The culture of a hospital unit not only lies within the culture of the organization, but it is also a dynamic process defined and reinforced every day by its staff members. In defining “culture,” we could refer to norms, values, and attitudes. However, we could also refer to leadership, membership, external network, and history. These latter facets are what staff believe and will be presented to have been the core contributions to this In-Patient Mental Health (IPMH) unit’s success at becoming restraint-free for well over a year in 2007–2008. Of note, this restraint-free culture has continued with only two occurrences up to the time of this submission.

This article briefly reviews: historical, organizational, and community background; results of an exploratory survey of the staff of IPMH; and summary of themes derived from this survey as suggestion for cultural assessment of a unit preparing for transforming to a restraint-free environment.

IPMH, currently a 10-bed closed unit in a Critical Access Hospital (CAH) in a small community in upstate New York, opened in 1990. The patient population encompasses 15 counties, ranging in age from 18 to 80, with primary diagnoses of bipolar, depression, and psychoses, with an average length of stay of 6.4 days. Staffing consists of Registered Nurses (RNs) and Counselors (Bachelor’s degree required in related field). The nurses have legal accountability and medication responsibility for all patients while the Counselors conduct all groups.

The Clinical Coordinator (RN responsible for orientation and clinical performance) hired then has since become the unit’s Nurse Manager (NM) with clear goals and a vision for becoming restraint-free. Other changes she was instrumental in implementing include:

Becoming smoke-free (years before the organization was fully implemented).
Encouraging a caffeine-free environment.
Providing a supervised social worker/discharge planner (usually under the jurisdiction of Social Services in a health care setting).

The NM actively participated in the hiring process for the new Director of Psychiatry in 2005. Together, their philosophies aligned for setting up teaching groups to provide the tools necessary for their patients to continue productive lives after discharge. These groups were developed with training of all counselors by the social worker to include discharge planning, goals and focus, activities of daily living, stress management, symptom management, healthy lifestyles, recreation, wrap-up, and relaxation.

Discharge planning meetings involving both nurses and counselors on this unit begin upon the patient’s admission and occur every morning. Notable is that either RN or counselor may initiate elopement warnings on any patient, a matter of mutual trust and respect. The psychiatrist’s office adjoins the nurses station, with the door always open when not in consultation with a patient.

The percentage of “Mr. Strongs” (our crisis response code) leading to restraint at this time hovered at 38%. The NM decided to send one RN and one counselor for the CAH employees (primarily for IPMH) to be trained as CPI Instructors in 2006. The two CPI Instructors, between organizational training commitments, trained the entire IPMH staff, reaching zero restraint use in May 2007. This appeared to be the turning point for achieving the restraint-free environment, maintained until the end of 2008 with their first restraint incident in over 15 months. Of note, the only staff injury during this period was a contused thumb during a Mr. Strong initiation.

The question now became, “What were the assumptions toward restraint use then as compared to now?” An anonymous, voluntary, exploratory survey was administered to all IPMH staff querying their experience using restraints, attitudes toward restraints, and open-ended comments. Response rate is estimated to be over 80%¹. Of note, no questions in this survey spoke to CPI training.

The results are presented by actual quoted comments without identifiers, followed by discussion on attributes and themes derived from the survey, summarized for lessons learned as suggested tactics for cultural assessment prior to implementation of a restraint-free environment.

Staff notions about the restraint process:

Tend to be very over stimulating and stressful for both the staff and the patient. Event is also confusing and is looked upon as an attack.
Can be very difficult depending on my team…. The intensity and limits set can be confusing for staff if the charge or leader does not set controls initially.
After years of experience, I think you’re prepared, but certainly not comfortable.

Staff notions about attempting to become restraint-free then:

It can’t be done.
We aren’t supposed to use restraint at all?
It would be difficult to achieve.

Notions about being restraint-free now:

Unable to remember [number of restraints participated in], but the number has dropped significantly in the past 2½ years.
[F]elt that other measures could have been used prior to restraints.
Having education and competent team members helps.
I don’t like to use restraints. My experience—I like to use progressive restraining—remove from area then quiet room, etc. Talk with patient.
Always been in favor of restraint-free environment.
Restraints should be used as a last resort but are still very necessary in some cases.
Encouraged that team is using restraint-free approach, but still feel restraints necessary at times to keep everyone safe.

Insights provided by staff in their own words:

Thought that this (restraint-free) has always been business (casual) and the need to acknowledge that the trauma (of restraining) isn’t worth it.
Changing the culture and mindset of all staff. We make every effort to talk and counsel before putting hands on. Now that we do that, it has been easier.
Encourage staff to spend time they are with patients listening in order to meet needs rather than have them escalate and possibly need restraints.
Have everyone understand that verbal de-escalation is just as, if not more, effective.
Consistency—educating everyone so we are all on the same page.
That it became a client-controlled environment and reduced professionals’ position, but that is not true. Having Instructors on site and invested makes it so much better.
To keep an open mind and don’t assume a patient is acting out and needs restraint before you talk to them or use non-restraint means.

Unexpected (unsolicited) comments speaking directly to the CPI program:

Combination of teamwork, education (CPI) management, change in culture (with new NM & psychiatrist)…. Taking time to do a good job and REALLY caring about our service.
Willingness to spend time getting to know patients, CPI training and updates, a team that works together in the best interest of the patient.
Techniques of CPI as well as a change in policy.
The way they (the Instructors) present their CPI training with a focus on verbal de-escalation and early staff intervention.

Attributes and themes extrapolated from the entire collection of responses are presented in the table below.

Discussion follows, speaking in general to each of the proffered themes in Figure 1 as derived from staff comments. These are themes offered for review within other work settings as baseline assessment for evaluating readiness for change to a restraint-free environment.

restraint use chart
Staff vs. Stakeholder Perspective
The foundation for implementing change lies with whether unit members come to work, perform their job description/duties, and go home…or, unit members own their work community, contributing to, or at least challenging, the current modes of operation. As clarification, while this was not the case with IPMH, this author believes those complaining loudest be heard and held accountable for assisting in moving forward toward improvements and change: a positive instigator.

Status Quo vs. Change
The trained response, “for patient safety and the safety of others,” needs to be questioned on two fronts. On the one hand, What is safe? On the other hand, Is safety the primary, overruling goal? Each automated response questioned challenges the comfort zone, bringing new scrutiny to the fore. Realize also that status quo may support experience over the newly hired. This badge of experience is not negated, merely supplemented, a necessary clarification. That two respected members of the IPMH unit were trained as CPI Instructors provided infrastructure for the upcoming change on this unit.

Congruency Through Competence
Restraint training is not part of the curriculum of nursing schools. As such, the learned approaches occur in actual work settings, a matter of variance by state, time period, and type of health care facility. To offer a uniform and unified program (in the case of IPMH, that of CPI) educates and coheres a staff for consistency in approaching potentially disruptive behaviors. This would nullify those staff comments stating inconsistencies with restraint processes as dependent on which staff members participated.

Sympathy vs. Empathy
Several staff comments spoke to their own discomfort as well as patients’ discomfort in being restrained. While the staff comment “Be patient” referred to staff demonstrating patience, taken out of context, it could be a slogan of empathy. Merely sympathizing with staff and/or patient after a restraining episode does not challenge why restraining was necessary. Empathizing from the patient’s perspective, or as staff stated, the 360 viewpoint, warrants closer scrutiny to issues of respect, trust, and empathy. As points for discussion, do these notions overrule safety?

Titanic vs. “Hail Mary” Perspective
The staff comment “not giving up on the patient” speaks to giving the benefit of doubt. This is a mindset, potentially challenging the issue of whose need reigns supreme (staff or patient), and what tactics can be utilized first before reaching a Titanic vs. Hail Mary conclusion.

Standardization vs. Individualization
Just as no two diabetic patients are exactly alike, neither are two psychotic patients. The Joint Commission for the Accreditation of Healthcare Organizations, as one accrediting body for hospitals, mandates that each patient care plan be individualized. It would follow then that different issues and circumstances could aggravate a patient to correspond with different de-escalating methods to be applied—a matter of critical thinking.

The literature supports decrease in use of restraints. Educational strategies such as role playing and case studies (Curran 2007) alone will not suffice. Case studies and role playing would need to include specific wording and rationale of approach to be seriously considered as tool for application. “The de-escalation skills of inpatient psychiatric nurses are considered key to violence prevention. Yet their efficacy and translation into practice remains in question.” (Delaney & Johnson 2006). Even when an “individualized, rather than standardized, approach to aggression management on inpatient psychiatric units” is utilized (Lindsey 2009), operationalizing the process, ironically, needs to be standardized.

For IPMH, CPI turned out to be the “missing link,” connecting intent of vision to accomplishment of a restraint-free environment. For those units in preparation to become restraint free, this article offers arenas for consideration in asking the right culture questions of staff to open the door for change.

¹Staffing positions have changed since administration of survey and author is not aware who did/not respond.

About the Author

Dr. Carol Chau currently serves as Nurse Researcher and Data Utilization Coordinator for Finger Lakes Health in Geneva, NY. She has previously served as a Mental Health Clinical Nurse Specialist at Indiana University-Purdue University-Indianapolis; and a Director of Nursing at Upstate Medical Center in Syracuse, NY. Carol's current projects include cultural issues in the acute care setting as related to Transformational Leadership and Transformational Care at the Bedside.

References:

Curran, S. S. (2007). Staff resistance to restraint reduction. Journal of Psychosocial Nursing, 45(5), 45–50.
Delaney, K. R., & Johnson, M. E. (2006). Keeping the unit safe: Mapping psychiatric nursing skills. Journal of the American Psychiatric Nurses Association, 12, 198–207.
Lindsey, P. (2009). Psychiatric nurses’ decision to restrain. Journal of Psychosocial Nursing, 47(9), 41–49.

Originally published in the Journal of Safe Management of Disruptive and Assaultive Behavior, March 2010 © 2010 CPI.

Restraint Use: Culture of Assumptions