Use of Seclusion and Restraint?

This is only part of the article....

Alternatives to Restraint and Seclusion in Mental Health Settings: Questions and Answers From Psychiatric Nurse Experts
Posted 05/03/2007
Laura Stokowski, RN, MS
from Medscape Website http://www.medscape.com/viewarticle/555686?src=mp

What Alternative Approaches Can Nurses Use to Avoid the Use of Seclusion and Restraint?

A reader asks, "What do you do when a 220-pound violent patient is throwing furniture or has already assaulted a staff member?" The first thing you should do is clear the area of others, and then remain quietly available at a safe distance until the peak of the crisis has passed. The risk of injury to both patients and staff is high when a direct verbal or physical intervention is attempted at the peak of a crisis. If a staff member has been assaulted, the staff member should be removed from the area and other staff must take the lead in intervening. A patient should not automatically be secluded or restrained following a staff assault, a response often born of fear or the conviction that the person needs "consequences." Seclusion or restraint should never be used to introduce consequences; instead, other approaches to supporting behavior change may be instituted once the crisis has passed.

Early identification of the problem and appropriate assessment of the situation are essential because different situations must be dealt with differently. Anger, fear, and frustration can all lead to violent behavior, and each calls for a specific approach. "Meet the patient where the patient is at" is a phrase commonly used to convey the need to match the approach to the patient's emotional state and to what has triggered that state.

An often overlooked but very simple crisis communication technique is to ask the patient "What would help you right now, at this moment?" It is surprising that this is a question we don't think of asking, yet it often yields a very specific and helpful response. A patient might just need clarification of a misunderstanding, some personal space, or might need to walk. Engaging the patient in the decision of how best to intervene can help them get through the situation without resorting to seclusion or restraint.

Chabora and colleagues[4] developed the Four S Model as a way of reducing the use of seclusion and restraint. The 4 S's are safety, support, structure, and symptom management. In brief:

Safety means assuring the individual's physical and emotional well-being via interventions such as modifying the environment to reduce stimuli and induce a calming ambiance.

Support involves listening and talking in a supportive way, offering comfort measures or whatever is needed according to the individual, and using verbal de-escalation.

Structure techniques, like limit setting, convey behavioral expectations and aid in constructive problem solving.

Symptom management is aimed at specific symptoms including stress and relaxation measures, diversionary activities, or medication.

The scenario described above (the 220-pound patient throwing furniture) is already an out-of-control situation. The question must be asked, what happened before this patient started throwing furniture or assaulted the staff member? At that point, engaging this patient might have led to a different outcome. When the patient is at the point of throwing furniture, the only option may be to clear the area and have everyone get out of the way until the patient winds down. This can be difficult and scary for staff to do, but it is likely to result in less injury than trying to physically contain the patient and apply restraints. When the patient is calmer, staff can proceed with crisis communication techniques that involve the patient, and the use of seclusion or restraints has been avoided.

Prevention is always easier and more effective than reacting to episodes of violent behavior. Careful patient assessments can identify risk factors for violence including triggers, previous restraint and seclusion history, and trauma and abuse history. At the same time, effective coping strategies previously used by the individual to safely manage behavior, as well as specific directions for what staff can do to help, should be elicited and documented in the treatment plan. Patients can be involved in developing their own de-escalation or safety and support plans (including psychiatric advance directives). Gathering this information at the point of admission provides a foundation for effective partnership when circumstances present that could give rise to a behavioral emergency. "I remember you saying...." is an opening statement that sets the stage for working together.