Death in Seclusion or Restraints

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Wanda K. Mohr PhD APRN FAAN received her doctorate in nursing from the University of Texas at Austin in 1995. Presently she is an Associate Professor of Psychiatric Mental Health Nursing at University of Medicine and Dentistry School of Nursing. She is a certified advanced practice nurse in Child and Adolescent Psychiatric Mental Health Nursing. She is a recognized leader in the movement to reform conditions in mental health settings, with special emphasis on seclusion and restraint. Dr. Mohr is recognized for her work on institutional violence on troubled children, and has testified before the United States Congress representing national agencies that advocate for children’s mental health. She has over 30 years of clinical experience with troubled children and their families ranging across a variety of health care settings. Since completing her doctorate in 1995, she has authored over 70 professional journal articles, chapters, and books on the subject of mental health and has been consulted by a variety of state and federal agencies on the issue of children’s responses to violence. Dr. Mohr is a fellow in the American Academy of Nursing and has been recognized by her peers as evidenced by numerous national and international awards.

Dr. Wanda Mohr answered these questions:

1. How many people die in seclusion or restraints each year?
2. Is there an impact on patients who watch another patient being restrained?
3. What are a few myths associated with restraints?
4. What are the conditions that cause people to die while in restraints?
5. How are you defining restraints- a product sold from a catalog or the act of preventing someone from hurting themselves or others?
6. What does the term “seclusion” mean?
7. What keeps a patient within a seclusion room?
8. What types of places within healthcare use the types of restraints that we have been discussing?
9. How often are leather restraints used at this time?
10. What entities regulate the use of restraints?
11. What type of training should be available for staff using restraints?
12. What group of healthcare providers typically does not get trained on using restraints?
13. Why would restraints be used in a public school?
14. What are the alternatives that are available to the staff when a patient needs to be restrained?
15. Do staff behaviors come into play in some of the injuries that you have seen in dealing with restraints?
16. What is a common staff behavior that affects the outcome of restraining a patient?
17. What would the ideal milieu look like to structure the environment or the interactions in such a way that the escalation wouldn’t occur?
18. What are the financial costs associated with a restraint episode?
19. How does the psychiatric illness of the patient affect the ability of the judge, jury or arbitrator to identify with the patient?
20. What are the psychological, sequelae or effects of being restrained or observing somebody who is being tied down or brought down to the floor?

Extracted from Wanda K. Mohr PhD, RN, FAAN, “Psychiatric Nursing Liability”, in Patricia Iyer and Barbara Levin (Editors), Nursing Malpractice, Third Edition, Lawyers and Judges Publishing Company

Restraints and seclusion are considered forms of restriction. The application of restraints and the use of seclusion are high-risk treatment modalities because they are dangerous interventions that can result in injury or even death. From a legal standpoint they are also high risk because patients may perceive such methods as a form of punishment, and these modalities greatly inhibit the patient’s right to freedom. Therefore, accrediting agencies and governmental entities require implementation of policies and procedures to govern these practices. Many states have developed statutes to define the use of restraints and seclusion within psychiatric facilities, and the federal government (Centers for Medicare and Medicaid Services) has issued strict guidelines for their use in facilities that receive federal funds as third-party reimbursement. The Joint Commission has revised the standards guiding the use of restraints and seclusion several times since 1996. These standards guide the application of restraints or initiation of seclusion, monitoring of the patient while these methods are imposed, and assessment for continuing need of the re¬straints or seclusion. The standards also specifically require the leaders of the ¬or¬ganization to limit the use of restraints and seclusion to clinically justified situations.

Until recently, seclusion and restraint have been an assumed part of the psychiatric nurses intervention armamentarium. However, in recent years reports of serious adverse effects (including death) have been published resulting from seclusion and restraint prompting critical examination of their utility. Because of safety concerns and lack of evidence of their efficacy, the federal government has passed legislation to limit the use of these coercive techniques.

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