Transcript Restraint and Seclusion Reduction and Elimination

Creating Violence-Free
Mental Health Settings:
Changing our Cultures of Care
Hogg Foundation for
Mental Health
Teleconference
Tuesday, April 4, 2006
Kevin Ann Huckshorn RN, MSN, CAP
National Technical Assistance Center NASMHPD
Outline
The Development of a Curriculum to
Reduce S/R Use in MH and other Settings
Identification of Key Constructs
Six Core Strategies for S/R Reduction©
Developing a S/R Reduction Plan
Training Activities and Next Steps
Closing Comments
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Development of a Curriculum to
Reduce the Use of S/R
NASMHPD Bias/Values:
We hold that all use of S/R should be
restricted to situations of imminent
danger and that the majority of our
efforts need to be focused on preventing
the need to use coercive interventions.
We also hold that while we are reducing
use it is of extreme importance to use
S/R as safely and briefly as possible
(NETI, 2003-05)
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NASMHPD Training Definitions
(2003 to present)
Restraint:
“A manual method or mechanical
device, material or equipment attached
or adjacent to a person’s body that is
not easily removed and that restricts the
person’s freedom or normal access to
one’s body” (HCFA Interim Rules, 1999)
NOTE: Suggest that child facilities separate
out manual holds from mechanical restraint
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NASMHPD Training Definitions
(2003 to present)
Seclusion:
“The involuntary confinement of a
person in a room where they are
physically prevented from leaving or
believe they are”
(NETI, 2005)
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Development of a Curriculum to
Reduce the Use of S/R
Extensive Review of Literature - 2001 to
present
Qualitative Reports emerging from
personal experiences (self and colleagues)
with direct experiences in successful
reduction projects across the country
Core strategies emerged in themes over
time
Expert Meeting(s) held in DC in 2001,
2002, 2003 to refine.
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Key National Activities Supporting
Ongoing Efforts
IOM describes new rules to transition the
redesign and improvement in care (IOM, 2001, 05)
Continuous healing relationships
Customized to individual needs/values
Consumer is source of control
Free flow of information/transparency
Reducing risk to ensure safety
Anticipation of needs
Use of Best Practices
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Key National Activities-MH Specific
The New Freedom Commission
A Call for System Transformation
System Goal=Recovery for everyone
Services/supports are customer/family
centered
Focus of care must increase service user’s
ability self manage illness and build
resiliency
Individualized Plans of Care critical
Consumers and Families are full partners
(NF Commission, 2003)
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The Identification of Core
Constructs to Guide Project
Public Health Prevention approach
Recovery/Resiliency Principles
Important Role of Leadership
Consumer and Staff Self Reports
Valued
Trauma Knowledge utilized
Framework of CQI
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The Public Health Prevention Model
The Public Health approach is a model of
disease prevention and health promotion
and is a logical fit with a practice issue
such as S/R reduction
This approach I.D.’s contributing factors
and creates remedies to prevent, minimize
and/or mitigate the problem if it occurs
It reconciles our focus on “safer use” to
preventing use in the first place
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The Public Health Prevention Model
Primary Prevention (Universal Precautions)
Interventions designed to prevent
conflict in the environment by
anticipating risk factors
Secondary Prevention (Selective
Strategies)
Early interventions to immediately
minimize and resolve conflicts when they
occur
Tertiary Prevention (Indicated
Interventions)
Post S/R interventions designed to
mitigate effects, analyze the event, take
corrective action, and avoid in future
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Recovery/Resiliency Principles
Partnerships, locus of control, life in
the community, illness selfmanagement, provision of hope
Concepts apply to adults and kids
The use of S/R is counter-intuitive
Coercive or traumatizing settings do
NOT foster hope, healthy
relationships, prosocial behaviors or
trust (NF Commission, 2003)
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Recovery/Resiliency Principles
Related Developmental Theories re S/R
The ability to form healthy relationships
is highly dependant on learned social
skills
Children’s social skill learning is directly
related to the chx of their environments
Disordered environments=dysfunctional
skills
Violence teaches withdrawal, anxiety,
distrust, over-reaction and/or aggression
as coping behaviors
(Saxe et al., 2003; SG Report, 1999)
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Recovery/Resilience Principles
National Child Traumatic Stress
Network
Extreme behaviors are rooted in
dysregulated emotional states
Effective interventions must target px in
social environ (milieu) and the child
Therapeutic milieus ensure safety and
limit exposure to stressors
Effective interventions are not shame
based, punitive or triggering
(Saxe et al., 2003)
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Traumatized Children:
Observations and Experiences
World is threatening and bewildering
World is punitive, judgmental,
humiliating and blaming
Control is external, not internalized
People are unpredictable and
untrustworthy
Defend themselves above all else
Believe that admitting mistakes is
worse than telling truth
(Hodas, 2004)
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J. Garbarino’s “lost boys” research
Issues of shame are paramount,
allowing child to “save face” important
Violence can be seen as an attempt
to achieve justice as child sees it
These children cannot afford empathy
as their needs are so great and
overwhelming; tend to de-personalize
others (Hodas, 2004)
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Self Reports on S/R Experiences
Research studies have found that people
who were secluded experienced
vulnerability, neglect, shame
Express feelings of fear, rejection, anger
and agitation
Felt they were being punished
Do not feel protected from harm
Feelings of bitterness and anger 1 yr later
(Wadeson et al., 1976; Martinez et al., 1999; Mann et al., 1993; Ray et
al., 1996)
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Staff Self Reports/Experiences
Female direct care staff:
I know that after a couple of difficult incidents on a
unit, I certainly felt like I had symptoms of PTSD,
about being hyper-aware when I walked to my car,
because some of the things that I saw and that I was
involved with were very traumatic. I think
consumers talk about what it is like to be in
restraints, it is also traumatizing to put people in
restraints in the same way that I think it is
traumatizing for soldiers to go to war and kill other
people. We don’t often talk about the impact of that
either.
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Principles of Trauma Informed
Systems of Care
Definition - Health Care that is
grounded in and directed by:
a thorough understanding of the
neurological, biological, psychological
and social effects of trauma and
violence on humans and
the prevalence of these experiences in
children and adults who receive mental
health and related services. (NETI, 2005)
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Prevalence of Trauma
Mental Health Population
90% of public mental health clients have
been exposed to trauma
(Muesar et al., in press; Muesar et al., 1998)
51-98% of public mental health clients have
been exposed to trauma
(Goodman et al., 1997, Muesar et al, 1998)
Most have multiple experiences of trauma
(Muesar et al, in press; Muesar et al, 1998)
97% of homeless women with SMI have
experienced severe physical & sexual
abuse – 87% experience this abuse both in
childhood and adulthood (Goodman et al., 1997)
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Prevalence of Trauma
Mental Health Population
Current rates of PTSD in people with
SMI range from 29-43%
(CMHS/HRANE, 1995; Jennings & Ralph, 1997)
Canadian study of 187 adolescents
reported 42% had PTSD
American study of 100 adolescent
inpatients; 93% had trauma histories
and 32% had PTSD
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What does this tell us?
The majority of adults and children in
psychiatric treatment settings have
trauma histories
Presume clients have had experiences
of traumatic stress
Impact of Trauma can be major
regardless of diagnosis
(Hodas, 2004, Cusack et al.; Muesar et al., 1998; Lipschitz et. Al, 1999,
NASMHPD, 1998)
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Impact of Trauma over the Life Span
Effects are pervasive (neurological,
biological, psychological and social):
Changes in brain neurobiology
Social, emotional & cognitive impairment
Adoption of health risk behaviors as coping
mechanisms (eating disorders, smoking,
substance abuse, self harm, sexual promiscuity,
violence)
Severe and persistent behavioral health, health
and social problems including premature death
(Felitti et al, 1998; Herman, 1992)
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Key Principles of TIC
Trauma Informed Care Systems
Integrate philosophy of care that guides all
interventions and interactions
Are based on current literature
Are inclusive of the consumer’s perspective
Recognize that coercive interventions can
cause trauma and re-traumatization and are
to be avoided
(Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)
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Trauma Informed Care Systems
Key Features
Recognition that mental health treatment
environments and related settings are often
traumatizing, both overtly and covertly
Recognition that the majority of human
service staff are uninformed about trauma
and its sequelae, do not recognize it, do not
treat it, and are not trained to do either
(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.;
Jennings, 1998; Prescott, 2000)
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Systems without Trauma Sensitive
Characteristics
Service users are labeled & pathologized as
“manipulative,” “needy,” attention seeking
Misuse or overuse of displays of power such
as keys, security, demeanor
Culture of secrecy - no advocates, poor
monitoring of practices
Culture of control, rules, consequences
(Fallot & Harris, 2002)
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How do we use this information to
reduce S/R use?
Develop a formal S/R Reduction
Action Plan (NETI, 2005)
Action Plan Essential Framework
 Prevention-Based Approach
 Continuous Quality Improvement
Principles
 Individualized for the Facility or Agency
 Focus on what to change (physical
environs, attitudes, leadership,
oversight, policy and procedures, rules
and regulations, staff management?)
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The Six Core Interventions©
(taken from NETI, 2005)
Leadership Toward Organizational
Change
Use Data To Inform Practices
Develop Your Workforce
Implement S/R Prevention Tools
Actively recruit and include service
users and families in all activities
Make Debriefing rigorous
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1st Core Strategy: Leadership
The most important component in successful
reduction projects.
Have the authority to make the changes that
are necessary for success:
Make/keep S/R reduction a high priority
Reduce/eliminate organizational barriers
Provide the necessary resources
Hold people accountable for their actions
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1st Core Strategy: Leadership
Leadership Creates the Vision Plan for
your System
Issue Policy Statement on S/R
Define rationale (why) for agency
Mandate inclusion of all key
stakeholders & people served
Review facility S/R policy &
procedures
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1st Core Strategy: Leadership
Organize S/R Reduction Team
Leadership Assigns Team
Identify Internal S/R Champions and
skeptics
– All levels of staff
– Include consumers/advocates
– Routine and consistent meetings
–
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1st Core Strategy: Leadership
Organize S/R Reduction Team
Assign plan responsibilities to people,
not groups
Document assignments
Manageable time frames
Sign off and monitor plan
implementation
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1st Core Strategy: Leadership
Elevate oversight of all S/R Events
In Curriculum called “Witnessing”
Refers to 24/7 off site executive level
on call response (by phone) to each
event
Every event becomes high priority
Executive role is to ask “Why”
questions
Assigns new responsibilities to all staff
Daily rounds are also suggested
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2nd Core Strategy: Use of Data
Using Data To Reduce Use
Gather baseline data by event/hours
(6 m to 1 yr) to start
Set realistic goals
Gather event data by
unit/day/shift/time/age/dx/gender/
race/individuals involved/MD/Date of
Admission
Post data on units monthly
(transparency)
Group outliers
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2nd Core Strategy: Use of Data
Using Data To Reduce Use
Monitor Progress
Discover new best practices
Target certain units/staff for training
Create a healthy competition
Assure that everyone knows what is
going on
Executive staff review data at least
weekly
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3rd Core Strategy: Workforce
Development
Integrate S/R Reduction in HRD Activities
Monitor Progress
New Hire procedures
Job Descriptions and Competencies
Performance Evaluations
New Employee Orientation
Annual Reviews
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3rd Core Strategy: Workforce
Development
Staff will require education on key concepts:
Common Assumptions about S/R
Experiences of Staff and Consumers with S/R
The Neurobiological/Psych Effects of Trauma
Creating Trauma Informed Systems and
Services
Principles of Recovery/Resiliency
Building non-coercive relationships
Use of S/R Reduction Tools (violence,
death/injury, de-escalation, trauma, etc.)
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3rd Core Strategy: Workforce
Development
Note about S/R Application Training
 Very important while reducing use
 Senior S/R Champions need to
experience whatever S/R application
training you are providing
Empower staff to question rules, policies
and procedures and to make decisions.
THIS MAY BE A BIG CULTURE CHANGE!
Reward Excellent Practice
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4th Core Strategy: S/R Prevention
Tools
Choose and Implement S/R
Prevention Tools
Assess risk factors for violence and S/R
use
Universal Trauma Assessment
Assess risk factors for death and Injury
Use Safety Plans/Crisis Plans/Advance
Directives: identify triggers/preferences/
and use
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4th Core Strategy: S/R Prevention
Tools
Choose and Implement S/R
Prevention Tools
Use of comfort/sensory rooms
Incorporate Person First Language
Building Relationships
Training Guidelines (De-escalation
models)
Effective Treatment Activities
Manage overcrowding
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5th Core Strategy: Full Customer
Inclusion
Consumer/Family Inclusion
Inclusion-MAKE IT HAPPEN! This is
not easy and usually a big change for
staff and executives sometimes
Clarify available roles (age
dependant)
Value information transparency
“Nothing about us without us”
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5th Core Strategy: Full Customer
Inclusion
Hire people in recovery, family
members/community advocates as staff
members, use volunteers
Make information available
Use to interview service user post-event
Attend meetings - all levels
Empower and support participation
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6th Core Strategy: Debriefing
Debriefing Specifics
Define what Debriefing is and what it is
not
Implement both types of Debriefing

Acute - immediate post event
response to gather info, manage
milieu, assure safety

Formal - rigorous problem solving
event
R
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6th Core Strategy: Debriefing
Acute and formal debriefing
events are best facilitated by a
senior staff person not involved in
event
–Include the service user
–Include the staff
–Entire staff team
Use a template or
guideline/checklist
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6th Core Strategy: Debriefing
Use root cause analysis steps
Non-punitive approach (be
consistent)
Goal is to find out what happened,
mitigate and how to prevent
reoccurrences
New info should change practice,
policies and operational rules
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NASMHPD S/R Training Evaluation 2003
National Executive Training Institutes
(NETI)
SAMHSA/CMHS funded
First 12 states trained/8 sent data
6-12 month pre-training data and 3-6 month
post-training data compared
Not research, simple evaluation
Not studied as to change “why’s”
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NASMHPD S/R Training Pre/Post Data
(NRI, 2003)
5 of 8 hospitals reduced hours of
restraint
5 of 7 reduced hours of seclusion
7 of 8 had fewer consumers
restrained
6 of 7 had fewer clients secluded
5 of 7 had fewer restraint events
6 of 6 had fewer seclusion events
(Conley et al., 2004)
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NASMHPD S/R Training Pre/Post Data
(NRI, 2003)
The data also showed that S/R hours
were reduced by as much as 79%,
the proportion of consumers in S/R
was reduced by as much as 62%, and
the incidents of S/R events in a month
were reduced by as much as 68%.
(Conley et al., 2004)
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NASMHPD/NTAC Activities and Next
Steps
NETI Training (50 states/DC/territories)
completed in 2003, 2005
8 State Incentive Grants to identify
alternatives to reduce use awarded in
2004 (HI, IL, KY, LA, MA, MD, MO, WA)
Three year project includes large scale
research study with HSRI, ongoing TA &
NREPP application
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Seclusion/Restraint Reduction
Final Comments
Significant S/R reduction is possible
Keep focus and vision on Prevention
and Improved Safety for all
Done correctly, these efforts positively
change our treatment cultures
S/R Reduction is primarily a
Leadership responsibility
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Seclusion/Restraint Reduction
Final Comments
Develop and implement a formal
Action Plan (aka treatment plan to
reduce S/R)
While reducing assure for safe use
Provide workforce with new tools/data
Support and include service users in
new roles and in managing their own
care
Make Debriefing activities effective
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Contact Information
Kevin Ann Huckshorn
Director, Office of Technical Assistance
National Association of State Mental
Health Program Directors
66 Canal Center Plaza, Suite 302
Alexandria, VA 22314
(703) 739-9333 ext. 140
[email protected]
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