restraint reduction through sensory modulation
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Restraint Reduction through Sensory Modulation
Caitlin Belvin MS, OTR/L
Colleen M. Glair PMHCNS-BC
+ Background The American Nurses Association promotes registered nurse
participation in reducing patient restraint and seclusion in
health care settings. Restraining or secluding patients either
directly or indirectly is viewed as contrary to the fundamental
goals and ethical traditions of the nursing profession, which
upholds the autonomy and inherent dignity of each patient
(ANA, 2012).
Regulatory standards from The Joint Commission require staff to
be able to demonstrate strategies to identify staff and patient
behaviors, events, and environmental factors that may trigger
circumstances that require the use of restraint or seclusion as
well as the use of nonphysical intervention skills (TJC, 2010).
Given the safety, ethical, professional, regulatory, and legal
standards related to reducing restraint, it is imperative that
alternative, evidence based strategies be employed throughout
our health care settings.
+ Seclusion and Restraint Reduction
through Sensory Modulation
This requires a culture shift!
National Executive Training Institute Seclusion and Restraint
Reduction Initiative (2003-present)
6 Core Strategies (EBP)
Trauma Informed Care
Recovery Model
Why Sensory Modulation?
MA State Initiatives
http://www.mass.gov/eohhs/gov/departments/dmh/restraintse
clusion-reduction-initiative.html
International Initiatives
http://www.tepou.co.nz/initiatives/sensory-modulation/103
+ 6 Core Strategies
Leadership toward organizational change
Use of data to inform practice
Workforce development
Use of seclusion and restraint prevention tools
Full inclusion of service users and families
Debriefing
(USDHHS, 2003; NASMHPD 2003-present).
+ The experience of being human is
embedded in the sensory events of our
everyday lives.
-Dunn, 2001
+ What is Sensory Modulation?
“The capacity to regulate and organize the degree, intensity,
and nature of responses to sensory input in a graded and
adaptive manner to achieve and maintain an optimal range of
performance and adapt to challenges in daily life”
(Miller, Reisman, McIntosh, and Simon, 2001, p. 57)
Ability to self-regulate or adapt one’s responses to sensory and
motor stimulation in an adaptive manner.
Self-regulation is the ability to attain, maintain, and change
one’s arousal level for a task or a situation.
It allows us to function and feel comfortable in different situations
and environments.
This approach involves providing sensory based therapy
tools or creating appropriate environments that engage the
user’s senses for emotional regulation to reduce the build up
of agitation and prevent the escalation of aggression.
+ The Sensory Connection to
Behavior
Our senses give us information about the physical experiences of our body and our environment. Activities that involve the senses can help us change our mood or state of being.
All of us have unique system tendencies and preferences we use to self-organize. This is why it is essential that we build engaging relationships with our patients to better understand their sensory needs.
A person may need to do something to “regulate” their level of alertness by introducing something that is perceived by that person as calming or alerting.
+ Sensory Systems
Vision
Hearing
Taste
Smell
Touch
Oral Motor
Vestibular (Balance)
It’s our personal GPS telling us
where we are in time and
space.
Proprioceptive (Kinesthesia)
A sense of one’s own body and
body movements provided by
the muscles and joints.
Deep Pressure Touch
External Senses Internal Senses
+ Sensory Input can be Calming or
Alerting
Helpful when we are
stressed, anxious, or
need to relax.
Slow
Soft
Familiar
Simple
Repetitive
Rhythmic
Positive Associations
Helps to energize us or
increase our ability to
pay attention.
Fast, quick paced
Loud
Novel
Complex
Unexpected
Non-rhythmic
Pronounced
Calming Alerting
+ Reviewing the Senses
Soothing scented candle
(vanilla, lavender)
Mild fragrances
Herbal teas
Scented bath powder or
shower gels
Scented Lotions
Cedar filled pillow
Positive associations
Candles with crisp strong scent
(lemon or peppermint)
Strong fragrances
Perfume
Noxious odors
Room fragrance spray
Citrus scents
Negative Associations
Calming Alerting
Olfaction
+ Reviewing the Senses
Mild
Sweet
Chocolate
Sweet fruits like apples and grapes
Pleasant tastes
Chicken noodle soup
Herbal teas
Oatmeal and brown sugar
Spicy
Sour candy
Bitter
Strong peppermints
Distasteful foods
Lemonade
Pickles
Coffee
Calming Alerting
Taste
+ Reviewing the Senses
Sucking or resistive
chewing
Hard candy
Thick liquid through a
straw
Sweet orange slices
Lollipops
Chewing gum
Crunchy
Popcorn
Pretzels
Raw vegetables
Cereal
Crushed Ice
Calming Alerting
Oral Motor
+ Reviewing the Senses
Soft colors
Dim lighting
Natural Lighting
Watching fish in an
aquarium
Bubble lamps
Serene paintings
Clean and sparsely
finished room
Bright Colors
Bright lighting
Flashing lights
Modern Art
Video games
Messy and cluttered room
Calming Alerting
Vision
+ Reviewing the Senses
Soft and slow music
Quiet
Familiar sounds
Humming
Singing quietly
Repetitive or rhythmic sounds
(drum beat)
Nature sounds
Meditation tapes
Loud noises
Rock music
Fast tempo or offbeat
Fire alarms
Thunder
Whistling
Changing sounds (city streets)
Hand held instruments
Calming Alerting
Auditory
+ Reviewing the Senses
Firm touch on shoulder
Using a heavy quilt or weighted blanket
Neutral warmth
Squeezing a stress ball
Foot roller
Use of hand lotions
Beanbag tapping
Massage
Unexpected touch
Light touch
Feeling something prickly
or squishy
Cool room
Use of “fidgets”
Snapping a rubber band on
wrist
Use of ice
Calming Alerting
Touch
+ Reviewing the Senses
Slow and rhythmic
Sustained
Joint compression or isometrics
Weight lifting or sports
Yoga, Tai Chi, or stretching
Walking
Gardening
Pushing heavy objects or adding
weight
Quick
Jarring
Jerky
Jogging
Aerobics
Boxing
Jumping Jacks
Calming Alerting
Proprioceptive
+ Reviewing the Senses
Rocking
Swinging
Stable
Slow
Using a glider chair or
rocker chair
Walking
Pacing
Jogging
Fast Dancing
Movement Activities
Spinning quickly
Bouncing
Jumping
Calming Alerting
Vestibular (Balance)
+ When is calming needed?
Physical Signs
Tense posture
Fidgeting
Increased
breathing
Increased heart
rate
Sweaty palms
Increased
energy
Hyperactivity
Sleeplessness
Emotional Signs
Anxiety
Agitation
Euphoria
Anger
Mania
Over excitation
Fear
Panic
Overwhelmed
Behavioral Signs
Hyper-vigilant
Intrusive
Noisy
Disruptive
Frustrated Easily
Over active
Distractible
Poorly self-
controlled
+ When is alerting needed?
Physical Signs
Low energy
Slouched posture
Lethargy
Sleepiness
Emotional Signs
Sadness
Hopelessness
Numbness
Discouragement
Feeling suicidal
Having flashbacks
Trouble with
disassociation
Behavioral Signs
Lack of interest
Withdrawal
Pre-occupation
Self-injurious
behaviors
Poor orientation
+ Sensory Diet
Menu of strategies that are strategically integrated into daily
routines to support health, wellness, and the recovery
process.
Includes prevention and de-escalation focused interventions
“Each person’s sensory diet is an important self-organizing
concept and needs to be considered in the identification of
individual crisis prevention strategies for use at critical
times” (Champagne, 2003).
For example, if an individual wishes to watch a relaxing video
tape at night to prepare for sleep but is prohibited from doing so
by institutional rules, he or she may experience increased
agitation or distress. If these needs are understood as part of the
individual’s sensory diet and as self-organizing activities, options
can be made available” (Champagne and Stromberg, 2004).
+ Individual Sensory Preferences
and Diet How do your own sensory preferences influence your actions
and relationships with others?
Self-awareness of our own patterns and habits helps us better
understand how we respond to people, life situations, and
our environment.
What is calming or alerting to you?
What is your ultimate work or home setting?
Quiet? Dark? Music?
What is a part of your personal “sensory diet” that you use
daily in response to stressful life situations and events?
+ Common Sensory Issues in Mental
Health Patients
People with mental illness may experience hyper or
hypo sensitivity to particular sensations including
touch, light, noise, and vestibular input.
How does this impact our patients?
Strong clothing preferences or avoidances.
Aversion to showers.
Discomfort with surprise touch (hugging, hand shaking).
Poor balance.
Sensitivity to visual stimuli like bright lights and contrast.
Distracted when other people are talking.
Sensitivity to loud noises or sounds.
Extreme food preferences.
Difficulty learning new skills.
Discomfort in crowded places.
Frequently feeling anxious/tense.
Need to maintain own space.
Avoiding routine medical procedures (shots, dentist).
+ Promoting Recovery
Building the capacity for:
Increased Resiliency
Development
Occupational Participation
Health and Wellness
Quality of Life
Gives patients a concrete strategy to help themselves in the
future, not just a temporary fix with PRN medication.
Allows staff to develop a therapeutic rapport and helps foster a
sense of safety and containment in the physical environment.
+ Trauma Informed Care
Collaborative care that recognizes the high prevalence and
pervasive impact of trauma and attachment-related
difficulties within their client population and provides care
that addresses the whole system (person, family,
organization) to help support the recovery process.
(Champagne, 2008, 2011a, 2011b, 2012)
Appreciation for the high prevalence of traumatic
experiences among consumers
An understanding of the profound neurological, biological,
and social effects of trauma and violence.
Care that recognizes and addresses trauma-related issues, is
collaborative, supportive, and skilled.
(NASMHPD, 2003-present)
+ Trauma Informed vs. Non-trauma
informed Care
Staff understands the
function of the behavior
(self-injury, rage,
compulsions)
Objective, neutral language
Recognition of culture and
practices that are re-
traumatizing
Power/control issues
minimized-constant
attention to culture of care
and individualized
approach
Most behavior seen as
intentionally provocative
(attention seeking)
Labeling language
(manipulative, needy,
attention-seeking)
“Tradition of toughness” or
primarily a behaviorist
approach valued as best
care approach
Rule enforcers- compliance
focused
Trauma Informed Non-Informed
+ Ourselves: the Caregivers
Identify our own sensory, trauma, and attachment
experiences.
Seek assistance as needed.
Create our own sensory supports and tool kits.
Consider your schedule (how many patients with
severe emotional disturbances, etc. do you see per
day/per hour, etc).
Find ways to embed sensory based strategies into your
daily routine.
Practice, practice, practice what we preach.
+ Implementation in Behavioral
Health• A sensory modulation
program was developed
and implemented on the
inpatient behavioral health
unit in 2016. The process
utilized a team
collaborative approach
with input from patients,
nursing, occupational
therapy, quality
management, infection
control, clinical practice
committee, employee
health, environmental
services, and the
department of facilities and
engineering.
+ Results
• Results suggest that the use of sensory modulation is an effective strategy for decreasing restraint and seclusion episodes on an inpatient psychiatric unit.
• Results suggest that the use of sensory modulation is an effective strategy as in decreasing employee workplace violence related injuries and lost or restricted work days due to injury.
• Sensory modulation provided an innovative approach that strengthened the therapeutic alliance between staff and patients. This approach assisted both the provider and the patient in the utilization of the patient’s preferred crisis prevention methods which decreased the need for seclusion and restraint.
2015 2016- ytd
# Staff Injured by Patients 7 3
Lost Work Days Due to
Injury35 0
Restricted Work Duty Due
to Injury27 0
05
10152025303540
Total Number
Staff Injuries
2015-Present
1Q
2015
2Q
2015
3Q
2015
4Q
2015
1Q
2016
2Q
2016
3Q
2016
4Q
2016
1Q
2017
2Q
2017
Seclusions 19 13 5 9 8 9 4 1 7 2
Restraints 6 10 7 13 0 1 0 0 0 1
0
2
4
6
8
10
12
14
16
18
20
Number
Seclusions and Restraints
2015-2017
+ References Adkinson, L. (2012) Understanding sensory stimulation.
ANA March 12, 2012, Reduction of Patient Restraint and Seclusion in Health Care Settings, Status: Revised Position Statement Originated by: Center for Ethics and Human Rights.
APNA 2014, Position Statement: The Use of Seclusion and Restraint.
AOTA 2014, Occupational Therapy’s Role with Restraint and Seclusion Reduction or Elimination, Fact Sheet.
Chalmers, A., S. Harrison, K. Mollison, N. Molloy, and K. Gray. "Establishing Sensory-based Approaches in Mental Health Inpatient Care: A Multidisciplinary Approach." Australasian Psychiatry 20.1 (2012): 35-39. Web.
Champagne, T. (2003). Sensory modulation and environment: Essential elements of occupation. Southhampton, MA: Champagne Conferences & Consultation.
Champagne, T. (2008). Sensory modulation & environment: Essential elements of occupation. Southampton, MA: Champagne Conferences.
Champagne, T. (2011). Sensory modulation & environment: Essential elements of occupation: Handbook & reference. Sydney, Australia: Pearson Australia Group.
Champagne, T. (2015, October). Sensory Processing, Trauma & Attachment Informed Care. Lecture presented at Course 1 Sensory Modulation & Trauma Informed Care: An Introduction in MA, Hadley.
Champagne, T., & Koomar, J. (2011, March). Expanding the Focus: Addressing Sensory Discrimination Concerns in Mental Health. Mental Health Special Interest Section Quarterly, 34(1), 1-4.
+ References continued Champagne, T., & Stromberg, N. (2004). Sensory Approaches in Inpatient
Psychiatric Settings: Innovative Alternatives to Seclusion and Restraint. Journal of Psychosocial Nursing, 42(9). Retrieved March 23, 2016.
Champagne, Tina, N. Stromberg, and R. Coyle. "Integrating Sensory and Trauma-Informed Interventions: A Massachusetts State Initiative, Part 1." American Occupational Therapy Association (2010). Web.
Dunn, W. (2001) The sensations of everyday life: Empirical, theoretical, and pragmatic considerations. American Journal of Occupational Therapy, 55(6), 608-620.
Masick, April, and Jennifer Landy. "Calming Rooms: A Sense-able Alternative." VA, Fairfax. 17 June 2015. Lecture.
Miller, L. J., Reisman, J. E., McIntosh, D. N., & Simon, J. (2001). An ecological model of sensory modulation. In S. Smith Roley, E. Blanche, & R. C. Schaaf (Eds.), Under- standing the nature of sensory integration with diverse popula- tions(pp. 57–82). San Antonio, TX: Therapy Skill Builders.
Moore, K. M. (2015). The Sensory Connection Program: Curriculum for Self-Regulation. Framingham, MA: Therapro.
NASMHPD (2006). Prevention Tools: A Core Strategy. Retrieved on March 28, 2016 from http://www.nasmhpd.org/sites/default/files/Consolidated%20Six%20Core%20Strategies%20Document.pdf
SAMSHA, (2006). Roadmap to Seclusion and Restraint Free Mental Health Services. Retrieved on March 28, 2016 from http://store.samhsa.gov/shin/content//SMA06-4055/SMA06-4055-F.pdf?
TJC 2010, The Hospital Accreditation Standards. Provision of Care, Treatment, and Services. Standards PC.03.05.01 through PC.03.05.19
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