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When patients are at their worst, mental health nurses are at their best


new study just released by UK researchers found that exposure to targeted, personal and verbal aggression by patients can adversely affect mental health nurses’ decision-making regarding physical restraint, explains Kim Sanders.

As a behavioral healthcare professional, these finding did not come as a shock to me. While not a nurse, I have worked with children and adults with co-occurring mental health conditions my entire career.

I know how physically and emotionally exhausting it can be. And though, I’m not proud to admit it, in the early part of my career, restraints were a normal part of my day.

I can tell you that no one enjoys restraining someone in their care. This might account for the fact that in the study – Mental health nurses’ emotions, exposure to patient aggression, attitudes to and use of coercive measures: Cross sectional questionnaire survey– there was not an increase in using restraint and seclusion, despite being more approving of these techniques.

“I can tell you that no one enjoys restraining someone in their care.”

Perhaps this is because mental health nurses in the study also understood that these techniques are ineffective; restraint and seclusion are not evidence-based practices. There is no data to suggest that either leads to reduced violent or uncontrolled behavior.[1]

In fact, behavioral research indicates that these approaches actually cause, reinforce and maintain aggression and violence.[2]

In addition, the risk of preventable adverse events and medical errors are higher immediately following the use of seclusion and restraint. Employing these methods leads to extended stays and increased recidivism/readmission.[3]

Most importantly, these practices have a negative impact on interpersonal relationships, damage the therapeutic alliance, and cause systemic mistrust.[4] Put simply, using these types of procedures often lead to increased violence and volatility for all involved.[5]

All of this begs the question: with so many reasons not to use restraint and seclusion, why do care providers continue to turn to them as a crisis management tool?

“With so many reasons not to use restraint and seclusion, why do care providers continue to turn to them as a crisis management tool?”

One reason is fear. When confronted by an aggressive child or adult patient, there is a genuine fear for their safety as well as for one’s own.

Frustration also plays a major part in the equation. Being a mental health nurse is an exhausting and stressful job. As they say, patience is a virtue.

But sometimes you find yourself in a situation where your patience has run thin. This new study also highlights an interesting corollary between the experiences the nurses endured and their approval to use restraint on those in their care.

Emotional and verbal abuse, such as that experienced by the nurses, leaves an imprint of trauma, which can then be triggered in future encounters. When a crisis situation arises, buttons can be pushed, triggering a fight or flight response. It’s not difficult, then, to imagine a reflexive, emotional reaction to the validity of restraint.

”When a crisis situation arises, buttons can be pushed, triggering a fight or flight response.”

Ultimately, much of the reason restraints are still used in behavioral healthcare is that providers have not been given alternatives to coercive techniques nor have they been taught the skills needed to implement a trauma informed approach.

Providing mental health nurses and others with training that offers meaningful intervention — including a safe, physical alternative to restraint — is the key to greatly reducing these practices and increasing the safety of the patient and caregiver.

Today, as President of Ukeru Systems, a division of Grafton Integrated Health Network, I travel across the country to work with healthcare professional to provide them better, healthier approaches that focus on comfort rather than control.

Preventing restraint not only enhances the quality of treatment, it also increases satisfaction for those both receiving and providing services.

We know this is true because we’ve seen it at our own organization.

“These professionals deserve the proper tools to successfully do their job so at that end of the day, no one has to experience irreversible trauma.”

Over a decade ago, Grafton, an organization serving children and adults with autism and co-occurring psychiatric diagnoses, implemented an organization-wide effort to minimize, or where possible eliminate, restraints and seclusions.

The effort has resulted in compelling data, experience and, most importantly, outcomes – we have reduced the use of restraints by 99.8 percent, lowered workers’ compensation costs and dramatically reduced employee turnover.

It is a selfless and courageous decision to become a nurse. These professionals deserve the proper tools to successfully do their job so at that end of the day, no one has to experience irreversible trauma.

Over time, I’ve had to forgive myself for those years of using restraint and seclusion. I used the tools I had at my disposal at the time, just as the nurses in this study are doing. But we have a better way. And, because we do, we must make sure that all patients benefit from our knowledge and our compassion. When they are at their worst, we must be at our best.


About the Author:

Kim Sanders, President of Ukeru Systems, has worked with children and adults with autism and other developmental disabilities for over 25 years, serving in a series of both hands-on and leadership roles at Grafton Integrated Health Network facilities. She has presented at the national and international level on the Minimization of Restraint and Seclusion model, and is recognized as an innovator for moving towards a physical restraint free environment at Grafton.


[1] IBID

[2] IBID

[3] LeBel & Goldstein, 2005; Thomann, 2009

[4] NASMHPD, 2009

[5] According to the Substance Abuse and Mental Health Services Administration


Readers' comments (2)

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  • Some interesting views here - also interesting to read employee reviews. If it is behavioural modification of staff not sure it is all what it's cracked up to what its mean't to be?

    lowered workers’ compensation costs or blame the worker schemes? = fear based environment? I don't know the answer to be honest but important to question.

    Dramatically reduced employee turnover or low numbers of staff at frontline/ high turn over of lowered numbers hidden by different and greater amount of other profession types in such an organisation? Is there more than meets the eye I wouldn't know?

    99.8% doesn't necessarily equate to harm caused to staff nor how risk is determined, measured, recorded or regarded. If lower amount of staff then recordings maybe lower but potentially more severe in event. To be honest I just find the stat very odd. Not saying behaviour modification or techniques not important but where nationally figures of aggression or violence against healthcare staff are high we have to be careful how such approaches are used. Worrying where or if emphasis is potentially placed disproportionately on workers and not environment, resources, appropriateness of referrals nor nature of hostility posed to workers.

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