Recent federal regulations have mandated that psychiatric facilities use
physical restraint only when patients pose a danger to themselves or others
and as a last resort.
Finding effective and safe alternatives to restraint or avoiding its use
altogether is critical for inpatient psychiatric facilities. Researchers in
the department of psychiatry at the University of Illinois at Chicago (UIC)
described an effective training program in the July issue of the APA journal
Psychiatric Services that led to a significant reduction in the use
of restraint with adolescent and adult psychiatric inpatients.
The first component of the program involves teaching psychiatric inpatients
to recognize what triggers their anger or aggression and strategies known as
crisis-management training. The second component involves training hospital
staff about factors that precipitate aggressive behaviors and nonviolent
interventions for managing patient crises.
Both training components were implemented in October 2001 on the adolescent
psychiatry and general adult psychiatry units at a hospital affiliated with
UIC. The clinical research psychiatric unit implemented the first training
component in July 2001 and the second component in October 2001.
The study was based on quarterly restraint data from the hospital's quality
improvement department examined from July 2000 through December 2002.
More than 2,000 patients were treated in the general psychiatry and
clinical research units of the hospital during the study period. A majority
were diagnosed with schizophrenia or other psychotic disorders or mood
About 220 patients were treated in the adolescent psychiatry unit from July
2000 through 2002. Their primary diagnoses were major depression or a
depressive disorder, adjustment disorder, conduct disorder, and schizophrenia
or a psychotic disorder.
The adolescent patients experienced a 48 percent decrease in the restraint
rate one quarter after the training occurred and a 98 percent decrease two
quarters after the training, the authors stated. The rate remained low
throughout the final two quarters of the year.
The general psychiatry patients experienced an 85 percent decline in the
restraint rate one quarter after the training and a 99 percent decline two
quarters after the training. "Once again, the rate remained low during
the final two quarters of the evaluation period," the authors
The clinical research patients experienced a 51 percent decrease in the
restraint rate in the quarter after they received crisis-prevention training
and a 49 percent decrease in the quarter after hospital staff were trained in
nonviolent interventions, the authors reported.
In the two quarters following both training components, the rate of
restraint use for the clinical research patients declined by 98 percent and
remained at zero for the final two quarters, the authors stated.
The training had a significant, positive effect on patients in all three
units. "Staff members and patients found the procedures easy to use and
expressed high satisfaction with the results," the authors said.
A major limitation of the study was the absence of a control group. Having
data on a control group would have clarified the direct effect of the
intervention on reducing the restraint rate, the authors commented. In
addition, the authors could not verify that the staff used crisis-management
or nonviolent crisis-management interventions correctly or consistently.
"However, all new staff members were trained immediately after their
hiring, and retraining was conducted annually," they noted.
"These findings have important clinical implications and suggest
areas of future research. Comprehensive staff training in crisis de-escalation
techniques and nonviolent interventions should be adopted by hospitals to
reduce the use of physical restraint with children and adults," the
There is also a "need for more rigorous evaluation of the
intervention's effectiveness and the satisfaction of staff members and
patients with noncoercive alternatives to restraint."
The study, "A Program to Reduce Use of Physical Restraint in
Psychiatric Inpatient Facilities," is posted online at<http://ps.psychiatryonline.org/cgi/content/full/55/7/818>.▪