Exploring the Use of Restraints and Seclusion Rooms in ...



Exploring the Use of Restraints and Seclusion Rooms in Psychiatric NursingAngel St.DenisStenberg CollegeExploring the Use of Restraints and Seclusion Rooms in Psychiatric NursingThe ethical dilemma of using restraints or placing a patient in a secluded room has been a topic of discussion among health care professionals for quite some time. It is also one that brings along with it much controversy as some believe it is against the ethical concept of patient autonomy to restrain or isolate someone against their will, whereas others view it as a way to maintain safety for the patient and others around them. This paper focuses on what restraining and using seclusion actually looks like in a mental health care setting as well as looking at both sides of the coin from a patient’s perspective and a nurse’s perspective. Furthermore, this paper will discuss how the bio-ethics theory plays a role in these situations. Ultimately the psychiatric nurse needs to ensure they are exploring every nursing intervention possible before using restraints or seclusion on their patients. First of all, restraint can be defined as a physical, mechanical, technological or psychological form of controlling someone’s behavior (Regan, Wihoite, Faheem, Wright, and Hamer, 2006). Physical restraint occurs in the mental health setting when a nurse uses holding techniques, or some sort of physical intervention to restrain the patient (Gallagher, 2011). For example holding down the arms of someone who is using aggression toward the nurse. Mechanical restraint on the other hand involves using interventions such as a Posey vest, bed rails, wheel chair confinement, baffle locks, tables or any item that may be used to restrict freedom of movement (Gallagher, 2011). John Cutcliffe (2005) wrote an article that states, “Mechanical restraints are used for gerontology clients seven times as often in Canada as in Britain (Bogaert, 1980, Canadian Psychiatric Association, 2004). By contrast there is a new form of restraint called the technology restraint. This means that the patient may have an electrical tag or bracelet that beeps when they go out of a certain area that they are not supposed to leave. A technical restraint may also be door alarms, or any surveillance equipment that helps the nurse know where the patient is at all times. Another form of restraint that a nurse may use to restrain their patient is chemical restraint. This is when the nurse uses medications to control aggressive or suicidal behaviors (Stewart, Baiden, Theall-Honey, 2013). The ethical issue that usually lies within this context is the over medicating patients and using medication when they don’t really need it, just to keep the work levels down. Unfortunately this incident often occurs when there are staff shortages and the nurses just really need a break from the business of the patients so they sedated them to de stimulate them and keep the atmosphere calm and quiet. Stewart et al (2013) reports, “psychiatric facilities are often frenetic places, characterized by high patient numbers, busy staff, and nurses who are dealing with new admissions, providing care, making appointments, and completing paperwork” (p.1). This author has observed this situation in her geriatrics clinical rotation where there were staff shortages, demands of workload and thus the fall out of that was using chemical restraints freely on patients before any other therapeutic interventions took place. Lastly, a psychological form of restraint occurs when the nurse deprives the patient of choices (Gallagher, 2011). An example of this is withholding items that contain sugar from a patient that loves to eat sugary sweets, but has diabetes. When working in on a special care unit in a older adult facility, the author observed the home to have a no restraint policy. Interestingly, there seemed to be confusion with this policy as mentioned above, the staff had no issues with administering chemical restraints, however there was a patient that had diabetes and was allowed to eat whatever she wanted despite the huge health risk it possessed. Studies have shown that the use of restraints with inpatients is associated with physical consequences such as bruises, broken wrists, even death (Stuart et al, 2013). Patients have also reported that intrusive measures such as restraints leaves them feeling abandoned, shameful, fearful and scared (Stuart, 2013). Health care workers on the contrary state that using restraints helps them to control aggression, minimize safety risks for other patients and staff, as well as help create a more stabilized environment for other patients in the facility (Stuart, 2013). Gallagher (2011) mentions that a great guideline for nurses to implement when making their decision to restrain or not restrain is by using the four quadrant approach. In this approach the nurse analyses first of all what the patient would prefer (if the patient has the capacity to do so), next the nurse analyses the medical indicators (what are the treatment goals and what are the alternatives) third the nurse analyzes the contextual features such as what are the family, religious, and cultural influences or is there a conflict of interest (Gallagher, 2011). Finally, the nurse analyzes the patient’s quality of life (what is causing the distress, what interventions will enhance the patient’s quality of life) (Gallagher, 2011). Using the four quadrant approach can greatly benefit the nurse to make the best choice possible for the patient and the situation at hand to ensure quality of care is given.Another controversial ethical dilemma in psychiatric nursing is the use of seclusion rooms. The British Columbia Ministry of Health (2012) defines seclusion rooms as, “A physicalintervention that involves containing a patient who is perceived to be in psychiatric crisis in a room that is either locked or “from which free exit is denied” (Mayers et al., 2010, p. 61). Although there are policies and standards that each jurisdiction must comply to with regard to the framework and implementation of seclusion rooms which also have a goal to minimize the use of them as much as possible (Ministry of Health, 2012). Sometimes, however there are times where psychiatric nurses have exhausted all other possibilities and therefore make the critical decision of placing a patient in an isolated room of seclusion. Happell et al (2012), shares the reasons for using seclusion rooms vary anywhere from the patient yelling uncontrollably, using aggression, violence, using inappropriate sexual behavior, for the safety of others, if the patient is trying to break something or if they are disrupting everyone else in the facility. Larue (2013) reports that there have been numerous studies done that report the use of seclusion negatively impacts patients. Patients have mentioned that when they have been in seclusion they have felt humiliated, helpless, shame, and may even relieve traumatic previous events (Larue, 2013). In fact, most patients in the studies shared that they would have preferred environmental or chemical forms of restraint instead of seclusion (Larue, 2013). On the other hand reports have shown that 72% of nurses favor using seclusion rooms (Happell, 2013). Happell (2013) also shares that the majority of the nurses in his study stated that they were relieved that the problem was resolved after using implementing the use of secluding their patients. Nurses also associated emotions related to burnout, depersonalization, and exhaustion were minimized from secluding patients that legitimately needed it (Happell, 2013). It was however identified that the nurses perceived their patients to feel angry, disempowered and frightened when placed in seclusion (Happell, 2013). The author observed a youth patient that was on the child psychiatric unit while in clinical. This patient was admitted for aggression and had also stabbed a girl at school with a pencil. The patient was highly elevated in mood, was aggressive, angry, yelling and would not calm down, nor would she listen to anything the nurse was directing her to do. She ended up being placed in a secluded room with nothing else except bare walls, cold floors and a hard bed. It should be noted that the door did have a window in which the nurse was able to monitor the patient, as well as make the patient feel like she was not completely abandoned. She attempted to bang on the door and on the walls attempting to release her aggression. It wasn’t long however until this patient started to deescalate and calm down. At that point the nurse opened the door and started having a conversation with her and began to establish a therapeutic relationship with her. Was seclusion the right thing to do in this situation? It was observed by this author to be an effective tool in stabilizing the patient’s emotion. The bio-ethical theory is a relevant and functional theory based on four main principles of autonomy, beneficence, nonmaleficence, and justice which can be used for a moral guideline for nurses to follow when facing situations such as restraining or secluding patients (Butts & Rich, 2005). Autonomy speaks to a patients freedom and right to self rule (Butts & Rich, 2005). Using restraints and seclusion rooms infringe on a patients own rights as they are held against their will thus restraining them from self rule. However, if the nurse were to use the four quadrant approach and give the patient a preference as to what they want then perhaps it could be said that the patient would still have their autonomy respected. Beneficence is the principle of the bio-ethical theory which refers to the deeds of mercy, kindness, and charity (Butts & Rich, 2005). It also means to take action on behalf of someone else (Butts & Rich, 2005). A psychiatric nurse may run into the situation where they may become an advocate for a patient and discourage other staff from using restraints such as chemical restraints or seclusion with a patient. In this way the nurse would be using their kind heart, and engage in an act of mercy to help out the patient and look out for their best interest. Nonmaleficence is the third principle in the bio-ethical theory and means to, “do no harm” (Butts & Rich, 2005, p.13). When a psychiatric nurse adheres to this principle they are using every measure possible to ensure that their patient is kept safe, and will also avoid every opportunity for neglect. An example of this is that the nurse would choose to use therapeutic intervention over chemical restraint. The fourth principle is that of justice and refers to the right to be treated with equality and to be treated justly (Butts & Rich, 2005). An obstruction of justice occurs when the nurse uses chemical restraints because they are short staffed or have a high workload. The nurse must always base their decisions according to their Standards of Practice (CRPNBC, 2010) and their Code of Ethics in which case, both of these encompass the very principle of justice. Through the Nursing Code of Ethics it states that, “the Registered Psychiatric Nurses upholds the values of: safe, competent, and ethical practice to ensure the protection of the public; respect for the inherent worth, right of choice, and dignity of persons; health, mental health, and well-being; and, quality practice” (p.6). In essence this is the ultimate goal of the psychiatric nurse. The nurse needs to implement every nursing intervention possible before using restraint or placing their patient in a seclusion room. Some examples of nursing interventions are to speak softly in a calm voice, speak in a non-judgemental manner, listen to the patient, do not make promises that cannot be kept, and be honest (Stuart, 2013, p.582). Other strategies include using snoezelen rooms especially with patients that have dementia (Cantley, 2001, p.151). In fact, Stuart et al (2013), states that using snoezelen rooms offer an atmosphere for recuperation which can lead to better therapeutic outcomes. In conclusion, restraints and seclusions should always be used as a last resort. The psychiatric nurse has many valuable options that they may implement which respect their patient’s autonomy and open the door for a therapeutic relationship as opposed to jumping in and using restraints or seclusion as a means to control their patient. Using strategies such as adhering to the four quadrants approach and the bio-ethical theory will assist the nurse to make wise choices that encompass empowering and supporting their patient which ultimately favor best quality of care.ReferencesButts, J.B., & Rich, K.L. (2005). Nursing Ethics: Across the curriculum and into practice. Sudbury, MA: Jones and Bartlett PublishersCantley, C. (Ed.). (2001). A handbook of dementia care. Philadelphia, PA: Open University PressCutcliffe, J. (2005). Seclusion rooms, fascism and social control: Are there alternatives out there? Retrieved from (2010). Professional standards for psychiatric nurses. Retrieved from?, A. (2011). Ethical issues in patient restraint. Nursing Times; 107:9, 18-20. Retrieved from , B. J. (2012). The Relationships between Attitudes toward Seclusion and Levels of Burnout, Staff Satisfaction, and Therapeutic Optimism in a District Health Service. Issues In Mental Health Nursing, 33(5), 329-336. Larue, C. (2013). The Experience of Seclusion and Restraint in Psychiatric Settings: Perspectives of Patients. Issues In Mental Health Nursing, 34(5), 317-324. Ministry of Health. (2012, September). Secure rooms and seclusion standards and guidelines: A literature and evidence review. Retrieved from , J., Wihoite, K., Faheem, U., Wright, A., and Hamer, G. (2006). The use of restraints in psychiatric settings. Tennessee Medicine. Retrieved from Psychiatric Nurses of Canada. (2010).?Code of ethics & standards of psychiatric nursing practice.?Retrieved from , S., Baiden, P., & Theall-Honey, L. (2013). Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities. International Journal Of Mental Health Nursing, 22(1), 56-68. doi:10.1111/j.1447-0349.2012.00831.xStuart, G.W. (2013).?Principles and Practice of Psychiatric Nursing?(10th?ed.). Mosby Elsevier, St. Louis, Missouri. ................
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