Culture Change to Reduce Use of Seclusion & Restraint-Creating a More Positive Work Environment

Purpose:
This project describes strategies that decreased seclusion and restraint (S&R) use in behavioral health patients which led to a sustained change in the safety and quality culture in psychiatric emergency and acute care units in an urban academic medical center.

Significance:
Use of S&R hinders therapeutic relationships and represents failure of treatment. Sanctuary trauma theory purports that S&R use has devastating and often lasting negative effects. Decreased S&R use increases patient and nurse safety, improves quality and contributes to a positive work environment.

Strategy and Implementation:
Complexities of managing aggressive patients requires a change in belief and understanding that S&R use is in fact harmful; a necessary discovery with subsequent internalization by unit leaders and staff. Literature review convinced clinical leadership that practice changes grounded in the Recovery Model and trauma informed care would reduce S&R use and injuries. Supporting each other in a protracted journey, psychiatric nurse managers and key clinical leaders developed and led strategies that were implemented over time. Staff nurses were required to read and discuss evidence with leadership. All events of S&R use were reported immediately to managers who modeled or reinforced therapeutic behaviors, helping providers problem solve as necessary. In-services, weekly review meetings, huddles, 1:1 coaching were provided. Debriefings which educated on Recovery Model principles and practice were open to all providers. Outcome data was reviewed weekly. Resistance and barriers were addressed.

Evaluation:
After two years, S&R use has decreased 79.4% and 90%, respectively. Patient injuries are unchanged. The number of staff injuries is unchanged, except in the Child unit where staff injuries increased briefly related to program transitions. Nurse satisfaction scores (NDNQI) are mixed in five units.

Implications for Practice:
Providers who realize that outdated practice is harmful to patients are key to sustaining a positive change in safety, quality and environment of care. Committed leaders, identification of learning needs, responsiveness to barriers, and modeling new behavior creates paradigm shifts in unit culture.