Abstract

Restraint use in the treatment of mental illness has Instead of reducing restraint use, it was decided to
long been a controversial practice. Regulatory agen- eliminate restraint use. Vision guided, the team de-
cies, licensing organizations, and professional and veloped an action plan. Culture change focused on
advocacy groups have called for reduction of re- the Mental Health Recovery Model and principles of
straint use. Responding to this call for action, the trauma-informed care. Emphasizing person-centered
leadership team of a behavioral health unit in a pri- care, this unit has now been restraint free for nearly
vate, nonprofit community hospital evaluated re- 2 years. A surprise finding was that restraint elimina-
2008 Sandra A. Barton, BSN, RN, BC

ducing restraint use. Following training through the tion accompanied a decrease in use of as needed
National Executive Training Institute of the National sedative-hypnotic medications. Person-centered care
Association of State Mental Health Program Direc- delivered by frontline staff led to culture change, a
tors, a restraint-reduction project team was formed. restraint-free environment, and less medication.

34 JPNonline.com

U
se of restraint in the
treatment of mental ill-
ness has long been con-
troversial. Regulatory agencies
and licensing organizations, as
well as professional and advocacy
groups, have called for restraint
use reduction. Responding to this,
the leadership team of a behavioral
health unit in a private, nonprofit
community hospital evaluated re-
ducing restraint use. However, in-
stead of reducing use, the team
decided to eliminate restraint
use. Using trauma-informed
care principles and apply-
ing the Mental Health
Recovery Model, the
goal of restraint-free was
achieved. This article
outlines how a restraint-
free vision became reality.
Background
Colaizzi (2005) reviewed
and summarized a brief his-
tory of restraint and the well-
intentioned initiation of restraint
use. As she noted, Dorothea Dix
is credited with the rise of state
asylums for the insane. This wide-
spread growth took place through-
out the 1800s. The new asylums
were barely built before problems
with overcrowding were encoun-
tered. By the 1840s, asylums had
already become so overcrowded
that behavior control had become
a central concern (Colaizzi,
2005, p. 33).
Mechanical methods for be-
havior control were believed to
be necessary. A variety of me-
chanical restraining devices were
introduced. From tranquilizer
Journal of Psychosocial Nursing Vol. 47, No. 1, 2009
chairs to cold wet sheet packs,
patients behaviors were restrict-
ed. Seclusion was one physicians
alternative to restraint use and
was deemed a more humane al-
ternative. Even so, seclusion was
considered controversial.
Back when alienist was the
term for psychiatrist, ethical con-
cerns seem to have been as much
an issue as they are today. Brit-
ish alienists were more critical of
restraint and seclusion use than
their American colleagues. Al-
though antipsychotic drugs had
not yet been developed, opiates,
bromides, and alcohol were avail-
able. These agents made patients
sleep, but sleep was considered
therapeutic. Excessive use of these
agents was recognized as chemical
restraint (Colaizzi, 2005). Colaizzi
(2005) concluded:
From the beginning of psy-
chiatric care, founded by the
Quakers, the use of mechanical
devices and drugs to control vio-
lent behavior has been viewed as
inimical to the ethical principles
of benevolence and nonmalfea-
sance. It is not always possible
to translate philosophical ideals
into practical realities and both
of these absolutes contain an ele-
ment of truth. (p. 37)
Restraint-Reduction
Perspectives
Restraint reduction has been
a major concern of the Penn-
sylvania Department of Health,
the Office of Mental Health and
Substance Abuse Services of the
Commonwealth of Pennsylvania,
and The Joint Commission. Since
Earn
4.0 Contact
Hours
before 1990, when the Pennsyl-
vania seclusion and restraint ini-
tiative began, Pennsylvania has
been a leader among states in re-
ducing seclusion and restraint use.
The process for accomplishing
this reduction was discussed by
Smith et al. (2005). They noted
that while the rate and duration
of time spent in restraint and se-
clusion decreased, there was not
a noticeable increase in staff inju-
ries related to patient assaults.
In 1998, the Hartford Courant
began a series of articles reporting
deaths that occurred while people
were being restrained or were in
seclusion (Weiss, Altimari, Blint,
& Megan, 1998). This series
prompted increased advocacy for
seclusion and restraint reduction.
In 2002, the National Association
of State Mental Health Program
Directors (NASMHPD) created
a national call to action. A na-
tional action plan was developed
and over the next several years,
incentives were developed at the
national level to bring all states
on board.
Trauma theory became wide-
ly understood during this
same time. Trauma-
informed care, as
described by Hodas
(2004), became the
base for care reform.
Pennsylvania re-
mains at the fore-
front as a leader in
trauma-informed
care initiatives and
humane treatment
models for individu-
als with mental illness.
35

20 19
18
16
Total Number of Patients
14
12
10
8 tute (NETI) (2005) program for
8 the reduction of seclusion and
6 5
4 3
2 The program provided the
0 direction needed to guide efforts
02 03 04
-20 -20 -20
01 02 03 04
20 20 20 20
Fiscal Year
Figure 1. Number of patients restrained on this behavioral health unit fiscal year
2001-2002 through 2007-2008.
Since recognition of trauma events
and trauma-informed care, consid-
erable energy has gone toward re-
ducing the use of restraints in the
care of people with mental illness
(Huckshorn, 2004).
Achieving a Restraint-
Free Environment
Description of the Unit
The leadership team of a 26-
bed behavioral health inpatient
unit within a private, nonprofit
248-bed community hospital
had been focusing on decreas-
ing restraint use. This unit is
locked and is licensed to provide
care for clients age 14 and older.
Eighty percent of admissions are
processed through the hospital
emergency department. All di-
agnostic categories are accepted,
and admissions are voluntary and
involuntary. The top three diag-
nostic categories are severe recur-
rent depression, bipolar disorder,
and schizoaffective disorder.
36
Restraint elimination
9 project initiated
4
05 06 07
-20 -20 -20 -20
05 06 07
20 20 20
The unit is in an older hospi-
tal structure and is configured in
a T shape. The central wing is an
intensive care psychiatric unit
(ICU) where more acutely ill in-
dividuals are held until they are
ready to move to the less acute
areas. This ICU wing is locked
as well. Elevators open into the
center of the unit, although these
are restricted in use to certain
hospital employees with badge-
activated access.
Cameras monitor all public
areas and hallways, with a tele-
vision monitor located at both
nursing station areas. There is a
main nursing station on the less
acute wing and a smaller, satellite
nursing station on the ICU wing.
The average daily census is 17,
and the average length of stay is
currently 5 to 7 days. Much lon-
ger stays of 4 to 6 weeks or more
occur when patients are awaiting
placement in longer term treat-
ment centers.
Initial Training Program
To respond fully to the call to
action to reduce restraint use, a
clearly defined plan was needed.
More material, resources, and
direction were needed in how
to achieve the goal of restraint
reduction. In March 2005, two
team members attended the Na-
tional Executive Training Insti-
restraint. Although this program
was for the public mental health
sector, the team members were
welcomed into the group.
0
08 to effect change. NETI gener-
ously provided volumes of edu-
cational and how-to materi-
als. The 3 days of presentations,
many interactive, were filled
with excellent examples of how
to proceed. A manual including
every PowerPoint presentation
was provided on the first day. A
DVD containing all of the Pow-
erPoint presentations was avail-
able as well.
Every presentation was rich
with ideas and suggestions. The
workshop opened with a film
showing, one after another, chil-
dren and adolescents who had
died during or in the process of
restraint or seclusion. Included
were the offenses of the in-
dividual who required restraint
or seclusion. The presentation
effectively communicated the
risksboth physical and emo-
tionalof restraint use.
Trauma theory was pre-
sented next, and with it came
many aha moments for those
who had no previous training
in trauma theory. Further pre-
sentations provided more exact
directions regarding what has
worked for others and what to
expect as movement is made
toward restraint reduction. For
JPNonline.com
example, staff reactions to pro-
posals to reduce or eliminate
restraint use can be unpredict-
able. Many staff react with fear,
voicing concern for their safety,
as well as patient safety. These
concerns must be addressed.
Steps to Goal Achievement
After completion of the pro-
gram and the decision to un-
dertake this project to reduce
restraint use, the project team
established an action plan and
time line. The first task was sort-
ing the volumes of material into
manageable, bite-size imple-
mentation pieces. The time line
proposed by the workshop lead-
ers was 18 months.
Restraint events were highly
traumatic for both patients and
staff on the unit. Physical injury,
even death, was always a possibil-
ity. Knowing death was a possible
outcome, the staff were chal-
lenged to reach beyond the goal
of restraint reduction. The vision
became restraint elimination.
Much of the information
provided was essential for the
culture change. Learning about
trauma theory was a major eye-
opener. According to Psychiatric-
Mental Health Nursing: Scope and
Standards of Practice (American
Psychiatric Nurses Association,
2007), The psychiatric-mental
health nurse provides, structures
and maintains a safe and thera-
peutic environment in collabora-
tion with patients, families and
other healthcare clinicians (p.
39). Restraining was retrauma-
tizing people. Many nurses saw
restraining as a violation of this
standard; knowing about retrau-
matization was even more dis-
turbing to staff. Restraint use was
viewed as treatment failure. Staff
wanted and needed more infor-
mation on alternative ways to
help agitated individuals.
Journal of Psychosocial Nursing Vol. 47, No. 1, 2009
From mid-2005, organization
of the project became a prior-
ity. A project chairperson was
appointed. Highest level man-
agement support was obtained.
The organizations senior leaders
supported restraint elimination
100%. They provided additional
guidance, access to specialty in-
formation service resources, and
visible leadership support. A
Project Charter and Statement
of Work was developed. A time
line and action plan was created,
and a project implementation
team was formed. The team in-
cluded risk management person-
nel, middle and top leaders, and
frontline nursing staff. Including
frontline nursing staff was criti-
cal for goal success. They were
the day-to-day champions of re-
straint avoidance.
Vision
The original goal was restraint
reduction, but after only approxi-
mately 2 weeks, the Director of
Patient Services for Behavioral
Health began calling it restraint
elimination and challenged ev-
eryone to think in that direction.
The direction was Reach for the
stars; you just might succeed.
The restraint elimination vi-
sion had to be kept constantly
in the forefront. As a key com-
ponent in achieving culture
change, restraint elimination
was constantly addressed, alluded
to, promoted, and talked up in
staff meetings and impromptu
gatherings. Staff safety concerns
were discussed repeatedly.
Curriculum Development
and Staff Training
The materials provided by
NETI were invaluable. Sorting
and condensing the PowerPoint
presentations and content book,
along with the DVD, provided
at the training conference was
Table
Comparison of rates of five
sedative-hypnotic agentsa the
year prior to initiation of the
restraint elimination project
to the first full year with
zero restraints
Year
Variable 2004 2007
Number of patient days 4,919 4,715
Number of total dosages 4,271 3,208
of the five agents
Dosage rate per patient 0.87 0.68
day
a
The five agents are lorazepam (Ativan),
haloperidol (Haldol), fluphenazine (Prolixin),
chlorpromazine (Thorazine), and olanzapine
(Zyprexa).
a major and occasionally over-
whelming task. Presentations to
staff were developed from these
conference materials and deliv-
ered during an 18-month period.
The first presentation, Child-
hood Trauma: Prevalence and
Effects, laid the groundwork.
Staff learned about trauma theo-
ry. Statistics of trauma cases, ex-
pected to be dull subject matter,
were too compelling to be dull.
This statistical portion now ap-
pears to have been a pivotal
point in realizing culture change
on the unit. Staff could relate to
these numbers. In many cases,
staff had personal experience
with trauma. It was necessary to
recognize and address staff be-
haviors and pain as they became
aware of their own trauma his-
tories. Support and opportuni-
ties to debrief and acknowledge
these feelings were essential.
Neurobiological Effects of
Trauma was the second subject
for discussion. Observable brain
37

2,500
2,113
2,000
Number of Dosages
1,500
1,000 928
630
500 589
0 l
am do
z ep n ) p eri ol )
ra a lo ld
Lo (Ativ Ha (Ha
Flu (Pr
Figure 2. Comparison of sedative-hypnotic agent use for years 2004 and 2007.
changes (differences) was new
information for staff. The visual
evidence of actual brain chang-
es resulting from emotional or
physical trauma (visible on a
positron emission tomography
scan) made the trauma damage
visible and real.
The third presentation,
Changing a Culture, looked at
the words used in conjunction
with patients and families. Re-
minders to see patients as people,
not disease processes, reframed
staff members orientation. Pa-
tients were Mary or Joe, not that
borderline or the schizophren-
ic. Patients were recognized
and acknowledged as mothers,
fathers, sisters, brothers, sons,
and daughters. Personalization of
patients, or person-first, became
a priority and a way of thinking
and behaving. Development of
relationships with newly admit-
38
2004
2007
1,325
1,173
248
235
9 229
ine ine ine
n az n )
i m
az e ) z ap a )
e ro in an x
ph olix rp oraz Ol ypre
l o h Z
Ch (T ( The Comfort Room
Drug
ted patients was a critical compo-
nent in being able to de-escalate
hazardous situations. Occasion-
ally, immediate relationship de-
velopment would be necessary.
Additional topics for staff edu-
cation involved summary reviews
of previous material with added
topics concerning intervention
skills and techniques.
Comfort Room
The seclusion room, which
had never been used, was con-
verted into a Comfort Room. The
comfort room is a preventive tool
used to help reduce anxiety and
agitation. It is well established
that environment significantly
affects mood and behavior. The
comfort room provides sanctu-
ary from stress, and it can be a
place for individuals to experi-
ence feelings within acceptable
boundaries (Bluebird, 2007).
The comfort room is painted pale
peach in color, with the ceiling
painted as a blue sky with soft
clouds. Occupants can choose
from selections of soothing na-
ture sounds or classical music
that is piped in through ceiling
speakers. A Comfort Box was
created, from which people may
select items to help them relax.
Items include a soft, washable,
handmade blanket; stress balls;
stuffed animals; and journaling
materials. Sensory approaches,
such as lavender hand lotion or
vanilla oil, are also available. A
sign is posted on the Comfort
Room door. Quoting from the
Substance Abuse and Mental
Health Services Administration
(2005, p. 25), the sign reads:
A special place where you
may spend some time alone. You
may ask any staff member to use
this room. There are items that
you can sign-out to help you calm
down and relax (stuffed animals,
soft blanket, music, magazines,
and more). Persons who wish to
use the room will be asked to first
sign their names in the sign-in
book and talk to a staff member
before entering.
Culture Change
From the beginning of this
project, the leaders had been
warned that culture change
would be the most difficult to
accomplish. This was not true
in this situation. At the very be-
ginning of the project, some staff
members questioned the safety of
eliminating restraint use. Con-
cerns were discussed repeatedly.
The possibility to use restraints
was always left open if the situa-
tion truly warranted such action.
At first, restraints were used on
occasion, but rarely. Finally, the
unit was down to no-restraint use
and achieved 1 restraint-free year
JPNonline.com
as of January 2008. To this date,
the unit remains restraint free.
Below are some staff quotes
reflective of attitude and culture
change. Pseudonyms have been
used to protect their anonymity.
l Jennifer, RN: Restraints
now seem barbaricsort of like
the days when insulin-shock
therapy was used, or cold-wet
packs.
l Beth, RN: I just tell pa-
tients up frontwe do not re-
strain hereit sets the expecta-
tions from the beginning.
l Katie, nursing assistant: I
KEY P OINTS
1. Restraint use is always a treatment failure.
2. Person-centered care focuses on maintaining the dignity of the individual.
3. Restraint elimination is possible in a recovery-oriented service system. Recovery
is not about implementing a new model of care but doing differently what we
do every day.
4. A comfort room is a prevention tool that can help people maintain their dignity
and assume responsibility for controlling their behaviors.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.
Were waiting to hear from you!

dont like it [restraint use]. I dont

like seeing it.
l Jesse, nursing assistant:
There were endless opportunities
for restraints, but we understood
more about difficult patients. We
were better able to intervene and
help people de-escalate.
l Vida, RN: Restraints are
inhumane and can cause harm or
even death to a patient.
l Ricardo, nursing assistant:
Our mission should always be
to be therapeutic with patients;
restraints seem like more of a
punishment.
Project Outcomes
For trending purposes, the re-
straint elimination project team
gathered data regarding the inci-
dence of restraint use beginning
with fiscal year (FY) 2001-2002.
Rate of restraint use varied prior
to the initiation of the project,
ranging from a high of 19 in FY
2001-2002 to 9 for FY 2004-
2005. As the project unfolded,
the incidence of restraint use
declined. The last restraint ap-
plication occurred early in Janu-
ary 2007. There have been no
restraint applications during FY
2007-2008 (Figure 1).
The first logical questions
are, Did you get to no-restraint
use by increasing use of sedative-
hypnotic agents? or Are you
substituting chemical restraint
for physical restraint? This
question has been asked, and
the answer is a resounding no.
In fact, use of sedative-hypnotic
agents decreased.
Comparison of administration
rates for sedative-hypnotic drugs
per patient day declined by 22%
from 2004 (the year prior to initi-
ation of the restraint elimination
project) to 2007 (the first full year
with zero restraints). The mean
dosage rate per patient day in 2004
was 0.9 as compared with a rate of
0.7 per patient day in 2007.
The study included the fol-
lowing five agents of choice by
our providers to treat agitation,
anxiety, and psychotic symp-
toms: lorazepam (Ativan), hal-
operidol (Haldol), fluphenazine
(Prolixin), chlorpromazine
(Thorazine), and olanzapine
(Zyprexa). Comparison of rates
of use for these sedative-hypnotic
agents is found in the Table and
Figure 2.
Conclusion and
Implications for
Practice
The evidence is compelling.
Application of person-centered,
recovery-oriented, and trauma-
informed care principles by
frontline staff makes a restraint-
free environment possible. It also
appears to reduce the need for
sedative-hypnotic medication to
control behavior.
Although restraint elimina-
tion was the term used to de-
scribe the goal, nursing staff of-
ten expressed concern for safety.
Leaving the possibility open to
use restraints as a last resort in
unsafe situations allayed fears.
In early stages of the project, re-
straints were used occasionally,
but as time passed, it became ap-
parent that few, if any, situations
required restraint use.
Ironically, these staff mem-
bers are now very inexperienced
in restraint use. Some staff
members have never cared for
a patient in restraints. Skills are
kept current by conducting skills
laboratories on restraint applica-
tion and face-to-face assessment,
but the truth remains that few
staff members have participated
in a restraining process.
A new set of keyless, ease-of-
use restraints had been purchased
midway through the project.
These restraints remain brand
new. They have never been used.

Journal of Psychosocial Nursing Vol. 47, No. 1, 2009 39

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Substance Abuse and Mental Health Ser-
vices Administration. (2005). Mod-
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and restraint. In Roadmap to seclusion
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(DHHS Publication No. SMA 05-
4055). Retrieved March 14, 2007,
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Weiss, E.M., Altimari, D., Blint, D.F., &
Megan, K. (1998, October 11). Deadly
restraint: A nationwide pattern of
death. The Hartford Courant.
Ms. Barton and Ms. Johnson are Clini-
cal Managers, Behavioral Health Unit,
Chambersburg Hospital, and Ms. Price is
Clinical Nurse Specialist in Adult Psychi-
atric and Mental Health and Director of
Patient Services and Behavioral Health,
Summit Health/Chambersburg Hospital,
Chambersburg, Pennsylvania.
The authors disclose that they have
no significant financial interests in any
product or class of products discussed
directly or indirectly in this activity,
including research support.
The authors thank the Behavioral
Health Unit staff for their courageous
undertaking, implementation, and
ongoing dedication to this vision and
change. The authors also thank Dr.
Rajnikant Lad, Child and Adolescent
Psychiatrist, for initial direction and
support of the change project.
Address correspondence to Sandra A.
Barton, BSN, RN, BC, Clinical Manager,
Behavioral Health Unit, Chambersburg
Hospital, 112 North Seventh Street,
Chambersburg, PA 17201; e-mail:
sbarton@summithealth.org.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.