Influence of Organizational Climate and Clinician Morale on Seclusion and Physical Restraint Use in Inpatient Psychiatric Units

Abstract

Reducing seclusion and restraint use is a prominent focus of efforts to improve patient safety in inpatient psychiatry. This study examined the poorly understood relationship between seclusion and restraint rates and organizational climate and clinician morale in inpatient psychiatric units.Methods: Facility-level data on hours of seclusion and physical restraint use in 111 U.S. Department of Veterans Affairs (VA) hospitals in 2014 to 2016 were obtained from the Centers for Medicare & Medicaid Services. Responses to an annual census survey were identified for 6646 VA inpatient psychiatry clinicians for the same period. We examined bivariate correlations and used a Poisson model to regress hours of seclusion and restraint use on morale and climate measures and calculated incident rate ratios (IRRs). Results:The average physical restraint hours per 1000 patient hours was 0.33 (SD, 1.27; median, 0.05). The average seclusion hours was 0.31 (SD, 0.84; median, 0.00). Physical restraint use was positively associated with burnout (IRR, 1.76; P = 0.04) and negatively associated with engagement (IRR, 0.22; P = 0.01), psychological safety (IRR, 0.48; P < 0.01), and relational climate (IRR, 0.69; P = 0.04). Seclusion was positively associated with relational climate (IRR, 1.69; P = 0.03) and psychological safety (IRR, 2.12; P = 0.03). Seclusion use was also nonsignificantly associated with lower burnout and higher engagement. Conclusions:We found significant associations between organizational climate, clinician morale, and use of physical restraints and seclusion in VA inpatient psychiatric units. Health care organization leadership may want to consider implementing a broader range of initiatives that focus on improving organizational climate and clinician morale as one way to improve patient safety.

The experiences of nurses following seclusion or restraint use and immediate staff debriefing in inpatient mental health settings

“…While nurses in our study found ways to learn from or cope with their emotions following stressful S/R events, it is also worth noting the link between nurses' level of stress and the use of S/R. In a recent study by Anderson et al (2021), the authors found that inpatient psychiatric settings with greater staff burnout had a higher incidence of physical restraint use. They proposed that clinicians with higher burnout have a lower threshold for restricting a patient's freedom of movement in response to violent or disruptive behaviour (Anderson et al, 2021).…”

“…In a recent study by Anderson et al (2021), the authors found that inpatient psychiatric settings with greater staff burnout had a higher incidence of physical restraint use. They proposed that clinicians with higher burnout have a lower threshold for restricting a patient's freedom of movement in response to violent or disruptive behaviour (Anderson et al, 2021). Indeed, burnout among mental healthcare providers has been tied to less empathic and more dehumanizing attitudes towards patients who are deemed as 'difficult' or 'challenging' (Bowers et al, 2010;Pereira-Lima & Loureiro, 2015).…”

Physical Restraint Usage in Hospitals Across the United States: 2011-2019

“… 25 , 26 The regional variation may be because of more closely connected hospital organizational cultures, similar staffing patterns, regional laws, and inconsistent adoption of evidence-based practices at large health systems in the western United States. 27 , 28 Future studies should investigate how regional characteristics, such as access to mental health services and local practices, impact the use of restraints.…”

Psychological Safety and Patient Safety: a systematic and narrative review

“…Addressing the abovementioned conflicts resulted in the final inclusion of nine articles for review. [32][33][34][35][36][37][38][39][40]…”

“…Of the nine studies, only five studies indicated a significant association between psychological safety and patient safety. 35,36,37,39,40 However, all five studies need further qualification to fully appreciate the complexity in linking psychological safety and patient safety. Anderson et al, 36 in a sample of US Veteran Affairs inpatient psychiatry clinicians, found that units with lower psychological safety reported a greater use of restraints with patients, but also found that units with higher psychological safety utilized seclusion more.…”