Alex Woodruff, MPH, is a Health Science Specialist at the Boston VA Healthcare System. He tweets at @aewoodru.
The use of restraints and seclusion is a long standing, yet controversial, measure for patients hospitalized in psychiatric settings. Reducing the unnecessary use of these interventions is imperative for patient health.
Restraint and seclusion fall under the umbrella of “coercive measures,” and are often used to address self-harm or violent behavior. But the use of these measures varies widely, suggesting that these criteria are subject to interpretation and may sometimes be used unnecessarily. The unnecessary use of coercive measures is problematic — they can be traumatizing to the patient, undermine effective psychiatric treatment, and are ethically suspect.
Reducing use of these practices to only when absolutely necessary is a priority for the treatment of psychiatric disorders. Research to date has suggested that a number of factors, such as staffing, internal policies, and leadership are linked to the use of these coercive measures. But new research highlights that clinicians’ morale and workplace culture are other factors to consider.
Study Design
Dr. Ekaterina Anderson, a health services researcher with the Center for Healthcare Organization and Implementation Research (CHOIR) at the VA Bedford Healthcare System, and colleagues from Boston Universities School of Medicine and School of Public Health, Department of Health Law, Policy and Management, UMASS Worcester, and UCLA analyzed Veterans Health Administration (VHA) data to better understand the impact of clinician morale and organizational climate on physical restraint and seclusion use in inpatient psychiatric units.
The study uses data from the All Employee Survey (AES), a survey routinely used by VHA to capture employee perceptions of organizational climate and well-being, and Centers of Medicare and Medicaid Services data on seclusion and restraint hours for VHA facilities in 2014 – 2016. The sampling of AES survey responses was focused to include those with direct inpatient psychiatric patient contact and those who could be involved in issuing seclusion and restraint orders (psychiatrists, registered nurses, or licensed practical nurses).
The AES measures included in the analysis were perceptions of burnout, engagement (sense of connection with one’s work), psychological safety (a sense of comfort with speaking up about issues in one’s workgroup), relational climate (a positive perception of teamwork and conflict resolution), and workload (a perception that one’s workload is reasonable). The CMS data for each VHA facility included the total average number of hours (per 1,000 patient hours) that patients in inpatient psychiatric units were maintained in physical restraints or held in seclusion. Using a Poisson model, restraint and seclusion hours were regressed on measures of clinician morale and workplace climate. The models also included covariates that could potentially have an influence on use of seclusion and restraint, such as average length of stay, patients per unit, and geography.
Findings
On average, facilities had a total of 0.33 restraint hours per month and 0.31 seclusion hours per month, although many sites used neither. The use of physical restraint in an inpatient psychiatric unit was associated with a number of factors. Facilities with higher rates of burnout were significantly more likely to report greater use of physical restraints, while those with greater ratings of psychological safety, relational climate, and employee engagement were significantly more likely to report lower rates of physical restraint use.
A different relationship was observed between seclusion and workplace attitudes. Greater psychological safety and relational climate were significantly associated with increased use of seclusion. There were also strong, but non-significant, relationships between the increased use of seclusion with lower burnout, as well as higher engagement.
Discussion
This study highlights an important relationship between organizational factors in inpatient psychiatric units and the use of coercive measures — particularly, that the use of these measures may be impacted by the clinical work environment. There are a number of explanations for the relationship between higher physician burnout and the use of restraints presented in the paper. For example, clinicians with higher burnout may be less empathetic towards patients engaging in disruptive behavior or may have less perceived or actual ability to deescalate disruptive patients. Conversely, units with higher psychological safety and workplace engagement may be more competent at conflict de-escalation and communicating about appropriate treatment expectations.
Unlike using restraints, staff who reported lower burnout and increased workplace safety also reported more seclusion hours. One possible explanation the authors provided is that staff with low burnout and increased workplace safety may consider the use of seclusion as a safe alternative to using restraints.
The authors note that that these findings may be limited by differences in clinic definitions of seclusion. Another limitation of the study is that there may be potential confounders that impact restraint and seclusion that are unobserved in this dataset. Additionally, because this study does not determine causality, it’s possible that the use of mechanical restraint and seclusion are driving poor clinician morale and organizational climate.
While this study was isolated to the impacts of clinician morale and organizational climate in psychiatric units, there are broader implications for these findings. Coercive measures are used across a variety of medical and social support systems. From similar uses of restraints, such as in police or emergency services settings, to alternative uses of coercive measures, such as restrictive child protection orders, there are many instances where the use of potentially damaging coercive measures could be influenced by workplace environments.
Teasing out all the factors that go into whether or not a psychiatric unit appropriately uses restraints can help health care regulators, administrators, and providers ensure that they are prioritizing patient safety. Focusing resources on organizational climate and morale may be key in interventions aimed at reducing the use of coercive measures.
