Alternatives to Restraints and Seclusion

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and Seclusion

January 2012

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Introduction … 4 Therapeutic Relationship Model … 5 Functions of Behaviour … 11 Responsive Behaviours … 12 The Learned Functions of Behaviour Disorders … 12 Identification of Alternative Interventions … 16 Engaging with Patients … 16

Communication of Alternative Interventions … 17 Behavioural Profile Tool … 17 Alternative Interventions/Activities … 20 Examples of Alternative Interventions with Specific … 23 Presenting Behaviours

Alternatives to Restraints Decision Tree … 28

De-escalation … 30

De-escalation Tips … 31

Interventions to Assist Patient to Cope … 32 Patient Debriefing Post Restraints and Seclusion … 34 Patient Debriefing Tool … 35 My Toolbox Activity … 37 Alternative Strategies to Restraints/Seclusion Checklist … 39

References … 42

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Introduction

Ontario Shores Centre for Mental Health Sciences (Ontario Shores) is committed to a recovery-oriented approach to patient care and treatment. This approach promotes a least restrictive and least intrusive philosophy of care through focusing on teaching, reinforcing and strengthening the patient’s development of internal controls, in the service of self-determination, and maximizing therapeutic treatment interventions that reduce and/or eliminate the need for external control.

Ontario Shores’ commitment towards restraint minimization means striving to reduce the frequency and duration of use of restraints and seclusion and increasing the use of

alternative interventions. The utilization of restraints and seclusion is only supported as a last resort when all other alternative interventions have been exhausted and there is a presence of imminent risk.

Collaboration with patients to identify alternative

interventions empowers and supports patients in dealing with frustrations, fear, anger and/or worry. A goal in a

preventative approach in care at Ontario Shores is the early identification of patients who may be at risk of restraint use, and proactive implementation of alternative interventions to help mitigate the use of restraints while strengthening the therapeutic relationship.

Therapeutic Relationship Model

Historically mental health care has focused on a

biomedical, paternalistic approach in managing therapeutic relationships with patients. Incidents of patient aggression and violence are common occurrences in inpatient mental health settings (Duxbury, Bjorkdahl and Johnson, 2006;

Duxbury and Whittington, 2005). Increasing evidence within literature supports the development of

multidimensional models for the management of violence and aggression in such settings (Duxbury, 2002). In recent years there has been a shift to a more proactive

patient-centred recovery-oriented approach to care with a focus on reducing aggression and violence. To promote quality of patient care and staff and patient safety, our specialized mental health facility developed the Therapeutic Relationship Model (TRM). This model enhances staffs knowledge, skill and attitude of a recovery approach to care in conjunction with the principles of managing therapeutic relationships while emphasizing the human contextual factors inherent in our practice.

The Therapeutic Relationship Model promotes patients’

well-being and strengths while including the evidence that supports the value of the therapeutic alliance. It also

supports a least restrictive and least intrusive approach with the ultimate goal to achieve positive patient outcomes. The model incorporates our recovery framework and promotes an understanding of the human contextual factors while utilizing the Six Core Strategies in Reducing Restraints and Seclusion as guiding principles.

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The Therapeutic Relationship Model promotes an

awareness of the multiple factors that can influence staff’s ability to effectively prevent and manage aggression.

Duxbury and Whittington (2005) have narrowed these down to three conceptual frameworks: internal, external and situational. Based on extensive literature review, Ontario Shores adopted these conceptual frameworks identified in the development of this model.

The Internal Framework: Human Contextual Factors The internal framework identified in literature views the individual patient variables as the source of violence and aggression. Within the TRM, the internal framework has been defined as the “human contextual factors”. These factors are seen as the foundational building blocks of human beings. They are the characteristics that make up

“who we are”. What creates the individuality amongst people is the extent to which each human contextual factor has been experienced and/or affected a person, resulting in variances in responses and behaviours towards similar situations.

Some examples of human contextual factors that are

imperative for clinicians to consider within their assessment and evaluation of patients behaviours are:

• Trauma exposure

• Personal insight

• Knowledge

• Immediate stressors

• Communication

• Transference/counter-transference

• Mental and physical health

• Assumptions, values and judgment

• Interpersonal functioning

• Experiences

• Relational history

External Framework: Six Core Strategies

The second framework identified in literature is the external model which has been described as the environmental factors influencing patient aggression. Studies have examined space, location, unit regimens, and

organizational routines as causative factor in patient aggression in mental health settings (Duxbury and Whittington, 2005). Historically studies have mainly

explored psychosocial and physical aspects of unit-specific factors contributing to patient aggression. There are limited studies focusing on organizational strategies in managing patient aggression in mental health settings. The National Executive Training Institute (NETT) has developed the Six Core Strategies for the Reduction of Seclusion and

Restraints based on extensive and ongoing literature

reviews and dialogue with experts successful in reduction of seclusion and restraints and trauma-informed care

(NASMHPD, 2003). The Six Core strategies focus on both the unit-specific and organizational perspectives which must be addressed from an external model standpoint related to management of patient aggression.

These strategies have been approved by the National Association of State Mental Health Program Directors

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(NASMHPD) and have been adopted within the Therapeutic Relationship Model to support the external model in the principles of managing therapeutic relationships within a mental health setting. The Six Core Strategies are

evidenced-based and provide guidance for mental health settings to transition towards minimization of seclusion and restraints and promotion of trauma-informed care. The Six Core Strategies have been incorporated within the model to highlight the crucial role of the organization’s support and commitment towards the management of relationships. The Six Core Strategies are: (1) Leadership towards

Organizational Change; (2) Use of Prevention/Proactive Tools; (3) Workforce Development; (4) Debriefing

Techniques; (5) Patient’s Role in an Inpatient Setting; and (6) Use of Data to Inform Practice (NASMHPD, 2003).

These strategies stress the importance of the alignment of organizational values, mission and philosophy, policies and procedures, and action plans to support the reduction of seclusion and restraints and promotion of trauma-informed care. The strategies focus on gathering and continuous monitoring of data to inform decisions and implementation of interventions in restraint minimization and managing relationships. The workforce development strategy

suggests “the creation of a treatment environment whose policy, procedures, and practices that are based on the knowledge and principles of recovery and the

characteristics of trauma informed systems of

care” (NASMHPD, 2003, p.2). The Six Core Strategies also support enhancing practice through staff development training and utilization of a variety of tools to support a proactive approach in managing relationships (NASMHOD, 2003). The highlighted key recommendations of the Six Core Strategies illustrate the value and influence the

external model identified in literature has on managing relationships within a mental health setting.

Situational Framework: Collaborative Recovery Model Duxbury (2002) reports a number of studies which support the value of a therapeutic nurse-client relationship, in particular when managing aggressive behaviours. These studies support the belief that a negative staff and client relationship leads to patient aggression. The situational/

interactional component is the third identified framework referring to the overall circumstance in which aggressive behaviours occur (Duxbury, 2002). The Collaborative Recovery Model (CRM) defines this framework within the Therapeutic Relationship Model.

TRM incorporates the two guiding principles and four

components of the Collaborative Recovery Model (Oades et al, 2005). The foundational principles of the Collaborative Recovery Model (CRM) support a preventative and therapeutic approach to mental health care, emphasizing recovery as a subjective and personal experience which requires extensive collaboration between the client and mental health care provider (Oades et al., 2005). The CRM creates a recovery oriented approach to mental health care with specific knowledge, skills and attitudes for

practitioners.

The attitudes that are critical to the success of this paradigm shift are the possession of a growth mindset.

Growth mindset is the hopefulness clinicians possess that

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patients have the ability to set, pursue and attain personally valued life goals. Other attitudes supported in this model is towards genuine collaboration, for clinicians to take partial responsibility in alliance ruptures (transference and counter-transference), the ability to use negotiation rather than coercion and staff understanding the value of between session activity (homework) (Oades et al., 2005).

Therapeutic Relationship Model

Overall, it is essential to be aware and take into consideration the multiple dimensions which affect

therapeutic relationships to ultimately promote a therapeutic alliance and support quality of patient care and staff and patient safety. Increasing staff awareness and knowledge of the compounding dimensions in managing relationships will further support the proactive patient-centred

recovery-oriented care in mental health.

Functions of Behaviour

All behaviour has meaning. In order to fully understand the meaning of behaviour, address unmet needs of a patient, and accurately determine the best patient specific

prevention and alternative approach strategies that would prevent or limit the use of restraints, the following

components need to be addressed:

Understand factors that lead to behaviours of harm to self/

others that could result in considering the use of restraints and know all behaviour has meaning;

Assess the patient for predisposing or precipitating factors that may result in unmet needs demonstrated in behaviours for which a restraint may be considered;

Develop a patient specific individualized plan of care to meet a patient’s therapeutic needs and wishes as indicated by short and long term goals for the prevention or

minimization of behaviours of harm to self/others;

Continuous collaboration and communication amongst the interprofessional team to ensure an awareness of the plan of care which contains the prevention and alternative approach strategies and de-escalation preferences to be considered to avoid the use of restraints;

Continuously assess a patient’s response to prevention and alternative approach strategies and evaluate and make changes to the plan of care and interventions. It may take several attempts to determine the alternative strategies that might work best for the patient based on the presenting problem, to prevent or limit the use of restraints;

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Be aware of own personal values and knowledge of the clinical issues to mitigate interference with patient’s choices and values; Self-awareness and self-management are highlighted to be significant in influencing a clinician’s ability to have therapeutic interactions and implement effective strategies with patients.

RNAO (2012). Promoting Safety: Alternative Approaches to Use of Restraints.

Responsive Behaviours

Responsive behaviours refers to behaviours that often indicate,

(a) an unmet need in a person, whether cognitive, physical, emotional, social, environmental or other, or

(b) a response to circumstances within the social or

physical environment that may be frustrating, frightening or confusing to a person; (Long-Term Care Homes Act, 2007) The term “responsive behaviours” emphasizes the

significance of having assessments and interventions that focus on the meaning behind behaviour rather than

behaviour itself.

The Learned Functions of Behaviour Disorders

Over the past 30-years of behaviour analytic research, there is strong evidence that most behaviour problems, such as aggression towards others, self-injury, and property

destruction are developed and maintained by the same processes that develop and maintain appropriate behaviour (Austin & Carr, 2000; Wallace, Kenzer, Penrod, 2004). The most influential processes involved in learning both

appropriate and inappropriate behaviour is positive and negative reinforcement. Reinforcement is how individuals learn and change their behaviour. Through understanding and utilizing reinforcement correctly, clinicians advance towards helping patients improve functioning in their environment. Reinforcement is something that occurs immediately after a behaviour, which strengthens the behaviour. When a behaviour is strengthened, it occurs more often and more reliably.

Although problem behaviour can take the same form across patients, the variables involved in shaping and reinforcing each person’s behaviour are the result of a unique learning history. By identifying and understanding the source of reinforcement for an individual’s pathological behaviour, it further enables clinicians to select and individualize approaches toward preventing and de-escalating within a recovery oriented model of care. These positive or negative reinforcers maintaining a behaviour can be further

delineated based on the source of reinforcement.

Positive Reinforcement

The occurrence of a problem behaviour from the patient sets the occasion for an immediate observable reaction from the clinician. These observable reactions fall into two categories; attention, and access to preferred items or activities (tangible/edible). Attention can come in the form of eye contact, laughs, reprimands, response interruptions,

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comfort, and physical contact as examples. On the other hand, the access to tangibles or activities occurs following the problem behaviour, such as, being told you cannot have something (toy, edible, cigarette), or an activity, such as, going for a walk, watching TV, or interacting with a peer, increases the frequency of the problem behaviour.

Moreover, access to the preferred item or activity is mediated by the responses of another person, thus if the motivation for a particular item is present then the item will function as a reinforcer. Furthermore, in most specialized settings, such as inpatient units in a specialized mental health hospital, access to preferred items and activities are mediated by staff, thus the responses of staff can act as evocative events and/or reinforcers for problem behaviour.

Negative Reinforcement

Socially mediated consequences that remove, attenuate, reduce, or avoid aversive events are considered negative reinforcers mediated by other persons in the immediate environment. These reinforcers, again, can be related to attention or objects and activities. The removal of attention is said to be reinforcing when it follows a problem behaviour and results in an increase in the behaviours frequency. For example, When Debbie is asked by staff to sit on a couch in a room with ten other people, Debbie screams and is then told by staff to go to her room. The aversive event (sitting in a room with a group of people) is avoided (reinforcer) by screaming (problem behaviour). Another group of negative socially mediated consequences is the removal of aversive tasks/activities (tangibles), contingent on the problem behaviour. For example, Billy’s teacher places five math

worksheets on Billy’s desk followed by saying “Billy finish these sheets”, Billy then screams and swears at the teacher, the teacher immediately tells Billy to “go sit in the hall”. In this example, Billy’s problem behaviours are being reinforced by removing the aversive stimulus (boring math sheets), this increases the future rate of the problem behaviour.

Crisis Prevention and Management: Removing the barriers

When barriers are placed around reinforcers, whether positive, negative, social, or nonsocial, distress ensues and problem behaviour becomes more frequent and intense.

By indentifying what is motivating a particular response, what that response has been reinforced with, supportive efforts can be taken by care givers to remove those barriers.

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Identification of Alternative Interventions

Engaging with Patients

The initial step in determining the types of activities/

interventions which help

patients, involves engaging in conversations around their interests. There are examples of activities/

interventions in this booklet which may be utilized with patients to support these conversations. Personalizing interventions according to the patient’s values, strengths, history and patient story is important in keeping with their individualized preferences and success in supporting patients during critical situations.

Communication of Alternative Interventions

Once alternative interventions have been identified through collaboration with the patient/SDM/family, it is important to communicate this information to the inteprofessional team caring for the patient. This communication can be done through documentation, transfer of accountability, and interprofessional team meetings (ie. Rapid Rounds, Kardex, patient treatment plan conferences, etc.).

Behavioural Profile Tool

The Behavioural Profile Tool is an assessment and

communication tool which currently exists on each patient’s health record. This is an interprofessional document that enables the team to communicate relevant and significant information related to the patient, such as:

• Unique behavioural patterns

• Antecedents to specific behaviours

• De-escalation preferences

• Alternative strategies and intervention to prevent and manage specific behaviours

This is an evolving tool which is initiated on admission and should be continuously updated with any new information related to the patient. Each clinician should review this tool every shift and update as needed.

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Below are instructions to access this document in Meditech.

Physician Instructions to View Behavioural Profile Tool:

Click on Patient Care tab

Sort by Assessment

Select the Behavioural Profile Assessment

Nursing and Allied Health Instructions to Document on the Behavioural Profile Tool:

Behavioural Profile Tool

Click on Worklist

Behavioural Profile is on your Worklist

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Alternative Interventions/Activities

Involving patients in identifying alternative interventions should be initiated as close to admission as possible. The purpose of alternative interventions is to provide comfort to the patient, provide meaningful activities to the patient and provide the patient with a safe environment (Snyder, 2004).This may be facilitated by asking the patient such questions as:

“It is helpful for us to be aware of the things that can help you feel better when you’re having a hard time. Are there any things that have worked for you in the past during difficult times?”

Throughout this booklet there are examples of various alternatives for situations. It may be helpful to provide some of these examples to patients if they are having difficulty identifying or articulating strategies that would help or that they would be interested in trying.

Identified alternative interventions should be clearly documented in the Behavioural Profile to ensure all

providers caring for the patient are aware of this information and ensure consistency in approach to care based on individualized needs of the patient.

Examples of alternative activities:

Arts and entertainment

• Draw, paint, collage or sculpt

• Make a puzzle

• Watch TV or a movie

Environmental

• Spend time in a quiet room, or schedule daily naps/

rest periods

• Spend time in a comfort room

• Spend time in the chapel, worship room or library Movement

• Engage in physical activity at a level recommended by the treatment team

• Go for a walk on hospital grounds (must have privileges)

• Get a book from the library

• Walk in the halls

• Clean room or do chores

• Punch a pillow Reading and writing

• Write in a journal

• Read a book, magazine or newspaper Relaxation, meditation and spirituality

•Engage in spiritual practices, such as prayer, meditation or religious reflection

• Practice relaxation and breathing exercises, or meditation

Sensory stimulus

• Have a warm or cold shower

• Listen to relaxing music

• Use ice or a cold face cloth on body

• Use a weighted blanket

• Play with a stress ball

• Massage hands with preferred essential oils or creams

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Supportive conversations/engagements

• Create a safety plan with interprofessional team

• Talk to a clinician, peer support specialist or spiritual care worker

• Sit with a clinician, peer support specialist or spiritual care worker

• Walk with a clinician, peer support specialist or spiritual care worker

• Call a friend or family member for calming support

• Discuss ways to reduce smoking, such as nicotine replacement therapy

Social

•Participate in group activities or therapeutic group sessions

• Play cards, board games or video games

CAMH (2011).Alternatives to Restraint and Seclusion.

Tip: Alternative activities should be clearly documented in the Behavioural Profile and part of the patient’s Plan of

Care to support quality of care.

Examples of alternative interventions with specific presenting behaviours

which may lead to the use of restraints or seclusion.

Presenting Suggested Behaviour Alternatives

Agitation • Mobility/ambulation/exercise routine • Identify de-escalation preferences

• Medication review

• Pain relief/comfort measures

• Normal schedule/ individual routine

• Assess for hunger, anger, loneliness, tired, heat, pain, cold

• Increase social interaction

• Redirect with simple commands

• Relaxation techniques

• Gentle touch

• Assess past coping strategies

• Involve family in planning care

• Diversion activities: pets, puzzles, music, crafts, cards, snacks

• Schedule daily naps

• Pacing permitted

Aggression • Medication review

• Normal schedule/individual routine

• Assess for hunger, anger, loneliness, tired, heat, pain, cold

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• Increase/decrease social interaction

• Soothing music

• De-escalation suggestions:

• Speak calmly and quietly. Reassure patient. Ask how we can help

• Ask patient perception of issue

• Ask patient/family their past preferred

coping strategies

• Do not react to responsive behavior

• Promote quiet time

• Request presence of staff with

therapeutic relationship

Acute Confusion - Delirium

• Work-up for underlying cause • Pain relief/comfort measures

• Glasses, hearing aids, walking aids

easily available

• Toileting regularly – every 2 hours

• Assess for hunger, heat, pain, cold

• Label environment i.e. bathroom door • Increase/decrease social interaction

• Gentle touch

• Alarm devices – bed/chair/door

• Clutter free rooms

• Night lights

Falls

• Quad exercise: mobility/ambulation

• Toileting regularly

• Routine positioning

• Increased participation in ADL • Pain relief/comfort measures • Normal schedule/individual routine

easily available

• Increase social interaction

• Scheduling daily naps

• Hi-Lo beds

• Non-slip strips on floor

• Night light

• Helmet

• Acceptance of risk

Cognitive Impairment – i.e. dementia

• Label environment i.e. bathroom door

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• Increase social interactions

• Gentle touch

• Assessing past coping strategies

• Reminiscence

• Night light

easily available

Wandering

• Buddy system among staff/

consistency

• Label environment i.e. bathroom door • Increase social interactions

• Assessing past coping strategies

• Tape (stop) line on floor

• Night light

• Room close to nursing station

easily available

Unsteadiness

• Mobility/ambulation/exercise

• Increase social interactions

• Hi-Lo bed

• Non-slip strips on floor

• Night light

easily available

Sliding

• Routing positioning (Q2H) • Pain relief/comfort measures • Consult Physio Therapist/

Occupational Therapist

• Wedge cushions/tilt wheelchairs

• Non slip cushion

The Ottawa Hospital (2010). Least Restraint Last Resort Policy.

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Alternatives to Restraints Decision Tree

Yes No

Assess Patient Behaviour

Explore etiology of behavior Implement alternative strategies/interventions

Are alternative interventions effective?

Review criteria for initiation of restraints and/or

seclusion, or safety devices

· Collaborate with team/

patient/SDM

· Discuss preferred coping strategies

· Assess needs (nutrition, pain, etc)

· Continue/initiate alternatves

· Document and monitor

· Attempt de-escalation preferences

· Code White as required

· continue to attempt de-escalation and offer alternative interventions

· Address needs i.e. ask: “What would help you right now, at this moment?”

Yes No

The Ottawa Hospital (2011). Least Restraint Last Resort Policy.

· If imminent risk of harm to self or other present, consider least restrictive methods for the shortest duration of time

· Refer to Restraints, Chemical, Mechanical and Seclusion policy (Admin, 12.01) or Safety Devices policy (Amin, 12.10)

· Initiate restraints/seclusion/safety devices

· Document and monitor patient as per policy

Reassess need for least restraint

· Code White as required

· Trial new alternatives

· Re-evaluate least restraint

· Renew order as per policy

· Discontinue restraints

· Debrief with patient when clinically

indicated

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De-escalation

Alternative approaches for agitated behaviours must be individualized within the context of the situation, the patients’ psychopathology, the age of the patient, and the degree of anxiety and agitation demonstrated by the patient on the continuum of escalating behaviours (from anxiety, agitation to verbal or physical aggression) (Johnson &

Hauser, 2001).

The diagram below illustrates patterns of action when de-escalating a patient.

Noticing the patient

Reading the Situation Reading the patient

Knowing where Understanding Knowing what the the patient the meaning patient needs is on the patient

continuum

Connecting with the patient Matching the Intervention

(Gelkopf et al., 2009).

De-Escalation Tips

1. Always identify yourself.

2. Talk and think calm.

3. Ask patients how they are doing, or what’s going on.

4. Ask patients if they are hurt (assess for medical problems).

5. Ask patients if they were having some difficulty or what happened before they got upset.

6. Remember why the patient is in the hospital.

7. Find a staff member that has a good rapport/relationship with the patient and have him/her talk to the patient. Let the patient know you are there to listen.

8. Offer medication if appropriate.

9. Help patients remember and use coping mechanisms they identified on the Behavioural Profile Tool.

10. If a patient screams and swears, reply with a calm nod, okay, don’t react.

11. Use team or third-party approach. If patient is wearing down one staff, have another take over (10 minutes of talking might avoid a restraint incident).

12. Reassure patients and maintain professional

boundaries (tell patients you want them to be safe, that you are here to help them).

13. Allow quiet time for patients to respond — silent pauses are important.

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14. As the patient if she/he would be willing to try and talk to you. (repeat requests, persistently, kindly).

15. Respect needs to communicate in different ways

(recognize possible language/cultural differences as well as the fear, shame, and embarrassment the patient may be experiencing).

16. Empower patients. Encourage them with every step towards calming themselves.

17. Make it okay to try and talk over the upsetting situation even though it may be very painful or difficult.

18. Acknowledge the significance of the situation for the patient.

19. Ask the patient how else we can help.

20. Ask the patient’s permission to share important

conversations with other caretakers for ongoing discussion.

Provided by the Milwaukee County Mental Health Division Milwaukee, WI

Interventions to Assist Patient to Cope

a) Listen to the patient’s concern even if you don’t understand.

b) Ask the patient to tell you what the problem is, and LISTEN sincerely.

c) Recognize and acknowledge the patient’s right to his/her feelings.

d) Sit down if possible (maintain safety) and invite the patient to do likewise.

e) Invite the patient to talk in a quiet room or area where there is less of an audience and less stimulation.

f) Apologize if you did something that inadvertently upset the patient. Acknowledge feelings (not reasons) and state that it was unintentional.

g) Let the patient suggest alternatives and choices.

h) To maintain patient and staff safety, have adequate personnel available for crisis situations.

i ) Speak in a calm, even, non-threatening voice. Speak in simple, clear, and concise language.

j) Use non-threatening non-verbal gestures and stance.

k) Be aware of language, hearing, and cultural differences.

l) Assure the patient that she/he is in a safe place and we are here to help.

m) Recognize your personal feelings about violence and punishment and how it affects you when a patient is violent.

n) Be aware of how other staff positively interact with angry patients and model their interventions.

Provided by the Milwaukee County Mental Health Division Milwaukee, WI

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Patient Debriefing Post Restraint and/or Seclusion

As it acknowledges the trauma and re-traumatization that may be caused in a restraint and/or seclusion event [debriefing with patients afterwards is highly

recommended]. The goal of patient debrief is to support the rebuild of the therapeutic relationship between the health care team and patient, as well as, maintain the patient’s dignity and well-being through respectful communication and collaboration. This is done by exploring and validating the patient’s feelings and views about the incident,

providing a clear explanation for the event, and

collaboratively identifying what both the patient and staff can do to prevent future restraint and/or seclusion.

Patient debriefing needs to formally be attempted and documented in the patient’s health record. An offer of the debriefing will be respectful and compassionate.

Re-engaging the patient by having a discussion is important because the restraint and/or seclusion may have impacted the therapeutic relationship. A clinician who has the best rapport or not directly involved in the event will initiate the debriefing with patient. This decision will be made by the interprofessional team involved with the patient’s care. A customized approach should be considered to best meet the patient’s needs (ie. setting, attention span, memory, etc.). The patient will participate to the extent that he or she is able and willing. The clinician conducting the patient debrief will avoid placing blame and discuss the event in a non-judgmental manner. The Patient Debrief Assessment tool is helpful in supporting and guiding clinicians to

collaborate with the patient in a debrief.

The purpose of obtaining input and perspective from the patient and clearly documenting it within the health record is to:

• Identify triggers and antecedent behaviour that may have resulted in the use of restraint

• Identify and evaluate alternative behaviour and healthy coping strategies that may effectively minimize the future use of restraint should similar situations reoccur

• Identify alternatives, de-escalation strategies and least restrictive interventions, and use these to revise the plan of care.

Patient Debriefing Tool

The purpose of this debriefing tool is to get the patient’s feedback and perspective related to a recent restraint and/

or seclusion event. In support of Ontario Shores’ proactive philosophy in care and promotion of healing and recovery, patient’s suggestions may help in preventing similar re-occurrences. This document provides the

interprofessional team involved in the event with the opportunity for continuous learning.

The following questions are to be completed in collaboration with the patient.

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1. (a) Why do you think the restraint and/or seclusion happened?

(b) Were you upset? Why?

2. (a) If you were upset, what did you do?

(b) What did staff do?

3. (a) What could you do differently when you get upset to prevent restraint and/or seclusion?

(b) What could staff do differently when you get upset to help you?

4. (a) Did you and the staff use your de-escalation preferences? Y N (b) Do we need to change it? Y N

5. Did you and the treatment team develop a plan of care to help prevent another restraint or seclusion? Y N

6. Do you have any physical complaints or injury(s) related to the restraint or seclusion? Y N If YES, describe:

7. How did the restraint or seclusion make you feel?

8. Who might be helpful for you to talk with about this experience? PPAO and/or Spiritual Care personnel are available to speak with you.

9. While you were either restrained and/or secluded, is there anything else staff could have done?

10. Is there anything else we can do now to help you recover from this incident?

□ Plan of care revised

□ Behavioural Profile Tool updated

□ PPAO notified

□ Spiritual Care

□ Other ______________

My Toolbox

Treatment Modality: Individual, group Goals

• To brainstorm positive and negative coping skills

• To develop a individualized toolbox of coping skills Materials

• Coloured cue cards 4 by 6 (construction paper or Bristol board)

• Envelopes (mid-size)

• Markers

• Scissors

• Worksheets – “Examples of Alternative Activities” and “Distraction Techniques”

Advance Preparation

• Cut out several different color cue cards from the construction paper or Bristol board

• Photocopy worksheets for each patient

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Description

• Begin the group by introducing the topic of “My Toolbox”

and discussing the importance of coping skills. Then brainstorm with the patients, positive and negative coping skills that they may already use to make themselves feel better.

• After the brainstorming, give out the worksheets to each patient and explain that the worksheets are to give more examples of positive coping skills.

• The next task is to handout the envelopes (My Toolbox) and have each patient decorate the outside of the envelope with there name and pictures of coping tools or things that make them happy. Then handout the cut out coloured cue cards, and have each patient pick a few colors each that will represent different moods or emotions and write a coping skill to help manage that mood or emotion. Use the worksheets or come up with own coping skills that work well for each individual and write them on the cue cards.

Discussion

The idea of this group is to have each patient develop a Toolbox of “Coping Cards” to take away from the group.

Each patient will keep their Toolbox envelope, so they can make reference to it when they are struggling with a

distressing thought, mood or feeling.

(Daniella Battaglia – CYW Student)

Alternative Strategies to Restraints/

Seclusion Checklist

• Assess patient behaviour

• Explore etiology of behaviour

• Explore meaning of behaviour

• Assess needs (HALT – Hunger, Anger, loneliness/

boredom, Tired/sleep pattern)

• Unmet needs have been identified with strategies developed to address and support patient’s needs

• Collaborate with team/patient/SDM/family to identify de- escalation preferences

• Attempt de-escalation preferences as clinically indicated

• Behavioural Profile Tool has been initiated to document identified:

• Unique behavioural patterns

• Antecedents to specific behaviours

• De-escalation preferences

• Alternative strategies

• Intervention to prevent & manage specific behaviours

• Clear plan of care documented and communicated to the interprofessional team

• Implement alternative strategies/interventions proactively in care (ie. part of daily routine incorporated in plan of care)

• If imminent risk of harm to self or other is present,

consider least restrictive methods for the shortest duration of time

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• Implement alternative interventions (ie. medication, comfort measures increase/decrease social interaction, relaxation techniques) when in restraints/seclusion

• Reassess need for least restraint – de-restraining, transitioning from mechanical restraints to seclusion to trialing out of seclusion

• Trial new alternatives

• Debrief with patient when clinically indicated

Alternative Activities Arts and entertainment

• Make a puzzle

• Watch TV or a movie

Relaxation, meditation and spirituality

• Engage in spiritual practices, such as prayer, meditation or religious reflection

• Practice relaxation and breathing exercises, or meditation Environmental

• Spend quiet time room, or scheduling daily naps/rest periods

• Spend time in a comfort room

• Spend time in the chapel, worship room or library Sensory stimulus

• Have a warm or cold shower

• Listen to relaxing music

• Use ice or a cold face cloth on body

• Use a weighted blanket

• Play with a stress ball

• Massage hands with preferred essential oils or creams Movement

• Walk in the halls

• Clean room or do chores

• Punch a pillow

Supportive conversations/engagements

• Create a safety plan with interprofessional team

• Talk to or sitting/walking with a clinician, peer support specialist or spiritual care worker

• Call a friend or family member for calming support

• Discuss ways to reduce smoking, such as nicotine replacement therapy

Reading and writing

• Write in a journal

• Read a book, magazine or newspaper Social

•Participate in group activities or therapeutic group sessions

• Play cards, board games or video games

Suggested Alternatives Interventions Related to Agitated, Aggressive or Cognitively Impaired Presenting Behaviours

• Mobility/ambulation/exercise routine

• Increase/decrease social interaction

• Involve family in planning care • Diversion activities:

pets, puzzles, music, crafts, cards, snacks

• Label environment i.e. bathroom door

• Gentle touch

• Reminiscence

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• Night light

• Glasses, hearing aids, walking aids easily available

References

American Psychiatric Association, American Psychiatric Nurses Association, & National Association of Psychiatric Health Systems (2003). Learning from each other: Success stories and ideas for reducing restraint/seclusion in behavioural health.

Centre for Addication and Mental Health (2011).Alternatives to Restraint & Seclusion. Ontario, Canada.

Duxbury, J. (2002). An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental heatlh unit: A pluralistic design. Journal of Psychiatric and Mental Health Nursing , 9, 325-337.

Duxbury, J. A., Bjorkdahl, A. & Johnson, S. (2006). Ward culture and atmosphere. In Richter, D., and

Whittington, R. (eds) Violence in Mental Health Settings. Causes, Consequesces, Management.

New York: Springer.

Duxbury, J. A. & Whittington, R. (2005). Causes and management of patient aggression and violence:

Staff and patient perspectives. Journal of Psychiatric and Mental Health Nursing, 50 (5), 469-478.

Gelkopf, M., Roffe, Z., Behrbalk, P., Melamed, Y., Werbloff, N., & Bleich, A. (2009). Attitudes, opinions,

behaviors, and emotions of the nursing staff toward patient restraint. [Review]. Issues in Mental Health Nursing, 30(12), 758-763.

Johnson, M. E. & Hauser, P. M. (2001). The practices of expert psychiatric nurses: Accompanying the patient to a calmer personal space. Issues in Mental Health Nursing, 22(7), 651-668.

Mildred, L. (2002). Seclusion and restraints: A failure, not a treatment. California Senate Office of Research.

NASMHPD/National Executive Training Institute (2009).

Training curriculum for reduction of seclusion and restraint. Draft curriculum manual. Alexandria, VA:

National Association of State Mental Health Program Directors (NASMHPD), National Technical

Assistance Centre for State Mental Health Planning (NTAC).

Oades, L., Deane, F., Crowe, T., Lambert, G., Kavanagh, D., & Lloyd, C. (2005). Collaborative recovery: An integrative model for working with individuals who experience chronic and recurring mental illness.

Australasian Psychiatry , 13 (3), 279-84.

Registered Nurses Association of Ontario (2012).

Promoting Safety: Alternative Approaches to Use of Restraints. Nursing Best Practice Guidelines.

Ontario, Canada.

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Sailas, EES., & Fenton, M. Seclusion and restraint for people with serious mental illness (Review).

Cochrane Database of Systematic Review, 2009, Issue 3. DOI: 10.1002/14651858.CD001163.

Snyder, B. S. (2004). Preventing treatment interference:

Nurses’ and parents’ intervention strategies.

Pediatric Nursing, 30 (1), 31-40.

The Ottawa Hospital (2010). Least Restraint Last Resort Policy. Ontario, Canada.

Austin J., Carr J.E. (Eds.) (2000). Handbook of applied behaviour analysis: Functional analysis model of behavioural assessment. CA: Context Press

Williams L.W. (Eds) (2004). Developmental disabilities etiology, assessment, intervention, and integration:

Inovation in functional behaviour assessment. CA:

Context Press

Cooper J.O., Heron T.E., Heward W.L. (2007) (Eds) Applied Behaviour Analysis: Functional Behaviour assessment (2nd ed.) Upper Saddle River, NJ:

Pearson Prentice Hall

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Tel: 905-430-4055