Roadmap to a Restraint Free Environment for Persons of All Ages National Association of Consumer/Survivor Mental Health Administrators.

Roadmap to a Restraint Free

Environment for Persons of All Ages

National Association of Consumer/Survivor Mental Health

Administrators

Roadmap to a Restraint Free Environment for Persons of All Ages

Dear Joyce, I wanted you to know that I have only been in the hospital 1 hour,

and already 7 people have come to me about the conference and how it changed their life,

and one person said, "The train has left the station. We are already doing great things and we will continue to do even better."

Another person used the word ‘patient’ and corrected themselves in front of others.

“I don't know if I like the word consumer, but it's what people with psychiatric illness want to be called and it is their right to have us do that."

They talked about the profound change that occurred for everyone in the room on Wed.

They said, "It was as though the earth moved and shifted inside all of us.”

This was a life changing experience and I will never be the same again.

There are already plans for a monthly workgroup. I am so thankful that you, Carol and Erica came to us now and are helping to shift the paradigm.

Thank you for all the wonderful presentations. We are very blessed to know you. Susan

“Be the change you want to see in others.”

Mahatma Ghandi

MESSAGE FROM SAMHSA ADMINISTRATOR

INTRODUCTION

HOW TO USE THIS MANUAL

MODULE 1: THE PERSONAL EXPERIENCE OF RESTRAINT AND SECLUSION

A. Background for the FacilitatorB. Setting the StageC. Overview D. Special Needs PopulationsE. Personal Perspective: ConsumersF. Personal Perspective: Line StaffG. Journal/Take Action ChallengeH. Wrap Up and EvaluationI. Resources for the Facilitator

Exercise: Getting to Know You

• OBJECTIVE: To give an opportunity for participants to get to know one another and begin discussing their own experiences related to seclusion and restraint.

• PROCESS: Ask participants to pair up with a person they don’t know very well. Have them introduce themselves to each other and share their first experience with seclusion and restraint. If time allows, also include their most difficult restraint and seclusion experience. What was their most recent experience with restraint and seclusion? Have each participant introduce their partner and at least one feeling word (e.g. sad, elated, scared, frightened, powerful, and repulsed) to describe their experience. On the chalkboard or dry erase board, keep a list of feelings expressed.

• DISCUSSION• QUESTIONS:• What are the similarities you heard

about first experiences of seclusion and restraint?

• Which feelings were most common?• How has your experience of restraint

and seclusion changed/stayed the same over time?

• MATERIALS REQUIRED:• Chalkboard or dry erase board and writing

utensil. • APPROXIMATE TIME REQUIRED:• 30 minutes. • SOURCE:• Buffington, Geisler, Jorgenson, 2002

Staff Responses to Participating in Seclusion/Restraint

Reliving violence from the past

Feeling helpless, what are we supposed to do?

ChaosUnpleasantLittle training-need to think quickly

Not sure if I could do itOnce hands on— I had to help

Felt bad

Intensity - hair rising on back of neck

ChokingFirst memory—faceless—body bag, person got out somehow

Awful, painful experience

Cold wet sheets, kids tied to chairs

Violent, handled with greater force than necessary

First experience with her mother, never forget

ScaredIndignity of stripping, cold wet sheets

Journal/Take Action Challenge

MODULE 2: UNDERSTANDING THE IMPACT OF TRAUMA

A. Background for the FacilitatorB. Setting the StageC. Overview D. Definitions Related To TraumaE. Common Reactions to TraumaF. Effects of Trauma on the BrainG. Differential Response to ThreatsH. Assessment of TraumaI. Retraumatization via HospitalizationJ. De-Escalation PreferencesK. What Survivors Want in Times of CrisisL. Secondary TraumatizationM. Healing from TraumaN. Grounding TechniquesO. Stress ManagementP. Journal/Take Action ChallengeQ. Wrap Up and EvaluationR. Resources for the Facilitator

Take Action Challenge

From Module 1

Module 2

Understanding the Impact of Trauma

Learning ObjectivesUpon completion of this module the participant will:

• Define trauma and describe how it can impact consumers in mental health settings

• List common reactions to trauma, and identify how trauma affects the brain

• Understand how hospitalization/restraint/ seclusion can be retraumatizing for consumers

• Incorporate Trauma Assessment and De-escalation forms into current practices

• Recognize and utilize positive coping mechanism to deal with secondary traumatization

Dealing with the Effects of Trauma: A Self-Help Guide

by Mary Ellen Copeland

MODULE 3: CREATING CULTURAL CHANGE A. Background for the FacilitatorB. Setting the StageC. OverviewD. Pennsylvania: A Model for ReformE. Cultural ChangeF. SafetyG. In Our Own VoicesH. Journal/Take Action ChallengeI. Wrap up and EvaluationJ. Resources for the Facilitator

Intrapersonal – occurring within the individual mind or self

Interpersonal – involving relationships between persons

Systems/Cultural Change

“Be the change you want to see in others.”

Mahatma Ghandi

Defining Culture

Culture: Who we are and how we do things

Exercise: My Organization Currently Is…

Lecture Let’s first start with a picture of where your organization is right now – before proposing any changes. Remember, all organizations have things they do well at and things they could improve on. Exercise/Discussion

“My Organization Currently Is…”

• OBJECTIVE: Participants will identify current ecology, relationships, and leadership in their organization.

PROCESS: Divide the group into three similar sized groups. Assign one group ecology, one group relationships, and one group leadership. Ask them to do an evaluation (positive and negative) of how their organization currently functions around these issues as it relates to the reduction of seclusion and restraint. Have each group report back their findings. The groups may want to write key points on the board or on a flip chart.

• PROCESS:Divide the group into three similar sized groups. Assign one group ecology, one group relationships, and one group leadership. Ask them to do an evaluation (positive and negative) of how their organization currently functions around these issues as it relates to the reduction of seclusion and restraint. Have each group report back their findings. The groups may want to write key points on the board or on a flip chart.

Leadership:

· Inspires others to see their own potential· Foster relationship building among all· Challenge process not people· Teach “there could be a better way” attitude· Remove barriers to possibility thinking· Be a learning organization

• Ecology:· Physical Surroundings· Formal Policies and Rules· Resources· The Unit Culture· Attitudes · Cultural Norms

Relationships: Front line staff peer relationships Front line staff to administration

• relationships Front line staff to consumer relationships Administrative staff to consumer

relationships

• DISCUSSIONQUESTIONS:· Which of the three areas, ecology, relationships, and leadership, is most likely to support the reduction of seclusion and restraint at your facility? · Which of the three areas might struggle with these changes and why? · What works well and what is a problem related to seclusion and restraint?

• MATERIALS REQUIRED:Handout Module 3 – My Organization Currently Is…”

Chalk Board or flip chart.

APPROXIMATE TIME REQUIRED: 30 minutes

SOURCE: Exercise by Geisler, Buffington, Jorgenson, 2002

MODULE 4: UNDERSTANDING RESILIENCE AND RECOVERY FROM THE CONSUMER PERSPECTIVE

A. Background for the FacilitatorB. Setting the StageC. OverviewD. ResilienceE. RecoveryF. Journal/Take Action ChallengeG. Wrap Up and EvaluationH. Resources for the Facilitator

Deegan Quote

“People diagnosed with mental illness are resilient and are more than passive victims of disease processes. Professionals who learn to collaborate with the active, resilient, adaptive self of the client will find themselves collaborating in new and rewarding ways with people who may have been viewed as hopeless by others who reify [to regard (something abstract) as a material or concrete thing] diagnoses and related prophecies of doom” (Deegan, Ph.D., 2001).

I DID WANT TO UPDATE YOU ON AN EXCITING EXPERIENCE LAST WEEK. I WAS ON THE UNIT WHEN A PATIENT TRIED TO HARM HERSELF , THEN SWUNG AND KICKED AT STAFF WHEN THEY INTERVENED…A MANUAL HOLD

• ONE STAFF NOTICED CUES THAT THE PATIENT WAS CALM AND MAY NOT BE AN IMMEDIATE THREAT AND BEGAN A DIALOGUE

• IS THERE ANOTHER WAY WE CAN DO THIS WITHOUT THE RESTRAINT SO THAT WE CAN KEEP EVERYONE SAFE

DO YOU PROMISE NOT TO HURT ANYONE NOW? THE STAFF ASSESSESD THE INFORMATION TO BE CREDIBLE AND THE TEAM DISENGAGED THE RESTRAINT PROCESS.

MODULE 5: STRATEGIES TO PREVENT RESTRAINT AND SECLUSION

A. Background for the FacilitatorB. Setting the StageC. OverviewD. Consumer Driven SupportsE. Journal/Take Action ChallengeF. Wrap Up and EvaluationG. Resources for the Facilitator

MODULE 6: STRATEGIES TO PREVENT RESTRAINT AND SECLUSION

A. Background for the FacilitatorB. Setting the StageC. OverviewD. Communication StrategiesE. Comfort RoomF. Alternative Dispute Resolution/MediationG. Journal/Take Action ChallengeH. Wrap Up and EvaluationI. Resources for the Facilitator

As we talked about communicating with the consumers, I had an overwhelming sensation of grief and guilt

and realized that as a nurse I tell patients that I am going to keep them safe

and one way of doing this

is to take from them anything that we see as dangerous such as shoe laces, belts

so they can’t hurt themselves with anything that could be a weapon.

But when they are very upset and losing control,

we come along with our restraint bag—

our bag of weapons

and we do hurt them and use harsh words.

It doesn’t make sense.

“It’s crazy making when we tell consumers that we are doing this to help them be safe!”

Jane B.Child/Adolescent Unit Manager

Communication Strategies

Exercise: How Hard Can Communication Be?

Comfort Rooms

Comfort Room Definition:

The Comfort Room (formerly called the Quiet or Time Out room) is a room that provides sanctuary from stress, and/or can be a place for persons to experience feelings within acceptable boundaries. (Gayle Bluebird)

Comfort Room Door Sign

A special place where you may spend some time alone. You may ask any staff member to use this room. There are items that you can sign-out to help you calm down and relax (stuffed animals, soft blanket, music, magazines, and more).

Exercise: What Makes Me Comfortable?

Handout:How to Set Up a Comfort Room

by Gayle Bluebird

MODULE 7: SUSTAINING CHANGE THROUGH CONSUMER AND STAFF INVOLVEMENT

A. Background for the FacilitatorB. Setting the StageC. OverviewD. LeadershipE. DebriefingF. Updating Treatment PlansG. Data CollectionH. External MonitoringI. Journal/Take Action ChallengeJ. Wrap Up and EvaluationK. Resources for the Facilitator

MODULE 8: ROLE OF THE CHAMPION A. Background for the FacilitatorB. Setting the StageC. ReviewD. Role of the ChampionE. Personal Action PlanF. Workplace Action PlanG. Certificate of CompletionH. Wrap Up and EvaluationI. Resources for the Facilitator

“It is rather impressive how creative people can be when restraint is simply not a part

of the treatment culture.”JCAHO Testimony

John N. Follansbee, M.D.Northern Virginia Mental Health

Institute

RESOURCES A. Web SitesB. Policies and Position Statements1. American Nurses Association2. American Psychiatric Nurses Association3. Federation of Families for Children’s Mental Health4. National Alliance of the Mentally Ill5. National Association of State Mental Health

Program Directors6. National Mental Health Association

Wow Joyce ! This is incredibly impressive work. I can’t wait to see the completed manual.

Roadmap to a Restraint Free

Environment for Persons of All Ages

To pair this type of consciousness raising with an actual program to reduce restraints is outstanding.

How can I access a copy of the manual when it is ready? I am so pleased that my paper is part of it. Pat

I found the most valuable aspect of the training to be the self-awareness that was awakened in me, and the awareness I saw awakened in other participants.

As you know, our desire to obtain training was based in our commitment to eliminate restraint and seclusion, but setting goals and achieving them are two different things, as you pointed out.

Your training showed us it can be done, that it has been done elsewhere, and I believe you built in us the internal strength to get it done.”

David K. Clinical Services Director

Roadmap to a Restraint Free Environment for Persons of All Ages National Association of Consumer/Survivor Mental Health Administrators.

restraint free environment

facilitator slide

necessary slide

manual slide

bad slide

susan slide

difficult restraint

ages module

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