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Reducing the use of seclusion and restraint

April 1, 2008
by Linda Witte
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A Michigan provider reduced its use of seclusion and restraint by 93% in one year on its child and adolescent unit

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








Physical interventions are viewed as a primary intervention.

Staff use more verbal deescalation with patients.

Staff have fairly rigid expectations—fixed consequences for actions

Patients are given more options and choices.

Doctor and therapist offices are in another part of the building.

Doctor and therapist offices are relocated to be directly adjacent to (in some cases on) the unit.

There is a hierarchical structure; doctors and therapists are removed from the daily milieu and called after a crisis is in progress.

There is more interdisciplinary teamwork; doctors and therapists are present more, paged sooner, and work as peers with nursing staff

Nursing staff reacts to person in crisis.

An interdisciplinary team comes together to brainstorm immediate options for a person as first stages of crisis are noted.

Behavior plans are reviewed two to three times per week

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.

Patients are randomly assigned rooms in all hallways.

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.”

There is no extra staffing when patients are in crisis unless seclusion or restraint techniques are used.

There is more 1:1 staffing when in the quiet hall. Safety guidelines are in place and negative behaviors are not rewarded with attention.

All patient interaction takes place within the sight or earshot of peers.

While isolated, a patient is able to “save face” with peers and work through issues causing crisis moments .

Private journaling time in individual rooms is scheduled for two hours per day.

There is much less quiet time in rooms.

Patients spend more time viewing educational videos, with not much planned physical activity time.

Physical activity is planned intentionally into the patients' day.

Patients are infrequently in the courtyard.

Patients spend more time in the courtyard.

A rigid structure is in place. For example, patients must drink all their milk before getting dessert. Attendance at scheduled groups is mandatory.