Thursday, August 02, 2007

Mental Health Care's New Model Shuns Restraint and Seclusion -
The Nursing Spectrum

Throughout her 26 years of working with patients who have acute psychotic episodes, Patti Morrison, RNc, has had to wrestle many of them into four-point harnesses and isolated rooms.

"It's absolutely horrendous," says Morrison, a staff nurse at Anna Jaques Hospital in Newburyport, Mass. "You're actually manhandling somebody."

One year ago, the staff at Anna Jaques attended state-sponsored training in restraint reduction. Now, intake counselors work with each patient to learn what triggers agitation and what activities can stop it. Staff nurses then review patient details at the beginning of a shift.

"Our goal now is to see the warning signs and do something to prevent episodes," Morrison says.

A painful history
Psychiatric facilities long have used seclusion and physical or chemical restraint as a way to handle violent or troublesome patients. In theory, it was the last resort of an older psychiatric model that focused on medication to control psychotic symptoms presumed to worsen over time. Resources would go toward safely housing patients rather than developing support outside the facility. At worst, floor nurses become babysitters who used rewards and punishments to ensure patient cooperation.

These practices jumped into public view in 1998 after a series of articles in Connecticut's Hartford Courant documented 142 restraint-related deaths during 10 years in facilities across the country. The dead patients included at least 30 adolescents and children ages 6 to 18. One 15-year-old girl died of asphyxiation after a physical restraint episode during which she refused to give staff a photo of her family.

"It's mythological practice based on no scientific evidence," says Kevin Ann Huckshorn, RN, MSN, CAP, ICADC, who researched the practice and ways to reduce it while working at South Florida State Hospital in the 1990s.

Huckshorn found inconsistent and subjective application of the restraint-and-seclusion intervention -- even among staff members within a single facility. The practice is underregulated, and administrators may not report problems with restraint use for fear of lawsuits, she contends.

Prodded by Congress as it reacted to media attention, the Centers for Medicaid and Medicare Services (CMS) adopted rules for safe restraint in 1999, requiring the facilities it funds to review each incident. The Joint Commission has adopted restraint-and-seclusion statistics as core indicators of quality in psychiatric inpatient facilities.

Neither organization has gone as far as Huckshorn, who, as the director of the office of technical assistance for the National Association of State Mental Health Program Directors (NASMHPD), wrote "Six Core Strategies for the Reduction of S/R" in 2003. The six steps include --

Involve management

Train staff

Provide tools

Include patients

Track relevant data

Rigorously review incidents to prevent reoccurrence

Huckshorn's strategies called for an organizational overhaul, with administrators, specially trained staff, and involved patients working to prevent psychotic episodes. Under Huckshorn's program, administrators must be willing to track restraint statistics and carefully review each incident to prevent its recurrence. Staff must be willing to consider restraint use from a patient's point of view.

These strategies reflect a newer "recovery model" of mental health care, which seeks to help patients help themselves, with an eye toward independence. Huckshorn found that offering classes and workshops on everything from hygiene skills to anger management helped patients in many ways, for example.

"Getting people off the units and engaged in active treatment reduces conflicts because people aren't bored anymore, just walking around and smoking cigarettes," she says.

Massachusetts ahead of its time
Massachusetts has led the way in mandating more progressive care, becoming the first state to make licensure dependent on restraint reduction. The state began adopting restraint reduction measures in child and adolescent psychiatric inpatient facilities in 2000. By 2005, episodes of restraint and seclusion dropped 84% and 80%, respectively. Hospitals also reported fewer staff and patient injuries.

Moe Lord, RN, OCN, director of Anna Jaques' adult psychiatric services, was skeptical when the new regulations went into effect.

"At first I thought the Department of Mental Health was too far from care," she says. Phrases like "partnering with the patient" seemed nothing more than politically correct until she attended the mandatory state training.

"It was the best two-day seminar I had ever attended," she says.

Now she helps her staff implement individualized programs featuring sensory relief and stimulation that help patients avoid the trauma of restraint. Morrison reads up on each of her patients before her shift begins so she can see signs of impending crisis. She often uses humor to diffuse situations. Sometimes she has patients ride on exercise bicycles, work on puzzles, or partake in warm footbaths.

"It is more work, but the outcome is 100 times better," she says. "They can use these skills when they leave here."

Nurses are well-suited to helping transition patients away from a punishment and control model, says Nan Stromberg, MSN, APRN, BC, director of nursing for the licensing division of the Massachusetts's Department of Mental Health.

"It's a natural fit to provide caring, collaborative, strength-based treatment that involves clients as partners," Stromberg says. "There's been a polarization between people who want to reduce restraint and seclusion and people who fear they need to protect themselves. When you change a culture to be softer, caring, connected, you protect everybody."

Strategies staff can embrace
Gayle Bluebird, RN, a NASMHPD consultant who trains staff on the "Six Core Strategies," says most nurses she meets want to learn what she has to teach. Even skeptics have changed their minds when they begin to see the program works, she says.

Her curriculum includes the biological and psychological effect of trauma on patients, and she trains nurses to shift their attitudes and behaviors in conflict situations. She describes the prevention-based approach to restraint and seclusion and talks about the need for flexibility. As a former patient and a longtime nurse, Bluebird can speak personally to the trauma of restraint and seclusion.

"There's been huge progress," says Bluebird. She has written about the importance of including patients in the changes that will affect their care. She worked with Huckshorn when the latter was implementing restraint reduction measures at South Florida State Hospital in the late 1990s. Bluebird saw an opportunity in the no-longer-needed seclusion rooms.

"You could create supply closets or do something more creative," she says. "I suggested designing rooms in which people could be more comfortable and have quiet alone time."

The idea spread to other facilities, and the rooms morphed into "comfort rooms" in which patients could escape the ward and find sensory relief. Bluebird says at least one facility has asked to include extensive patient input into the rooms' design.

"The more patient ownership, the more they use it and enjoy it," Bluebird says.

Some facilities look to patients to liaison with their population.

"Consumer advocates can provide peer support and share common experiences and solutions and motivate and inspire others," Bluebird says.

The job gives back to patients as well, says Ana Wolanin, RN, MS, who directs adult psychiatric services at UMass Memorial Medical Center in Worcester.

"There is a trend in psychiatry to try to involve patients more in their care," Wolanin says. "Being dependent and passive in care isn't helpful."

Wolanin recalls a patient who volunteered to join the hospital's restraint-reduction committee. Since then, this patient has enjoyed the longest period without hospitalization in her lifetime, Wolanin says. The woman takes peer-counseling training and will soon sit for certification.

Wolanin and her staff continue to turn to the patient liaison as a sounding board for new ideas. She meets monthly with nurse managers for each ward, the medical directors, and the patient liaison.

In the past, floor staff called Wolanin only if restraint use or seclusion lasted a certain amount of time. Now she gets a call every time restraints or seclusion are used. In every instance, she uses a questionnaire that helps her determine what led to the restraint.

"This is called 'witnessing,'" Wolanin says. "Now when I talk to staff, I'm in a position to make changes that need to be made the next day."

Restraint use has dropped by about 50% since the effort began at UMass last year.

Julie Hetherington, APRN, chief nurse executive of Westwood Lodge Hospital in Westwood, Mass, is a successful leader, but her road to success was not an easy one to navigate.

"I had to fire an awful lot of people," Hetherington says. "Many were long-time employees unable to support the culture change. We had to raise the bar on the type of staff we're hiring."

Hetherington asked managers to observe potential employees interact with patients on the unit for an hour to assess their demeanor. Restraint reduction is an agenda item at every meeting. Restraint use has dropped by up to 89% on some wards, and staff satisfaction has soared, she says.

Robert Plant, PhD, the chief executive officer who oversaw restraint reduction at Riverview Hospital in Middletown, Conn., in the late 1990s, says balancing staff concerns with patients' needs is critical.

Using grants from the Substance Abuse and Mental Health Administration, Plant and others designed their own tools and met with other grantees to share successful strategies. Plant wanted staff to view physical and verbal outbursts among restrained patients as acts of self-defense, not assault. At the same time, he supported staff through peer debriefing and recognition of the difficulties of the job.

"If we take better care of our employees, they are less likely to feel the need to use police or press charges," Plant says.

Although the Riverview Hospital program needed refinement at every turn, success eventually evolved. Plant de-emphasized an old point system that calculated a patient's success for the day and asked staff to talk to patients about how their behavior affected the behavior of others.

For her part, Huckshorn isn't waiting around for the bureaucracy to catch up with best practices in mental health care. If most hospitals adopt newer practices, those that do not will be in a more difficult position to defend their practices in a court of law, she contends.

"This is a journey that I hope will significantly change our field," she says.

Heather World is a freelance writer. To comment, e-mail