Reducing the Use of Restraints

Reducing the Use of Restraints
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Overview

This toolkit is focused on reducing the use of restraints and preventing the deliberate inappropriate use of restraints for people in care.  

Placing a person in a restraint puts the person and staff member at risk of trauma, injury, and even death.  According to one study, between 50 to 150 people die each year in the United States as a result of seclusion and restraint practices.  Furthermore, injury rates to staff in mental health settings where seclusion and restraint are used have been found to be higher than injuries that are sustained by workers in high-risk industries including lumber, construction and mining. Medical providers now recognize that placing a person in care in a restraint can be highly traumatic and often works against the model of trauma informed care.  While crisis management programs support the use of restraints when absolutely necessary, restraints are commonly used to address loud, disruptive, resistant behavior and can originate from a power struggle between a person in care and staff.

The Issue

The Medical Director’s Council of the National Association of State Mental Health Program Directors (NASMHPD) have deemed the use of restraint as a “treatment failure,” and recommend a focus on preventing the use of restraint and seclusion.  Given the risks associated with restraints for everyone involved, it is important to aim to find safe alternatives for de-escalating and preventing a crisis.  

Despite the availability of these crisis management programs, the Justice Center has received numerous reports of incidents involving a person in care being subjected to a deliberate, inappropriate use of a restraint.  A deliberate, inappropriate use of a restraint is defined in NYS Social Services law.  It means the technique or amount of force used, or situation in which the restraint was used was inconsistent with a person’s treatment plan, generally accepted treatment practices and/or applicable state laws, regulations or policies except when the restraint is used as a reasonable emergency intervention to prevent imminent risk of harm.v  Restraint is defined by statute as any manual, pharmacological or mechanical measure or device used to immobilize or limit the ability of a person to freely move their arms, legs or body.  

The Justice Center analyzed two and half years of data on substantiated cases of deliberate inappropriate use of restraints to identify the factors contributing to this form of abuse, and to identify strategies to prevent it.  

The areas analyzed included: 

  • precipitating factors leading to the restraint,  

  • time and location of the restraint,  

  • demographic information on the person in care and staff member(s) including length of employment of the staff, and  

  • injury and/or impact of the restraint on the person in care.   

The associated article is available for download in the Toolkits section below.  It includes an analysis of data of reports made to the Justice Center, as well as benefits of reducing the use of restraints identified by programs. Look for Reducing the Use of Restraints Article.

 

Case Studies

These case reviews involve fictitious victims and represent a collection of facts identified from multiple case investigations. They are used for illustrative purposes only.

Case #1
Issues:
• Power and control
• Staff member escalation

Case Description
Jacob, a nine-year-old in care, had more than the three books that were allowed in his room. Kyle, a staff member, told Jacob he could not have that many books. Jacob became upset and said that he needed the extra books for school. A supervisor intervened and Jacob eventually put some books in the storage room. Kyle began to antagonize Jacob, making comments about Jacob’s mom and further escalating the situation by verbally threatening Jacob. Jacob pushed Kyle away and carried his books back to his room. Kyle followed Jacob and initiated a restraint.
After the incident, Jacob reported that he was frustrated and confused and said he could not believe staff treated him this way because he wanted more books. Jacob stated he felt fearful during the verbal exchange with Kyle.

Problem Solution
Rules in place that are inflexible do not reflect rules people follow in everyday life leading to tension between staff and people in care. Allow staff to adjust their approach to help prevent hostile or dangerous situations.
Staff did not use prevention or de-escalation techniques. Retrain staff on how to prevent triggering people in care and use de-escalation techniques.
Staff engaging in behaviors like verbal antagonism, which results in increased likelihood of usage of a restraint. Avoid all un-therapeutic interactions that might trigger a person in care.

 

Additional case studies are detailed in the article available in the Toolkits section below. Look for Reducing the Use of Restraints Article.


 

What You Can Do

Partners in Prevention
Agencies Staff People in Care, Advocates, Families and Friends
Establish a mission statement emphasizing a safe and therapeutic environment that promotes positive behavioral supports and alternatives to restraint. Know the agency’s restraint reduction goals. Become educated on the specific restraint techniques the agency is approved to use.
Provide comprehensive employee orientation with clear and concise written guidance for easy reference once on the job. Remain up to date on all behavior plans for people in care.

Ask about the agency’s process for developing support plans: How often are support plans reviewed and updated? Do people in care, family members or advocates have input in the development of the support plan, treatment goals, or other treatment guidance?

Provide annual refresher trainings on the health and safety risk associated with conducting restraints.

Keep a clean and organized environment.

Ask about the agency’s practices regarding their process for reducing the use of restraints.

Foster a trauma informed care environment that includes staff exercising flexibility with applying rules to prevent a person from going into crisis.*

Maintain a self-awareness of personal triggers that are counterproductive to treatment and may contribute to an inappropriate restraint.

 

Foster an environment which supports open communication between staff and people in care while maintaining healthy boundaries.

Attend all required trainings on crisis prevention and restraints.

 

 

Additional suggestions on how to reduce restraints is available in the article located in the Toolkits section below.

 

Toolkit Resources

Reducing the Use of Restraints for People in Care Toolkit Resources

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    Reducing the Use of Restraints Article

    Article details the factors behind the need for reducing the use of restraints for people in care.  Includes Justice Center analysis of available data, case reviews, lessons learned, as well as what an individual can do about the problem.

     

    Download