfukwa did research on reducing restraints and seclusion in acute mental health units. This study found a total of four major factors that would reduce the rates of restraints and seclusion among adults in mental health units. These four factors included: (1) leadership and support from management in nursing practices, (2) increased multidisciplinary team input, (3) renovations to the inpatient setting, and (4) changes in treatment-related factors ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
4 such as collection of behavior management history and improving documentation in patient files (Sivakumaran, George, Pfukwa, 2011). Kim Sivak conducted qualitative research regarding the implementation of comfort rooms in order to reduce seclusion, restraint use and acting-out behaviors. This study addressed that the use of restraints has resulted in the occurrence of many negative outcomes, including deaths, to both the nurses and clients involve. Sivak defines a comfort room, as a room that is small in size, calm in nature, with nothing harmful in it (Sivak, 2012). With the use of these rooms, 92.9% of the clients who used these rooms found them to be helpful when they experienced increasing levels of distress (Sivak, 2012). Sivak noted how important it is for nurses to play a role in promoting autonomy, but making sure to give patient- centered care. In doing this, nurses must reduce environmental stress potential negative outcomes and triggers that can cause acting-out and escalating behaviors. Morales and Duphorne researched less restrictive measures, such as, alternatives to four-point restraints and seclusions when trying to control aggressive behaviors. The goal of this study was to decrease the use of restraints and seclusions by implementing the least restrictive measures first. Staff at this unit implemented alternative measures when clients were displaying aggressive behaviors. The alternative measures in this study included verbal interaction for de- escalation, offering medication, limit setting, listening to soft music or having quiet time (Morales, Duphorne, 1995). After the implementation of less restrictive measures, the nursing staff felt more comfortable giving care to these aggressive patients. Nurses felt that hey were able to offer patients choices before their behaviors escalated and they had no choice but to put them in physical restraints and/or seclusion. ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
5 Champagne and Stromberg took a more sensory approach to finding alternative measures. This study focused on patient-centered care and how to appropriately care for each patient individually. It asked the question How would you act if you were feeling overwhelmed, unsafe, and bombarded by unfamiliar stimuli, and imagine entering a complex and overstimulating health care setting (Champagne, Stromberg, 2004). This allowed nurses to get a better understanding of how patients may act at different points during their hospitalization, as well as, what can be done to reduce these patients challenging behaviors and aggressiveness. This study looked at the different types of comfort rooms, like Sivak did in her study, to see if this would help reduce the frequency of the use of physical restraints. To reduce stimuli, Champagne and Stromberg looked at the implementation of multisensory rooms. These rooms consisted a variety of seating options, music, and self-help books and magazines focusing on health, wellness, yoga, and nature (Champagne, Stromberg, 2004). In doing their research, they found that sensory-based approaches and multisensory treatment rooms are beneficial to the individual in inpatient psychiatric programs. These approaches expand the range of what therapeutic interventions are available/useful in helping to avoid or resolve crisis situations that could lead to seclusion and restraints (Champagne, Stromberg, 2004). Kontio et al, found that providing patients with meaningful activities, planning beforehand, documenting the patients' wishes, and making patient-staff agreements reduced the need for restrictions and offered alternatives for seclusion/restraint (Kontio et al, 2012). However, it was noted that patients felt they werent getting the attention they thought they deserved while being in seclusion and/or restraints. Sullivan et al, reviewed the use of confinement, the use of physical restraints and seclusion at the same time, on a psychiatric unit from 1998-2003. They found that patients confined declined ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
6 from 5.8 in 1998 to 1.6 in 2003 (Sullivan et al, 2005). This reduction was indicative of the nursing staff doing their job to use alternative measures and make sure that patients were fully participating in their treatment plans. McCain and Kornegay found eight emerging themes amongst the interviews from eight nurses. The seasoned nurses all stated that the use of behavioral health restraints should be resorted to only after less restrictive measures, safely implemented, failed to control potentially harmful behavior, avoided through early recognition and the subsequent implementation of less restrictive interventions (McCain, Kornegay, 2005). Lindsey explored the reasoning behind a nurses decision to use restraints and whether or not it had to do with empowerment of individual factors. More importantly, this study examined the decision patterns used by psychiatric nurses in response to patient situations in which restraints might be considered (Lindsey, 2009). This study concluded that participants who rated themselves high on two aspects of empowerment (opportunity and information) were less likely to choose restraints as the initial intervention to address the potentially violent situations (Lindsey, 2009). Critical Approach Sivakumaran, George, and Pfukwa did research on reducing restraints and seclusion in acute mental health units. This study was considered an empirical study using both a qualitative and quantitative approach. The researchers used a random approach in gathering patient files and qualitative data obtained by a survey given to the nursing staff (Sivakumaran, George, Pfukwa, 2011). Kim Sivak conducted qualitative research regarding the implementation of comfort rooms in order to reduce seclusion, restraint use and acting-out behaviors (Sivak, 2012). Each client ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
7 would have to sign an agreement to use the comfort room. This agreement stated the rules regarding this room and what it entailed. This meant that clients knew ahead of time what was expected of them in this room, and what they could and could not bring into the room. For example, one personal belonging was allowed, no food or drink, etc. Sivak use appropriate measures to conduct this study, allowing for feedback from the clients who stayed in these comfort rooms. Morales and Duphorne did research on alternative measures and how nurses played a role in doing this. This study was conducted over a 3-month period on an acute psychiatric unit in Colorado (Morales, Duphorne, 1995). The population of this study consisted primarily of men ranging from late twenties to late sixties, who had a stay of at least 2 weeks on a behavioral health unit. To evaluate alternative measures nurses were asked to meet weekly and discuss the measures they have implemented and how effective they were on these patients. In this study, there was bias present as it asked nurses to meet weekly to discuss the measures, and many of the nurses were in disagreement with what was being implemented and what wasnt in this specific unit. Champagne and Stromberg did research using a qualitative approach. This study was conducted by the implementing the use of quiet rooms as an alternate to restraints and then to further evaluate them. (Champagne, Stromberg, 2004). Kontio et al, conducted research on this topic about how to improve the use of alternative measures and what patients thought about them. These studies were conducted using focused interviews (n= 30) and were analyzed with inductive content analysis (Kontio et al, 2012). The methods used in this study were appropriate. It allowed the researchers to get a feel for what the ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
8 patients thought rather than the members of the interdisciplinary team i.e. nurses. However, the sample size of 30 was also a small sample for this type of study. Sullivan et al, conducted an empirical quantitative study to evaluate the use of safe effective methods to treat violent patients on an inpatient, 117 adult bed psychiatric units. (Sullivan et al, 2005). This study was more difficult because it focused on confinement, which is, the use of seclusion and restraints at the same time, rather than researching the use of one or the other. McCain and Kornegay conducted a phemenological study looking at the views of eight seasoned nurses. It addressed how they experienced the therapeutic use of physical restraints in their current practice settings (McCain, Kornegay, 2005). Interviews were conducted on each of these nurses using a qualitative approach. These interviews were taped and analyzed looking for emerging themes. With the use of this type of method, these researchers experienced the use of bias. They interviewed seasonal nurses about their experience with the use of seclusion and restraints over their career. Therefore, this was not an appropriate measure to use to accurately evaluate the effectiveness of alternative measures to restraints. Lindsey used a quantitative approach to conduct her study. The population consisted of 30 nurses who participated from four different sites. Surveys were given to each nurse in the form of a case study. Each nurse would have to read the case, and then prioritize which intervention they would perform first, second, third, etc. The interventions listed included verbal de- escalation techniques, PRN medications, room time, seclusion, and restraint. The method Lindsey used to conduct this study was appropriate, however, the influence of the nurses and their backgrounds was not an accurate way to evaluate when to use a restraint and when not too. The use of seclusion and restraint should be based off the level of aggressiveness the client is ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
9 displaying. From here, the nurses should make a decision, disregarding their personal thoughts behind the matter. (Lindsey, 2009) Implications for Nursing Practice When caring for an escalating client who is acting-out or displaying aggressive behaviors, nurses need to know how to appropriately respond to their actions. Seclusions and physical restraints, as discussed in this paper, should be used as the last resort in the majority of psychiatric settings. Its important for nurses to understand and to be able to implement alternative measures appropriately in order to provide the best care to aggressive patients. The alternatives to physical restraints and seclusion mentioned in this paper include: Therapeutic communication, quiet rooms/time out, walking with staff, talking with favorite staff members, music, movies or TV, calling a person on the phone in which you wish to speak to, decrease in stimulation, deep breathing, medication (specifically IM STAT meds), and 1:1 Sitters. All of these measures are considered the least-invasive alternatives to seclusions and physical restraints. As well, the least invasive measures should be exhausted before the implementation of physical restraints and/or seclusion. Seclusion rooms and restraints are usually ordered for the shortest duration necessary and only when the least-restrictive measures have been deemed unsuccessful. These measures are used only to protect the client the staff from physical harm. When caring for clients with aggressive behaviors, nurses must know that seclusion and restraints must never be used for convenience of the staff, punishment to the client, or on unstable clients. If and when a client is placed in a seclusion room or in restraints, it is up the to the nurse to properly care for these clients. This means that a nurse is to assess them frequently, offer food and fluids, toileting, and monitor vital signs. Lastly, its a nurses responsibility to appropriately document the behaviors ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
10 that warranted the implementation of restraints/seclusion and what their current behavior may be (Prater et al, 9 th edition)
ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
11 References Champagne, T., & Stromberg, N. (2004). Sensory approaches in inpatient psychiatric settings: innovative alternatives to seclusion & restraint. Journal Of Psychosocial Nursing & Mental Health Services, 42(9), 34. Kontio, R., Joffe, G., Putkonen, H., Kuosmanen, L., Hane, K., Holi, M., & Vlimki, M. (2012). Seclusion and Restraint in Psychiatry: Patients' Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives. Perspectives In Psychiatric Care, 48(1), 16-24. doi:10.1111/j.1744-6163.2010.00301.x Lindsey, P. (2009). Psychiatric nurses' decision to restrain: the association between empowerment and individual factors. Journal Of Psychosocial Nursing & Mental Health Services, 47(9), 41-49. doi:10.3928/02793695-20090730-02 McCain, M., & Kornegay, K. (2005). Behavioral health restraint: the experience and beliefs of seasoned psychiatric nurses. Journal For Nurses In Staff Development, 21(5), 236-242. Morales, E., & Duphorne, P. (1995). Least restrictive measures: alternatives to four-point restraints and seclusion. Journal Of Psychosocial Nursing & Mental Health Services, 33(10), 13. Prater, D., Lenox, S., Renner, M., Tallmadge, & M., Von Lunen, K. RN Mental Health Nursing (Edition 9.0). USA: Assessment Technologies Institute, LLC Sivak, K. (2012). Implementation of comfort rooms to reduce seclusion, restraint use, and acting-out behaviors. Journal Of Psychosocial Nursing And Mental Health Services, 50(2), 24-34. doi:10.3928/02793695-20110112-01 ALTERNATIVE MEASURES TO PHYSICAL RESTRAINTS
12 Sivakumaran, H., George, K., & Pfukwa, K. (2011). Reducing restraint and seclusion in an acute aged person's mental health unit. Australasian Psychiatry, 19(6), 498-501. doi:10.3109/10398562.2011.603326 Sullivan, A. M., Bezmen, J., Barron, C. T., Rivera, J., Curley-Casey, L., & Marino, D. (2005). Reducing Restraints: Alternatives to Restraints on an Inpatient Psychiatric Service Utilizing Safe and Effective Methods to Evaluate and Treat the Violent Patient. Psychiatric Quarterly, 76(1), 51-65. doi:10.1007/s11089-005-5581-3
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