Multinational Experiences in Reducing and Preventing the Use of Restraint and Seclusion

Restraint and seclusion (R/S) have been used in many countries and across service sectors for centuries. With the recent and increasing recognition of the harm associated with these procedures, efforts have been made to reduce and prevent R/S. Following a scathing media exposé in 1998 and congressional scrutiny, the United States began a national effort to reduce and prevent R/S use. With federal impetus and funding, an evidence-based practice, the Six Core Strategies1 to Prevent Conflict, Violence and the Use of Seclusion and Restraint, was developed. This model was widely and successfully implemented in a number of U.S. states and is being adopted by other countries, including Finland, Australia, and the United Kingdom. Recently, the first cluster randomized controlled study of the Six Core Strategies in Finland provided the first evidence-based data of the safety and effectiveness of a coercion prevention methodology. Preliminary findings of some of the international efforts are discussed. Reduction in R/S use and other positive outcomes are also reported

PSRO update

Newsletter for Massachusetts physicians, providing updates on the development of Professional Standards Review Organizations (PSROs) as Medicare and Medicaid standards were established

Decreasing Duration of Mechanical Restraint Episodes by Increasing Registered Nurse Assessment and Surveillance in an Acute Psychiatric Hospital

Background Application of mechanical restraints is a high-risk emergency measure that requires psychiatric intensive care in order to assure patient safety and expedite release at the earliest opportunity. While current regulations require that trained staff continuously observe restrained individuals, assessment by a registered nurse is required only once an hour. This project builds on research that demonstrated a regulatory change requiring more frequent registered nurse assessments led to decreased duration of mechanical restraint episodes in an acute psychiatric hospital. Purpose The purpose of this project was to implement and evaluate a practice change that required increased frequency of registered nurse assessment and surveillance during mechanical restraint episodes. Methods The nursing department standard requirement for frequency of face-to-face registered nurse assessment and surveillance of patients during episodes of mechanical restraint was increased on pilot units from once every thirty minutes to continuous assessment and surveillance throughout the duration of the restraint application. Quantitative data was collected on hours of duration of restraint episodes on four pilot units for three months before and three months after the intervention and mean duration of episodes was compared before and after the practice change. Results Mean duration of episodes on pilot units decreased 44% in the three months post intervention: 15% on adult units and 70% on the adolescent unit. Conclusion and Recommendation Increasing the frequency of registered nurse assessment and surveillance during mechanical restraint has been shown to decrease duration of restraint episodes. Nurses are encouraged to change practice standards for mechanical restraint, which is a high-risk emergency measure, to provide continuous psychiatric intensive care by a registered nurse. Keywords: mechanical restraint, physical restraint, psychiatric patient

Mental Health And The Role Of The States

Researchers from the State Health Care Spending Project -- a collaboration between The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation -- sought to better understand the country's mental health challenges and, in particular, the states' role in addressing them. The project found that:In 2013, approximately 44 million adults -- 18.5 percent of the population 18 and older -- were classified as having a mental illness. Of these, 10 million had a serious mental illness. The rate of serious mental illness varied from state to state.In 2009, the most recent year for which national mental health data are available, $147 billion was spent on mental health treatment in the United States. A majority of the spending, 60 percent, came from public sources such as Medicaid, state and local governments, Medicare, and federal grants. Private sources, including health insurance and individual out-of-pocket spending, made up the difference.Funding from states and localities totaled$22 billion (15 percent) in 2009. This total does not include state and local Medicaid expenditures. Counting those contributions brings total state and local spending up to $35.5 billion (24 percent).This report is intended to help federal, state, and local policymakers working to address the country's mental health challenges to better understand their prevalence, treatment, and funding trends

Implementing an Intervention to Reduce Seclusion and Restraints in an Inpatient Psychiatric Hospital

The need to enhance nursing staff’s knowledge, perceptions and attitudes around alternatives to seclusion and restraint has been well validated in the literature. Seclusion and restraint use in the inpatient psychiatric setting are highly dangerous physical interventions, used to control the behavior of a mentally ill patient who is a danger to self or others. Seclusion and restraint events have the potential to cause emotional trauma, physical injury to patients or staff and the possibility of patient death. The purpose of the capstone project was to implement an evidence-based education program to, improve nursing staff’s (RN, LPN, MHA and SRNA) knowledge and attitudes of alternatives to seclusion and restraint in an inpatient psychiatric setting. As part of annual mandatory education requirements for the agency, thirty-five nursing staff (MHA,SRNA, LPN, and RN) participated in the project and completed the 3 hour course, CPI: “How To” Strategies for Intervening With Challenging Individuals; including pre and post measures, CPI Knowledge Assessment and Reducing Seclusion and Restraint Organizational Questionnaire (RSROQ); assessing perception and attitudes. Results of the project indicated, significant increases in knowledge of alternatives to seclusion and restraint in MHA/SRNA’s and RN/LPN’s from baseline. RN/LPN’s had significant increases in the attitude subscore of the RSROQ and total RSROQ score

Expenditure and Revenue Patterns of State Mental Health Agencies from 1981 to 1987

This paper documents expenditure and revenue patterns of state mental health agencies from 1981 to 1987. Expenditure data show an overall decline of mental health expenditures of 4.9% over this period. States with declining overall expenditures were more likely to make deep cuts in hospital expenditures and little or no increases in community programs, while the few states with increasing expenditures showed substantial increases in community programs and contant funding for hospitals. A relatively more dramatic shift was noted across states of shifting expenditures from inpatient to ambulatory care. Revenue data reveal that federal support for state mental health agencies increased slightly during this period, but solely as a function of the introduction of the Block Grant in 1982. However, once introduced, both the Block Grant and other federal sources show steady losses against inflation. State sources also show a decline of 4% during this period, most of which was felt between 1981 and 1983, after which there has been no further decreases. Interstate variability in percapita spending on mental health is described and found to significant even beyond adjustments for costs of services. Expenditures on mental health also show relatively greater declines compared to overall state budgets and state health and welfare budgets during this period, suggesting an increasingly lower priority for mental health services in the state budget alloction process

Olmstead Mandated Statewide Implementation of Assertive Community Treatment: Precipitating Factors and Participant Experiences

Evidence-based practices for individuals with serious mental illness have not been widely implemented in United States public mental health systems. Mental health advocates have used the Supreme Court’s Olmstead decision to force states with underfunded community mental health services to develop more robust treatment systems. Using a case study, this article-based dissertation examines the process of mandated widespread implementation of Assertive Community Treatment (ACT) in Kentucky through the experiences of individuals involved in ACT creation and documents related to implementation and the state mental health system. Study 1 identifies precipitating factors to the Kentucky Olmstead settlement agreement that contributed to a lack of research-informed practices for individuals with serious mental illness. Study 2 examines how ACT knowledge was communicated by exploring the learning experiences of individuals involved in implementation. Study 3 investigates the impact of requiring program creation through a settlement agreement on individuals responsible for building these new practices. All 3 studies used qualitative methods determine findings. Study 1 used a content analysis of publicly available documents related to the Kentucky mental health system while Studies 2 and 3 relied on the thematic analysis of semi-structured interviews with individuals involved in ACT formation. Findings highlight the importance of governments prioritizing evidence-based practice for individuals with serious mental illness. The use of settlement agreements to force service provision may accomplish an important goal of providing needed services to a vulnerable population. However, rushed or poorly planned program creation strains systems of care and is detrimental to the wellbeing of individuals involved. By engaging in a thorough assessment of barriers prior to program creation, entities using settlement agreements can facilitate more effective implementation of evidence-based practice for individuals with serious mental illness

Therapy Using Interpreters: Questions on the Use of Interpreters in Therapeutic Settings for Monolingual Therapists

The use of sign language interpreters in mental health is a subject that has not received a great deal of attention in the literature in recent years. It is critical that interpreters be competent, but not much attention has been paid to other critical elements in the therapeutic triad, specifically what is required of clinicians in order to make therapy using interpreters work. This article explores some of those issues and makes specific recommendations regarding how it maximize effectiveness of this approach to bridging the gap between the need for mental health services and the supply of clinicians who are fluent in American Sign Language

Sensory-based Services in Adult Mental Health

Purpose: The purpose of this Capstone Project was to evaluate the sensory room program used by occupational therapy to determine whether use of the sensory room and the elements within the room reduced perceived levels of distress and acting out and/or aggressive behaviors of patients with mental illness. Methods: This Capstone Project was an outcome evaluation of a routine clinical program using retrospective analysis of existing patient records to ascertain physical aggression episodes, sensory modulation ability, and self-ratings and staff ratings of patient distress levels pre- and post-sensory intervention. Results: Through analysis of quantitative data, the results of the project demonstrated a statistically significant difference in Subjective Units of Distress Scale ratings, reflecting an overall decrease in patient distress levels from time of entry to time of exit of the sensory room. The majority of patients did not exhibit acting out behaviors within 24 hours post sensory intervention. Though there were no significant correlations identified via SPSS data analysis, the patient ACL scores generally indicated less personal insight. Conclusion: Data analysis confirms that the use of a sensory room and sensory-based treatment approaches had positive effects among patients of varied ages, diagnoses, and ACL scores. Outcomes of this study align well with person-centered and recovery-oriented mental health care that supports the patient’s preferences, responsibility and accountability, and oversight of their own recovery

State Efforts To Expand Transition Supports for Young Adults Receiving Adult Public Mental Health Services

Summary: Psychiatric disorders present during the transition to adulthood (ages 16-30) impede the development of adult role functioning. Most adolescents with serious mental health conditions continue to have those conditions into adulthood, and many adults with psychiatric disorders developed those conditions at the threshold of adulthood (ages 18-21). Taken together, these findings from various studies confirm that, whether psychiatric disorders develop before or during the transition to adulthood, their presence seriously hinders the successful assumption of adult roles. These findings underline the importance of mental health (MH) services throughout this stage of life, and the need for interventions that facilitate the development of adult functioning. Adolescents and young adults with serious mental health conditions may receive services from a variety of service systems, including special education, child welfare, vocational rehabilitation and the like. However, the target populations for all but state MH systems are much more broadly defined than those with serious mental health conditions. Thus, it is important to know what is being done within state MH systems to address the transition needs of their adolescents and young adult clients. Further, transition support innovations from these systems could be a critical resource for the development and dissemination of programs, strategies, and technical assistance to improve transition support targeted at adolescents and young adults with serious MH conditions in all systems. A previous study of all U.S. state child MH systems showed that almost all were at least talking about the need to provide and improve transition support services, and most provided some, although limited, transition support services (Davis, 2001; Davis & Sondheimer, 2005). One of the ultimate limitations though, was the upper age limit of their services; most ending at age 18, with a smaller number extending to age 21. Thus, the primary agency that can address the continued transition and MH needs of young adults with serious MH conditions after ages 18-21 is the state adult MH system. There is no current literature on transition services or services for young adults within state adult MH systems. The present study was designed to parallel the earlier study of the child MH system, and describe efforts that state adult MH systems were making to address the needs of their young adult population transitioning into adulthood