DDES INFO MEMO 2005-04
April 7, 2005
TO:
County Inpatient Psychiatric Hospitals
CC:
Area Administrators/Assistant Area Administrators
County Departments of Human Services Directors
County Departments of Social Services Directors
County Department of Community Program Directors
County Mental Health and AODA Coordinators
CSP Directors and CSP Coordinators
DDES, Bureau of Mental Health and Substance Abuse Services
DDES, Bureau of Quality Assurance
Directors, DDES Mental Health Institutes
Grass Roots Empowerment Program
ISP Directors and Coordinators
Mental Health Association of Milwaukee
Mental Health Consumer Organizations
NAMI Wisconsin and Local Chapters
Trempealeau County IMD
Wisconsin Coalition for Advocacy
Wisconsin Council on Mental Health
Wisconsin Family Ties
From:
Sinikka Santala
Administrator
Re:
Promotion of Recovery and Healing within the Mental Health Treatment
Culture without the Need to Use Seclusion and Restraints in County
Inpatient Psychiatric Units/Hospitals
I. PURPOSE AND APPLICABILITY.
The purpose of this information memo is to serve as a best practice
guide for County operated inpatient psychiatric units/hospitals for the
promotion of recovery and healing within mental health treatment without
the need to use seclusion and restraint. A draft of the memo has been
shared with representatives of county inpatient psychiatric
units/hospitals and modified, based on comments received.
DDES has already taken action in its own psychiatric inpatient
facilities by issuing a DDES policy directive to Mendota Mental Health
Institute and Winnebago Mental Health Institute that are involved in the
effort to reduce and eventually eliminate the need to use seclusion and
restraint.
II. OVERVIEW.
A. Philosophy and Vision
The vision of DDES is to promote recovery and healing within the
mental health treatment culture that is free from violence and coercion.
This is accomplished through the development of partnerships with
consumers, in an atmosphere of dignity and respect. A draft of this memo
has been shared with representatives of county inpatient psychiatric
units/hospitals and modified based on comments received.
Within this philosophy, mission, vision, and values, the public
mental health system must have the goal of reduction and eventual
elimination of the need to use seclusion and restraint in treatment
settings. This requires a change in the "culture of care" that
is based upon a shared vision and values.
A team of DDES institute management and union staff, central office
staff, county hospital staff, consumers, advocates and family members
have articulated this vision. These shared values guide and direct the
actions of the administrative and treatment staff in providing active
treatment while maintaining the safety of all individuals.
We recommend that the public mental health system adheres to the
following shared core values in this effort:
- We believe in the principles and values of recovery, and the
importance of developing a culture of recovery.
- We believe that individualized treatment works and supports people
in their recovery process.
- We believe that the key to a successful treatment program is the
active collaboration between service provider and person served.
- We believe in the expectation that leadership, at every level,
sets a standard for positive interactions.
- We believe that the leadership is responsible for setting
measurable standards and providing a system for monitoring these
outcomes and offering regular feedback to staff and
patients/consumers on the progress.
- We believe staff training begins with a common understanding and
appreciation of the vision and then mastering communication skills
to develop therapeutic alliances. Our success at fostering an
environment free of violence and coercion depends on increased
understanding of patients' rights, the development of improved staff
communication skills and verbal de-escalation skills and safe
physical management techniques in situations where there is risk of
physical injury or harm.
- We believe that merely expressing anger or distress does not
require the use of a restrictive measure.
- We believe that successful reduction in the use of seclusion and
restraints requires a basic and profound respect for every
patient/consumer and caregiver.
- We believe that the use of seclusion or restraint is not
treatment.
The Wisconsin Department of Health and Family Services, Division of
Disability and Elder Services is in full support of the national trend
to reduce restrictive procedures. DDES recognizes that movement toward
restraint-free facilities involves major system changes that require
changes in values, beliefs, and practices. In furthering this effort
toward restraint-free facilities, the Division of Disability and Elder
Services is issuing this best practice guideline to county operated
inpatient psychiatric units.
B. Background
Seclusion and restraint have in the past been viewed as a therapeutic
mechanism to decrease agitation or aggression and to maintain safety in
psychiatric hospitals. The current use of seclusion and restraint is a
product of the treatment system's history in which the use of seclusion
and restraint as a safety measure was thought to be necessary and a
therapeutic technique. This belief was taught and promulgated from
teachers, colleagues, co-workers, and mentors, as staff prepared for
careers in mental health. Its use became part of the inherited culture
of mental health care.
Risks associated with the use of seclusion and restraint include, but
are not limited to: accidental death, injuries, emotional harm to staff
and consumer, disruption of the therapeutic alliance, and exposing the
consumer, his/her family and staff involved to further trauma. DDES
recognizes the use of seclusion and restraint is a reflection of this
historical, but limited model and culture of care, based on the
erroneous belief that the use of restrictive procedures are therapeutic
and has therapeutic value.
Overcoming this cultural acceptance of seclusion and restraint as
part of the treatment process can be the biggest obstacle in reducing
the use of these procedures. Facilities that have been successful in
reducing and eliminating the use of seclusion and restraint have
recognized and addressed this cultural change as the first step in
accomplishing the goal. In recent years, Wisconsin has been involved in
a national movement toward the reduction in the use of seclusion and
restraint in health care facilities.
III. PROCEDURES.
STRATEGIES FOR CREATING HEALING/THERAPEUTIC ENVIRONMENTS THAT RESULT
IN THE REDUCTION AND EVENTUAL ELIMINATION OF THE NEED OF SECLUSION AND
RESTRAINT
A. CONCEPTUALIZING CHANGE IN PRACTICE - THE PUBLIC HEALTH MODEL
Those states that have been very successful in reducing the use of
seclusion and restraints have adopted the public health model as a
strategy. The Public Health Model is a three-stage model of disease
prevention and includes a health promotion focus. Stage one, primary
prevention includes interventions aimed at preventing and reducing the
need for seclusion and restraint. Stage two, secondary prevention
includes early interventions designed to minimize and quickly resolve
conflicts if they occur, using the least restrictive method possible to
avoid the use of seclusion and restraint. Stage three, tertiary
prevention includes those interventions that attempt to repair harm and
minimize the negative effects when seclusion or restraint is used. The
health promotion aspect of the Public Health Model includes the
collaborative development of healthy coping skills.
The process of change is conceptualized to include leaderships'
responsibility to provide the education, training, experience, and tools
necessary for staff to provide and maintain coercion and violence free
environments.
B. PRIMARY PREVENTION
1. LEADERSHIP AND ORGANIZATIONAL CULTURE CHANGE
Leaders create culture and it is their responsibility to change it.
Organizational culture refers to the basic values, norms, beliefs, and
practices that characterize the functioning of an institution. At the
most basic level, organizational culture defines the assumptions that
employees make as they carry out their work, it defines "the way we
do things here." Culture is a powerful force that can persist
through reorganizations and the change of essential personnel. It can be
a positive or a negative force.
Leadership, not direct care staff, is responsible for the
organization's use of seclusion and restraint. Leadership has the
authority to make the changes necessary for success by making seclusion
and restraint reduction a high priority, reducing or eliminating
organizational barriers, providing the necessary resources, and holding
people accountable for their actions. The role of leadership is the most
important component in a successful seclusion and restraint reduction
initiative.
To reduce the use of seclusion and restraint, leadership defines,
communicates, the vision, values, and implements an action plan. This
begins with re-characterizing the use of seclusion and restraint as a
crisis, a high-risk and problem-prone intervention, which can be
dangerous for patients/consumers and staff. The use of seclusion and
restraint is a risk management and performance improvement issue,
requiring daily specific executive oversight.
Leadership addresses the organizations culture issues based upon the
most profound respect and belief that recovery is possible. Leadership
establishes a positive culture of healing, characterized by tolerance,
listening, empathy/compassion, respect, safety, trust, and cultural
competence. A positive culture of healing is established and maintained
through empowered professionals, collaborative and participatory
relationships, patient/consumer rights, and staff engagement in support
of the patient/consumer's recovery.
Lastly, leadership must consolidate and institutionalize the changes
and approaches, while reinvigorating the seclusion and restraint
reduction initiative with new projects, themes, and change agents.
Credibility of the initiative is achieved by changing systems,
structures, and policies that do not fit the vision, while hiring,
promoting, recognizing and developing employees that can implement the
vision.
2. BUILDING THERAPEUTIC ALLIANCES
DDES recognizes that relationships between the consumer and direct care
staff ultimately makes the biggest difference for developing an
environment where a positive culture of healing can flourish. The goal
is to influence consumers' beliefs, values and trust that recovery is
possible. It is believed that when staff exhibit genuine hope and a
belief in the recovery of patients/consumers, it can be a critical
ingredient toward the person's improvement.
The therapeutic impact of the direct care staff depends upon the
therapeutic relationship, therapeutic alliance, and specific therapeutic
skill sets. Therapeutic relationships involve a caring, respectful
relationship between the consumer and direct care staff, in which staff
maintains appropriate boundaries while supporting the consumer toward
recovery. A therapeutic alliance involves the focused use of the
therapeutic relationship in collaboration with the consumer, to help the
person identify and achieve individualized treatment goals, improve
socialization and support recovery. Therapeutic skill sets are tools
used by direct care staff to engage, motivate, support, problem solve,
and de-escalate the consumer.
Direct care staff achieves a therapeutic alliance by using
comprehensive individualized information about each consumer, strength
based mindset, and strength based actions. A strength-based mindset
requires that leadership supports the direct care staffs' sense of
mission, self, professionalism, and awareness of their influence on
consumers. Direct care staff may not be aware of how strong an impact
their interventions and responses, both positive and negative, actually
have on consumers.
A strengths-based mindset uses specific means to achieve and maintain
a therapeutic relationship. This includes, but is not limited to, active
listening, seeking clarification, conveying respect, offering empathy,
and being genuine, accessible, and non-intimidating. Strength-based
mindsets support consumers' interests and strengths, while positively
supporting consumer efforts at coping and learning. Strength-based
orientation uses a balanced recognition of strengths to motivate and
mobilize. Direct care staff restores hope and a sense of efficacy,
employing on-going attention to the treatment plan and using regular,
respectful feedback to the consumer. Direct care staff also requests
feedback from the consumer, and uses this feedback to learn and improve.
A strength-based action set employs the therapeutic use of self to
engage, know, support, model, mentor, and instill hope. This action set
encourages, motivates, and draws upon teachable moments to assist
consumers in attaining treatment goals, learn coping skills, and improve
their quality of life. Using a consumer's own words, whenever possible,
direct care staff emphasizes self-determination through collaboration.
The language of hope is used to convey belief and expectation for
positive change. Strength-based actions avoid shaming, blaming, or
comparing consumers.
3. TRAUMA INFORMED CARE
DDES supports the use of trauma-informed mental health care based upon
the latest research literature. Trauma-informed care, grounded by a
thorough understanding of the neurological, biological, psychological
and social effects of trauma and violence, provides direction for mental
health care. This care, informed by research and evidence of effective
practice, recognizes that coercive interventions can cause
traumatization and re-traumatization and are to be avoided.
Features of trauma-informed mental health care includes recognition
of high rates of Post Traumatic Stress Disorder (PTSD) and other
psychiatric disorders related to trauma exposure in people with serious
mental illness. Routine trauma assessment and diagnostic evaluation with
consideration of trauma is especially important to be completed for
people with complicated treatment resistant illnesses. There is
recognition that coercive mental health treatment environments are
traumatizing, both overtly and covertly. The majority of mental health
staff need much more information about trauma and its consequences in
order to recognize it and treat it. Leadership must be responsible for
provision of training to increase awareness about re-traumatizing
practices used intentionally or unintentionally among staff, and in
assessment and treatment of people with trauma histories. Leadership
also develops or revises policies to assess and treat people with trauma
histories, to avoid and eventually eliminate re-traumatizing practices.
4. CONSUMER ROLES
DDES encourages using consumers in roles such as providing peer support,
being a peer advocate or a peer mentor. Consumers in various roles can
provide support from the experiential perspective and offer unique
insights into the process of recovery. Self-help, peer support, and
self-advocacy are components of wellness and recovery and provide
opportunities for consumer involvement. Other opportunities for
consumers include operating a drop-in center and providing wellness
education and recovery programs. It is the position of DDES that
superior services can be provided when patients/consumers are helped to
find appropriate peer support. Consumers have an important role in
changing an organizational structure away from control and maintenance
to one based in recovery, choice, and successful living.
5. DATA TO INFORM
Data is used to measure progress toward seclusion and restraint
reduction, inform practice, and positively recognize incremental
achievements for both treatment teams and patients/consumers. It is used
to motivate, encourage, and support change, when provided in a timely
manner. It is critical for leadership to actualize the culture change,
to "walk-the-talk", of a positive culture of healing and
recovery and to measure progress achieving this.
6. RISK ASSESSMENT
The purpose of risk assessment is to identify individuals or situations
that may be more prone to anger, aggression or violence, as well as
recognizing the physical and behavioral signs of impending aggression or
violence. Risk assessments assist staff with identifying effective
preventive interventions, while avoiding violence and coercive measures.
In assessing risk, consideration is given to using a combined clinical
judgment and statistical (rating scale). Current research suggests a
structured clinical judgment and an assessment tool, focusing on the
most well documented risk factors, is a promising approach to
identifying risks of aggression or violence.
7. HEALTH PROMOTION
There is another side of the public health model, in addition to
prevention, which is health promotion. Health promotion teaches and
provides practice in health behaviors and alternatives skills to replace
old problematic behavior patterns. Health promotion includes, but is not
limited to, healthy living, health behaviors, developing self-esteem
skills, healthy relationship skills, spirituality, and developing
expressive and artistic skills. The goal is health promotion for the
whole person.
C. SECONDARY PREVENTION
1. TRAUMA INFORMED TOOLS
Trauma-informed tools, are a set of secondary prevention tools designed
to avoid or mitigate trauma and re-traumatization in treatment
environments. This includes, for example, therapeutic communication
strategies and the recognition and reduction of overt/covert coercion.
Another example is providing a formal, trauma-sensitive, training
program in advanced de-escalation skill development. De-escalation
preference tool is a personalized crisis plan used to help the consumer
during the crisis to avoid the need to use seclusion or restraints.
2. DISPUTE MEDIATION/RESOLUTION
Dispute mediation/conflict resolution is a continuum of processes which
begins at the point when a potential problem is identified and extends
through resolution using non-violent means. Within a mental health
environment dispute mediation skills, once mastered, allow direct care
staff to diffuse escalated situations more quickly. Institutes are
encouraged to use these conflict resolution processes that assist in
resolving disputes between staff, between staff and consumers, and
between consumers. Provision of training in mediation skill development
for staff and consumers, along with the development of a specialized
Dispute Mediation and Resolution Crisis Team, is highly encouraged.
3. PHYSICAL ENVIRONMENT TOOLS
Physical and environmental modifications and tools have an important
role in secondary prevention. Physical and environmental modifications,
made with consideration to the consumers served, include sensory
modification rooms and comfort rooms. Sensory modulation rooms assist
consumers to regulate the degree, intensity, complexity, and nature of
responses to sensory input. Comfort rooms are designed to provide
sanctuary from stress and/or provide the consumer a place to experience
feelings within acceptable boundaries.
D. TERTIARY PREVENTION
1. ADMINISTRATIVE REVIEW
Administrative review is the process of elevating every seclusion and
restraint event 24-hours a day, 7-days per week. This involves
significant organizational changes in the level and importance of
oversight, accountability, communication, and follow-through of every
seclusion and restraint event.
Direct care Registered Nurses are expected to report every seclusion
and restraint event to the Supervisor. The Supervisor leads an acute
post-event analysis, gathers information, documents an event on a
timeline, and interviews the charge RN, other involved staff, and the
consumer. The Supervisor, after the fact gathering or
"mini-root-cause-analysis" notifies the assigned Executive
Staff Member with the information. The Executive Staff then calls the
Unit RN for any additional information or clarification. The Supervisor
sends the written report to the Executive Staff where the situation is
reviewed, patterns identified, and changes suggested and discussed with
the treatment team.
The goal of the Administrative Review is to increase the visibility
of seclusion and restraint events, evaluate policies, procedures, unit
rules, guidelines, and practices, that contributed to a situation, which
escalated into seclusion and restraint, and to make necessary changes.
The Administrative Review also identifies opportunities for staff
training or re-training by noting patterns of increase in seclusion and
restraint use by certain staff or groups of staff. While training or
retraining is the preferred intervention, continued disregard or
unwillingness to adopt the new philosophy by any staff member results in
leadership action to address the employee's performance problem.
2. DEBRIEFING (Post Event Evaluation)
Debriefing is a stepwise tool designed to rigorously analyze a critical
event like seclusion/restraint, to examine what occurred, and to
facilitate an improved outcome next time. This could include the
improvement in managing the events as they unfolded, or methods to avoid
the event. The process of debriefing also provides an opportunity to
assess the traumatic aspects of seclusion/restraint, how consumer and
staff involved were affected and to identify any follow-up needed for
either consumer or staff.
There are two types of debriefing. The first is an immediate
"post-event" debriefing that includes a consumer interview.
The focus of the "post-event" debriefing is survival, safety,
security, returning to a pre-crisis milieu, and communication with
administrative staff. There is a need for emotional support for the
consumer directly involved in the situation, the staff, and consumer
observers of the situation. The second type is a "formal
debriefing" the next working day, which includes the consumer and
member of the treatment team. The goal of "formal debriefing"
is to identify clinical interventions for effective primary or secondary
prevention of the situation. The results of both "post-event"
and "formal debriefing" are used to consider revisions or
changes to the treatment plan, treatment planning procedures,
policies/procedures, staff training, staff competencies/skills, unit
milieu/environment, staffing patterns, and/or communication procedures.
III. CONCLUSION
It is the Division of Disability and Elder Services belief that
seclusion and restraint are not treatment, they are not therapeutic, and
they reflect a failure of the therapeutic alliance between consumers and
staffs. The goal of DDES is to emphasize the prevention of situations
giving rise to crisis, and when they do occur, the crises are
therapeutically de-escalated and evaluated. In those situations where
seclusion/restraint have been used, there is a critical need debrief and
analyze events that occurred so they can be prevented in the future.
DDES recognizes and supports the changing standards of care, which
focuses on the prevention, reduction, and eventual elimination of the
need to use seclusion and restraint.
CENTRAL OFFICE CONTACT:
Vaughn Brandt
Client Rights Office
1 West Wilson Street, Room 850
P.O. Box 7851
Madison WI 53707-7851
Phone: (608) 266-9369
FAX: (608) 266-2579
E-mail: brandv@dhfs.state.wi.us
MEMO WEB SITE:
http://dhfs.wisconsin.gov/partners/local.htm
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