Director, Investigations Unit
Disability Rights California
(510) 267-1200
Leslie.Morrison@DisabilityRightsCA.org
February 2013
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Restricting freedom of movement, physical activity or normal access to one’s body
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Medical
Postural/Supportive
Behavioral
 Physical force; manual holds
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Mechanical device, material or equipment
Chemical [drugs]
Not:
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Briefing holding to calm or comfort
Brief assistance to redirect or prompt
Devices used from transportation or security
Involuntary confinement alone in a room or an area from which the resident is physically prevented from leaving
Doesn’t matter if door is locked or even closed
Not:
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Voluntary time out
Restriction to area consistent with unit rules or an individual’s treatment plan

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Not medication routinely prescribed to treat individual’s psychiatric condition to improve functioning.
Not necessarily all PRNs but often PRNs are used.
Often used in combination with other forms of restraint or seclusion.
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know
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Have no therapeutic value or basis in clinical knowledge.
Does not positively change behavior
 May increase negative behavior and decrease positive behavior.
Is traumatic and potentially physically harmful to staff and the individual.
Does not keep people safe.
 May cause death even when done “safely” and correctly.
Leaves lasting psychological scars.
Decision is almost always arbitrary, idiosyncratic, and generally avoidable.
Facility culture (staff role perceptions, training, program philosophy, facility leadership) has greater influence on the use of restraint & seclusion than clinical factors.
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Restraint and seclusion is often staff’s first, automatic response to difficult behavior.
Generally stems from a power struggle .
Mostly used for loud, disruptive, non-complaint [but not violent] behavior.
 Lack of training in managing behavioral crisis contributing factor 90% of JCAHO restraint deaths.

vs.
 Keeps people (staff
& consumer) safe
 Known to cause injury, death and last psychological trauma;
 Higher worker injury rate than in lumber, construction and mining
 Only used when absolutely necessary and for safety reasons
 Most often used for non-compliance, inappropriate behavior or power struggle
 (1) study 73% (560 consumers) not dangerous but
“inappropriate” at time restrained/secluded
 Staff can recognize potentially violent situations
 Nurses agree on use 22% of time; mental health professionals can only predict violence potential 53% of time; least clinically experienced were most restrictive

 Staff know how to deescalate
 De-escalation used < 25% of time;
 Most frequent antecedent was staff-initiated encounter = staff escalate;
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Lack of training in managing behavioral crisis contributing factor 90% of JCAHO restraint deaths;
1/3 of staff surveyed didn’t get mandatory crisis training
 Used without bias and only in response to objective behavior
 Cultural and social bias, staff role perception, administrator attitudes
 Therapeutic and based on clinical knowledge
 No controlled studies, no measure of efficacy or therapeutic value; shown to increase negative behavior
 Restraint/seclusion used for safety not punishment
 (6) studies = 58-75% perceived as punishment
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No “typical” patient profile
 No consistent demographics
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No consistent clinical characteristics
Although individuals w/trauma or abuse history at greater risk…
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√ Staff profile
 Mostly used for loud, disruptive, non-complaint behavior
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Generally stems for power struggle
Based on cultural bias & staff perception
Belief that it is safe/harmless & reduces risk of injuries
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√ Facility culture
 Automatic response to difficult behavior
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Insufficient alternatives
Insufficient staff training in de-escalation
Little to no focus on reduction; not seen as a critical event/ treatment failure
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 Psychological
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Physiological
 Death
 Asphyxiation
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Strangulation
Aspiration
Cardiac and/or respiratory arrest
Fractures, dislocation/sprains
Lacerations, abrasions
Injury to joints and muscles,
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Dislocation of shoulder and other joints,
Hyperextension or hyperflexion of the arms,
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Overheating, dehydration, exhaustion,
Exacerbation of existing respiratory problems,
Decreased respiratory efficiency,
Decrease in circulation to extremities,
Deep vein thrombosis,
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Pulmonary embolism,
Cardiac and/or respiratory arrest.
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Last psychological trauma
Loss of dignity
Triggering flashbacks
Recurrent nightmares, intrusive thoughts, avoidance behaviors,
Enhanced startle response,
Feelings of guilt, humiliation, embarrassment, hopelessness, powerlessness, fear, and panic
Compromised ability to trust and engage with others,
Environmental
Creates a violent and coercive environment that undermines forming trusting relationships
Risks with Medication
Sedation contributing to respiratory depression & arrest
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 Only used:
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◦ in emergencies, to prevent imminent risk of physical harm when other less restrictive alternatives have failed, for the least amount of time necessary, and in least restrictive way.
 Never for coercion, discipline, convenience or retaliation by staff
 Only by staff with specific, current training and demonstrated competence in application
 Only upon MD order OR , in emergency, at discretion of RN
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Never as a standing order
Limits on order duration
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Face to face assessment by MD or specially trained RN/PA within one hour [at hospital]; other timeframes apply for other settings
 Requires certain level of monitoring or observation

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 Hospitals
 Residential Facilities for
Adolescents
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 By facility type
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Not all facilities
By facility type
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 Duration of orders
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Type of observation frequency of monitoring
MD consultation & oversight
Documentation requirements
Staff training elements
Reporting requirements, data collection
Quality Improvement criteria
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Prohibits risky practices:
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Obstruct airway or impair breathing
 Pressure on back or body weight against back or torso;
Anything covering mouth;
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Restraint w/known medical or physical risk if believe it would endanger life or exacerbate medical condition;
Prone with hands restrained behind back;
Containment as extended procedure
 If prone, must observe for distress
Prone mechanical restraint with those at risk for positional asphyxiation, unless written authorization by MD .
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Intake assessment with consumer input
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Advanced directive on deescalation or use of R vs. S
Early warning signs/ triggers/precipitants,
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Techniques that help person maintain/regain control,
Pre-existing medical conditions, trauma history.
Post-Incident Debriefing
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ID & understand precipitant(s);
Alternatives/other methods of responding;
Revise plan to address root cause;
Was it necessary & done right?
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 Data

 Involvement by top leadership
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Create a vision and culture that prevents the risk of conflict and violence and respects personal liberties
Maintain sufficient staffing & programming
 Keep reduction in use & duration as constant priority and focus
 Integrating the principles of recovery and trauma informed care
 Implement restraint/seclusion prevention tools & alternatives
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Trauma assessments
Crisis plans
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Comfort rooms
Sensory modulation tools

 Workforce development
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Build relationships
Avoid power struggles
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Built into staff competencies and performance evaluations
On-going training (not only point in time)
 Rigorous debriefing of every incident with involvement of senior administration
 Use data to inform practices
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Public reporting & posting
Rigorous analysis
Actively Recruit & Involve Consumers and Families
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Peer advocates in debriefing
Facility committees & positions
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Understanding vulnerabilities and triggers of trauma survivors that can be triggered in traditional service delivery systems
Designed to be supportive and avoid re-traumatization
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 Keep them informed, connected and hopeful about their recov ery
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Learning together vs. Helping (one individual has agenda for the other)
Relationship vs. the Individual
Responding out of Hope (caring, patient, & supportive) vs.
Reacting out of Fear (rule driven, reactive, restrictive)

focus on prevention NOT how to do more safely or better
Universal Precautions
Administrative & clinical treatment environment that minimizes potential for conflict by anticipating risk factors
 Trauma informed care
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Recovery Model
Stigma awareness
Early assessment of risk factors
Organizational values
Secondary Intervention
Immediate & effective early intervention strategies to minimize conflict and aggression when they occur o Individual assessment of risk o Individual crisis plans to teach emotional self-management o De-escalation skills
Tertiary
Intervention
After incident, rigorous problem solving, mitigate effects, take corrective action
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Post S/R interventions to mitigate effects
Debriefing
Corrective Action o Staff training on attitude & self-awareness during conflict o Sensory modulation tools o Comfort rooms
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