We are fortunate to have this column from Wanda K. Mohr, Ph.D., R.N., an international expert in the field of seclusion and restraint. She has published over 150 articles and collaborated with Theodore Petti, M.D. also a well known expert and Academy member. Professor Mohr is the only professional I have met who has a greater distaste for the use of restraints than I do. She is an indefatigable champion for the rights and dignity of patients.
Kim J. Masters, M.D.
Wanda K. Mohr, Ph.D., R.N., FAAN
By now it should be apparent to those of us in the psychiatric professions that restraints and seclusion are not benign procedures. To date there is no precise way to measure the number or extent of the injuries to children and injuries also to staff as a result of restraint use. Most recently, the Child Welfare League of America (CWLA) estimated that between eight and ten children in the U.S. die each year due to restraints, while numerous others suffer injuries (CWLA, 2002). As caregivers who have chosen to work for the well-being of children, we can all agree that even one of these deaths is unacceptable.
Psychiatrists and psychiatric nurses have called for more staff training in de-escalation techniques and they have issued numerous position papers and guidelines asserting that restraints and seclusion are interventions of last resort. There is little to disagree with in any of these well-meaning pronouncements. However, the position papers and statements fail to convey the complexity of the factors involved in patient aggression, its management, alternatives to, and death and injury proximal to the use of physical or mechanical restraints. Nor do they address the key elements that should be foundational with respect to the consideration of any intervention that we include in our therapeutic armament. Such interventions should be informed by a solid knowledge enterprise that deals with questions of: 1) How much do we know? 2) How well do we know it? and 3) With whom are we knowing it?
Three areas beg for attention in our knowing enterprise with respect to the above questions: education, research, and practice. In the area of education, our professions have failed to educate our students and residents adequately with respect to the multi-factorial reasons for aggression and violence, how to de-escalate potentially violent situations, what risks are inherent in their use, and how to apply restraints safely. In the area of practice, health care professionals have been remiss in failing to identify patients who, because of potential risk factors, might be at high risk for death and injury. In the research arena, the situation is even more dismal. Research is urgently needed to address risk factors associated with death proximal to physical restraint of patients. Studies should be conducted on independent, interactive, and cumulative effects of these risk factors on death and injury rates (Mohr, Petti, & Mohr, 2003). Multidisciplinary research is also needed in determining what programming actually constitutes a best practices approach with respect to primary and secondary prevention of violence, and which constitutes the safest approaches in the unavoidable event that a restraint becomes necessary. In sum, our knowing enterprise needs serious focus before our positions can be fully realized.
Although the above areas do not exhaust what needs to be known or done, their daunting challenges suggest that an effective agenda and strategic approach cannot be developed by professionals in isolation from each other. It must be collaborative. The principle of collaboration underscores the importance of forging dynamic and workable partnerships between physicians, nurses, and patients. Nurses assess patients; physicians assess them as well and write the orders for their restraint; nurses and other caregivers implement the orders and evaluate the outcomes. Patients endure the procedure. It is clear that the knowing enterprise involves more than one group of participants.
Unfortunately, wide gaps separate us from each other as professionals and from our patients (Mohr, 2000). These gaps are the source of mistrust and tension that too often impede or block the implementation and use of research findings by members and nonmembers of the scientific community. For example, how many physicians read nursing research journals? This reality is most acute where members of a profession and our society feel alienated and not adequately regarded as participants in the mainstream decision-making or research process. Unfortunately, professionals and patients can feel this way in today’s legally challenged and over-regulated health care environment that spawns feelings of political disenfranchisement and disempowerment.
But, the very realities of the health care environment and the complexities and exigencies of what we must do in the area of aggression, violence, and their safe containment beg for the establishment of a multi-directional flow of effort that will help professional and patient groups to co-construct, research, and assess effective and safe intervention strategies. Such an effort must involve breaking out of the status quo of our narrow professional categories. It means that we must first honestly share fears, expectations, and mistrust of prospective collaboration, and agree to a sharing of power.
Out of this dialogue should come a recognition of the strengths that each partner brings to the collaboration and a commitment to cultivate these strengths. Second, there must be a genuine flow of information to enable partners to learn the value of each other’s unique perspective and knowledge related to their joint ventures. Finally, partners must together translate their trust and information exchange into useful assessment, intervention, and evaluation strategies. Establishing and maintaining effective partnerships on behalf of children and families must be an end in and of itself, before it can be a means to an end that results in therapeutic and safe interventions that will benefit them.
Dr. Masters is Chief Medical Officer of ABS New Hope Treatment Centers and Assistant Clinical Professor of Health and Behavior at the Medical College of Georgia.
Dr. Mohr is Associate Professor of Psychiatric Mental Health Nursing at the UMDNJ School of Nursing in Newark, NJ.
Mohr, W.K. Re-thinking professional attitudes in mental health settings. Qualitative Health Research. 2000; 10(5): 595-611.
Child Welfare League of America. Advocacy: Seclusion and restraints: Fact sheet, 1-2. 2002. http:// cwla.org/ advocacy/seclusionrestraints.htm. Retrieved March 23, 2002.
Mohr, WK, Petti, TA, & Mohr, BD. Adverse effects associated with the use of physical restraints. Canadian Journal of Psychiatry. 2003; 48, 330-337.