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

























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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
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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
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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.
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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
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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
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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
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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
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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
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that warranted the implementation of restraints/seclusion and what their current behavior may be
(Prater et al, 9
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References
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