Creating Violence-Free Mental Health Settings: Changing our Cultures of Care Hogg Foundation for...

Creating Violence-Free Mental Health Settings:

Changing our Cultures of Care

Hogg Foundation for

Mental HealthTeleconference

Tuesday, April 4, 2006

Kevin Ann Huckshorn RN, MSN, CAP

National Technical Assistance Center NASMHPD

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Outline

The Development of a Curriculum to Reduce S/R Use in MH and other Settings Identification of Key ConstructsSix Core Strategies for S/R Reduction©Developing a S/R Reduction PlanTraining Activities and Next StepsClosing 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 presentQualitative Reports emerging from personal experiences (self and colleagues) with direct experiences in successful reduction projects across the countryCore 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 SpecificThe New Freedom Commission

A Call for System TransformationSystem Goal=Recovery for everyoneServices/supports are customer/family centeredFocus of care must increase service user’s ability self manage illness and build resiliencyIndividualized Plans of Care criticalConsumers 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 ModelPrimary 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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Partnerships, locus of control, life in the community, illness self-management, provision of hope

Concepts apply to adults and kids

The use of S/R is counter-intuitiveCoercive or traumatizing settings do NOT foster hope, healthy relationships, prosocial behaviors or trust (NF Commission, 2003)

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Related Developmental Theories re S/RThe 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 environmentsDisordered environments=dysfunctional skillsViolence 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 statesEffective interventions must target px in social environ (milieu) and the childTherapeutic milieus ensure safety and limit exposure to stressorsEffective 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 bewilderingWorld is punitive, judgmental, humiliating and blamingControl is external, not internalizedPeople are unpredictable and untrustworthyDefend themselves above all elseBelieve 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 itThese 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 agitationFelt they were being punishedDo not feel protected from harmFeelings 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 TraumaMental 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 TraumaMental 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 neurobiologySocial, emotional & cognitive impairmentAdoption 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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Trauma Informed Care SystemsIntegrate 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

Key Principles of TIC

(Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)

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Trauma Informed Care SystemsKey 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 FrameworkPrevention-Based ApproachContinuous Quality Improvement

Principles Individualized for the Facility or AgencyFocus 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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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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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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Organize S/R Reduction TeamAssign plan responsibilities to people, not groups

Document assignments

Manageable time frames

Sign off and monitor plan implementation

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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 UseGather baseline data by event/hours(6 m to 1 yr) to startSet realistic goalsGather event data by unit/day/shift/time/age/dx/gender/ race/individuals involved/MD/Date of AdmissionPost data on units monthly (transparency)Group outliers

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2nd Core Strategy: Use of Data

Using Data To Reduce UseMonitor 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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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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Note about S/R Application Training

Very important while reducing useSenior 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 ToolsAssess 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 InclusionInclusion-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 SpecificsDefine 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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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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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 events6 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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