30 June 2008
Several facilities reported that they had made substantial strides in reducing restraint, including the facility with the highest rate of restraint use. Administrators and staff at these facilities shared their strategies for accomplishing this reduction. Youths also had recommendations on how to reduce restraints.
A few of these efforts map directly onto the SAMHSA recommendations. For example, a focus on de-escalation in formal restraint training was mentioned by several programs. De-briefing with staff following restraint incidents was another common strategy. Workforce development, including selection of staff and utilizing staff to create a culture where restraint was used only as a last resort, were also mentioned. From the initial hiring process, one program had implemented efforts to screen out staff who may be inclined to use inappropriate discipline. Explained one administrator, "We've instituted some things in our application process where we're asking them to consider some scenarios, `Johnny does this and you've got three choices, you can either spank him, put him in a chair, or you can make him write a hundred sentences.' And we try to identify people that do not believe in any kind of corporal punishment. So we do some of those things to try and weed people out up front."
Many programs discussed how they used data about restraint frequency to inform practice. Programs often had a committee who regularly reviewed incident reports or aggregated information about restrictive behavior management practices. One administrator found that having direct care staff on the committee increased its effectiveness. "Many times [direct care staff] say, `You guys don't know what it's like, you don't work with the kids, we do.' Well, we're talking about people who do work with the kids who are saying, `In that situation maybe you should have tried something else before you put your hands on the kid."'
The interest in using data to monitor
restraint may be partly driven by demands of accreditation. However, one
administrator described the importance of data beyond just for
"Part of the impetus was accreditation because JCAHO requires that. And what I hope to do is really fine tune that, in a way that it will be more useful in terms of really improving practice and measure outcomes for improvement's sake and not for compliance with outside agencies. It's not data collection for data collection's sake. It's data collection for foresight. You gotta know what's happening... that's the only thing that really allows you to know where things are going awry and how to intervene."
The study participants also identified five other strategies that are not part of SAMHSA's restraint reduction plan. These ideas include individualizing treatment, the use of specialized crisis staff, paying attention to organizational culture, the use of incentives, and program structure.
B.R. LEE, J.C. MCMILLEN
AND N. FEDORAVICIUS
Lee, B.R.; Mcmillen, J.C. and Fedoravicius, N. (2007).
Use and views of physical restraint in select residential treatment
programs. International Journal of Child and Family Welfare,10,
3-4. p. 145.