The Sensory Room: An Alternative to Seclusion and Restraint

An Expert Interview With Janice Adam, RN-BC, and Timothy Meeks, BSN, RN-BC

Elizabeth McGann, DNSc, RN-BC

November 21, 2011

November 21, 2011 — Editor's note: Maintaining a safe milieu on an inpatient psychiatric unit is an important aspect of delivering safe care. Seclusion and restraint should be considered a last resort. An alternative intervention using a sensory room, called sensory modulation, is available. "Sensory Room: Reducing Violent Behavior and a Viable Alternative to Seclusion and Restraints" was featured as a podium presentation at the American Psychiatric Nurses' Association (APNA) 25th Annual Conference, held October 19 to 22 in Anaheim, California.

To find out how sensory modulation is used as an intervention for aggressive patient behavior on an inpatient psychiatric unit, Medscape Medical News interviewed Janice Adam, RN-BC, and Timothy Meeks, BSN, RN-BC. Ms. Adam is nurse manager of a psychiatric intensive care unit (ICU) and medical–surgical units at Harborview Medical Center in Seattle, Washington. She has worked in inpatient psychiatry for more than 30 years, has been involved in research on seclusion and restraints and staff safety, and has developed staff education around these issues. Mr. Meeks has been a nurse on Harborview's psychiatric ICU for 4 years, and currently serves as assistant nurse manager, education lead. In addition to supervising staff and providing direct patient care, he teaches nonviolent crisis intervention to hospital staff.

Medscape: What is considered aggressive patient behavior on an inpatient psychiatric unit?

Ms. Adam: Aggressive and violent behavior can be viewed as a continuum, from verbal aggression to physical violence. Acts and/or threats to harm oneself or others, and the destruction of property are all considered aggressive behavior.

Some specific examples of behavior characterized as aggressive are an intimidating posture (which can include clenched fists, angry affect, or approaching peers or staff in a menacing manner), throwing objects at peers or staff, attempting to grab or strike people, invading the personal space of others, yelling loudly in an angry tone, emphatically gesticulating with arms or finger pointing within someone's personal space, verbally abusing others, and destroying property.

The staff must consider the context accompanying any behavior that appears aggressive, and respond by attempting to understand what is motivating the behavior. Only then can the staff best assist the patient in expressing his or her needs in a manner that does not frighten others.

Medscape: What do seclusion and restraint interventions generally entail?

Ms. Adam: Seclusion and restraint are used only as a last resort, when there is imminent risk of harm to self or others and alternatives have not been effective. Seclusion and restraint are not viewed as a therapeutic option, but as a means to deliver safe care and to maintain a safe milieu for all. Early intervention is critical.

Often, the first sign of a patient escalating is a loud voice. Staff will move toward loud voices or noise, or will respond by calling for assistance. One person will talk to the escalating patient. A show of support will be organized, with one person being responsible as leader. The leader will make assignments to the responding staff as needed, taking into consideration the different skill sets of the responding staff and the needs of the patient. We utilize the Crisis Prevention Institute's "nonviolent crisis intervention," in which all staff are trained yearly. All verbal attempts to deescalate the patient are used to empower the patient to maintain control of their behavior. If the patient is unable to engage in safe behavior, "hands on" will be called by the leader, and staff will engage the patient in "nonviolent physical crisis intervention" techniques to ensure the safety of the patient and others.

At each step, the patient is given the choice to engage in safe behavior. The patient is given specific information as to what the unsafe behavior is, and what they need to do to demonstrate safe behavior. If the intervention results in a restraint episode, the least restrictive restraint is used to ensure the safety of the patient and others. Seclusion is considered least restrictive and mechanical restraint is considered more restrictive. In my work setting, chemical restraint is not permitted.

Medscape: What major challenges do psychiatric nurses face when dealing with patients needing seclusion or restraint?

Mr. Meeks: Balancing the right of patients to be free of restraints with the right of all patients and staff to a safe and therapeutic milieu is a constant challenge. A patient may not escalate to the point of becoming physically out of control and requiring restraint. However, they may be disruptive enough that they begin to agitate or frighten other patients in the milieu. Do we allow the individual to continue disrupting the milieu? At what point should we remove the patient from the environment, perhaps with a show of support, and risk further escalating this patient?

If the patient continues to escalate and requires a manual hold, the primary concern of staff is safety. We need to be able to support the individual in a way that does not harm the patient or our staff. We do everything possible to avoid touching the patient. We only place our hands on the patient after all verbal deescalation efforts have failed and we have no other choice.

After a seclusion or restraint episode, the challenge for caregivers is to reestablish therapeutic rapport. It is important that a staff member's first interaction after placing someone in seclusion or restraints is to be supportive and compassionate. We ensure that the patient's basic needs are met and continually assess the patient for a reduction in restraints.

After seclusion or restraint incidents, we debrief with staff to determine if there are any areas for improvement. In addition, we debrief with the patient to ascertain their perspective of the incident, and make changes to the care plan if necessary.

Medscape: What interventions, besides seclusion and restraint, are used to manage aggressive behavior on inpatient psychiatric units?

Mr. Meeks: The use of seclusion and restraint is never seen as a therapeutic tool, but rather as a necessary intervention so that staff can safely provide care and treatment to the patient. In our experience, the best way to manage aggressive patients is by using recovery principles. When you treat a patient with dignity and respect, that patient is less likely to harm you or others. Early intervention is critical to help the patient maintain control of their behavior. Staff education involving recovery principles, trauma-informed care, and deescalation techniques are key. Whenever possible, we avoid power struggles and offer our patients choices. We interview our patients on admission to determine their triggers and preferred coping skills, so we can offer them to the patient during a difficult time.

Collaboration is the best way to help patients remain in behavioral control. One of the options that we offer our patients is the sensory room. Besides sensory modulation, we may also offer medications, food and fluids, various distractions, a radio for music, or a change in the environment. In addition, it is helpful to establish behavioral care plans for volatile patients early in their hospitalization. If everyone is consistent in his or her care, the patient is more likely to succeed. If we have a patient who is treatment-resistant despite our interventions, we find it helpful to convene a leadership review. These reviews include doctors, nurses, social workers, occupational therapists, and pharmacists. A reemphasis on the team approach is sometimes necessary to make sure that we are providing the best care to our most aggressive clients.

Medscape: What prompted the national change toward less use of seclusion and restraint?

Ms. Adam: There has long been debate over the practice of using seclusion and restraint to prevent injury or reduce agitation in patients with mental illness. Reports of patient injury and death while in restraint and studies of patient experiences while in seclusion or restraint began to be published in the mid-1990s. Psychiatric nursing professional organizations, patient advocacy groups, and federal regulatory agencies have become active in the work to reduce or eliminate the use of seclusion and restraint. There is a great deal of research being done to develop evidence-based practices around the use of seclusion and restraint; this includes highlighting the influence of unit culture and philosophy, staff attitudes, availability, and treatment approaches. Recovery principles and trauma-informed treatment options have also been highlighted and researched.

Medscape: What is a sensory room?

Mr. Meeks: Sensory modulation is the ability for someone to process sensory stimuli in a graded and adaptive manner. A sensory room is a space where patients experience sensory stimuli in a controlled environment. Exposure to either activating or calming sensory modalities can help patients learn coping skills so they can function optimally in their environment. There are different modalities or sensory objects that patients can use to either calm or activate their senses. For instance, peppermint- and citrus-scented lotions to energize or lavender- and sage-scented lotions to calm are offered.

We have modalities for all of the senses: auditory, visual, olfactory, gustatory, tactile, proprioceptive, and vestibular. When patients are agitated, the sensory room is a peaceful quiet space where they can choose certain modalities to help them to calm. We can offer them soothing music, lavender-scented lotion, a rocker, and a weighted stuffed animal or blanket. For patients who need activation, we may offer energetic music, brighter lights, and textured tactile objects.

Medscape: What is the evidence regarding the effectiveness of the multisensory room?

Ms. Adam: There is little research available on this topic. This is a new use of an old intervention that was designed in the 1970s by occupational therapy and used for children with developmental delay or autism. The first published reports of a sensory room used with an adult psychiatric population were in the early 2000s. This research suggested that the use of a sensory room can be effective in decreasing anxiety in patients, and offered another tool for staff to use with patients who may be having difficulty modulating their emotions. Our research confirmed these results. There is also evidence that shows that the sensory room is not an effective intervention for high-risk patients, who generally receive a disproportionate amount of restrictive measures. Much more research needs to be done to evaluate the effectiveness of the sensory room to determine its value in patient care and the potential to decrease the use of seclusion and restraint.

Medscape: What can you share about your experiences in developing a sensory room and an outcomes-oriented quality-assurance project?

Ms. Adam: This was an exciting process that was begun in 2008. A small multidisciplinary group consisting of 2 occupational therapists, a clinical nurse specialist, and myself began meeting to discuss the possibility of making a sensory room a reality. A great deal of time was spent researching the literature, creating a proposal, writing a grant, researching sources for supplies, and achieving buy-in from administration. We created policies and procedures, a training manual, set up the room, and developed a quality-improvement project.

We encountered a number of problems that we needed to overcome, as well as barriers to the use of the room. Patience, perseverance, and flexibility were needed, as this project took longer than initially expected. Administration was supportive of this project, which was critical in its creation.

Staff buy-in and culture change was one of the many barriers we experienced, as was the amount of time that was required to train staff in the use of the room and the quality-improvement project. Our staff was remarkable in their support of the room, once the evidence began to mount that the use of the room actually was effective in decreasing anxiety in some patients.

Medscape: Are there any resources related to sensory rooms that you would recommend?

Ms. Adam: There are very few resources available regarding the use of a sensory room with the acute psychiatric population. There are no national guidelines or best practices. Sensory Modulation and Environment, written by Tina Champagne in 2008, is an excellent book. The Sensory Connection is a useful online resource.

Medscape: What were the 2 most significant aspects of your presentation?

Mr. Meeks: The sensory room is an effective behavioral intervention in decreasing anxiety and offers staff an alternate way of dealing with patients having difficulty modulating their emotions. More research is needed to advance the knowledge and use of sensory modulation on inpatient psychiatric units.

Ms. Adams and Mr. Meeks have disclosed no relevant financial relationships.