Journal of the American Psychiatric Nurses Association

http://jap.sagepub.com/ Relationship of Less Restrictive Interventions with Seclusion/Restraints Usage, Average Years of Psychiatric Experience, and Staff Mix
J. Earle Williams and Rachel E. Myers Journal of the American Psychiatric Nurses Association 2001 7: 139 DOI: 10.1067/mpn.2001.118178 The online version of this article can be found at: http://jap.sagepub.com/content/7/5/139

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Relationship of Less Restrictive Interventions with Seclusion/Restraints Usage, Average Years of Psychiatric Experience, and Staff Mix
J. Earle Williams, RN, MSN, and Rachel E. Myers, RN, CDE, MSN
BACKGROUND: Seclusion and/or restraints (S/R) usage is a legal, moral, and ethical issue of patient rights and safety. Current emphasis is on using lesser restrictive interventions (LRI) in crisis management. OBJECTIVE: This descriptive/correlational study examined the relationship of LRI with S/R usage, average years of psychiatric experience of nursing staff, and staff mix. STUDY DESIGN: The sample included 82 events requiring crisis intervention. Data were collected at a state mental health facility using a crisis cycle intervention tool and staff questionnaire. RESULTS: Data revealed a significant relationship between LRI and S/R usage and a significant positive relationship between percentage of licensed nurses and LRI. However, the relationship between average years of psychiatric experience and LRI was not significant. Fourteen percent of LRI could be predicted by percentage of licensed staff. CONCLUSION: The findings supported using LRI in crisis management. Using LRI individualized to the crisis event promotes a safer, more therapeutic environment for both parties and staff. The findings revealed the need to evaluate the impact of a change in staff mix on quality of care and desired outcomes. Further research is needed to explore the multiple variables that influence LRI. (J Am Psychiatr Nurses Assoc [2001]. 7, 139-44.) he use of seclusion and/or restraints (S/R) in a psychiatric facility is a highly controversial issue of patient rights and patient safety. Historically, the use of S/R has been a common practice in managing psychiatric
J. Earle Williams, RN, MSN, is a hospital nursing supervisor at Northern Virginia Mental Health Institute in Falls Church, Virginia. Rachel E. Myers, RN, CDE, MSN, is the director of medical staff affairs at Northern Virginia Mental Health Institute in Falls Church, Virginia. Reprint requests: J. Earle Williams, RN, MSN, 9932 Pinehurst Ave., Fairfax, VA 22030. Copyright 2001 by the American Psychiatric Nurses Association. 1078-3903/2001/$35.00 + 0 66/1/118178 doi:10.1067/mpn.2001.118178

patients. But, with the emergence of the patient bill of rights, advocacy groups and new legislation (Childrens Health Act, 2000) an emphasis has been increasingly placed on achieving an environment in which lesser restrictive interventions (LRI) are used and S/R are only used as a last resort. However, limited research has been published supporting this change in practice. The purpose of this study was to examine the relationship between the use of LRI and the use of S/R. In addition, this study explored the relationship among average years of psychiatric experience of nursing staff, the percentage of licensed nurses, and the number of LRI used. BACKGROUND Significance In the United States, the use of S/R has increasingly become a legal, moral, and ethical issue. The courts

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have often ruled that the use of S/R is a violation of a persons liberty and basic rights. The courts have also upheld the principle of least restrictive interventions. These principles have been incorporated into professional standards, such as those of the Joint Commission on Accreditation of Healthcare Organizations and the Scope and Standards of Psychiatric-Mental Health Nursing Practice (American Nurses Association, 2000).

The courts have often ruled that the use of S/R is a violation of a persons liberty and basic rights.
According to Fisher (1994), the growth of the psychiatric consumer/survivor movement has given a new and forceful voice to criticisms of the use of seclusion and restraint (p. 1585). There are marked differences in viewpoint between persons who have experienced S/R and those who feel obliged to use them (Brown & Tooke, 1992; Fisher, 1994; Outlaw & Lowery, 1992). Research is essential to help bridge the gap between these viewpoints. Outlaw and Lowery (1992) stated that nurses need to be at the forefront in generating empirical data that guide seclusion decisions, that guard against injustices, and that look to promising alternatives to seclusion (p. 17). However, little research has been reported on staff interventions before seclusion. This study provides the groundwork for future investigation to validate the LRI needed to manage psychiatric patients during an active phase of the crisis cycle. Review of Literature Over the last 25 years, there have been numerous studies on the use of S/R within the psychiatric setting. Fisher (1994) reviewed the S/R literature from a 20year time span. Fishers review focused on indications and contraindications for S/R, the effect of clinical and nonclinical factors on S/R rates, the effects of S/R on patients and staff, implementation of S/R, and the importance of staff training on S/R. However, Fishers review provided only limited support for the relationship between LRI and S/R use. Several authors have written that seclusion is a violation of a persons right to freedom and that clients have the legal right to the least restrictive conditions (Brown & Tooke, 1992; Craig, Ray, & Hix, 1989; Mason, 1993; Morales & Duphorne, 1995; Myers, 1990). Myers commented that the nurses moral and legal responsibility is to use the least restrictive means possible to deal with potentially destructive behavior.

Indeed, seclusion should always be used as a last resort measure (p. 24). Morales and Duphorne added that the use of LRI is a more humane means of treatment for the mentally ill (p. 15). Canatsey and Roper (1997), Kirkpatrick (1989), Morales and Duphorne, and Myers described several effective alternative treatments to S/R. Only a few studies have actually focused on the empirical effect of LRI on the rate of S/R usage. Canatsey and Roper (1997) studied the effect of using removal from stimuli, a less restrictive measure, as an alternative to S/R on a psychiatric intensive care unit. Their results confirmed that quality of patient care can be improved by using a less restrictive mode of intervention (p. 42). The use of removal from stimuli and other nonrestrictive measures resulted in decreased use of S/R. The authors concluded that using LRI can successfully curtail hostile, aggressive behaviors among psychiatric inpatients. Morales and Duphorne (1995) described how anger or aggressive behavior begins a destructive cycle, which, if not interrupted, leads to loss of control and violence. Nursing staff must counter this and interrupt the cycle by using LRI early in the cycle. If they do not, escalation occurs and the need for restraint becomes greater. The authors initiated a 3month staff inservice project on an acute psychiatric unit in a Colorado hospital. Their goal was to decrease the use of S/R by anticipatory planning and early intervention. As a result of these inservices, nursing staff recognized more effective use of LRI and increased the use of these measures. By the end of the project, the total time spent by patients in S/R was estimated to have been reduced by approximately 50%. The most effective LRI were verbal interaction, limit setting, as-needed medication, and quiet time. Several researchers have studied or hypothesized about the relationship of staff psychiatric experience with the use of LRI and S/R. However, very few have studied the relationship of staff mix (i.e., licensed vs. unlicensed) with the use of LRI and S/R. Brown and Tooke (1992) cited research that claimed that experienced nursing staff can calm most agitated patients by simply providing human interaction and that high seclusion rates have been linked to lack of staff experience in dealing with disruptive behavior. Thompson (1996) found that if staff members are inexperienced, seclusion may be chosen rather than other less restrictive responses. Craig and associates (1989) conducted research that revealed that efforts to increase the percentage of registered-nurse coverage per unit and per shift and to train staff on crisis management significantly decreased the number of restraint hours per month.

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Other research revealed a discrepancy in the relationship between staff experience and the use of LRI and S/R. Schwab and Lahmeyer (1979) found no relationship between seclusion rates and staff experience. Mason (1993), based on an extensive review of the seclusion literature, reported that although some investigators found that experience of nursing staff was strongly related to the tendency to use seclusion, others found no correlation between these variables. Fisher (1994) and Crenshaw and Francis (1995) hypothesized that these variations may result from powerful local effects of staffing patterns, staff/administration beliefs, and hospital policies. RESEARCH QUESTIONS The research questions in this study were (a) Is there a significant relationship between the number of LRI implemented during the third phase of the crisis cycle (i.e., crisis) and the use of S/R? (b) Will the number of LRI implemented during the first three phases of the crisis cycle increase as the average number of psychiatric years experience among nursing staff increases? and (c) Will the number of LRI implemented during the first three phases of the crisis cycle increase as the percentage of licensed nurses increases? Definitions For the purpose of this study, the researchers defined seclusion as the placement of a patient in a room with the door secured in such a way that will not permit the patient to open it, and restraint as the use of any mechanical device that restricts the physical movement of a patient (Northern Virginia Mental Health Institute, 1996, p. 1). LRI are alternative treatments to seclusion and restraint during a crisis event that are used to assist the patient with managing self using the least restrictive means (Myers, 1990). In this study, an event refers to an occurrence in which a patient experiences/expresses verbal or physical symptomatology in relation to external or internal stimuli. In addition, this occurrence must require crisis intervention and the initiation of the crisis cycle intervention tool. Crisis cycle refers to a progression of internal and external behavior exhibited by the patient while experiencing a stressful situation. Mandt (1994) identified the following six stages within the crisis cycle: stimulation, escalation, crisis, deescalation, stabilization, and postcrisis drain. The crisis cycle intervention tool, developed at Northern Virginia Mental Health Institute, is a tool for staff to indicate which phase of the crisis cycle the patient is

experiencing and the associated nursing interventions used to assist the patient during that time. And, in this study, nursing staff refers to registered nurses, psychiatric practical nurses, and unlicensed psychiatric technicians. METHODS Study Design A descriptive/correlational design was used. The researchers collected data at a 148-bed state mental health facility. Population and Sample The population consisted of all voluntary and involuntary patients in-hospital over a 5-week period who had Axis 1 and/or Axis 2 diagnoses. Patients ranged from 18 to 64 years of age. The sample consisted of all events in which a patient required crisis intervention which led to the initiation and completion of the crisis cycle intervention tool per the researchers protocol. Eighty-two crisis events were identified. Of this, 66 involved the third phase of the crisis cycle. For analysis of reasearch question one, the subsample of 66 was used, whereas the total sample (N = 82) was used to address research questions two and three.

The state mental health facility advocates and supports staff education for crisis management.
Measurement The researchers used the following instruments to collect data: the crisis cycle intervention tool used at the state mental health facility to identify LRI used during crisis management and a staff questionnaire distributed to all nursing staff to collect demographic information. The researchers designed a staff questionnaire and asked the director of human resources and unit managers to assess it for content validity. The researchers piloted the questionnaire with eight stafffour licensed and four unlicensed psychiatric technicians. Space was left for staff to write comments regarding issues or concerns they had with the survey. None were made. To test the first research question, for each crisis event involving the third phase of the crisis cycle (i.e., crisis), the researchers used the crisis cycle intervention tool to count the total number of LRI implemented by nursing staff during the third phase

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only. Then, they determined whether S/R were used. To test the second research question, the researchers determined how many years of psychiatric experience each nursing staff had; the staff questionnaire was used for these data. For each patient event, the researchers calculated the average years of psychiatric experience for the nursing staff on duty at that time. This number was compared with the total number of LRI implemented during the first three phases of the crisis cycle. To test the third research question, the researchers calculated the percentage of licensed nurses of the nursing staff on duty at the time of each patient event. This number was compared with the total number of LRI implemented during the first three phases of the crisis cycle. Data Collection Inservice meetings to discuss research protocols were provided for all staff. Meetings lasted approximately 20 minutes. During these meetings, participants were asked to complete the staff demographic questionnaire, which took approximately 5 minutes. For each event, staff initiated and completed a crisis cycle intervention tool. The unit charge nurse provided a copy of all tools completed during his or her respective shift to the unit manager. At least once a week, the researchers collected these completed tools from the unit manager, along with the staffing lists from each unit in which a crisis event was reported. FINDINGS By using 2 to test the first research question, a cross-tabulation shows that out of 66 crisis events, S/R were used on 17 occasions (25.8%). There was a significant relationship between LRI and S/R usage, 2(1, N = 66) = 13.390, p < .001. For the second research question, with N = 82 crisis events, the mean years of psychiatric experience was 4.89 (SD = 1.68) and the mean number of LRI used was 11.28 (SD = 5.47). Using Pearson r, there was no significant relationship between average years of psychiatric experience and LRI, r = 0.146, p = .096, onetailed. For the third research question, with N = 82 crisis events, the mean percentage of licensed staff on a nursing team was 58.79%, and the mean number of LRI used was 11.28 (5.47). The researchers used Pearson r (one-tailed) and simple regression to test the relationship between these two variables. There was a positive significant relationship between staff mix and LRI, r = 0.379, p = .000, one-tailed. Simple regression further reveals an R2 change of 0.143, indi-

cating that 14.3% of the variability in the number of LRI used can be explained by the percentage of licensed staff. DISCUSSION AND IMPLICATIONS There was a significant relationship between the number of LRI implemented during the third phase of the crisis cycle (i.e., crisis) and the use of S/R. The findings illustrate that nursing staff are attempting many LRI before resorting to the use of S/R. Staff are not immediately using S/R at the start of a crisis event without exploring other alternatives. In addition, S/R were only used for about a quarter of the crisis events. Minimal usage of S/R allows patients more freedom and enables them to more actively participate in effective problem-solving during crisis situations. Avoiding physical interventions during crisis events promotes an overall safer and more therapeutic environment for both patients and staff.

Minimal usage of S/R allows patients more freedom and enables them to more actively participate in effective problemsolving during crisis situations.
LRI use did not significantly increase as the average number of psychiatric years experience among nursing staff increased. Previous research about the relationship between these two variables is inconclusive. These variations most likely result from many other variables that affect the use of LRI, making it difficult to accurately measure the impact of one specific variable. Also, it is possible that seasoned staff are able to use fewer LRI to achieve the same desired outcome as a result of the skills they have developed from their past work experiences. Thus, the number of LRI should not be the only measure to consider when evaluating the quality and effectiveness of crisis management. The type of LRI selected in relation to the individual patient and situation must also be taken into account. Nursing staff should treat each crisis as a unique event and select the amount and type of LRI to implement based on their previous experience and their knowledge of the individual patient and situation. Finally, the number of LRI implemented significantly increased as the percentage of licensed nurses increased. As mentioned in the literature review, minimal research has been done on the relationship between these variables. With current emphasis on decreasing costs, many health care facilities are replac-

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ing licensed staff with unlicensed assistive personnel. However, little research has been conducted on analyzing the effect of staff mix changes on clinical outcomes. If nursing departments decide to change their staff mix, it is crucial that they establish a mechanism to evaluate the impact of this change on quality of care and desired outcomes.

With current emphasis on decreasing costs, many health care facilities are replacing licensed staff with unlicensed assistive personnel.
There are multiple variables associated with the use of S/R and LRI, and it is difficult to single out the effect each one has on the outcome. Many factors, such as staff attitudes and demographics, patient behaviors and diagnoses, patient population, hospital setting (e.g., private vs. public), hospital mission and policies, and administrative philosophies and beliefs, need to be considered, as well as the effect of extraneous variables. The impact of staff education is another crucial variable to consider. Of importance, the researchers did find that the state mental health facility advocates and supports staff education for crisis management. In fact, it is mandatory training for all clinical staff during their orientation and must be renewed every year. This emphasis on staff education, along with the facilitys strong philosophy of using the least restrictive means in managing patients in crisis, most likely are significant contributing factors to the low use of S/R. The lack of validity and reliability testing of the crisis cycle intervention tool was a limitation of the study. The completion of this tool was dependent on individual nursing staff members, so accuracy could have been an issue. The number of LRI indicated on the tool may have differed from the actual LRI used by the staff. Also, all staff demographics were obtained by voluntary participation; thus, some staff may have misreported information. Future studies should examine specific events, patient characteristics, impact of staff education, and those staff involved with the direct care of the patient. As specific demographic factors are isolated, there may be a higher correlation between variables. Finally, the study was conducted at only one psychiatric facility; therefore, the findings cannot be generalized to all settings. Future research should include multiple facilities of diverse type, size, mission, and other variables. In conclusion, this study provides the groundwork for future investigation to determine the need for and

expansion of LRI used in crisis management. Data analysis revealed that LRI were used by nursing staff and that S/R actually occurred only after a substantial number of LRI had been attempted. These are very encouraging findings that reflect the current emphasis on patient rights and safety. The psychiatric community will continue to face many challenges in attempting to achieve and maintain an environment that emphasizes the use of LRI. The American Psychiatric Nurses Association (2001) recently published a position statement and standards of practice on the use of S/R. They provide guidelines for promoting patient and staff safety and a platform on which to initiate dialogue related to staffing and other organizational changes necessary to support reduced use of S/R.
The authors acknowledge the Department of Nursing at Northern Virginia Mental Health Institute in Falls Church, Virginia.

REFERENCES
American Nurses association, in collaboration with the American Psychiatric Nurses Association and the International Society of Psychiatric-Mental Health Nurses. (2000). Scope and standards of psychiatric-mental health nursing practice. Washington, DC: Author. American Psychiatric Nurses Association. (2001). Seclusion and restraint: Position statement and standards of practice. Arlington, VA: Author. Brown, J. S., & Tooke, S. K. (1992). On the seclusion of psychiatric patients. Social Science and Medicine, 35, 711-721. Canatsey, K., & Roper, J. M. (1997). Removal from stimuli for crisis intervention: Using least restrictive methods to improve the quality of patient care. Issues in Mental Health Nursing, 18, 35-44. Childrens Health Act of 2000. Pub. L. No. 106-310, 42 U.S.C. 201, H.R. 4365 (2002). Craig, C., Ray, F., & Hix, C. (1989). Seclusion and restraint: Decreasing the discomfort. Journal of Psychosocial Nursing and Mental Health Services, 27(7), 16-19. Crenshaw, W. B., & Francis, P. S. (1995). A national survey on seclusion and restraint in state psychiatric hospitals. Psychiatric Services, 46, 1026-1031. Fisher, W. A. (1994). Restraint and seclusion: A review of the literature. American Journal of Psychiatry, 151, 1584-1591. Kirkpatrick, H. (1989). A descriptive study of seclusion: The unit environment, patient behavior, and nursing interventions. Archives of Psychiatric Nursing, 3, 3-9. Mandt, D. (1993). The Mandt system: Managing non-aggressive and aggressive people. Richardson, TX: Author. Mason, T. (1993). Seclusion theory reviewed: A benevolent or malevolent intervention? Medicine, Science, and Law, 33(2), 95-102. Morales, E. & Duphorne, P. L. (1995). Least restrictive measures: Alternatives to four-point restraints and seclusion. Journal of Psychosocial Nursing and Mental Health Services, 33(10), 13-16. Myers, S. (1990). Seclusion: A last resort measure. Perspectives in Psychiatric Care, 26(3), 24-28.

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Northern Virginia Mental Health Institute. (1996). Seclusion and Restraint 1996 (No. 5210.1A). Falls Church, VA: Author. Outlaw, F. H. & Lowery, B. J. (1992). Seclusion: The nursing challenge. Journal of Psychosocial Nursing and Mental Health Services, 30(4), 13-17.

Schwab, P.J., & Lahmeyer, C.B. (1997). The uses of seclusion on a general hospital psychiatric unit. Journal of Clinical Psychiatry, 40, 228-231. Thompson, P. (1986). The use of seclusion in psychiatric hospitals in the Newcastle area. British Journal of Psychiatry, 40, 228-231.

EXECUTIVE DIRECTOR APPOINTED APNA President Dorothy Hill has announced that Jane H. White, RN, CS, DNSc, has been appointed to the position of Executive Director at APNA. Dr. White has been a psychiatric nurse for more than 30 years and has held many positions in clinical practice, beginning with staff nursing. For the past 20 years she has held a variety of academic positions, including tenured faculty member, professor, and director of the Psychiatric Mental Health Nursing (PMHN) Advanced Practice Program at Catholic University of America in Washington, DC. She has maintained her own psychotherapy practice since 1978. For 8 years she worked diligently as a leader in revising the nurse practice act in Washington, DC, so that psychiatric clinical nurse specialists would be among those eligible for advanced practice licensing, independent

practice, and reimbursement. Dr. White has been the author of numerous publications and has made national and international presentations relating to her research regarding eating disorders, her area of expertise. Dr. White earned a diploma from Hartford Hospital School of Nursing, a BSN from Purdue University, an MSN in PMHN from the University of Alabama at Birmingham, and a doctorate in nursing from The Catholic University of America. She has received many honors, including membership in Phi Kappa Phi, Sigma Theta Tau, and recognition in Whos Who in America, and Whos Who in American Nursing. She has received funding for her own research, as well as for the development of the innovative Community Mental Health Nursing Advanced Practice Graduate Program. Jane was elected to the Board of Directors of APNA and, as the Director of the Division of Education in 1999, she was responsible for the annual conference. Before that she served on the Legislative Affairs Committee. Her vision for APNA

includes increasing the number of members (especially through the formation of international chapters), addressing current certification issues, assisting in the development of a core curriculum for basic and advanced psychiatric nursing, and obtaining funding for scholarships and research for APNA members. She says, The best thing about the position is the ability to interact with knowledgeable, supportive colleagues in all types of psychiatricmental health practices and in various roles. I look forward to continued work with the Board of Directors on the many initiatives they have outlined in the strategic plan. Because I am a psychiatricmental health nurse, I will be able to knowledgeably and confidently represent APNA as a stakeholder and major player at national and local meetings; this will be a priority of mine. President Dorothy Hill said, We are fortunate to have such a dynamic and experienced psychiatric nurse as executive director. Join me in welcoming Jane. She can be reached at jwhite@apna.org.

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