Patient Restraint and Seclusion

Restraints and seclusion are often used in mental health settings to manage the behavior of patients and minimize the perceived risk of danger, at times leading to patient harm or abuse. An international consensus acknowledges that there are adverse physical and psychological consequences from using restraints and seclusion and that these practices should be reduced or eliminated. The use of restraints and seclusion can lead to patient falls, pressure injuries, positional asphyxiation, musculoskeletal injuries, drug reactions, and even death. Families and staff members may experience helplessness, distress, and injuries. The primary goal of behavioral interventions is to help the patient regain control over their behavior, thereby enabling meaningful participation in treatment. The United States Code of Federal Regulations specifies that all patients have the right to be free from restraints and seclusion when used as a means of coercion, discipline, convenience, or retaliation.[Code of Federal Regulations. §482.13] Restraints and seclusion may only be used when other less restrictive measures are unavailing to secure the immediate physical safety of the patient or others, and restraints and seclusion must be discontinued as soon as it is safe to do so. According to the World Health Organization (WHO) publication , implementing a recovery approach is essential for individuals overcoming life challenges. Recovery-oriented mental health services are not coercion-based, and instead provide hope, empowerment, choices, and opportunities. Several strategies can be used to respond to tense situations without escalating to the use of restraints or seclusion, including: Developing individualized treatment plans to explore patients' needs and preferences, including how they wish to be responded to when they have signs of distress. Calming actions should be tailored to each individual and each situation. Using de-escalation techniques to engage individuals and establish a collaborative relationship when they are extremely distressed or upset to resolve or defuse the situation. De-escalation includes active listening, a structured form of listening that focuses full attention on what someone is saying to understand the true meaning of what is said and the reason behind the person's distress. Fostering a  and  culture that creates a nonjudgmental space to consider how decisions are reached and whether it is possible to say  instead of  to a patient's request. Creating supportive environments, including the use of comfort rooms as places of sanctuary and healing. Establishing a response team of experienced and committed individuals who can intervene when a conflict arises using good communication, de-escalation techniques, and violence prevention skills to safely resolve the situation. All staff should receive training in trauma-informed care, sensory modulation techniques, wellness or recovery, and de-escalation techniques, such as active listening. There is a lack of uniformity and clarity in describing different types of restraints and seclusion, and how they are implemented in actual practice. This inconsistency makes it challenging to accurately measure and understand the true usage of restraints or seclusion in different settings. According to the WHO, the types of restraints and seclusion include the following: : Seclusion refers to the practice of isolating an individual by physically restricting their ability to leave a designated area. This practice can be done by locking someone in a certain space, by locking access doors, restricting an individual's movement to a certain area by telling them they are not allowed to leave, or intimidating them to stay in a certain space. Patients who are in seclusion are at risk of intentional self-harm. Manual restraint or holding refers to hands-on control of a person without the use of a device. This practice may involve physical struggles using force and includes painful positions to exert control, such as arm-twisting. Prone or face-down manual restraints are common and risk positional suffocation and sudden death. Manual holds are the most commonly used form of restraint. Physical or mechanical restraint refers to the use of devices to immobilize an individual or their ability to freely move a part of their body. Physical and mechanical restraints include ambulatory restraints such as belts, ropes, chains, shackles, straitjackets, disabling gloves or mittens, and disabling furniture, such as restraint beds with wrist, body, or ankle straps; cage beds; net beds; and restraint chairs. Restraint chairs prevent patients from standing using seat belts and limb restraints, lap trays, or structural design that the patient can not self-release. Restraint chairs have advantages over other physical or mechanical restraint devices, as their upright position is better for a patient's dignity and sense of control. The upright position reduces the risk of oxygen desaturation, allows for eye contact with staff, and avoids the vulnerable supine position with splayed extremities, which is not trauma-sensitive. Chair restraints are associated with shorter periods of restraint, increased likelihood of patients accepting oral medications, and reduced incidence of staff injuries. Chemical restraint refers to the use of medications that are not part of the individual's standard treatment and are administered against the person's will to control their movement or behavior. Common drug classes include benzodiazepines and antipsychotic medications.  . According to the Center for Medicare Services, within 1 hour of initiating seclusion or restraint, a patient must be evaluated face-to-face by a clinician or other licensed independent practitioner or by a registered nurse or physician assistant who has met specified training requirements. This requirement may be more restrictive and varies by state laws. Many times, a combination of restraints and seclusion techniques is used. All these interventions fall under the umbrella of coercive practices associated with physical and psychological harm, including feelings of humiliation and retraumatization. Patients who are restrained are unable to care for their personal needs, such as using the toilet or showering, and at times are deprived of personal items, shoes, pillows, and blankets. Coercive practices disrupt the therapeutic relationship between members of the interprofessional team and the patient. When using restraints and seclusion as a last resort, the restraint team should include sufficient team members to safely treat the patient. Policies and procedures on how to safely restrain and seclude patients vary by setting, and institutional guidelines should be consulted. The Joint Commission requires time-limited orders in accordance with laws and regulations. There is no evidence-based research supporting the idea that restraints and seclusion are therapeutic or diminish aggression. Higher risk for the use of coercive measures is associated with the following characteristics: Male gender. Single or divorced marital status. Receipt of disability benefits. History of multiple psychiatric hospitalizations. Younger age. Diagnosis of psychotic and bipolar illnesses. Involuntary admission. Staff stressors contributing to the use of coercive practices include heavy workloads, understaffing, poor training, and misperceptions about a patient's behavior.