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Use of Restraint and Seclusion in Psychiatric Settings

A Literature Review
Obay A. Al-Maraira, PhD, RN; and Ferial A. Hayajneh, PhD

ABSTRACT straints are “any manual strategy or

The purpose of the current literature review was to critically review studies re- physical or mechanical equipment
that immobilizes or reduces the abil-
lated to the use of restraint and seclusion in psychiatric settings across cultures,
ity of [an individual] to move his or
identify ethical principles regarding restraint and seclusion, and generate a her arms, legs, body, or head freely”
clear view about patients’ perspectives and factors that influence use of these (Negroni, 2017, p. 100). Seclusion is
measures worldwide. Use of restraint and seclusion in daily nursing practice is “a control measure that consists of
confining an individual to a location
controversial. Previous studies have shown variation in the types, frequency, and
for a specific period of time and from
duration of restraint and seclusion across different countries and differences in which the person may not leave free-
the perception of restraint and seclusion between nurses and patients. Where- ly” (Goulet, Larue, & Lemieux, 2018,
as some mental health staff members have positive attitudes toward restraint p. 120).
The traditional justification for
and seclusion, others have negative attitudes. The current analysis found that
using restraint and seclusion among
restraint and seclusion should be used as a last resort measure. [Journal of Psy- psychiatric patients is derived from
chosocial Nursing and Mental Health Services, 57(4), 32-39.] paternalism (O’Brien & Golding,
2003). Beauchamp and Childress
(2001) defined paternalism as “the

R
estraint is defined by the U.S. physical) of restricting an individual’s intentional overriding of one person’s
Joint Commission on Accredi- freedom of movement, physical preferences or actions by another per-
tation of Healthcare Organi- activity, or normal access to the body” son, where the person who overrides
zation as “any method (chemical or (Negroni, 2017, p. 100). Physical re- justifies the action by the goal of ben-

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efiting or avoiding harm to the person a clear view about patients’ perspec- and physical restraint was used instead
whose preferences or actions are over- tives and factors that influence use of (Steinert et al., 2010).
ridden” (p. 178). The paternalistic restraint and seclusion worldwide. Reported levels of restraint and se-
view justifies the use of restraint and clusion in the literature vary. Use of
seclusion to protect patients from their METHOD seclusion varied between less than 1%
non-autonomous actions. Sjöstrand A comprehensive literature review of admissions in Norway and Wales
and Helgesson (2008) supported the was conducted using MEDLINE, (Keski-Valkama, 2010) and 15.6% of
paternalistic justification; they stated CINAHL, PsycINFO, and ProQuest admissions in New Zealand (El-Badri
that patients with psychiatric disor- online databases to answer the ques- & Mellsop, 2002). Use of physical
ders are considered incompetent and tion: what is known regarding the use restraint varied between 1.2% of ad-
cannot make independent decisions. of restraint and seclusion in psychiatric missions in the Netherlands (Abma,
Hence, others need to make decisions settings? Keywords used were restraint, Widdershoven, & Lendemeijer,
and intervene for the patient. seclusion, coercive measures, control 2005) and 8% in Germany (Steinert,
Use of restraint and seclusion in measures, culture, perspective, attitudes, Bergbauer, Schmid, & Gebhardt, 2007).
psychiatric settings is a controversial and mental health. Identified literature Furthermore, use of physical restraint
measure, with some arguing that the was discussed based on substantive varied between 2.5% of admissions in
control of patient behavior seems to topical themes regarding restraint and several European countries and 7.5% in
be unethical (Välimäki et al., 2017). seclusion, including reported types, the United Kingdom (Keski-Valkama,
Several countries have begun legisla- frequency, and duration; ethical issues; 2010). Eastern countries seem to fall in
tive efforts to control or reduce use patients’ perspectives and associated the average range in preliminary inter-
of restraint and seclusion in clinical factors; and staff attitudes. Studies national statistics on implementation
psychiatric settings (Gallagher, 2011; related to nursing and other health- of restraint and seclusion. The World
Hughes & Lane, 2016). However, related disciplines and studies reported Health Organization (WHO) in col-
psychiatric literature has reported in English were included. A date range laboration with the Jordanian Ministry
that legislative and policy change is was not used, as the process was ex- of Health (MOH) collected informa-
inadequate in terms of reducing use ploratory. A total of 62 articles were tion on the mental health system in
of restraint and seclusion (Gallagher, included in the review. Jordan to improve the system and pro-
2011). Because of these findings, vide a baseline for monitoring change.
health care providers should be en- RESULTS They reported that 10% of psychiatric
couraged to create or design a treat- Study Description patients admitted to Jordanian MOH
ment culture that emphasizes minimal Identified studies on restraint and hospitals were restrained or secluded at
use of restraint and seclusion measures seclusion were mostly quantitative and least once in the past 1 year (WHO &
when handling aggressive psychiatric descriptive, with only one experimen- Jordanian MOH, 2011).
patients (Keski-Valkama et al., 2010; tal design. Most studies were conducted The mean duration of seclusion was
Marx & Baker, 2017). Use of restraint in acute psychiatric inpatient units in 3 hours in Norway and 294 hours in
and seclusion should be monitored the United States and Europe. the Netherlands. The mean duration
closely and ethical questions regard- of mechanical restraint was 7.9 hours
ing restraint and seclusion should be Reported Types, Frequency, and in Norway and 1,182 hours in the
continuously evaluated (Huckshorn, Duration of Restraint and Seclusion Netherlands (Abma et al., 2005; Keski-
2012). One systematic review revealed The results showed variations in Valkama, 2010).
that limited evidence exists for mental the types, frequency, and duration of
health researchers to decide whether restraint and seclusion across different Ethical Issues Regarding Use of Restraint
use of coercive measures such as re- countries. In the United Kingdom, and Seclusion
straint and seclusion is considered eth- seclusion is rarely used and is substituted Nursing practice has several dimen-
ical, effective, and safe for short-term by physical restraint. Furthermore, sions of care, of which ethical issues
management of aggressive behavior of mechanical restraints are avoided in are an essential part. For health care
psychiatric patients in clinical settings the United Kingdom (Jarrett, Bowers, professionals to arrive at thoughtful
(Nelstrop et al., 2006). & Simpson, 2008). Countries such as and balanced decisions concerning
The purposes of the current litera- Austria, Germany, Japan, and Norway their patients, health care professionals
ture review were to critically review used mechanical restraint more of- should reflect on the ethical aspects of
studies related to the use of restraint ten than seclusion, whereas seclu- the decision, as well as their attitude to-
and seclusion in psychiatric set- sion was used more often in Finland, ward their patients (Goethals, Dierckx
tings across different cultures, iden- the Netherlands, New Zealand, and de Casterlé, & Gastmans, 2012).
tify the ethical principles behind using Switzerland. In Iceland, mechanical Coercive measures are widely used
restraint and seclusion, and generate restraint and seclusion were outlawed among psychiatric health care providers

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 57, NO. 4, 2019 33

as means of preventing suicidal behav- sures. Furthermore, they did not view evoked memories of previous traumatic
iors and helping patients regain control restraint and seclusion as treatment events (Wynn, 2004). Moreover, in
over their psychiatric symptoms. More- options, even in dangerous or emer- one qualitative study, patients noted
over, these measures are used in situ- gency situations (Keski-Valkama et al., that restraint and seclusion during
ations in which a patient’s aggressive 2010). Hence, more evidence is needed treatment boosted their feelings of stig-
behavior threatens the safety of self to support the development of clinical matization, thus increasing recovery
or others (Vieta et al., 2017). Despite alternatives that will reduce the use of time (Robins, Sauvageot, Cusack,
longstanding traditions of using re- restraint and seclusion and improve Suffoletta-Maierle, & Frueh, 2005). In
straint and seclusion in psychiatric care, personalized care plans (Canadian addition, restraint and seclusion caused
use of these measures is a controversial Institute for Health Information, 2011; patients to feel angry, lonely, rejected,
area of practice (Välimäki et al., 2017). Keski-Valkama et al., 2010). and abandoned (Bonner, Lowe,
Rawcliffe, & Wellman, 2002; Gaskin,
Elsom, & Happell, 2007).
Although nurses considered restraint
and seclusion effective techniques to
Although nurses considered restraint and calm patients’ agitation and prevent
harm, patients considered these mea-
seclusion effective techniques to calm patients’ sures to be punishment. Keski-Valkama
agitation and prevent harm, patients considered et al. (2010) discovered that 66.3% of
patients viewed restraint and seclusion
these measures to be punishment. as punitive measures that limited their
autonomy. In addition, Keski-Valkama
et al. (2010) showed that forensic psy-
chiatric patients are more likely to
view seclusion as a punitive measure.
Use of restraint and seclusion to main- Patients’ Perceptions of Restraint and In contrast, one study indicated that
tain patients’ safety may undermine Seclusion some patients viewed restraint and se-
patient autonomy and violate human As previously mentioned, restraint clusion as helpful techniques (Larue et
rights. As a result, use of restraint and and seclusion in psychiatric units are al., 2013).
seclusion has been increasingly chal- used to protect patients from hurting Multiple factors contribute to use
lenged (Hui, 2015). On the contrary, themselves or to protect staff mem- of restraint and seclusion. According
Hui (2015) and Prinsen and Van bers or other patients from being hurt. to Kong and Evans (2012), psychiatric
Delden (2009) argue that respecting Restraint and seclusion have been mental health nurses reported using
autonomy and human dignity are not used worldwide to ensure safety when restraint and seclusion for various
sufficient reasons to reduce or elimi- patient behaviors are difficult to man- reasons, including “being too busy,
nate use of restraint and seclusion. Due age or control (Presley & Robinson, lack of resources, beliefs and con-
to these varying viewpoints, nurses may 2002). Previous research has found that cerns, lack of education, differences
experience difficulty balancing their decreasing use of restraint and seclusion and inconsistencies, and relationship
responsibilities of protecting patients’ results in increasing incidences of as- issues” (p. 176). Furthermore, Knox
rights and preventing harm to patients sault on staff members and other and Holloman (2012) found that
and staff. Coercive interventions such patients (Khadivi, Patel, Atkinson, & use of restraint and seclusion among
as restraint and seclusion are common Levine, 2004). nurses in acute and emergency wards
psychiatric practices that create ethical However, negative outcomes is significantly higher than in chronic
dilemmas for nurses (Keski-Valkama et regarding the use of restraint and se- care wards, as patients who are chroni-
al., 2010). clusion have been found. One study cally ill may develop a rapport with
Keski-Valkama et al. (2010) found reported that restraint and seclusion staff over a period of time.
that policymakers, the public, and that take place in contained environ- In addition, patient characteristics
mental health care providers were con- ments result in delayed development influence use of restraint and seclusion.
cerned about the ethical treatment of of life skills necessary outside of these One patient characteristic that affects
mental health patients and legal de- environments (Donat, 2005). Patients the use of restraint and seclusion is
bates over the use of restraint and se- often view restraint and seclusion migration status. Use of restraint and
clusion. The researchers recommended as bullying and traumatic (Sheline seclusion is related to cultural tradi-
avoiding use of restraint and seclusion & Nelson, 1993; Walsh & Randell, tions, norms, and issues (Knutzen,
as control interventions in routine 1995). In addition, some patients Sandvik, Hauff, Opjordsmoen, & Friis,
care and using them as last-resort mea- reported that restraint and seclusion 2007). One study showed that patients

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who are immigrants have higher inci- tion, patients with low socioeconomic Hutschemaekers (2013) used the
dence of restraint (21.6%) than na- status are more likely to be restrained PATS-Q to determine whether profes-
tive patients (12.9%) (Knutzen et al., or secluded (Khandelwal, Deb, & sionals from four acute admission wards
2007). Another study demonstrated Krishnan, 2015). in an adult mental health institute
that immigrants were less likely to be changed their attitudes toward seclu-
voluntarily admitted due to the higher Staff Members’ Attitudes Toward sion after implementation of a seclu-
likelihood of restraint and seclusion Restraint and Seclusion sion reduction program. Professionals’
(Berg & Johnsen, 2004). Two addi- Restraint and seclusion are associated attitudes toward seclusion were assessed
tional studies conducted in psychiat- with several negative consequences at the start (2004) and end (2008) of
ric emergency care settings indicated for patients and staff members. Due to the program. The main elements of
that patients’ cultural background nurses’ direct role in using restraint and the program included development of
significantly contributed to their like- seclusion, it is important to understand multidisciplinary teams, on-the-job
lihood of being restrained or secluded their attitudes toward restraint and se- training on topics such as risk taxa-
(Telintelo, Kuhlman, & Winget, 1983; clusion to reduce the use of these mea- tion and proactive working, weekly
Zun, 2003). sures (Happell & Harrow, 2010). meetings with an external supervisor,
Moreover, patients’ clinical back- van Doeselaar, Sleegers, and monitoring and feedback for seclusion
ground was found to affect the duration Hutschemaekers (2008) conducted a rates, and participating in national and
of restraint and seclusion (Noda et al., prospective study using the Profession- international conferences. Findings
2013). Patients with brief psychotic al Attitudes Toward Seclusion Ques- indicated that after implementation of
episodes are less likely to have long tionnaire (PATS-Q) with a sample the program, during which professionals
durations of restraint and seclusion of 540 Dutch professionals in mental reflected on ethical questions about the
(Noda et al., 2013). Thus, patients health care who had previously used se- necessity and desirability of the use of
with complicated or prolonged psychi- clusion to determine their attitudes re- seclusion, they were significantly more
atric conditions, such as schizophrenia garding use of seclusion. Results showed knowledgeable about ethical issues
or bipolar disorder, would have longer that professionals’ attitudes fell into and benefits of using alternatives to
durations of restraint and seclusion. three major categories: transformers, seclusion. Results also indicated an in-
Another patient characteristic that maintainers, or doubters. Transformers crease in criticism of seclusion, and an
influences restraint and seclusion is included professionals who had little increased willingness to change their se-
gender. Previous studies have found faith in seclusion, were strongly in favor clusion practices, thus allowing them to
that male patients are more likely to of alternative strategies, and wanted to be categorized as transformers. Findings
be restrained or secluded (Zun, 2003). change seclusion practices. Maintainers indicated that participation in similar
In addition, male patients have signifi- considered safety to be more important training reduction programs may be in-
cantly longer durations of restraint and than their personal beliefs about seclu- fluential on attitudes of mental health
seclusion than female patients (Noda sion, believed alternatives were less workers (Mann-Poll et al., 2013).
et al., 2013). However, one study re- effective than seclusion, and did not However, as individual participants in
vealed that there was no difference believe they needed to reduce seclu- the four wards changed over time due
between male and female patients re- sion rates, despite their ethical objec- to regulatory rotations, it would not
garding the incidence and duration of tions. Unlike transformers and main- have been beneficial for researchers to
restraint and seclusion (Knutzen et al., tainers, doubters comprised individuals analyze attitude changes on individual
2007). who believed that seclusion was valu- levels. Therefore, conclusions were
Furthermore, patient age was a able as an intervention despite ethi- drawn on a group level. According to
significant factor affecting the inci- cal considerations; however, they were Ramadan (2007), there is a need to use
dence and duration of restraint and also interested in alternative options. less restrictive or alternative measures
seclusion. A study conducted by Zun Furthermore, Husum (2011) investi- before using restraint and seclusion.
(2003) showed that most patients gated the attitudes of Norwegian staff These measures may include environ-
who were restrained were between members toward restraint and seclu- mental manipulation and de-escalation
ages 31 and 40, whereas only a few sion and found similar results, includ- techniques. Environmental manipu-
were older adults (Zun, 2003). Anoth- ing staff members who desire and work lation involves minimizing environ-
er study supported this finding, indi- toward reducing use of restraint and se- mental stimuli after assessing patients’
cating that patients ages 18 to 29 were clusion, staff members who do not have triggers. For example, environmental
more vulnerable to restraint and seclu- clear opinions regarding restraint and manipulation may include improving
sion (Knutzen et al., 2007). Moreover, seclusion, and those who oppose alter- patients’ comfort, training staff about
younger patients were more likely to natives to restraint and seclusion. emergency psychiatric care and crises
have longer durations of restraint and An experimental study by Mann- management, and giving respect and
seclusion (Noda et al., 2013). In addi- Poll, Smit, van Doeselaar, and sufficient time to patients.

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 57, NO. 4, 2019 35

 Happell et al. (2012) investigated Results also indicated that nursing and seclusion (Nijman, Palmstierna,
the relationship between attitudes staff members with less education and Almvik, & Stolker, 2005). However,
toward seclusion and levels of burn- experience should be targeted for future these findings from the Netherlands
out, staff satisfaction, and therapeu- educational programs on alternatives to might be at least partly explained by
tic optimism. The sample comprised restraint and seclusion. its negative attitude toward chemi-
54 staff members recruited using conve- cal restraint. On the contrary, in the
nience sampling from one adult health DISCUSSION United Kingdom, mechanical restraint
service inpatient unit. Findings indi- In the review process, the current in prohibited and seclusion is rarely
cated that nurses played a large role in authors found numerous limitations to used. It has been found that involun-
deciding whether to seclude patients; definitions of seclusion and restraint. tary chemical restraint is more likely to
72% of participants indicated that the In particular, there was discrepancy be used in the United Kingdom than in
decision to seclude a patient was made in the definition of types of restraint, other European countries (Jarrett et al.,
by a nurse. Only 6% of participants with physical and mechanical re- 2008). All other European countries, as
reported that seclusion should never be straint often used inconsistently and well as the United States, fall between
used. Happell et al. (2012) found that interchangeably. Most studies did not these two extremes, with most using
nurses experienced feelings of satisfac- specify or define which type of restraint mechanical restraint (Steinert et al.,
tion when a patient was punished by and seclusion they had targeted, and 2010).
seclusion. However, in cases in which numerous studies combined different The current review indicates that
individuals asked to use the seclusion types of restraint and seclusion in out- the literature lacks studies on the types
room, nurses did not perceive seclusion come reporting, making it difficult to and duration of restraint and seclusion
as an accomplishment, as it was not compare and amalgamate findings. used in Arabic countries, which repre-
their decision, indicating that nurses’ The current study indicated that sent a different culture than those of
attempts to create a therapeutic envi- preferences, frequency, and duration of Western countries. Only one published
ronment were unsuccessful. Further- restraint and seclusion varied among Jordanian report (WHO & Jordanian
more, when staff members were asked countries studied. These differences MOH, 2011) stated that the level of
about when seclusion should be used, may reflect the different cultural beliefs restraint and seclusion use in Jordan
they provided various responses, raising and values within which a psychiatric was parallel to levels found in studies in
doubts about whether seclusion is used system is situated (Bowers et al., 2007). New Zealand and Germany (El-Badri
only as a last resort. However, results In other words, there is a discrepancy in & Mellsop, 2002; Steinert et al., 2007).
of this study cannot be generalized, as the literature between those who agree Based on findings of the current re-
the sample was a convenience sample and disagree with the use of restraint view, feelings of abandonment, anger,
recruited from only one unit. and seclusion (Dean, Duke, George, loneliness, and rejection, as well as
In Kuwait, Elgamal (2006) & Scott, 2007). Therefore, the use of perceptions of restraint and seclusion
conducted a study to explore the these practices in nursing is controver- as punishment, are all common patient
effect of gender, educational level, and sial. Individuals supporting use of re- perspectives regarding use of restraint
years of experience on the attitudes of straint and seclusion do so to maintain and seclusion. However, nurses per-
62 nurses toward restraint. This study the safety of patients and others (Vieta ceive restraint and seclusion as effec-
is significant as it reflects attitudes et al., 2017). However, restrained or tive ways to control patient aggression
of nurses within Arabic and Islamic secluded patients might be exposed to and prevent harm, demonstrating that
cultures. Data analysis revealed that injuries, disabilities, and even death. nurses and patients perceive restraint
nurses displayed aggressive attitudes Thus, use of restraint and seclusion and seclusion differently. Consider-
and admitted that force is typical on might be associated with legal and ethi- ing the varying perspectives of nurses
the unit. Use of continuous restraint is cal dilemmas (Abdeljawad & Mrayyan, and patients, negative perception of
more frequent among male nurses and 2016). For example, involuntary chem- restraint and seclusion among pa-
nurses working on male wards. Regard- ical restraint in Dutch mental health tients is likely to be a result of nurses’
ing level of education, nurses with less settings is considered more invasive practices. One possible cause is lack of
education or less experience preferred and a more serious violation of pa- therapeutic communication between
to use restraint and were more likely to tients’ integrity than use of other types nurses and patients. The literature
display aggressive attitudes. In contrast, of restraint and seclusion (Steinert & indicates that negative feelings of pa-
nurses with higher levels of education Lepping, 2009). Consequently, the tients are a result of absence of proper
or more experience were significantly international literature indicated that interaction with nurses before, dur-
more likely to report conservative atti- the Netherlands appears to have the ing, and after the use of restraint and
tudes toward constraint, preferred short highest rate of inpatient violence in seclusion (Keski-Valkama et al., 2010;
restraint times, and disagreed with the Europe, as well as a relatively high Nijman et al., 2005). Many studies re-
use of restraint for hyperactive patients. incidence of mechanical restraint port that patients did not receive infor-

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mation regarding restraint and seclu- experience (Lavik, Hauff, Skrondal, & assessment of the risk of disturbed be-
sion; thus, they did not understand why Solberg, 1996). Therefore, nurses may haviors, and adequate alternative mea-
they were restrained or secluded, which interpret symptoms following such ex- sures are essential factors for enhancing
led to them perceiving these measures periences (e.g., fear, agitation, pacing, staff attitudes toward reducing use of
as punishment (Donat, 2005; Holmes, aggression) as harmful and requiring restraint and seclusion. The findings of
Kennedy, & Perron, 2004; Meehan, use of restraint and seclusion. In ad- these studies are encouraging in terms
Bergen, & Fjeldsoe, 2004; Mohr, Petti, dition, immigrants are more likely to of reducing restraint and seclusion, as
& Mohr, 2003). In addition, patients develop posttraumatic stress disorder well as the effectiveness of alternative
conveyed that their basic needs (e.g., (PTSD) due to the distressing events measures.
eating, drinking, excretion, security) they experienced. One clinical study
were ignored and not met during use confirmed that patients with PTSD are LIMITATIONS
of restraint and seclusion (Holmes et more susceptible to stress factors that The current results are preliminary.
al., 2004; Okanli, Yilmaz, & Kavak, initiate agitation and consequently Definitions of restraint and seclusion
2016). A study conducted in a psychi- aggressive behaviors (Hummelvoll & are different across studies; however,
atric hospital in Turkey revealed that Severinsson, 2001). standard definitions have recently been
training for patients on skills to man- It is important to note that refugee recognized by consensus and could
age challenges related to mental illness psychiatric patients are individuals be used in future studies (Steinert &
decreases the incidence and duration of with different and special needs com- Lepping, 2009). For example, data on
restraint and seclusion among 23.9% pared to native psychiatric patients. the use of mechanical restraint in some
of patients and improves the recovery For better care and maximum benefits, studies include an unknown proportion
process (Donat, 2005). nurses must carefully examine the of physical restraint.
Thus, to decrease the gap in percep- needs and problems of this population.
tions of restraint and seclusion between In addition, nurses should be aware of CONCLUSION
nurses and patients, nurses should the effects of forced migration on refu- Much research has been conducted
increase proper therapeutic interaction gee psychiatric patients; this awareness to investigate the use of restraint and
with patients before, during, and after may help nurses identify aggressive be- seclusion among mental health staff
use of restraint and seclusion. Before havior due to these experiences and members. Use of restraint and seclusion
use of these measures, nurses should ex- decide on an appropriate treatment is a controversial measure in psychiatric
plain the procedure and why it is nec- technique. Moreover, nurses’ aware- settings. However, psychiatric pa-
essary. This explanation may decrease ness about issues facing refugee psy- tients have the right to be cared for in
patients’ uncertainty regarding the rea- chiatric patients outside clinical areas a respectful, safe, and non-restrictive
sons for restraint and seclusion. Dur- is vital to ensure that these patients environment. Mental health profession-
ing restraint and seclusion, interaction feel understood. Involving patients als may differ on ethical issues related to
should include regular checkups for pa- and their families in the treatment and use of restraint and seclusion, yet all seek
tients’ basic needs. These checkups will decision-making processes leads to to maximize benefits and minimize risks
help avoid malpractice and prevent best results. Thus, nurses working with to their patients (Dean et al., 2007).
further harm. After restraint and seclu- such patients need more patience, bet- One argument in favor of restraint and
sion, interaction should include train- ter communication skills, and the abil- seclusion is that these measures are
ing regarding daily life skills, which ity to build therapeutic relationships needed to ensure a safe environment.
may promote recovery and prevent fu- with these patients. The literature revealed that although
ture use of restraint and seclusion. Previous research on nurses’ at- safety must be a driving concern, a pa-
Another cultural issue that should titudes toward restraint and seclu- tient’s autonomy and rights might be
be considered is patients’ migration sion indicated that although nurses violated when using restraint and seclu-
status. Previous studies have revealed have negative feelings toward use of sion (Hui, 2015). Thus, use of restraint
that immigrants are more likely to be such measures, they believe they are and seclusion may be considered un-
restrained or secluded (Knutzen et al., necessary (Möhler & Meyer, 2014). ethical, as alternative measures exist.
2007; Zun, 2003). This could be due However, lack of knowledge or un- However, empirical research indicates
to differences in ethical beliefs, race, derstanding of alternatives to restraint that preferences regarding restraint and
ethnicity, and language barriers be- and seclusion among nurses has been seclusion and frequency and duration of
tween nurses and patients (Knutzen identified as a barrier to reducing or restraint and seclusion vary significantly
et al., 2007). These differences could eliminating their use (De Bellis et al., across cultures.
increase communication problems 2013). Based on scientific evidence,
and decrease trust between nurses and researchers (Mann-Poll et al., 2013; REFERENCES
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JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 57, NO. 4, 2019 37

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Patients’ perspectives on and nurses’ atti- literature review and survey of international is Professor, Adult Nursing, School of Nursing,
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with prevention in the healthcare arena. psychiatric emergency room. Hospital & College, Al Rahmaniyah District, Jeddah 23643,
Nursing Clinics of North America, 37, 161- Community Psychiatry, 34, 164-165. Saudi Arabia; e-mail: [email protected].
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