There are many ways to reduce or eliminate the use of restraints. NAPPI accomplishes this by providing staff with strategies that include: behavior assessment, de-escalation and defusing skills, humane and effective response options, and the development of a culture of cooperation.
The Dangers of Physical Restraints
A physical restraint is one in which you use bodily force to limit someone’s freedom of movement. It is important to note that restraints should only be used as a last resort to keep everyone safe. The following should be taken into consideration when applying the restraint:
- The type of restraint/hold used should match the level of danger.
- The restraint should only be used when it is the safest possible outcome.
- The restraint must be terminated as soon as it is safe to do so.
Restraints can almost always be avoided. Nurses, Care Givers, Educators etc. need many skills to do their jobs; they also need skills to help create environments where restraints are unlikely to happen. NAPPI’s culture helps to develop powerful and positive relationships and creates a culture of cooperation and partnership. In addition, NAPPI’s refocusing, defusing and de-escalation techniques along with our SMART Principles and use of the Lalemand Red Scale teach staff how to assess the early warning signs of violence and make it possible to avoid almost every restraint.
A number of restraint events can occur because a minor event has escalated out of control. NAPPI’s Lalemand Red Behavior Scale along with the SMART Principles empowers staff with strategies to intervene at the earliest antecedent behavior, thus avoiding a restraint. Power struggles between a consumer and staff can escalate and become a volatile or dangerous situation. By using NAPPI’s Principles of Restraint Avoidance, and Developing a Partnership of Cooperation, the power struggle can be avoided. It is possible that situations with the potential of becoming dangerous can be turned into non-restraint events by using the above strategies. Ask yourself, “Will what I am about to do, be safer than what I am doing now?”
- Behavior Assessment - Lalemand Red Behavior Scale De-escalation Skills
- De-escalation Skills
- Making a Clear Request
- Keeping a Conversation on Track
- Offering Choices
- Defusing Techniques
- Restraint Avoidance Techniques –
- Restraint Prevention and Elimination
- Staying Inside the Box
- Restraint Event Timeline
- Levels of Resistance
- Post Incident Review
When Restraints are Simply Unavoidable
Restraints can be physically and emotionally damaging to both the restrained and the restrainer. Applying a restraint is an enormous responsibility because the restrainer is responsible for the safety of the person being restrained. Once hands are placed on an individual in your care, it is the restrainer’s responsibility that no injury or harm come to the restrained. NAPPI has designed a number of restraints that are effective without pain compliance. Our “Following to the Floor” skill prevents injury that can happen during a “take down”. This floor hold is in the side recovery position with no supine or prone placement, thus making it safer.
Dr. Van E, the Biomechanical Engineer, has evaluated our holds and found them to be the safest possible. Please find his report attached. We believe that because the risk of personal injury during a restraint is very high, it is important that those involved in this activity are highly trained with on-going refreshers and annual re-certifications.
Creating a Restraint-Free Culture
A restraint-free organization is a desirable goal that requires the following:
- A high level of cultural, environmental and programming improvements;
- Comprehensive policies, procedures and practices;
- Comprehensive training and supervision;
- Competency assessments and follow ups;
- And specific and concrete measurement and improvement processes.
- How do the adults treat each other?
- How do the grownups treat the kids?
- Does each segment of your organization value and respect the other segments, and work to support them in their jobs – regardless of pay grade?
- Is there an underlying current of commitment to safety?
- Does your organization feel like a safe, welcoming, place that is a joy to enter?
- Do people take responsibility, maintain dignity for themselves and others, and show respect for all?
- Is everyone engaged and motivated to do the right thing?
Improving your environment can be very challenging, especially in difficult economic times. Clean, well-maintained, well-lit, odor-free, and clutter-free environments can help improve attitude and moral. When dealing with dangerous consumers it is important that the environment be free of unnecessary hazards such as sharp objects and office clutter which could cause someone to become injured during a restraint event.
Creating programs that support a restraint free environment is crucial. Implementing a system based on positive, proactive interactions has been proven repeatedly to reduce unwanted behaviors by replacing them with better, more socially adaptive skills, thereby reducing emergency responses. This leads back to culture – does your staff model positive, socialized behavior throughout the day?
As all administrators know, developing comprehensive policies and procedures, will help to establish a workplace free of restraints by establishing a culture of partnership, cooperation, respect, and dignity. Policies that support the culture you are trying to achieve will ultimately be the most successful policies you ever write.
The only way to ensure that people have all the right tools to keep everyone safe is through comprehensive training. NAPPI partners with organizations to develop a training program and culture that correspond with the policies, procedures, program improvements, and practices of the existing organization.
If training is the only way to give people new tools, then the only way to know that the tools are used correctly is through constant supervision. Quality supervision, even though it can be very difficult, is the only way to ensure that the skills are being applied in accordance with the underlying culture and policies.
Organizations should implement competency assessments for behavior and safety management. Assessing someone’s capacity, knowledge and actual performance on the job gives you an invaluable tool for determining how well he/she will handle unexpected and difficult situations. Far better to know, in advance, how someone is likely to perform and take remedial steps if necessary.
Specific and Concrete Measurement to Improve the Process
- Collect the data
- Determine what needs to be improved
- Develop a plan
- Implement the plan and collect the new data
- Assess results against original data
- Make necessary modifications to the original plan
Suggested Reading & Resources
The reading below will give you a good sense for how restraints and seclusion affect children and educators, and some tools to begin discussions from a common understanding.
Achieving Better Outcomes for Children and Families – Reducing Restraint and Seclusion (2004), Child Welfare League of America, Washington, DC. www.CWLA.org
Convention on the Rights of Persons with Disabilities (2009). United Nations, New York, NY.
Seclusion and Restraints: Selected Cases of Death and Abuse at Public and Private Schools and Treatment Centers (2009). Gregory D Kutz, GAO-09-719T http://www.gao.gov/new.items/d09719t.pdf
School is not Supposed to Hurt: Investigative Report on Abusive Restraint and Seclusion in Schools (2009). National Disability Rights Network, Washington DC, www.ndrn.org
Six Core Strategies for Reducing Restraint and Seclusion (2005). Technical Assistance Office of the National Association of Mental Health Program Directors, Washington DC http://www.nasmhpd.org/ntac.cfm
In the Name of Treatment (2005). Alliance to Prevent Restraint, Aversive Interventions and Seclusion. Washington DC www.aprais.tash.org