Reducing the Use of Seclusion and Restraint: A Michigan Provider Reduced Its Use of Seclusion and Restraint by 93% in One Year on Its Child and Adolescent Unit
Witte, Linda, Behavioral Healthcare
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).
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. …