Seclusion & restraint: a historical perspective

(1) The use of restraints in the care of psychiatric patients has been a topic of ethical controversy since the beginning of psychiatric medicine. (2) Enlightenment physicians regarded psychiatric illness as the loss of reason, and many advocated the use of restraints to help violent patients regain the use of reason. (3) John Conolly, a British alienist (a term used for psychiatrists) of the mid 1800s, claimed it was possible to treat psychiatric patients without the use of mechanical restraints, but he made liberal use of seclusion and physical restraint by attendants to manage violent behavior. (4) American alienists expressed misgivings about the use of mechanical and chemical restraint but most were reluctant to relinquish any usable intervention.     

Seclusion & restraint. Understanding recent changes

1. Seclusion and restraint must be a last resort, emergency response to a crisis situation that appears to present imminent risk of harm to the patient, staff, or others. 2. JCAHO-accredited hospitals billing for Medicare or Medicaid must meet HCFA requirements to maintain compliance. 3. Policy writers and administrators must carefully scrutinize all applicable regulatory standards to ensure all requirements are met.     

Disabling Africa: the power of depiction and the benefits of discomfort

Despite the fact that the vast majority of disabled people live in low and middle-income countries, the field of disability studies is dominated by research on disability in wealthy contexts. Although there are encouraging signs of this pattern changing, there are challenges to researchers about how to represent and think about disability in African contexts, and it is difficult not to reproduce unhelpful stereotypes. We use the example of an encounter we had with an expatriate Deaf South African to reflect on the complexities of representation facing people working on disability issues in Africa and what has been termed the Global South. We suggest that an appreciation of the productive value of discomfort about issues of representation may help move the field forward.     

Patient Abuse and Trauma: A Policy Analysis of the Regulation of Seclusion and Restraint in Mental Health Care

Historically, justifications for the seclusion and physical restraint of hospital patients have stereotyped individuals with mental illness as “dangerous” to themselves and others (Huckshorn, 2004a). It can be argued, however, that it is the policies that regulate the use of seclusion and physical and chemical restraints that are dangerous. This article analyzes the Patients’ Rights section of the Hospital Conditions of Participation (CoPs), Part 482 of CFR 42, including sub-sections: e. Standard: Restraint or seclusion; f. Standard: Restraint or seclusion: Staff training requirements; and g. Standard: Death reporting requirements. The set of CoPs regarding Patients’ Rights are analyzed from a value-critical, process-oriented perspective. This article proposes the following six-point framework as uniquely suited to evaluating 42 CFR 428.13: 1) introduction to the background and historical significance of the problem; 2) evaluation of the clarity and measurability of the goals and objectives of the policy; 3) overview of the intended impact of the policy; 4) examination of the value criteria; 5) examination of existing power struggles for those impacted by the policy; and 6) examination of the actual impact of the policy. Results of the policy analysis suggest that the policy does not go far enough to reach its stated goals and objectives in full. In the conclusions, suggestions for further protection of patients’ rights are provided. Examples of alternatives to restraint and seclusion are discussed. Finally, the grave importance of reshaping the culture of mental health care, in terms of life-and-death consequences, is considered.     

Work-related musculoskeletal discomfort and injuries in Australian optometrists

Work-related musculoskeletal discomfort and injuries are reported by optometrists. The purpose of this paper is to describe the process used to investigate work-related discomfort in Australian optometrists. A multistage project was conducted which included questionnaires, interviews and onsite observations. Participants, with and without self-reported discomfort, included clinical optometrists, optometry students and clinical teachers. The various stages of the study developed over the course of the project, primarily in response to results collected at various stages. A multistage approach proved valuable for confirming results and testing hypotheses, and for investigating different groups of workers (clinicians, teachers and students). General guidelines to reduce the risk of work-related discomfort in optometrists can be developed from this project. Specific recommendations and teaching curricula have been identified in this project as areas of future research and development.     

Perceptions of physical restraint use and barriers to restraint reduction in a long-term care facility

The use of restraints in nursing homes has been curtailed in the United States since the passage of the 1987 federal legislation regulating restraint practices. This study used focus groups with administrators and nursing staff in a skilled nursing facility to examine their views of restraints and perceptions of conditions in the nursing home environment that affect restraint use. Although respondents lacked a shared definition of a "restraint," they did identify contextual factors that in combination with resident characteristics produced situations in which restraint use was justified. Implications of these findings for staff education on restraint reduction are discussed.     

Pedagogies of discomfort and empathy in multicultural teacher education

To show the potential and limitations of pedagogies of discomfort and empathy in anti-racist and multicultural teacher education, this paper engages in an in-depth analysis of two ‘critical moments’ that are drawn from a series of teacher workshops. The purpose of the analysis is to show how discomfort and empathy may be combined together pedagogically in the context of multicultural and antiracist teacher education. The contribution to the literature is to highlight the importance of foregrounding attention to teachers’ discomfort and its pedagogical implications in multicultural teacher education.     

Staff resistance to restraint reduction: identifying & overcoming barriers

Professional organizations, regulating agencies, and hospital administrators have taken a strong stance on restraint reduction policies. When implementing a restraint reduction initiative, it is important to identify the barriers to restraint reduction, such as concern for personal safety, lack of knowledge about and practice using alternate de-escalation skills, and fear of disrupting the therapeutic milieu by using a variety of de-escalation methods. Education aimed to reduce the use of restraints needs to do more than simply provide information. It is important to acknowledge the emotional response of the nursing staff and the culture of the current practice. A variety of educational strategies, including role-playing, and case studies will help identify attitudes, beliefs, and behaviors that are congruent with reducing the use of restraints. If the ultimate goal of restraint reduction is philosophical change, it will eventually lead to a new culture of practice.     

Stress and musculoskeletal discomfort among hydrocarbon industry workers in Mexico

This study of 114 workers in the hydrocarbon industry was conducted to identify the relationship between stress and musculoskeletal discomfort, and to view the roles played by such factors as age, schooling, obesity, workplace and job seniority. All factors except seniority were found to affect the presence of musculoskeletal discomfort in some area of the body.     

New enhancements and validation of force based posture and discomfort predictions

Many digital human models provide the crucial method to calculate postures in virtual environments. Traditionally these methods refer to experiments and make use of statistical modeling. They provide sufficient results in their specialized domain, but cannot be used in general applications. In addition they do not consider important design aspects as forces and discomfort. Hence a new force based approach has been introduced in order to overcome these shortcomings. Based on biomechanical models of active maximal and passive receding joint torques, a mechanical optimization generates static stable postures and related discomfort ratings. The results were promising, but showed some model deficiencies and were not validated in detail. The present paper continues this work and provides necessary model enhancements. Finally the new prediction models are validated on real experiments. The validation results are presented and discussed regarding to usability aspects and future development work.     

The intersection of youth masculinities,decreasing homophobia and class: an ethnography

This article examines the emergence of progressive attitudes toward homosexuality among working‐class boys in a sixth form in the south of England to develop an intersectional analysis of class, youth masculinities and decreasing homophobia. Drawing on three months of ethnographic data collection, I find that working‐class male youth intellectualize pro‐gay attitudes and that homophobic language is almost entirely absent from the setting. I document the presence of homosocial tactility, as well as the valuing of friendship and emotional closeness. However, these behaviours are less pronounced than documented among middle‐class boys, and I use these findings to advance understanding of how class influences the development of inclusive attitudes and behaviours. Inclusive masculinity theory is used to understand these findings, refining the theory and extending it to a new demographic.     

Condom discomfort and associated problems with their use among university students

In addition to consistent use, condoms must be used correctly. The purpose of this study was to identify prevalence and types of condom-associated discomfort among university students, the outcomes of this discomfort, and the role of discomfort in condom breakage. We conducted a cross-sectional study of 206 students attending a private university in the southern United States. We assessed 3 potential outcomes: breakage, not using condoms throughout sex, and low condom-use motivation. Nearly one third reported discomfort, including tightly fitting condoms, vaginal irritation, and loss of sensation. Discomfort was associated with breakage (p = .0001), incomplete use (p = .0001), and less motivation to use condoms (p = .018). Gender moderated the latter 2 findings. Adjusted findings indicate that students reporting discomfort were 3.6 times more likely to also report breakage (p = .0009). Continued investigation of this topic is warranted. Prevention education may benefit university students by promoting several key practices, such as adding lubricant to condoms before they dry out and acquiring condoms that fit properly.