Transcript DSQ PowerPoint presentation in blue
Myths and Assumptions about Seclusion and Confinement in Disability Services Jeffrey Chan, PhD Chief Practitioner Disability and Director of Forensic Disability Queensland Advocacy Inc. Seclusion and Solitary Confinement 27 July 2011, Banco Court, Brisbane
Myth and Assumption – Restraint and seclusion keep people we serve safe
• • •
142 deaths found from 1988 to 1998, reported by the Hartford Courant 50 to 150 deaths occur nationally each year due to seclusion and restraints estimated by the Harvard Center for Risk Analysis (NAMI, 2003) At least 14 people died and at least one has become permanently comatose while being subjected to S/R from July 1999 to March 2002 in one state alone (Mildred, 2002)
What do people with disabilities feel when they were subject to restrictive practices?
• They do not feel safe • They recount their trauma and negative experience • They feel violated and go through cycle of psychological distress • They feel practices are unethical • They feel helpless, hopeless and “spirit broken” • They view their behaviours are in response to an offending or maladaptive environment • • Ramcharan et al. (2009) Strout (2010)
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Myth and Assumption – Restraint and seclusion keep staff safe For every 100 mental health aides, 26 injuries were reported in a three-state survey done in 1996
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The injury rate was higher than what was found among workers in:
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Lumber Construction Mining industries (Weiss et al., 1998)
Myth and Assumption – Restraint and seclusion are used when absolutely necessary, not punitive and for safety reasons
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Andrew McClain
was 11 years old and weighed 96 pounds when two aides at Elmcrest Psychiatric Hospital sat on his back and crushed him to death. •
Andrew’s offense?
• Refusing to move to another breakfast table.
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Myth and Assumption – Restraint and seclusion are used when absolutely necessary, not punitive and for safety reasons Edith Campos
, 15, suffocated while being held face-down after resisting an aide at the Desert Hills Center for Youth and Families.
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Edith’s offense?
• Refusing to hand over an “unauthorized” personal item. The item was a family photograph.
(
Lieberman, Dodd, & De Lauro,
1999)
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Myth and Assumption – Restraint and seclusion are used when absolutely necessary, not punitive and for safety reasons Ray, Myers, and Rappaport (1996) reviewed 1,040 surveys received from individuals following their New York State hospitalization
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Of the 560 who had been restrained or secluded:
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73% stated that at the time they were not dangerous to themselves or others
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¾ of these individuals were told their behavior was inappropriate (not dangerous)
Myth and Assumption – Restraint and seclusion are used when absolutely necessary, not punitive and for safety reasons
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Analysis of six studies reported 58 – 75% conceptualized seclusion as punishment by staff
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Many persons-served believed:
Seclusion was used because they refused to take medication or participate in treatment program
Frequently, they did not know the reason for seclusion
Assumption: Staff know how to identify potentially difficult situations
• • • •
Holzworth & Willis (1999) conducted research on nurses’ decisions based on clinical cues of patient agitation, self harm, inclinations to assault others, and destruction of property Nurses agreed only 22% of the time When data was analyzed for agreement due to chance alone, agreement was reduced to 8% Nurses with the least clinical experience (less than 3 years) made the most restrictive recommendations (Holzworth & Willis, 1999)
Assumption: Staff know how to de-escalate potentially difficult or violent situations
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In a study conducted by Petti et al. (2001) of content from 81 debriefings following the use of seclusion or restraint, staff responses to what could have prevented the use of S/R included:
36% blamed the patient
Example:
“He could have listened and followed instructions”
15% took responsibility
Example:
“I wish I could have identified his early escalation”
Assumption: Staff know how to de-escalate potentially difficult or violent situations
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Other responses included:
15% provided no response
12% were at a loss
Example:
“I don’t see anything else…all alternatives used.”
11% blamed the system
Example:
change” “Need to make a plan for shift
9% blamed the level of medication (Petti et al, 2001)
The dollars of restraint and seclusion: Organisational cost
• Flood, Bowers & Parkin (2008) – study on conflict and containment using an interview schedule with key staff and event data from 136 wards and costs from 15 wards.
– Cost of a single episode of physical restraint = $240.24 and seclusion = $330.88
– 50% of all UK nursing resources were expended to manage conflict and implement containment procedures
The dollars of restraint and seclusion: Organisational cost
• US restraint use of an adolescent inpatient service claimed (Lebel, 2011) – – > 23% of staff time – > $1.4M in staff related costs – 40% of operating budget • Medication – 26 - 11.07 hrs staff time - $287 per event • Physical – 25 – 11.57 hrs staff time - $302 per event • Mechanical – 25 – 11.90 hrs staff time - $309 per event • Combination – 29 – 13.40 hrs staff time - $355 per event
Grafton Inc., Virginia – Four year data reveal
• • • • • • • •
41.2% reduction in client-related staff injuries 10% reduction in staff turn-over and estimates annual savings of $500K 94% reduction in employee lost time and lost time expenses 50% reduction in workers’ compensation claims 21% reduction in liability premiums Cumulative savings in excess of $1.2M
$483K cumulative workers compensation costs savings Increased staff satisfaction and staff perception of greater safety
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Other evidence
John Hopkins Hospital – 75% reduction in restraints and seclusion with no increase in staff or consumer injuries
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Florida State Hospital length of stay costs – 54% restraint reduction and realised nearly $2.9M in cost savings from reduced workers compensation, staff and consumer related injuries, and
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Forster et al (1999) – staff training decreases use of seclusion and restraint in an acute psychiatric hospital resulted in 13.8% reduction in annual restraint rates, 54.6% decrease in average duration of restraint per admission and 18.8% in reduction in staff injuries
Mindfulness – Singh et al
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Adult offenders with intellectual disability benefits), reduction in physical.
– Singh et al (2008): Reduction in lost work hours to $2244 from $53K 12 months prior. (Note: further unpublished studies note significant reduction in overall organisational cost
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Other studies by Singh et al showed reduction in restraints and seclusion, increase in staff well-being, increase in staff satisfaction and happiness, and safety. Improvement in client well-being.
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See also studies on parents of children with autism.
Lebel & Golstein (2005) – restraint reduction strategy
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Benefits for the person –
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Decreased injuries, length of stay and readmissions Significantly increased functioning at discharge
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Benefits for staff and facilities –
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Decreased injuries, sick time, replacement staff Decreased staff turnover, hiring costs, workers compensation (medical claims and compensation)
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Increase in cost savings and redeployed staff
Characteristics of success in safe elimination strategies
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Leadership with clear goals in policy direction and implementation driven by compassion and human rights Systematic collection and analysis of the evidence (e.g. episodes of incidents and restrictive interventions, OHS data, support plans data, processes etc) Translating evidence into organisational practice and learning – preventative environmental and support strategies, communication strategy etc Quality support plans and monitoring of implementation Practice leadership in supporting and training staff Implementation of a range of protective supports (e.g. debriefing, staff training and support, staff well being/mindfulness etc)
Myths
• Need more $$ • More staff or new staff • Micromanage • State of the art environment • Control and limitation • No data or strict use of data
Facts (Lebel, 2011)
Flexible use of resources Core staff, OPEN to change Pragmatic teaching, mentoring Flexible and creative use of space Collaborate and negotiate Data drives practice and meaningful
Andy Pond, LICSW President & CEO of Justice Resource Institute
“Restraint and seclusion are costly in all kinds of ways – they are just plain costly. Whatever new costs we had were minimal.
Most of the training
we put in place to reduce restraint and seclusion
were really good clinical practice and what we should be doing anyway
.”