Practice Experience: Quality Improvement Storyboard

I realized I had no references attached, also I still used FOCUS as my Quality Improvement Model but changed my steps to the following if allowed

Steps to decrease the excessive or unnecessary use of restraints/seclusion in mental and behavioral health hospital

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F-find a process that needs improvement. Define the beginning and end of the process, and determine who will benefit from the improvement

The process that needs improvement is the excessive or unnecessary use of restraints/seclusion in mental and behavioral health hospital. Coercive measures such as excessive restraints and seclusion are employed to limit the freedom of movement among psychiatry patients, usually to contain aggressive behaviors.  Seclusion and restraint are being often used a scrisis intervention techniques in mental health facilities especially when patients are aggressive and violent. However, these coercive raises ethics and legal concerns as they cause harm to patients which is tantamount to the abuse of human rights.

O-organize a team of people knowledgeable about the process, this team should include employees from various levels of the organization. This knowledgeable people to be involved in solving the problem are the health workers (doctors, nurses and support staff) and other stakeholders such as the management and board of the hospital.

C- clarify the current process of using excessive or unnecessary restraints/seclusion in the mental and behavioral health hospitaland the changes that are needed to make improvements. The effects of using excessive restraints and seclusion include:

  • Occurrence of pain and deep vein thrombosis caused by restraint
  • Incidence of post traumatic stress disorder
  • Psychological trauma
  • Hallucinations may occur during seclusion
  • Restraints and seclusion may cause agitation, self-harm, suicide attempt or self-harm, fracture, or death.

U-understand the causes of variation by measuring performance at various steps in the process

There are different kinds of physical restraint that are used on mental health patients. The restraints could be either mechanical such as devices are used to immobilize patients or manual restraints when the patient is held down by hospital staff. Seclusion is the confinement of a patient in a locked room from which the patient cannot make an exit on his/her own. These measures are used to curtail aggressive behaviour in mental health patients

S- select actions needed to improve the change process such as:

  1. Use of Data to promote evidence-based practice—Collection of accurate data is used to assess the scope of the issue, and the harmful effects of excessive restraint and seclusion.
  2. Nursing interventions – Nursing staff should always be available for regular conv
  3. Workforce training and development—Ensure that staff members receive training and continuous mentoring on prevention and intervention skills that avoid the use of physical struggles with patients that may lead to excessive restraint.ersations with the patients to calm down the patients and reduce the incidents of aggression.
  4. Effective leadership—Leaders should promote the use of alternatives to seclusion and restraint, develop clearly articulated plan, take an active lead role in the process of reducing the use of seclusion and restraint and hold staff members accountable as well.
  5. Use of preventive measures—Staff should assess the risk for violence among patients, identify the medical risk factors and past traumatic histories of patients, and develop safety plans in collaboration with the patient and family/caregivers. A creative and serene environment such calming rooms may be used to prevent violent behavior and de-escalate aggressive behavior.
  6. Increased support and advocacy for patients-This implies the promotion of advocacy for inpatients in mental health hospitals. This should involve youths, family members/caregivers of patients, and advocates in a variety of settings to curb the use of excessive restraint and seclusion.
  7. Multi-professional collaborative care involving patients – Collaborative care that involve physicians, nurses, and the patients about their medications, drug dosage, challenges in the ward, and the established criteria for restraint and seclusion will encourage the patient to participate in the treatment process and be less aggressive.
  8. Debriefing measures—There should be continuous debriefing to inform policy, procedures, and practices that reduce the use of restraint and seclusion as well as addressing the adverse effects of the excessive restraint and seclusion.



Chieze M., Hurst, S., Kaiser S., & Sentissi O. (2019). Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review. Frontiers in psychiatry10, 491.

Gowda G., Lepping P., Noorthoorn E. et. al (2018) Restraint prevalence and perceived coercion among psychiatric inpatients from South India: A prospective study. Asian J Psychiatr. 2018;36:10-6.

Raveesh B., Gowda G., & Gowda M. (2019). Alternatives to use of restraint: A path toward humanistic care. Indian journal of psychiatry61(Suppl 4), S693-S697.

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