Reducing Behavioral Restraint & Seclusion & SB 130


The Basics of Behavioral

Restraint and Seclusion

Leslie Morrison

Director, Investigations Unit

Disability Rights California

(510) 267-1200

February 2013


Defining Terms



Restricting freedom of movement, physical activity or normal access to one’s body




 Physical force; manual holds

Mechanical device, material or equipment

Chemical [drugs]



Briefing holding to calm or comfort

Brief assistance to redirect or prompt

Devices used from transportation or security

Involuntary confinement alone in a room or an area from which the resident is physically prevented from leaving

Doesn’t matter if door is locked or even closed


Voluntary time out

Restriction to area consistent with unit rules or an individual’s treatment plan

What is “ chemical restraint ”?

Medication used as a restriction to manage an individual’s behavior, generally unplanned and in emergency/ crisis.

Not medication routinely prescribed to treat individual’s psychiatric condition to improve functioning.

Not necessarily all PRNs but often PRNs are used.

Often used in combination with other forms of restraint or seclusion.


What we


about restraint and seclusion…


Have no therapeutic value or basis in clinical knowledge.

Does not positively change behavior

 May increase negative behavior and decrease positive behavior.

Is traumatic and potentially physically harmful to staff and the individual.

Does not keep people safe.

 May cause death even when done “safely” and correctly.

Leaves lasting psychological scars.

Decision is almost always arbitrary, idiosyncratic, and generally avoidable.

Facility culture (staff role perceptions, training, program philosophy, facility leadership) has greater influence on the use of restraint & seclusion than clinical factors.

Restraint and seclusion is often staff’s first, automatic response to difficult behavior.

Generally stems from a power struggle .

Mostly used for loud, disruptive, non-complaint [but not violent] behavior.

 Lack of training in managing behavioral crisis contributing factor 90% of JCAHO restraint deaths.




 Keeps people (staff

& consumer) safe

 Known to cause injury, death and last psychological trauma;

 Higher worker injury rate than in lumber, construction and mining

 Only used when absolutely necessary and for safety reasons

 Most often used for non-compliance, inappropriate behavior or power struggle

 (1) study 73% (560 consumers) not dangerous but

“inappropriate” at time restrained/secluded

 Staff can recognize potentially violent situations

 Nurses agree on use 22% of time; mental health professionals can only predict violence potential 53% of time; least clinically experienced were most restrictive

 Staff know how to deescalate

 De-escalation used < 25% of time;

 Most frequent antecedent was staff-initiated encounter = staff escalate;

Lack of training in managing behavioral crisis contributing factor 90% of JCAHO restraint deaths;

1/3 of staff surveyed didn’t get mandatory crisis training

 Used without bias and only in response to objective behavior

 Cultural and social bias, staff role perception, administrator attitudes

 Therapeutic and based on clinical knowledge

 No controlled studies, no measure of efficacy or therapeutic value; shown to increase negative behavior

 Restraint/seclusion used for safety not punishment

 (6) studies = 58-75% perceived as punishment


Whose Pre-disposed?

No “typical” patient profile

 No consistent demographics

No consistent clinical characteristics

Although individuals w/trauma or abuse history at greater risk…

√ Staff profile

 Mostly used for loud, disruptive, non-complaint behavior

Generally stems for power struggle

Based on cultural bias & staff perception

Belief that it is safe/harmless & reduces risk of injuries

√ Facility culture

 Automatic response to difficult behavior

Insufficient alternatives

Insufficient staff training in de-escalation

Little to no focus on reduction; not seen as a critical event/ treatment failure



 Psychological


 Death

 Asphyxiation



Cardiac and/or respiratory arrest

Fractures, dislocation/sprains

Lacerations, abrasions

Injury to joints and muscles,

Dislocation of shoulder and other joints,

Hyperextension or hyperflexion of the arms,

Overheating, dehydration, exhaustion,

Exacerbation of existing respiratory problems,

Decreased respiratory efficiency,

Decrease in circulation to extremities,

Deep vein thrombosis,

Pulmonary embolism,

Cardiac and/or respiratory arrest.

Last psychological trauma

Loss of dignity

Triggering flashbacks

Recurrent nightmares, intrusive thoughts, avoidance behaviors,

Enhanced startle response,

Feelings of guilt, humiliation, embarrassment, hopelessness, powerlessness, fear, and panic

Compromised ability to trust and engage with others,


Creates a violent and coercive environment that undermines forming trusting relationships

Risks with Medication

Sedation contributing to respiratory depression & arrest


Conditions on Use

 Only used:

◦ in emergencies, to prevent imminent risk of physical harm when other less restrictive alternatives have failed, for the least amount of time necessary, and in least restrictive way.

 Never for coercion, discipline, convenience or retaliation by staff

 Only by staff with specific, current training and demonstrated competence in application

 Only upon MD order OR , in emergency, at discretion of RN

Never as a standing order

Limits on order duration

Face to face assessment by MD or specially trained RN/PA within one hour [at hospital]; other timeframes apply for other settings

 Requires certain level of monitoring or observation

Where & What are the Standards ?

Federal law

 Hospitals

 Residential Facilities for


State Law and Regulations

 By facility type

Joint Commission

Not all facilities

By facility type

What standards?

 Duration of orders

Type of observation frequency of monitoring

MD consultation & oversight

Documentation requirements

Staff training elements

Reporting requirements, data collection

Quality Improvement criteria


Additional State Requirements

Health & Safety Code §1180

Prohibits risky practices:

Obstruct airway or impair breathing

 Pressure on back or body weight against back or torso;

Anything covering mouth;

Restraint w/known medical or physical risk if believe it would endanger life or exacerbate medical condition;

Prone with hands restrained behind back;

Containment as extended procedure

 If prone, must observe for distress

Prone mechanical restraint with those at risk for positional asphyxiation, unless written authorization by MD .

Intake assessment with consumer input

Advanced directive on deescalation or use of R vs. S

Early warning signs/ triggers/precipitants,

Techniques that help person maintain/regain control,

Pre-existing medical conditions, trauma history.

Post-Incident Debriefing

ID & understand precipitant(s);

Alternatives/other methods of responding;

Revise plan to address root cause;

Was it necessary & done right?


 Data

How does a facility prevent R/S?


From Control → to Empowerment

 Involvement by top leadership

Create a vision and culture that prevents the risk of conflict and violence and respects personal liberties

Maintain sufficient staffing & programming

 Keep reduction in use & duration as constant priority and focus

 Integrating the principles of recovery and trauma informed care

 Implement restraint/seclusion prevention tools & alternatives

Trauma assessments

Crisis plans

12 

Comfort rooms

Sensory modulation tools

 Workforce development

Build relationships

Avoid power struggles

Built into staff competencies and performance evaluations

On-going training (not only point in time)

 Rigorous debriefing of every incident with involvement of senior administration

 Use data to inform practices

Public reporting & posting

Rigorous analysis

Actively Recruit & Involve Consumers and Families

Peer advocates in debriefing

Facility committees & positions


Principles of Trauma-Informed Care

Program and services based on:

Understanding vulnerabilities and triggers of trauma survivors that can be triggered in traditional service delivery systems

Designed to be supportive and avoid re-traumatization

Respect individuals.

 Keep them informed, connected and hopeful about their recov ery

Work collaboratively in a way that empowers the individual.

Learning together vs. Helping (one individual has agenda for the other)

Relationship vs. the Individual

Responding out of Hope (caring, patient, & supportive) vs.

Reacting out of Fear (rule driven, reactive, restrictive)

Public Health Model

focus on prevention NOT how to do more safely or better

Universal Precautions

Administrative & clinical treatment environment that minimizes potential for conflict by anticipating risk factors

 Trauma informed care

Recovery Model

Stigma awareness

Early assessment of risk factors

Organizational values

Secondary Intervention

Immediate & effective early intervention strategies to minimize conflict and aggression when they occur o Individual assessment of risk o Individual crisis plans to teach emotional self-management o De-escalation skills



After incident, rigorous problem solving, mitigate effects, take corrective action

Post S/R interventions to mitigate effects


Corrective Action o Staff training on attitude & self-awareness during conflict o Sensory modulation tools o Comfort rooms