Preventing Violence and the Use of Seclusion and Restraint: An Expert Interview With Kevin Huckshorn, RN, MSN, CAP, ICADC

Laurie Barclay, MD

November 02, 2009

November 2, 2009 —- Editor's note: The problem of violence often requiring the use of seclusion and restraint has continued to be a widespread concern in mental health inpatient settings, according to a presentation at the American Psychiatric Nurses Association (APNA) 23rd Annual Conference. The conference, entitled "Many Differences, One Voice: Practice, Research, Education, Administration" was held from October 7 to 10 in Charleston, South Carolina.

To find out more about a 3-year study testing the efficacy of 6 core strategies to prevent violence and the use of seclusion and restraints, which was funded by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), Medscape Nurses interviewed presenter Kevin Huckshorn, RN, MSN, CADC, ICRC, Director, Division of Substance Abuse and Mental Health, Delaware Health and Social Services, in New Castle.

The 6 core strategies are leadership organization principles in effective change, the public health prevention approach, use of recovery and resiliency principles, valuing consumer and staff self-reports, trauma-informed care, and the ability to take risks to ensure individualized treatment.

Medscape: What was the impetus behind your study, "Six Core Strategies Model to Prevent Violence, Coercion, and the Use of Seclusion and Restraint?"

Ms. Huckshorn: The impetus was the release of the Hartford Courant's series "Deadly Restraint" in 1998, the subsequent Governmental Accountability Office's report on seclusion and restraint use in behavioral health settings in 1999, changes in the Conditions of Participation by the Centers for Medicare and Medicaid that related to seclusion and restraint use in 1999 and 2001, the work by the National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council, and the growing voices of consumers and other stakeholders saying that seclusion and restraint were traumatizing both to people receiving services and to staff.

As the new director of NASMHPD's Office of Technical Assistance, I, my staff, and our members had been introduced to the successful reductions in use being enjoyed in the adult state hospital system in Pennsylvania, the child and youth public system in Massachusetts, and individual model programs, including South Florida State Hospital (run by GeoCare, Inc), where I had previously been employed.

The arrival of Charles Curie as the administrator of SAMHSA focused federal attention on reducing the use of seclusion and restraint in a way that possibly no other person could have done, and the addition of A. Kathryn Power as the director of the Center for Mental Health Services (CMHS) cemented the full involvement of our federal partners. Robert Glover, PhD, as executive director of NASMHPD, was very supportive, and the work of the National Alliance on Mental Illness, the APNA, the American Psychiatric Association, National Association of Consumer/Survivor Mental Health Administrators, the Bazelon Center, and many others provided extremely important information and resources.

Back at NASMHPD, we reached out to states and facilities that we knew had made progress, and brought groups of experienced experts from those facilities together for a series of brainstorming meetings with funding support from SAMHSA's CMHS. During this process, we found that most successful programs had implemented similar strategies, although the names and language were different. These common strategies emerged and were narrowed down to the 6 core strategies over time. During this time, we also began to collect every piece of literature and research available on the topic of seclusion and restraint use, violence in inpatient settings, staff development strategies, risk assessments, consumer and staff stories about seclusion and restraint, and media publications. There was a lot of opinion about seclusion and restraint in print, but very little research, so I and a handful of other experts, including people in recovery, started to draft a training curriculum for use in public state facilities serving children, youth, adults, and people in forensic settings.

Medscape: Please describe the Six Core Strategy training curriculum.

Ms. Huckshorn: We based the Six Core Strategy training curriculum on core tenets: principles of effective leadership based on situational theory, principles known to support recovery-oriented environments of care, the public health prevention approach, trauma-informed care strategies, and the steps involved in continuous performance improvement.

Our first multisite training was in February 2002. It was hosted by South Florida State Hospital and attended by 7 other state leadership teams. We held 3 more regional training sessions that year and 2 the next, often training more than 10 state teams at a time. The training curriculum lasted for 2 days and each of the 15 modules was carefully evaluated at every training session so that we could continue to update and improve the training.

By the end of 2003, we had started to see effective reductions occurring, and requests for training continued to grow. Also in 2003, SAMHSA's CMHS and NASMHPD determined that the Six Core Strategies should be formally evaluated through a multistate study, and the Human Services Research Institute was hired to develop the study design and coordinate the data collection and analysis.

Medscape: Please describe the study design and setting.

Ms. Huckshorn: The evaluation study is entitled Alternatives to Seclusion and Restraint State Infrastructure Grant Project (ASRSIG). The first study involved 8 states, with multiple facilities in each. An innovative linear modeling and meta-analytic approach was used to examine changes in seclusion and restraint rates in facilities implementing the Six Core Strategies.

Facilities were divided into 5 groups of implementation, based on the pattern of Inventory of Seclusion and Restraint Reduction Initiatives (ISRRI) scores over time: stable implementation (n = 28); implementing, did not stabilize (n = 7); implementation followed by a discontinuation (n = 1); implementation followed by a decrease (n = 5); and never implemented (n = 2). A dose-effect analysis assessed the relation between the degree of implementation and changes in seclusion and restraint rates over time.

The evaluation collected 4 types of information: characteristics of the facility (such as mission, size) using an instrument known as the Facilities and Program Characteristics (FPCI); the extent to which elements of the 6 core strategies were implemented by the facilities over time, as measured by the ISRRI fidelity scale developed for the project; individual consumer-level information for all admissions to the facility during the study period, as the denominator for constructing facility-specific seclusion and restraint events; and consumer-level information on individual seclusion and restraint events, as the numerator.

Data covered the period from 2003 to 2007. The original FPCI was developed by the NASMHPD Research Institute (NRI), in consultation with the Office of Technical Assistance. Information about the types of units and the data on admissions and seclusion and restraint events were consistent with the format of the NRI Behavioral Healthcare Performance Measurement System used by most facilities in the study for Joint Commission Accreditation, and licensed from NRI for purposes of the evaluation.

The settings were quite varied. The unit of analysis for this study was the individual facility, and the study includes 43 (82.7%) of 52 facilities that participated in the first round of the SAMHSA-funded ASRSIG and the consumers within those facilities. The 43 facilities came from 7 of the 8 states of ASRSIG. One state's data were so different that they could not be included, although that state has reported some success.

The majority of the facilities (79.0%; n = 34) were free-standing psychiatric facilities, 7.0% (n = 3) were residential programs, and 14.0% (n = 6) were other types of facilities/programs (i.e., psychiatric units at public health or private hospitals). The facilities varied in size: 20.9% (n = 9) had between 0 and 50 beds; 27.9% (n = 12) had 51 to 100 beds, 27.9% (n = 12) had 101 to 200 beds; and 23.3% (n = 10) had more than 200 beds. The majority of the facilities served adults (72.1%; n = 31), 9.3% (n = 4) served children and adolescents; and 18.6% (n = 8) had units that served adults, children, and adolescents.

Medscape: What were the main findings from this study?

Ms. Huckshorn: The majority of the facilities (n = 28; 65.1%) reached stable implementation of the 6 core strategies at the end of the project period. A random-effects meta-analysis of the seclusion outcomes for the 28 facilities that reached stable implementation showed positive results in reductions in the use of seclusion between pre- and stable implementation. The majority of the 28 facilities (n = 20; 71.4%) were able to reduce seclusion hours per 1000 treatment-hours by an average of 19% (P = .001). These facilities were also able to reduce the percent of consumers restrained by an average of 17% (P = .002). Of the 20 facilities, 16 (80.0%) reduced seclusion hours per 1000 treatment-hours (P < .10), and 12 (60.0%) reduced the percent of consumers secluded (P < .10).

Significant reductions in seclusion hours per 1000 treatment-hours and the percent of consumers secluded, as well as in restrained hours per 1000 treatment-hours and the percent of consumers restrained, were found in facilities with different missions, specialties, security, ownership, size, and receipt of technical assistance and site visits.

Facilities that reached stable implementation showed the greatest decrease in seclusion hours per 1000 treatment-hours between pre- and postimplementation, compared with facilities in the other implementation groups (r = 0.88; P = .02). Facilities that were still implementing the 6 core strategies at the end of the project showed the greatest decrease in the percent of consumers secluded (r = 0.40; P =.03), compared with the facilities in the other implementation groups.

The random-effects meta-analysis of the restraint outcomes for the 28 facilities that reached stable implementation showed positive results in reductions in the use of restraint. Over half of the 28 facilities (53.6%; n = 15) were able to reduce restraint hours per 1000 treatment-hours by an average of 55% (P = .083); 16 of the 28 facilities (57.1%) in this group were also able to reduce the percent of consumers restrained by an average of 30% (P = .027). Thirteen facilities (86.7%) reduced restraint hours per 1000 treatment-hours (P < .10); and 9 (56.2%) reduced the percent of consumers restrained (P < .10).

Facilities that reached stable implementation showed the greatest decrease in restraint hours per 1000 treatment-hours for pre- and postimplementation, compared with facilities in the other implementation groups (r = 0.46; P = .05).

Because this study is considered "services research," it is not able to standardize participants or settings as in a randomized controlled study. The facilities that participated were in very different places when this evaluation study started, in that some had been working on reducing seclusion and restraint for several years and some had not, some had been trained already and some not, some had already greatly reduced the use of seclusion or restraint and some had not, and several facilities did not even know they had been included in the study. As such, there was no shared "baseline" and each facility could only be measured against itself from the start of the study.

Medscape: What strategies are most effective in preventing violence and the use of seclusion and restraint?

Ms. Huckshorn: More research is needed to determine definitively whether one strategy is more effective than another. What we have found is that most of the strategies have some overlap and, together, "build a culture" that replaces the use of seclusion and restraint with multiple other interventions. NASMHPD's core faculty experts for this project would state that the leadership strategy is mandatory and that consistent and committed daily involvement by senior facility leaders is necessary for success.

Medscape: How expensive and practical would these strategies be to implement in other settings?

Ms. Huckshorn: The strategies are not expensive per se. Many facilities attended only 1 training session and went back to their hospitals and implemented the 6 core strategies with great success. Some facilities requested several training sessions for different groups of staff. The 6 core strategies are highly practical and are based on several core constructs or principles, as noted above. All of this information is in the public domain and can be retrieved freely. Facility leaders must determine if this work is a priority for them and then manage accordingly.

Changing mental health inpatient cultures and practices that have been in place for decades is not easy and generally takes at least several years of concerted focused attention by senior leaders and middle managers. Facilities that are in crisis, for whatever reason, will have a hard time being successful because of competing priorities. Direct care staff need to be trained, but more important, facilities must have in place effective and consistent supervision processes in which managers understand the goals and the changes that need to take place, can model these new behaviors, and reward (or hold accountable) individual staff for behavior change.

Medscape: What is the take-home message from your presentation at APNA?

Ms. Huckshorn: Significant reduction of the use of seclusion and restraint is possible, and strategies are available that have been effective in all sizes and types of facilities. Reducing the use of seclusion and restraint is really about preventing violence and coercion from occurring in the first place and realizing that we, as leaders and staff, have control over preventing and minimizing violence and conflict.

Reducing seclusion and restraint (and violence and conflict) on inpatient units is a cornerstone of the implementation of the trauma-informed, person-centered, and recovery-oriented approach that has been mandated by the US Surgeon General, the Institutes of Medicine, the New Freedom Commission, and decades of writing by people who are in recovery from mental health conditions themselves.

Any facility wishing to get some assistance, direction, or help should contact NASMHPD's Office of Technical Assistance (703 739-9333).

Medscape: What additional research should be done in this area?

Ms. Huckshorn: Most of the research on seclusion and restraint has been single studies of specific training programs implemented in single sites or studies of "what the violent patient looks like." The field needs more research on the successful implementation of large scale culture change; implementing the 6 core strategies in additional settings, especially from "pure baseline," if possible, in 2009; and the way each strategy works if implemented alone.

Additionally, research needs to continue to develop the knowledge base on how people experience being treated in inpatient facilities and what makes one setting therapeutic and another traumatizing. Finally, instead of trying to find the profile of the violent patient, which does not appear to exist, we need to explore what makes people violent in health care settings. It is much more about staff attitudes, values, training, and practices that treat everyone the same, are shaming or disrespectful, or just are impersonal. We need research on this issue because it could greatly inform who we hire, how we supervise, and what we train.

Ms. Huckshorn has disclosed no relevant financial relationships.

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