Securing the dignity of patients and protecting them against harm is among the main mandates of mental health professionals. These professionals are expected to take all necessary steps to ensure that the patients experience comfort and are held in conditions which facilitate the recovery process. Despite this expectation, it has been observed that the mental health practitioners are employing questionable methods that strip patients of their dignity and expose them to harm. Seclusions and restraints are among these methods. They are usually used in instances where the patient poses a danger to themselves and others. However, given the negative effect that they have on the patients, calls are being issued for their elimination and the adoption of more effective and humane approaches. If the Anoka Metro Regional Treatment Center (AMRTC) is to improve the wellbeing of both staff and patients, it should explore alternatives to seclusion and restraint.
Problem Statement
The PICOT framework guides the development of solutions that can be implemented to replace seclusion and restraint. In the following section, the different components of this framework as they relate to the situation at the Anoka Metro Regional Treatment Center are explored in detail.
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Need Statement
The need that requires solution is the use of seclusion and restraint in the treatment of the dozens of patients with severe mental health, criminal and behavioral issues who are hosted at the Anoka Metro Regional Treatment Center. Research has shown that by secluding and restraining patients, practitioners expose themselves and the patients to the risk of sustaining injuries (Wale, Belkin & Moon, 2011). Moreover, these methods could cause the patients to suffer trauma. The need to limit the application of seclusion and restraint is concerned with both quality improvement and safety of patients and practitioners. By addressing this need, progress will be made in the establishment of conditions that promote patient recovery while safeguarding the wellbeing of practitioners. The main goal that the ANOKA facility will strive to achieve is to reduce the use of restraint by at least 25% while lowering the restraint time by 1/3. In analyzing the need to lower the use of these approaches, various assumptions are made. These assumptions include the presupposition that the entire hospital is dedicated to solving the problem and that no major hurdles will be encountered as the hospital implements the proposed solutions.
Population and Setting
Population and setting are critical components of the PICOT framework. The interventions will be implemented at the Anoka Metro Regional Treatment Center. This facility offers mental health services to psychiatric patients exhibiting behavioral problems, and those involved in the criminal justice system. Furthermore, the center attends to patients with comorbid conditions. Serving the eight counties in the Twin Cities metropolitan area of Minnesota, AMRTC has adopted the inpatient model and collaborates with the neighboring communities in the treatment of its patients. The population targeted with the interventions is comprised of the dozens of the inpatients who are receiving treatment at the facility. Special focus will be given to the patients on whom seclusion and restraint have been administered. As it works with this population, the hospital should brace for some challenges. For example, the interventions will require the full cooperation of the patients. Given the fragility and instability of their mental states, the patients are unlikely to cooperate.
Intervention Overview
A variety of interventions are available for limiting the use of restraint and seclusion. They include the adoption of dialectical behavioral therapy and the accelerated deployment of response teams (Smith et al., 2015). These are the primary interventions that will be recommended for AMRTC. The dialectical behavioral therapy is traditionally used in the treatment of patients with borderline personality disorder. However, since its focus is on changing such behaviors as self-harm, it can be extended to the treatment of patients with other mental conditions. Even as it implements dialectical behavioral therapy, the hospital should be wary of its weaknesses. The limitations of this intervention include the heavy time commitment it requires and the fact that it is rather difficult to persuade patients to participate in the intervention (Carmel, Rose & Fruzzetti, 2014). On the other hand, the use of response teams involves training mental health professionals about the procedures that they are to follow when attending to a patient exhibiting dangerous behaviors like self harm (Smith et al., 2015). As is the case with dialectical behavioral therapy, the use of response teams also has weaknesses. The major weakness is that it is human capital intensive. Given the staff shortage that many mental health facilities face, it may be difficult to implement this intervention.
Comparison of Approaches
To understand why the two interventions outlined above are needed, it is essential to compare them to the approaches that are currently in use at AMRTC. As noted earlier, AMRTC relies heavily on seclusion and restraint. When a patient poses a threat to others and themselves, the hospital’s staff respond quickly by either placing the patient in a secluded area or restraining them. Consequently, the hospital has witnessed injuries among its patients and practitioners. The rapid response teams and the dialectical behavioral therapy are promising alternatives that could facilitate the hospital’s efforts to promote a safety culture and to adopt effective evidence-based practices. It can be expected that as it integrates the two interventions into its practices, the hospital will witness drastic declines in such adverse outcomes as injuries. In the discussion above, the respective weaknesses of the dialectical behavioral therapy and the deployment of response teams have been outlined. While these weaknesses could frustrate the implementation of the two interventions, by taking appropriate steps, AMRTC could ensure that the implementation process occurs smoothly.
Initial Outcome
It is important for AMRTC to develop metrics against which the successes of the proposed solutions will be measured. The number of cases in which seclusions and restraints are applied will serve as the primary outcome for evaluating the two recommended approaches. As noted earlier, the hospital aims to reduce the use of restraint and seclusion by 25% and 33% respectively. If these goals are met, the hospital will have a basis to conclude that dialectical behavioral therapy and the response teams have had the desired effect. In addition to driving the reduction in the use of seclusion and restraint, the interventions are also expected to minimize injuries and traumatic experiences among the patients and staff.
Time Estimate
The implementation of the recommended solutions will involve various complex processes. For this reason, it is expected that the implementation process will take at least six months. During this time, the hospital will train its practitioners, acquire the necessary resources and facilities, and ready its patients for the adoption of the interventions. It is worth noting that there are a number of uncertainties that could extend the timeline. For example, the hospital is unable to predict how the interventions will be received by patients and practitioners. If these stakeholders oppose these interventions, the implementation process may take longer. Another uncertainty that could complicate the implementation process is inadequacy of funding. For example, the hospital will need to train its employees who will form part of the response teams. Without adequate funding, the deployment of the response teams may have to be delayed.
Literature Review
Evidence found in literature offers an avenue for validating the importance of limiting and eventually eradicating the use of seclusions and restraints in the treatment of patients with mental illnesses. Various scholars have decried the continued application of these techniques. Knox and Holloman (2012) are among these scholars. In their text, they acknowledge the necessity of seclusions and restraints. They note that emergency departments may be forced to employ these techniques. However, they do not hesitate to caution that these techniques have adverse effects on patients and should therefore be phased out. Scanlan (2009) is yet another scholar who urges the mental health community to embrace alternatives to seclusion and the use of restraints. He dedicates his article to recommending such solutions as able leadership and staff training. Scanlan expresses optimism that the adoption of his recommendations will result in tremendous improvement in the experiences of both mental health personnel and patients. His concerns are echoed in the article that Masters (2017) authored. The focus of this article is the history and practice of seclusion and restraint. Masters present these techniques as antiquated, harmful and ineffective. He proceeds to advise mental health institutions to take steps to replace these methods. The damaging effects of the continued use of restraints and seclusions are also the subject of the article that Larue (2013) authored in collaboration with Dumais, Boyer, Goulet, Bonin and Baba. They lament that these techniques leave patients feeling ashamed, helpless and traumatized. Furthermore, these researchers report that the techniques have a humiliating effect and should therefore be eliminated from practice. Essentially, all these scholars recognize the dangers that secluding and restraining patients has on the safety and general wellbeing of both the patients and their practitioners.
To fully understand why the issues of seclusion and restraint are important and relevant, it is worth examining why they remain in use despite the negative impacts that they have. Newton-Howes (2013) addresses the necessity of these techniques. He notes that most facilities employ these methods when dealing with aggressive patients who exhibit disturbed behavior. Left to roam free, these patients would pose a serious danger to themselves, other patients and mental health professionals. Oster, Gerace, Thomson and Muir-Cochrane (2016) confirm that restraints and seclusions are necessary tools that mental health professionals rely on to maintain safety and prevent injuries to themselves and patients. One should understand that there appears to be consensus within the research community regarding the need for efforts to reduce the use of restraints and seclusions. For example, Goulet (2017) joined Larue and Dumais in recognizing that the reduction in the use of these techniques will lead to tremendous enhancement of mental healthcare quality. In summary, the research community appears united in its recognition of the role that seclusion and restraint play in mental health care. However, more importantly, the members of this community agree that reforms are needed.
Above, various researchers have been cited as part of efforts to underscore the relevance and significance of the problem of secluding and restraining mentally ill patients. In determining the research to consult, a rigorous criterion was applied. This criterion included such factors as the relevance, currency, sufficiency and trustworthiness of the evidence contained in the research literature. All of the articles are current and relate directly to the question of the use of restraints and seclusions. Furthermore, these articles were found to be credible and trustworthy as their authors are experienced professionals in various healthcare fields. The articles gain further trustworthiness from the fact that they featured in credible peer-reviewed journals. One of the drawbacks of the articles is that they were not sufficient. While they attempted to be comprehensive, the articles failed to adequately address all critical aspects of seclusions and restraints. For instance, some of the articles failed to provide solutions. Instead, they gave intense focus to the problems arising from the application of restraints and seclusions.
So far, focus has been given to the views of the research community regarding the effects and the role of seclusions and restraints. For an even better understanding of these techniques and how they pose a problem to be gained, it is important to explore existing health policies as they relate to these techniques. The American Psychiatric Nurses Association (APNA) is among the organizations that have developed policies and guidelines that govern the use of restraints and seclusions. One of the key guidelines that the APNA requires professionals to use is concerned with conducting skilled and thorough assessments on patients who are to be restrained or held in seclusion. Furthermore, the APNA urges practitioners to terminate the use of these techniques when it is determined that they are no longer needed (“APNA Position on the Use”, 2018). The US Department of Health and Human Services (HHS) has also developed policies. This department advises practitioners to minimize their application of seclusions and restraints and to closely monitor patients on whom these tools have been administered. Overall, there appear to be clear guidelines that mental health professionals should uphold in their work with aggressive patients. While the guidelines are comprehensive, they tend to prioritize the needs and rights of patients at the expense of the safety and wellbeing of practitioners. To be fairer and more complete, these guidelines should be updated to include insights on how professionals can stay safe when secluding and restraining patients.
In conclusion, the AMRTC is among the institutions that work tirelessly to improve the outcomes of mentally ill patients. As part of its efforts to ensure the safety of all stakeholders, this hospital has incorporated seclusions and restraints into the management of its patients. Research has shown that while they may be necessary, these tools are largely ineffective and harmful. They expose both practitioners and patients to the risk of injury. It is patients who bear the brunt of the continued application of these techniques. AMRTC should move with speed to phase out these approaches. It should replace them with dialectical behavioral therapy and response teams, interventions that research has shown to be far more effective and safer. As it implements these alternatives, AMRTC should be guided by applicable policies and should be wary of the challenges that usually frustrate the implementation of change.
References
APNA position on the use of seclusion and restraint. (2018). APNA. Retrieved February 27, 2019 from https://www.apna.org/i4a/pages/index.cfm?pageid=3728
Carmel, A., Rose, M., & Fruzzetti, A. E. (2014). Barriers and solutions to implementing dialectical behavior therapy in a public behavioral health system. Administration and Policy in Mental Health, 41 (5), 608-14.
Goulet, M., Larue, C., & Dumais, A. (2017). Evaluation of seclusion and restraint reduction programs in mental health: A systematic review. Aggression and Violent Behavior, 34, 139-146.
Knox, D. K., & Holloman, G. H. (2012). Use and avoidance of seclusion and restraint: consensus statement of the American Association of Emergency Project (BETA) seclusion and restraint workgroup. The Western Journal of Emergency Medicine, 13 (1), 35-40.
Larue, C., Dumais, A., Boyer, R., Goulet, M., Bonin, J., & Baba, N. (2013). The experience of seclusion and restraint in psychiatric settings: perspectives of patients. Issues in Mental Health Nursing, 34 (5), 317-24.
Masters, K. J. (2017). Physical restraint: a historical review and current practice. Psychiatric Annals, 47 (1), 52-55.
Newton-Howes, G. (2013). Use of seclusion for managing behavioural disturbance in patients. Advances in Psychiatric Treatment, 19 (6), 422-8.
Oster, C., Gerace, A., Thomson, D., & Muir-Cochrane, E. (2016), Seclusion and restraint use in adult inpatient mental health care: An Australian perspective. Collegian, 23, 183-190.
Wale, J. B., Belkin, G. S., & Moon, R. (2011). Reducing the use of seclusion and restraint in psychiatric emergency and adult inpatient services: improving patient-centered care. The Permanente Journal, 15 (2), 57-62.
Smith, G. M., Ashbridge, D. M., Davis, R. H., & Steinmetz, W. (2015). Correlation between reduction of seclusion and restraint and assaults by patients in Pennsylvania’s state hospitals. Psychiatric Services, 66 (3), 303-9.
