Archives of Psychiatric Nursing
Volume 22, Issue 6 , Pages 315-317, December 2008

Perilous Omissions and Misinformation

Child Adolescent Advanced Practice Psychiatric Nursing, UMDNJ School of Nursing, Newark, NJ

Article Outline

 

During the past decade, a remarkable phenomenon occurred. Prompted by a series of media exposés, notably the Hartford Courant series Deadly Restraint (Weiss, Altimari, & Blint, 1998) and the Sixty Minutes II special entitled Unsafe Haven (Malmgren, 1999), lobbying by advocates and federal government attention resulted in a sustained examination and subsequent regulation of the use of restraints and seclusion in psychiatric settings. Such sustained attention was noteworthy as too often the history of the psychiatric care has been marked by scandal eruptions that were exposed and then forgotten after a flurry of attention. Since the late 1990s, the psychiatric community has seen an astonishing number of research and other scholarly articles discussing the dangers associated with restraint use (Mohr, Petti, & Mohr, 2003) and describing successful efforts at the reduction of restraint and seclusion procedures (Delaney, 2001, Huckshorn, 2004, Huckshorn, 2006, LeBel & Goldstein, 2005, Martin et al., in press). Nurses took the lead in many of these publications, and various position statements on the topic have been developed by psychiatric nursing organizations. With the exception of the community psychiatrists and the Academy of Child and Adolescent Psychiatry, organized psychiatric medicine was slow to focus on the dangers associated with these coercive practices.

For close to a decade, the psychiatric medical community failed to incorporate such findings into their major textbooks. With documentation of deaths from the use of restraint and what continues euphemistically to be called “therapeutic hold” making their way into well-regarded international journals (Nunno, Holden, & Tollar, 2006), this could no longer be viewed as hysteria promulgated by the news media. That situation has changed with one major psychiatric texts (Tasman, Kay, Lieberman, First, & Maj, 2008) featuring material discussing the dangers of seclusion and restraints and reduction data. A new textbook on psychiatric emergencies will also have a chapter devoted to seclusion and restraint that stresses the risk of restraint use (Riba & Ravindranath, in press).

Although nurses played a prominent part in bringing attention to the myths (Evans & Strumpf, 1990) and faulty assumptions (Mohr & Anderson, 2001) underlying restraint use, documenting their dangers, and discussing reduction efforts, much of this content has not made its way into psychiatric nursing textbooks. An examination of some bestselling texts finds not only the wholesale omission of this critical information but also the inclusion of some dangerous disinformation. Two instances of misinformation stand out as particularly disturbing. The first is the idea of a show of force in the face of violent or aggressive patient behavior. Not only is this counterintuitive but also potentially dangerous. Several disciplines, including nursing (Johnson & Hauser, 2001) and criminal justice, document that in incidents involving an individual with mental illness, the aggressiveness and assertiveness which usually helps nurses or police officers gain control of a situation will often cause an individual with mental illness to escalate further (see: www.consensusproject.org; Council of State Government Justice Center, n.d.).

The second is the inclusion of Nursing Intervention Classification assertion that anger control assistance includes physical, manual restraints, or seclusion as needed to calm patient who is expressing anger in a maladaptive manner (Dochterman & Bulechek, 2004). Nothing can be further from the truth; indeed restraints can escalate patients in many instances, and they do not constitute a therapeutic intervention, rather they are control/containment procedures that are used when all actual therapeutic interventions have failed. Some within the advocacy and nursing communities have called them treatment failures (O'Brien & Cole, 2004).

Finally, despite the strong effects of context, specifically staff provocation or staff (training) in both escalating patients and being a factor in those deaths that have been documented (Duxbury, 2002, Goren et al., 1993, Huckshorn, 2004, Huckshorn, 2006, O'Brien & Cole, 2004, Ryan et al., 2004), nursing textbooks continue to downplay these factors, if they deal with them at all. The problem of aggression and violent behavior remains almost exclusively within the purview of the patient's individual locus of control.

Well over a decade ago, Stillwell (1991) conducted a study that determined that more than half of nurses (51.8%) whom she surveyed reported having no instruction in the use of restraints and their effect on patients. In that same study, only 8% reported knowing that restraint use could be dangerous. It is disconcerting to think that these numbers may be as true today as they were then.

Among other responsibilities, education is an integral and vital function within the practice of professional nursing. In academia, education is even more crucial in that what we teach trickles down to our students who apply what we teach and pass some of that knowledge to the general public. Part of that responsibility involves imparting comprehensive and accurate information when it is available. With respect to restraints, nurses are often the decision makers and on the frontlines in situations that are often volatile. Not conveying current information that is vitally needed to meet the work needs of future psychiatric nurses is simply unacceptable. Not conveying that information and the research underpinning it while paying lip service to evidence-based practice holds our specialty back when it should be moving forward with other disciplines.

Back to Article Outline

References 

  1. Council of State Government Justice Center . The Consensus Project Report. Available: http://consensusproject.org/the_report/
  2. Delaney KR. Developing a restraint-reduction program for child/adolescent inpatient treatment. Journal of Child and Adolescent Psychiatric Nursing. 2001;14(3):128–140
  3. Dochterman JM, Bulechek GM. Nursing intervention classification (NIC). St. Louis, MO: Mosby; 2004;
  4. Duxbury J. An evaluation of staff and patient views of and strategies employed to manage inpatient aggression. Journal of Psychiatric Mental Health Nursing. 2002;9(3):325–337
  5. Evans LK, Strumpf NE. Myths about elder restraint. Image - The Journal of Nursing Scholarship. 1990;22(2):124–128
  6. Goren S, Singh NN, Best AM. The aggression–coercion cycle: Use of seclusion and restraint in a child psychiatric hospital. Journal of Child and Family Studies. 1993;2(1):61–73
  7. Huckshorn KA. Reducing the use of seclusion and restraint in mental health settings: Core strategies for prevention. Journal of Psychiatric and Mental Health Nursing. 2004;42(9):22–33
  8. Huckshorn KA. Re-designing state mental health policy to prevent the use of seclusion and restraint. Administration and Policy in Mental Health. 2006;33(4):482–491
  9. Johnson ME, Hauser PM. The practices of expert psychiatric nurses: Accompanying the patient to a calmer personal space. Issues in Mental Health Nursing. 2001;22(7):651–668
  10. LeBel J, Goldstein R. The economic cost of using restraint and the value added by restraint reduction or elimination. Psychiatric Services. 2005;56(9):1109–1114
  11. Malmgren, H. (1999, April). Unsafe Haven. Sixty Minutes II. New York, NY.
  12. Martin, A., Krieg, H., Esposito, F., Stubbe, D., & Cardona, L. (in press). Restraint and seclusion reduction through Collaborative Problem Solving: A five-year prospective inpatient study. Psychiatric Services.
  13. Mohr WK, Anderson JA. Faulty assumptions associated with the use of restraints with children. Journal of Child and Adolescent Psychiatric Nursing. 2001;14(3):141–151
  14. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with the use of physical restraints. Canadian Journal of Psychiatry. 2003;48:330–337
  15. Nunno M, Holden M, Tollar A. Learning from tragedy: A survey of child and adolescent restraint fatalities. Child Abuse & Neglect. 2006;30(12):1333–1342
  16. O'Brien L, Cole R. The concept of physical restraint as a nurse sensitive adverse outcome in acute care psychiatric treatment. Archives of Psychiatric Nursing. 2004;20(4):648–652
  17. Riba, M., & Ravindranath, D. (in press). Handbook of psychiatric emergencies. Washington, DC: American Psychiatric Press.
  18. Ryan E, Hart V, Messick DL, Aaron J, Burnette M. A prospective study of assault against staff by youth in a state psychiatric hospital. Psychiatric Services. 2004;55:665–670
  19. Stillwell EM. Nurses education related to the use of restraints. Journal of Gerentological Nursing. 1991;17(2):23–26
  20. Tasman A, Kay J, Lieberman JA, First MB, Maj M. Psychiatry. 3rd ed.. West Sussex, England: John Wiley & Sons; 2008;
  21. Weiss EM, Altimari D, Blint DF. Deadly restraints: A nationwide pattern of death. Hartford Courant. 1998, October;Available at: www.courant.com/news/specia/restraint/stm

PII: S0883-9417(08)00162-3

doi:10.1016/j.apnu.2008.08.006

Archives of Psychiatric Nursing
Volume 22, Issue 6 , Pages 315-317, December 2008

Article Tools