reducing restraints and eliminating seclusion: struggles and strategies presented by: keith a....
TRANSCRIPT
REDUCING RESTRAINTS AND ELIMINATING SECLUSION: STRUGGLES AND STRATEGIES
PRESENTED BY: KEITH A. BAILEY, PH.D.
A National Movement in the U.S. 1996 -- Pennsylvania State Mental Health Hospitals begin reduction
initiative 1997 -- American Academy of Pediatrics position paper on “Therapeutic Holding” vs. mechanical/chemical restraints 1998 -- Hartford Courant investigative report 2000 -- Children’s Health Act defines standards for restraint and seclusion 2001 -- CMS writes more stringent standards for youth services 2001 -- SAMHSA funds study with 7 youth programs 2003 -- President’s New Freedom Commission on Mental Health report comments on restraint and seclusion 2003 -- CWLA and NTAC begin nationwide training events 2004/2007 -- SAMHSA funds grants for 8 states for reduction efforts 2004 -- State of Tennessee requires more stringent standards for use of restraint and seclusion 2009 -- State of Tennessee enacts laws regarding use of restraints
and seclusions with Special Education students
International Concern and Action Canada
2001 – Patient Restraints Minimization Act 2003 – Implementation of The Six-Point Action Plan for youth residential facilities licensed under CFSA 2006 – Review suggested addressing restraint usage
in amendments to the Safe School Act (2000)
Great Britain Australia Israel
New Developments
Prohibiting use of prone (face down) restraints by some licensing bodies in U.S.
The Personal Side
There is a risk of serious injury or
death each and every time we attempt to restrain or seclude a child!
True and Tragic Accounts
Edith Campos 15 years old
Chris Campbell
13 years old
Angellika Arndt
7 years old
Stories of Success
Buckeye Ranch – Ohio Klingburg Family Centers – Connecticut Brewer-Porch Children’s Center –
Alabama Cambridge Hospital Child Assessment
Unit – Massachusetts Holston Home - Tennessee
Agency Restraints Seclusions
Buckeye Ranch 5 year period
99%
reduction
46%
reduction
Klingburg2000-2004
500 to 100
per year
300 to 50
per year
Brewer-Porch2002-2004
25 – 0
per month
18 – 1 to 2
per month
Cambridge CAU2000 - Present
From 140 R/S events per 1000 client days to 0
Holston Home
Started as an orphanage in 1895 Multi-program agency
Continuum of Care Model Foster Care (100 youth)
medically fragile, low intensity, therapeutic In-Home Services (20-30) Adoptions (60 placements in 2005-2006 FY)
special needs, domestic, international Child Day Care (100, infant – 5 yrs. old)
Holston Home
Day Treatment School (75 youth, K-12) Residential Group Care & Treatment (84)
Assessment (8) Boy’s Treatment (40 – Lv. 2 & Lv. 3) Girl’s Treatment (8) Girl’s Developmental Home (8) Boy’s Group Home (8) Preparation for Adult Living (12)
Juvenile Justice and Social Services Youth
[2007 Residential Numbers: 50]
Staff : 175+ in four sites Budget: $10 M
Why Change?
It looked bad and felt bad 1998 – 1400+ restraints, 2600+ seclusions High number of disruptions,
“bouncebacks,” and runaways Staff were not given enough skills to
appropriately deal with negative behavior Some staff began to raise concerns about
the therapeutic quality of our “treatment” approach
Culture Analysis –Crisis Creators
High staff turnover Inexperienced staff Poor training Shorter ALOS of
youth Higher numbers of
more difficult youth Older youth
Leadership turnover poor leadership in
various positions Perceived lack of
support from administrative staff
Control-oriented culture of care
Fear(With Gayle Mrock)
Beginning the Change
Decision by leadership Move to new crisis intervention model
(1997) CWLA Consultant
Change in Behavior Management Plans More strengths based approach Youth requested “time-outs” Create a culture where restraints are viewed
negatively by both staff and youth Researched/explored what others were
doing
Beginning the Change
Setting goals for % reduction Tracking through CQI process More responsibility on directors and
supervisors to hold staff accountable More training in de-escalation
techniques and more instructors Changes in Behavior Management Plans Restraint review process put in place
Restraint ReductionYear Restraints Youth Injuries
Requiring Medical Attention
Staff Injuries Due to Physical
Management
(Workers Comp)
1998 1447 6 36
1999 660 2 27
2000 169 0 4
2001 93 3 12
2002 169 0 17
2003 116 0 11
2004 151 1 5
2005 77 0 3
2006 67 1 3
Restraint Reduction
Ratio - restraints : 1,000 client days[Residential treatment, day treatment, group
care]
1998 - @ 40 : 1,000 (1447 restraints) 2005-2006 - 3.2 : 1,000 (70
restraints)
Seclusion ReductionYear Seclusions
1998 2642
1999 2114
2000 1259
2001 940
2002 607
2003 386
2004(Jan-Jun)
201[1st Q = 166 2nd Q = 35]
July 2004 Stopped Seclusion
2003
80% of restraints were associated with the use of seclusion
2004 January – May
8 staff injuries due to seclusion
4 staff injuries due to restraint
Mistakes & Successes
Mistakes Went cold turkey Didn’t give other
“tools” early on Some hired-in
directors didn’t buy in
Held on to some staff who didn’t buy in
Successes Support from
leadership Data and goal-
setting Training on staff
resistance Training, Training,
Training Celebration Consistent review
process
Restraint Review Committee: Attendees Administrator of Residential Services
(Chair) * Administrator of Best Practices TCI Instructor * Residential Directors * Therapist Staff from outside of residential treatment * Other staff as needed (e.g. direct care,
supervisor)
Restraint Review Committee: Purpose
Tracking through data gathering Emphasis on detail of report writing
Identifying trends Sending a message of importance Giving feedback to staff
Learn from mistakes and successes
Restraint Review Committee: Agenda Follow-up items from previous meeting New restraints presented (narrative
read) Critique/Questions/Discussion/
Suggestions Corrective action assigned (via director) Minutes typed and distributed
Review Serious Incident ReportIncludes: Child’s name Program Date of incident Time of incident Contract information Precipitating behavior
(including any children or staff involved)
Alternatives offered/de-escalation techniques
WHAT IS THE SAFETY ISSUE JUSTIFYING THE RESTRAINT?
Restraint technique used
Positioning of staff Length of restraint Processing/debriefing
completed, and by whom
Accident and injury report
Post Restraint / Seclusion Debriefing With youth involved With youth who witness the event With staff involved
To reduce the impact of trauma To learn from the event
Seclusion
Not as much attention given to seclusion Sometimes addressed alongside restraints, but
few, if any unique strategies given for reduction Often used as a behavior modification technique
to extinguish behavior vs. a safety technique
Like restraints, should only be used for safety Can give implicit negative messages and be
traumatizing
PRN Medication
Can be overused as a way to avoid physically intrusive interventions
Can become a substitute for teaching coping strategies
Can set up a dependency on the drug and/or the system to supply the drug
Sustaining Success
Cannot focus on restraint and seclusion alone
Requires a culture change !
Holston Home’s Changes in CultureHolston Home Treatment Model Task Force - 1999 Training in Mediation – 2001 Expanded Staff Training – Addition of Staff
Development & Training Coordinator - 2001 Best Practices Department Created - 2003 A move away from points and levels and to a
relational model of care – using natural and logical consequences, “refocusing”, making amends From “controlling” to “connecting”
What We Learned
It gets worse before it gets better When you take away a tool, you have to put
another one in its place Plan thoroughly and prepare staff
Orientation and ongoing training is essential !!! Power struggles must be recognized and
redirected Staff have to be supported and empowered Involve youth – listen and learn
What We Learned
Training – Training – Training Data collection is key – show them the
numbers! Review process is critically important It is a process Expect resistance and address it! You must address all aspects of the
agency culture
SUCCESS in beginning and maintaining restraint and seclusion reduction efforts
requires nothing less than …
…a change in the culture [mindset] of care
Changing the Culture of CareTreatment Understanding children’s behavior
and where it comes from Understanding treatment
Treatment statements More than a mission & values
statementsUnderstandable and applicable by all
staff and youth Including the family and community
Sample Treatment Statement:Cognitive – Behavioral approach:
[The Agency] uses a treatment approach that emphasizes positive thinking skills, emotional coping skills, and appropriate choices for behavior in an environment that is safe and supportive to all [youth and staff].
Changing the Culture of CareGuiding Principles related to use of
restraint and seclusion: Restraints and seclusions are not
therapeutic techniques. They can, in fact, further traumatize youth
Restraints should only be used as a last resort, when all other interventions have failed, and only when there is an imminent risk of harm to the youth or others if a restraint is not properly used.
Changing the Culture of CareInfrastructure that supports treatment Staff
Hiring – Firing – Credentials – Scheduling – Training
Supervision and Support Physical environment
Space – Décor – Upkeep Policies and Procedures
Forms - documentation
Changing the Culture of CareTraining Child Development and Children’s Mental Health Trauma Informed Care
Bruce Perry, MD, Ph.D. – impact on brain and development
Sandra Bloom, M.D. – Sanctuary Model Goals of Behavior/Behavioral Support
Parenting Treatment Techniques Communication and Mediation Skills De-escalation Techniques Skills Processing Skills
Changing the Culture of CareSupervision and Accountability Training – skill development A style that promotes a parallel process
of support and growth between direct care staff and youth
A Balance Administration Accountability of staff Coaching – Support
Commitment to Culture Change - Schein“Converting” staff:
20 / 50 / 30Rule
5-15 years to change a culture
Resources
Organizational Change
Leaf. S. (1995). The journey from control to connection. Journal of Child and
Youth Care 10 (1), 15-21.
Organizational Culture
Schein, E. (1992). Organizational culture and leadership. 2nd edition.
San Francisco: Jossey Bass Publishers.
Restraint and Seclusion Reduction
Child Welfare League of America. (2002). CWLA best practice guidelines for behavior management. Washington, DC: CWLA.
Child Welfare League of America. (2003). Reducing the use of restraint and seclusion: Promising practices and successful strategies. Washington, DC: CWLA.
Resources
Trauma Informed Care
Bloom, S. (In print). Creating sanctuary for kids: Helping children to heal from violence. The International Journal for Therapeutic and Supportive Organizations.
ww.magnasystems.com/c-5-childhood-trauma.aspx (DVD’s -Dr. Bruce Perry)
www.childtrauma.org (on-line trainings - Dr. Bruce Perry)
www.nctsnet.org/nccts/nav.do?pid=ctr_cwtool (fully developed curriculum & tutorial)
Resources
NTAC-NASMHPD Six Core Strategies for reducing and eliminating restraints and
seclusions Role of Leadership toward Organizational
[Culture] Change Analysis of Data to Inform Practice Staff Development and Training Debriefing Techniques Use of Restraint Reduction Tools Youth and Family Input
National Technical Assistance Center - National Association of State Mental Health Program Directors
Training Curriculum for the Reduction of Seclusion and Restraint, 2004)