Pine Rest Christian Mental Health Services (PRCMHS) in Grand Rapids, Michigan, provides outpatient, inpatient hospitalization, developmentally disabled, adolescent residential, and addiction services. PRCMHS is dedicated to expressing the healing ministry of Jesus Christ through professional excellence, Christian integrity, and compassion. While PRCMHS has been recognized for its high standards, the organization has struggled with the issue of using seclusion and physical restraints, especially on our child and adolescent (C&A) unit. In order to live out our mission of expressing the healing ministry of Jesus and to provide professionally excellent care, we knew we needed to make this issue a priority.
Using seclusion and restraint as a treatment intervention can be counter-therapeutic, both physically and psychologically, and should be used only as a last resort. Research indicates that “The use of seclusion and restraint creates significant risks for people with psychiatric disabilities. These risks include serious injury or death, retraumatization of people who have a history of trauma, and loss of dignity and other psychological harm.”1 In addition, “the injury rate to staff during the use of restraints was higher than that found among lumber workers, construction workers, and miners.”2
In 2006, PRCMHS had 240 seclusion and restraint episodes involving 92 patients in the C&A unit, a figure that did not meet our goal of providing professionally excellent care in a safe and compassionate manner. As PRCMHS prepared to limit the use of seclusion and restraint techniques, some staff members voiced concerns such as, “The patients will rule the units and things will be out of control if we don't use seclusion and restraints” and “It's not possible to be seclusion/restraint-free with a mentally ill population.”
Yet after we implemented several changes, the number of seclusion and restraint episodes dropped to just 18 in the C&A unit in 2007. Staff changed their tune, saying, “It's much calmer on the unit now,” “Our patients are learning to calm themselves,” and “It's about giving our patients choices to empower them to make good behavioral decisions.” This article identifies six steps that were key to our initiative's success.
Six Steps to Success
1. Acknowledge the problem. Data compelled our leadership to seek change. Many direct-care staff, however, seemed threatened by talk of changing practices, and they were less forthcoming in acknowledging the problem. Some staff resisted until the new approach's benefits were obvious.
2. Assemble an interdisciplinary team. Senior leadership appointed a task force comprised of the director of operations for hospital-based services, the clinical services manager, a psychiatrist, a case manager (social worker), the lead RN, two direct caregivers, the director of clinical practice, and the staff educator. All team members worked as equals and felt empowered to propose ideas and think creatively. The resulting solutions were more effective since representatives from all disciplines were involved in the process. Team members were role models in implementing new treatment approaches (table 1).
Table 1. Changing approaches to treatment
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2006
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2007
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Physical interventions are viewed as a primary intervention.
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Staff use more verbal deescalation with patients.
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Staff have fairly rigid expectations—fixed consequences for actions
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Patients are given more options and choices.
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Doctor and therapist offices are in another part of the building.
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Doctor and therapist offices are relocated to be directly adjacent to (in some cases on) the unit.
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There is a hierarchical structure; doctors and therapists are removed from the daily milieu and called after a crisis is in progress.
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There is more interdisciplinary teamwork; doctors and therapists are present more, paged sooner, and work as peers with nursing staff
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Nursing staff reacts to person in crisis.
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An interdisciplinary team comes together to brainstorm immediate options for a person as first stages of crisis are noted.
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Behavior plans are reviewed two to three times per week
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Behavior plans are reviewed frequently—at a minimum every 24 hours—both as a team and with the patient; for a person in crisis moments, they can be reviewed several times per day.
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Patients are randomly assigned rooms in all hallways.
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One hallway of rooms is designated as a quiet area to bring patients to as initial stages of a crisis are noted so the patient no longer has an “audience.”
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There is no extra staffing when patients are in crisis unless seclusion or restraint techniques are used.
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There is more 1:1 staffing when in the quiet hall. Safety guidelines are in place and negative behaviors are not rewarded with attention.
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All patient interaction takes place within the sight or earshot of peers.
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While isolated, a patient is able to “save face” with peers and work through issues causing crisis moments .
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Private journaling time in individual rooms is scheduled for two hours per day.
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There is much less quiet time in rooms.
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Patients spend more time viewing educational videos, with not much planned physical activity time.
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Physical activity is planned intentionally into the patients' day.
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Patients are infrequently in the courtyard.
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Patients spend more time in the courtyard.
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A rigid structure is in place. For example, patients must drink all their milk before getting dessert. Attendance at scheduled groups is mandatory.
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A less rigid structure is in place. Patients may negotiate with staff.
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3. Ensure consistent leadership support. Senior leadership supported the task force by applying for grants to fund additional training. They presented task force members to staff as leaders modeling a different way of approaching patients. Initially, a few staff members challenged the task force's leadership role, but management encouraged staff to cooperate with the coaching.
4. Conduct research. The task force conducted research in three main areas.
Analyzing PRCMHS data. The task force realized that it needed to know what happened in the past to identify areas to target for change. Assembling and reviewing C&A unit seclusion and restraint data were the team's first priority.
Reviewing the literature. The task force reviewed published literature from other organizations, which showed that change was possible.
Identifying additional resources. Task force members consulted with a vendor (Crisis Prevention Institute, Inc.), which supplied a curriculum for the C&A unit's crisis-management program. The vendor directed our focus to additional literature, training curricula, and a starting point for our initiative—improving verbal skills, especially in the debriefing process.
5. Ensure that staff members have the necessary tools. The interdisciplinary team identified a knowledge and training gap in developing strong verbal skills, and senior leaders secured a grant to fund training to strengthen verbal skills. The focus was directed toward the new tools learned in the training classes that staff could use, rather than on taking away a known practice (i.e., seclusion and restraint). To fully integrate new approaches, task force members received the training first and became role models.
6. Introduce changes incrementally. For example, staff were united in their willingness to reduce episodes of seclusion and restraint, whereas some expressed resistance to eliminating these techniques. Thus, the initiative was introduced as a way to reduce seclusion and restraint techniques, not eliminate them.
We recognize that elimination of seclusion and restraint is becoming a more recent trend in the profession. As we strive to provide professionally excellent care, we are working through this issue. Is it possible, given the population we serve, to be seclusion/restraint-free? Does that help us fulfill our mission? These are issues we are grappling with.
Results
Between 2006 and 2007 the use of seclusion and restraint techniques declined by 93% in the C&A unit. As staff began to focus on reducing seclusion and restraint use, additional positive outcomes became evident. Staff found that they became a more cohesive team. A strategy of having a brief team consultation during a crisis developed, resulting in a more patient-centered approach. Staff felt free to give each other feedback regarding perceptions and actions during crises. They reconsidered unit routines and structures, as well as made changes to incorporate flexibility and individual choice. Staff reported feeling more professional as they exercised creativity and worked together as team members.
An unanticipated outcome of the initiative was an 8% reduction in staff injuries related to patient care (table 2). In addition, patient injuries from physical abuse or threatening actions from patient-patient and patient-staff interactions were reduced by 24% (table 3).
Table 2. Staff injuries related to patient care
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2006
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2007
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Number of injuries
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87
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73
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Patient days
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8,353
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7,597
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Staff injuries per 1,000 days
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10.4
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9.6
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Table 3. Patient injuries from inappropriate patient-patient and patient-staff interactions
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2006
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2007
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Number of injuries
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24
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17
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Patient days
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8,353
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7,597
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Injuries per 1,000 days
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2.9
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2.2
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PRCMHS's performance improvement auditor for seclusion and restraint reports no significant change in the number of “as needed” medications being given. Thus, chemical restraints have not been a factor in reducing physical restraint and seclusion. Instead, patients learn new ways to cope with turbulent emotions. They increasingly claim responsibility for their own behaviors. They learn to identify triggers and intervene before emotions become overwhelming.
Conclusion
We have been encouraged by the positive outcomes of our initiative to reduce episodes of seclusion and restraint on the C&A unit. As we continue the initiative with our remaining inpatient units, we anticipate more effective treatment results as we empower both patients and staff to manage crises using tools other than seclusion and restraint.
References
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Linda Witte is the Staff Educator for Hospital Based Services at Pine Rest Christian Mental Health Services in Grand Rapids, Michigan, where she has worked for 25 years. Linda Witte is a Senior Associate Level Instructor for the Crisis Prevention Institute. To contact her, e-mail 
