+ 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 External Senses Internal Senses 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
+ Sensory Input can be Calming or Alerting Helpful when we are stressed, anxious, or need to relax. Slow Soft Familiar Simple Repetitive Rhythmic Calming Positive Associations Helps to energize us or increase our ability to pay attention. Fast, quick paced Loud Novel Complex Alerting Unexpected Non-rhythmic Pronounced
+ Reviewing the Senses Olfaction Soothing scented candle (vanilla, lavender) Mild fragrances Herbal teas Calming Scented bath powder or shower gels Scented Lotions Cedar filled pillow Positive associations Candles with crisp strong scent (lemon or peppermint) Strong fragrances Perfume Alerting Noxious odors Room fragrance spray Citrus scents Negative Associations
+ Reviewing the Senses Taste Mild Sweet Chocolate Sweet fruits like apples and grapes Pleasant tastes Chicken noodle soup Herbal teas Calming Oatmeal and brown sugar Alerting Spicy Sour candy Bitter Strong peppermints Distasteful foods Lemonade Pickles Coffee
+ Reviewing the Senses Oral Motor Sucking or resistive chewing Hard candy Thick liquid through a straw Sweet orange slices Lollipops Calming Chewing gum Alerting Crunchy Popcorn Pretzels Raw vegetables Cereal Crushed Ice
+ Reviewing the Senses Vision Soft colors Dim lighting Calming Natural Lighting Watching fish in an aquarium Bubble lamps Serene paintings Alerting Bright Colors Bright lighting Flashing lights Modern Art Video games Messy and cluttered room Clean and sparsely finished room
+ Reviewing the Senses Auditory Soft and slow music Quiet Familiar sounds Humming Singing quietly Repetitive or rhythmic sounds (drum beat) Nature sounds Meditation tapes Calming Alerting Loud noises Rock music Fast tempo or offbeat Fire alarms Thunder Whistling Changing sounds (city streets) Hand held instruments
+ Reviewing the Senses Touch 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 Calming Unexpected touch Light touch Feeling something prickly or squishy Cool room Use of fidgets Snapping a rubber band on wrist Use of ice Alerting
+ Reviewing the Senses Proprioceptive Calming Slow and rhythmic Sustained Joint compression or isometrics Weight lifting or sports Yoga, Tai Chi, or stretching Walking Gardening Alerting Quick Jarring Jerky Jogging Aerobics Boxing Jumping Jacks Pushing heavy objects or adding weight
+ Reviewing the Senses Vestibular (Balance) Rocking Swinging Stable Slow Using a glider chair or rocker chair Walking Calming Alerting Jogging Fast Dancing Movement Activities Spinning quickly Bouncing Jumping Pacing
+ When is calming needed? Emotional Signs Anxiety Agitation Euphoria Anger Mania Over excitation Fear Panic Overwhelmed Physical Signs Tense posture Fidgeting Increased breathing Increased heart rate Sweaty palms Increased energy Hyperactivity Sleeplessness Behavioral Signs Hyper-vigilant Intrusive Noisy Disruptive Frustrated Easily Over active Distractible Poorly selfcontrolled
+ When is alerting needed? Emotional Signs Sadness Hopelessness Numbness Discouragement Feeling suicidal Having flashbacks Trouble with disassociation Physical Signs Low energy Slouched posture Lethargy Sleepiness 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 Trauma Informed Staff understands the function of the behavior (self-injury, rage, compulsions) Objective, neutral language Recognition of culture and practices that are retraumatizing Power/control issues minimized-constant attention to culture of care and individualized approach Non-Informed 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
+ 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. Number 20 18 16 14 12 10 8 6 4 2 0 Seclusions and Restraints 2015-2017 1Q 2015 Total Number 2Q 2015 2015 2016- ytd # Staff Injured by Patients 7 3 Lost Work Days Due to Injury 40 35 30 25 20 15 10 5 0 Restricted Work Duty Due to Injury 3Q 2015 4Q 2015 1Q 2016 2Q 2016 Staff Injuries 2015-Present 3Q 2016 4Q 2016 35 0 27 0 1Q 2017 Seclusions 19 13 5 9 8 9 4 1 7 2 Restraints 6 10 7 13 0 1 0 0 0 1 2Q 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%2 0Strategies%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