Safety in mental health
Introduction and Alignment
This workshop focuses on clinical practice issues involving consumer/client safety that have the potential to negatively impact client and organizational outcomes. Understanding the interaction of biopsychosocial aspects that the client brings into the therapeutic relationship and staff and organizational influences can provide insights to guide effective care planning and advocacy activities.
Upon completion of this assignment, you should be able to:
Compare and contrast characteristics of the client, healthcare provider, and healthcare organization that contribute to positive and negative client safety outcomes.
Discuss strategies to minimize healthcare-associated risk or harm to the client (consumer) that incorporates client preferences and strengths, and healthcare provider factors.
Formulate a plan to maintain a practice environment that emphasizes client safety in diverse mental healthcare settings.
Resources
Website: Culture of Safety, Just Culture: The Joint Commission- Safety Systems in Behavioral Healthcare
Website: ANA Position Statement ‘Just Culture’ (2010)
Website:Seclusion and Restraint- Consequences, Alternatives: Substance Abuse and Mental Health Services Administration (SAMHSA)
Website: The New York State Office of Mental Health Positive Alternatives to Restraint and Seclusion (PARS) Project
Website Publication “Issue Brief #4 Promoting Alternatives to the Use of Seclusion and Restraint: Making the Business Case”
Website: National Association of State Mental Health Program Directors Six Core Strategies:
Website: SAMHSA Intimate Partner Violence
Video: Violence Risk Assessment A Practical Guide for Mental Health Clinicians
Instructions
Prepare a 1-2 page paper that reflects the readings for this week.
The paper should include the following:
Characteristics of the provider and organization that lead to both positive and negative patient safety outcomes.
Develop a plan/discuss strategies that will allow for positive interactions with patients and provides patient safety in diverse mental health care settings.
When youve completed your paper save a copy for yourself and submit a copy to your instructor using the Dropbox by the end of the workshop.
Select here to access the Dropbox.
Assessment Criteria
Criteria
Points
Question answered comprehensively
Characteristics – both positive and negative addressed (20 pts)
Plan/strategies discussed for safe patient care (20 pts)
40
Paper APA formatted, references and citations in correct APA format
5
Writing style/punctuation/grammar, minimum length of 3 pages
5
Total Points
50
The New York State Office of Mental Health Positive
Alternatives to Restraint and Seclusion (PARS) Project
Jennifer P. Wisdom, Ph.D., M.P.H., David Wenger, M.A., L.M.S.W., David Robertson, R.N., Jayne Van Bramer, M.A.,
Lloyd I. Sederer, M.D.
Objective: The Positive Alternatives to Restraint and Seclusion
(PARS) project of the New York State Office of Mental Health
(OMH) was designed to build capacity to use alternatives to
restraint and seclusion within state-operated and licensed in-
patient and residential treatment programs serving children
with severe emotional disturbances. Its long-term goal was to
eliminate the use of these restrictive interventions throughout
the states mental health system of care by creating coercion-
and violence-free treatment environments governed by a phi-
losophy of recovery, resiliency, and wellness.
Methods: The central feature of the PARS project was training
in, implementation of, and engagement with the Six Core
Strategies to Reduce the Use of Seclusion and Restraint,
a comprehensive approach developed by the National Asso-
ciation of State Mental Health Program Directors. This report
provides an overview of the project, results from January 2007
through December 2011, and lessons learned by OMH.
Results: The three participating mental health treatment
facilities demonstrated significant decreases in restraint
and seclusion episodes per 1,000 client-days. Each identi-
fied specific activities that contributed to success, including
ways to facilitate open, respectful two-way communication
between management and staff and between staff and
youths and greater involvement of youths in program de-
cision making.
Conclusions: All three facilities continued to implement
key components of the PARS initiative after termination
of grant-funded activities, and OMH initiated multiple ac-
tivities to disseminate lessons learned during the project to
all inpatient and residential treatment programs throughout
the state mental health system.
Psychiatric Services 2015; 66:851856; doi: 10.1176/appi.ps.201400279
For over 20 years, mental health providers have questioned
the efficacy of restraint and seclusion as treatment inter-
ventions for maintaining safety in inpatient and residential
psychiatric programs (13). The Joint Commission has en-
couraged the reduction of the use of restraint and seclusion
(4). Consumer advocacy groups (1,5,6), public reports (7,8),
and the National Association of State Mental Health Pro-
gram Directors (NASMHPD) (9) have recommended the
elimination of restraint and seclusion and have voiced con-
cerns about their deleterious effects.
The New York State Office of Mental Health (OMH) over-
sees a mental health system serving approximately 700,000
persons annually. Since the 1990s, OMH has taken a pro-
active approach to reduce the use of restraint and seclusion
through data analysis, policy and clinical practice initiatives,
and workforce development. In 2007, OMH implemented
the Positive Alternatives to Restraint and Seclusion (PARS)
project. Promoting a philosophy of recovery, resiliency, and
wellness, this project aimed to implement evidence-based
practices to create violence- and coercion-free cultures where
use of restraint and seclusion is reduced and ultimately
eliminated. This article describes the implementation of the
PARS project, outcomes of efforts to reduce the use of re-
straint and seclusion, and lessons learned.
METHODS
Three facilities participated in an in-depth intervention to
reduce use of restraint and seclusion that included training,
on-site mentors and peer specialists, and on-site consulta-
tion from the NASMHPD Office of Technical Assistance.
The intervention used performance improvement techniques
(10,11), direction by a central OMH steering committee and
facility leadership teams, consultation with NASMHPD ex-
perts, implementation of service innovations suggested by
best practices and research, and benchmarking and feedback
on progress. The interventions primary methodology was
implementation of NASMHPDs Six Core Strategies to Reduce
the Use of Seclusion and Restraint (12). These strategies,
designed to establish a comprehensive, systemwide inte-
gration of positive alternatives to restraint and seclusion,
embrace the principles of child-centered, strengths-based,
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and trauma-informed care and are included in the National
Registry of Evidence-Based Programs and Practices (www.
nrepp.samhsa.gov; select 6CS.)
The first core strategy is leadership toward organiza-
tional change, evidenced by ensuring that the organizations
values, policies, and practices are consistent with a restraint
and seclusion reduction initiative and by forming a steering
committee to provide oversight. Leaders partner with staff
and youths to implement the other core strategies: work-
force development, devising tools to prevent use of restraint
and seclusion, consumer involvement, use of data to inform
change, and postevent debriefing.
The OMH Institutional Review Board (IRB) for the Protec-
tion of Human Subjects determined that the quality improve-
ment activities described in the study did not constitute human
subjectsresearchandthatIRBreviewthereforewasnotrequired.
Setting and Participants
OMH focused on childrens facilities because children in OMH
facilities were five times as likely as adults to be placed in
restraint or seclusion (13). OMH contacted three facilities
in the central and western regions of New York that were
among the highest utilizers of restrictive interventions in the
state and invited them to participate in the study. They were
an OMH-operated childrens psychiatric center (facility 1),
an OMH-licensed childrens residential treatment facility
(facility 2), and the unit of an OMH-licensed private psy-
chiatric hospital serving children and adolescents (facility 3).
All three facilities agreed to participate, indicating their
desire to improve service delivery. No additional facilities
participated.
To guide project implementation, OMH created a central
PARS steering committee comprising the OMH director of
quality management, the director of the Bureau of Education
and Workforce Development, and the director of Consumer
Affairs; representatives from the Division for Children and
Families, the states Council on Children and Families, the
Commission on Quality of Care and Advocacy for Persons
With Disabilities and consumer advocacy groups, including
youth advocacy; and the director of an OMH-operated psy-
chiatric hospital. National experts in reduction of restraint
and seclusion and creation of violence- and coercion-free
environments served as committee consultants and advisors.
Each facility was assigned a trainer-mentor to provide on-
going consultation, modeling, and coaching in PARS concepts,
techniques, and methods. Trainer-mentors were masters-
level mental health professionals with strong leadership,
educational, and interpersonal skills and familiarity with
evidence-based mental health practices, workforce and organi-
zational development, and prevention and management of crisis
situations in childrens mental health programs. Peer specialists
adults who were parents of a child with a mental illness and
who were trained at an OMH-supported Parent Empowerment
Program (14)contributed to the project at meetings.
Throughout the project, NASMHPD consultants visited each
siteand provided comprehensivereports and recommendations.
The providers incorporated these recommendations into
their plans, policies, and practices, and the trainer-mentors
monitored their progress.
Application of the Core Strategies Intervention
Leadership toward organizational change. Facility leaders
received extensive training on the Six Core Strategies to
Reduce the Use of Seclusion and Restraint (12). Each facility
developed a comprehensive action plan that addressed each
of the core strategies and also formed a steering committee
to oversee ongoing development, implementation, moni-
toring, and refinement of the plan. As the project developed,
the steering committees increased consumer participation
and included a broader array of staff, including nurses and
other milieu staff. Throughout the project, facility leaders
and the OMH steering committee consulted monthly to
monitor plan implementation and progress toward PARS
goals, and discuss how to more effectively reach these goals.
Workforce development. NASMHPD provided two-day train-
ing, where national experts presented sessions that focused
on core strategies. Topics included identifying risk factors,
understanding trauma and trauma-informed care, recovery-
oriented and person-centered care, strategies for changing in-
teractions between staff members and patients from coercive
to collaborative, proactive violence prevention, and use of sen-
sory modulation (15) and comfort rooms (16,17). In addition,
facility 2 staff received training in dialectical behavior ther-
apy (18) and the sanctuary model (19). Staff members from
all disciplines, including psychiatry, psychology, nursing,
social work, and paraprofessional staff, were trained. Facil-
ities started emphasizing the importance of hiring staff who
demonstrated commitment to coercion-free care.
Use of tools to prevent restraint and seclusion. Focusing on
primary prevention, each facility utilized tools from the
core strategies and other sources (13,15,19) to enhance its
therapeutic environments and foster noncoercive, person-
centered, resiliency-based care. Each facility created comfort
rooms and comfort carts equipped with sensory modulation
items that could be brought to children experiencing dysre-
gulation. For each youth, individual calming plans were de-
veloped that identified triggers, warning signs, and effective
coping strategies. Facility 1 purchased a trained therapy dog
and a climbing wall. Facility 2 purchased a set of high-quality
drums to provide a sensory modulation activity and upgraded
furnishings and common areas to provide a more soothing
environment. Facility 3 made environmental improvements,
such as adding chalkboards outside each childs room to allow
children to display whatever they wished, building an outdoor
playground, and expanding its recreational and activity
programs.
Promotion of consumer involvement. During the first two years,
peer specialists worked with each site to develop programs
that reflected input from the youths in care. In subsequent
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years, staff at the three facilities developed other methods to
enhance consumer involvement in decision making, including
replacing points-and-levels systems of earning privileges with
more person-centered approaches. Providers also worked to
substantially increase parent and family involvement through
the work of parent advocates, extensive outreach, invitations
to kickoff celebrations, and family nights. Because youths
could better represent the youths interests and because the
youths served were more willing to work with them, youth
peer specialists replaced adult peer specialists.
Use of data to inform change. Episodes of restraint and se-
clusion were defined as events where restrictive interventions
were used, regardless of duration. Facilities tracked episodes
online in a secure module of the New York State Incident
Management and Reporting System (NIMRS), including pa-
tient information, precipitating actions, and length of epi-
sode. The OMH Bureau of Quality Improvement assisted
the facilities in analyzing data to identify when targeted
interventions were needed, such as at particular times of
the day or at transition points in the program, when rules
contributed to tension, or when staff members had high
rates of using restraint and seclusion. The bureau also pro-
duced reports monthly for benchmarking and process im-
provement. In addition, the facilities displayed information
about PARS progress in public spaces and in newsletters.
Postevent debriefing. When restraint or seclusion was used,
providers conducted debriefings with staff members and
youths to better understand what happened and why, to
mitigate the adverse and potentially traumatic effects of the
event, to learn what could have been done differently, and to
identify opportunities for improvement in treatment plans
and facility policies.
Data Collection and Analysis
With data that facilities provided via NIMRS, linear re-
gressions determined the strength of the rate of restraint and
seclusion episodes per 1,000 client-days against time (20072011)
to determine whether episodes were reduced during the
course of the intervention.
Qualitative data were collected via notes from facility
consultations, site visits, steering committee reviews, site
conference calls with OMH, and site reports. Basic qualita-
tive thematic analysis techniques were used to identify les-
sons learned (20).
RESULTS
Table 1 presents demographic and diagnostic information
for youths served at each facility and for the two regions
from which the facilities were selected. Youths served in the
participating facilities were similar to those served across
the Western and Central regions of New York. For both
populations, males and non-Hispanic whites predominated,
and youths with ADHD or conduct disorder made up the
largest primary diagnostic group at all but facility 2, where
mood disorders predominated.
Change in Incidence of Restraint and Seclusion
The use of restraint and seclusion was significantly reduced
at all three sites over the course of the project (Figure 1). At
facility 1, the trend in number of incidents per 1,000 client-
days showed a decrease of 62%, from 67 to 25 (R2=.27,
p=.019); at facility 2, the trend was a decrease of 86%, from 63
to 7 (R2=.50, p=.001); and at facility 3, the trend was a de-
crease of 69%, from 99 to 13 (R2=.29, p=.007).
Lessons Learned
All three facilities reported that incorporating the Six Core
Strategies was essential to creating environments to reduce
restraint and seclusion, and all chose to continue these ef-
forts when the grant terminated. Lessons learned follow.
To achieve success in reducing use of restraint and seclusion,
treatment facility providers and leadership must thoroughly
examine their own culture and practices. Facility 1 reported
that although administrators were aware of the Six Core
Strategies before the project, their expectation was that
these would be a golden key to solve problems. They re-
alized, however, that they needed to examine their leader-
ship styles and practices, the facilitys policies and practices,
and the facilitys environment to effectively integrate the core
strategies into their milieu. They involved a cross-section of
staff on their steering committee rather than those always
involved on committees. Their key to success was increased
commitment: medical staff demonstrating commitment to the
projects aims, leaders trusting staff to try out new interven-
tions, and staffs commitment to embrace new methods and
make changes. As a result, the culture became more flexible
and open to alternative approaches, with staff using less stig-
matizing and more supportive language.
Creating the culture of change necessary to reduce the use of
restraint and seclusion means making major changes at all
levels of an organization and requires a major commitment
over an extended period. The change process was not fully
implemented until 2011, the fourth year of the project. Until
then, each facility had periods of forward movement and
retreat. It was important to use each period to reassess the
extent to which each of the strategies had been imple-
mented, actions had been effective, and culture had changed.
Conducting effective postevent debriefing plays a critical role
in reducing use of restraint and seclusion but requires on-
going commitment and willingness to learn. At facility 2, staff
learned that the earlier the staff intervened, the more ef-
fective they were in preventing stressful situations from
escalating into crises. Staff members shifted the primary
focus from preventing problematic behavior from escalating
to addressing the residents unmet needs. In postincident
debriefings, staff members shifted from looking at what
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happened immediately before the incident to looking back
farther, to when there were earlier options to intervene ef-
fectively. From that perspective, they identified what could
have been done differently. Debriefing time increased to one
hour. Staff members shared responsibility for what hap-
pened and focused on how to respond more effectively in
future situations. When the number of restraint and seclu-
sion events was low, facility 2 analyzed situations in which
crises were prevented by early intervention, to better un-
derstand how best to prevent escalation. Using data, the staff
systematically reviewed factors that precipitated child dis-
tress and identified more effective staff interventions.
Manager treatment of staff affects how staff members treat
persons served. Facility 2 reported that culture change oc-
curred when the staff began embracing the core strategies.
The program director led the change process by reassessing
her management style and concluding that her role was to
lead rather than manage. This meant deemphasizing control
and valuing the skills, creativity, and contributions of each
staff member. Conveying that everyone had a voice included
them in decision making, which enhanced program perfor-
mance. Each staff members unique talents contributed to
team-based problem solving.
Consumer input and involvement in decision making are
critical to improving a facilitys culture and reducing use of
restraint and seclusion. Facility 3s chief operating officer
personally participated in debriefings; visited persons served
to solicit their opinions on
programming, including what
they liked and disliked; and
made changes based on their
responses. Youths who may
never have had anyone to
listen to them were being
heard by a hospital chief. At
facilities 2 and 3, feedback
from persons served resulted
in significant change to the
facilities points-and-levels
systems, which required in-
dividuals served to display
appropriate behavior to reach
levels and earn privileges or
home visits. Feedback that
the levels system led to power
struggles over denial of priv-
ileges led facilities to better
meet youths needs and mini-
mize conflict by replacing the
system with individualized
planning. For example, a child
who experienced a trigger
would be placed on a modi-
fied program to ensure that
his or her needs were met, rather than having restrictive
interventions imposed on him or her. Facilities retained rules
required for safety and deemphasized less important rules.
Rather than reducing privileges after problematic behavior,
staff focused on restorative tasks that allowed the child to
make amends. Facility 2 also recognized the need to involve
youths in decision making and expanded the Residents
Councils role to include making decisions regarding pro-
gram expectations and behavioral norms. Facility 2 also
involved youths in staff selection and found that they often
raised insightful questions in interviews.
Staff from facilities participating in a project such as PARS
can play a key role in disseminating alternatives to restraint
and seclusion throughout the state. While the primary focus
of the project was to implement change at the three par-
ticipating facilities, the PARS steering committee imple-
mented several initiatives to promote alternatives to restraint
and seclusion throughout the state. In each initiative, the
PARS facilities became engaged as learners and as promoters
of core strategies. In 2009, PARS sponsored two statewide
training conferences and awarded facilities that demonstrated
significant commitment to reducing use of restraint and se-
clusion. In 2010, PARS initiated five learning collaboratives.
Each held monthly teleconference sessions led by national
experts on prevention of restraint and seclusion. In these
learning collaboratives the PARS facilities, multidisciplinary
performance improvement teams from more than 30 faci-
lities, persons served, parents, and advocates participated
TABLE 1. Characteristics of children and youths served per week by PARS-trained mental health
facilities versus all mental health facilities in two regions of New York statea
Facility 1
(N=27)
Facility 2
(N=17)
Facility 3
(N=20)
Western and
central
New York
(N=10,118)
Characteristic N % N % N % N %
Age (years)
012 13 48 6 35 10 50 5,304 52
1317 14 52 11 65 10 50 4,814 48
Gender
Male 20 74 9 53 14 70 6,056 60
Female 7 26 8 47 6 30 4,051 40
Race-ethnicityb
White, non-Hispanic 16 59 14 82 11 55 7,276 72
Black, non-Hispanic 2 7 2 12 6 30 1,252 12
Hispanic 5 19 0 1 5 756 7
Other and multiple race 4 15 1 6 2 10 701 7
Primary diagnosis
ADHD or conduct disorder 11 41 2 12 12 60 3,908 39
Adjustment disorder 0 0 1 5 1,514 15
Anxiety disorder 3 11 4 24 0 863 9
Mood disorder 7 26 8 47 7 35 2,099 21
Personality and impulse control disorder 0 1 6 0 175 2
Schizophrenia and related disorders 3 11 1 6 0 62 1
Other disorder 3 11 1 6 0 1,497 15
a PARS, Positive Alternatives to Restraint and Seclusion
b Unknown for 133 (1%) children and youths in the Western and Central regions of New York state
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together in educational forums and discussed, planned, im-
plemented, and tested changes to reduce use of restraint and
seclusion. Finally, a Lessons Learned conference showcased
progress at the three PARS facilities and included presen-
tations by national experts. PARS leaders reinforced a
central PARS theme: culture change can be most effectively
accomplished when persons served are involved in all
aspects of decision making, including selection and evalu-
ation of staff and modification and even elimination of long-
standing rules.
DISCUSSION AND CONCLUSIONS
This report outlines the effectiveness of an intervention that
used NASMHPDs Six Core Strategies to reduce use of re-
straint and seclusion through creation of a positive thera-
peutic environment free of violence and coercion. In this
effort, OMH led three facilities in training and consultation
to enact changes in management style, policies, procedures,
and methods for obtaining consumer perspectives. OMH
also implemented learning collaboratives to increase sus-
tainability of changes made, encourage other facilities to
adopt these strategies, and provide a forum for discussion of
means to successfully overcome emerging challenges.
Consistent with other efforts to specifically reduce use of
restraint and seclusion in psychiatric facilities (21,22), key
elements of the intervention were commitment by leaders to
culture change, participation by persons served, training,
data analysis, and individualized treatment. This project
included transformation of the physical environment and
enhanced postevent debriefing as additional mechanisms for
change, which are each consistent with promoting person-
centered care (22) and facilitating staff efforts to deescalate
conflict rather than using restraint or seclusion (23). We
note that the intervention was not a one size fits all ap-
proach, and sites reported that freedom to choose activities
based on stakeholder suggestions was key to change.
The study had several limitations. These findings may not
generalize beyond facilities that provide psychiatric services
to children and adolescents. Given that the facilities vol-
unteered to participate, it is unclear how well the interven-
tion will work with facilities less committed to change. A
reasonable assumption is that facilities in various service
systems that have the desire to improve and the commit-
ment of their leadership could successfully implement the
intervention.
The core strategies intervention was associated with fewer
restraint and seclusion episodes even though each facility
chose somewhat different activities to achieve this outcome.
Although leadership at all facilities promoted culture change,
the empowerment of staff and youth involvement in decision
making were particularly strong at facilities 2 and 3. At
facility 1, both staff and youths emphasized that the trained
therapy dog was emblematic of leadership flexibility and
staff empowerment and was a strong factor in creating a
calm, accepting environment for persons served.
The primary finding of this project was that creation of
coercion- and violence-free environments where use of re-
straint and seclusion is markedly decreased requires a major
commitment by all staff over an extended period to fully
understand and internalize the strategies involved and em-
brace the changes in facility culture. In New York, OMH is
promoting facilities engagement in learning collaboratives
so that facilities can reduce use of restraint and seclusion and
realize significant positive outcomes.
AUTHOR AND ARTICLE INFORMATION
Dr. Wisdom is with the Department of Health Policy, George Washington
University, Washington, D.C. (e-mail: [emailprotected]). All other
authors are with the New York State Office of Mental Health in Albany,
except for Dr. Sederer, who is at the New York City location.
The project was funded by a program grant from the Substance Abuse
and Mental Health Services Administration (SM 058127).
The authors appreciate assistance from E. Kevin Conley, M.B.A., and
Maria Pangilinan, Ph.D., from the New York State Office of Mental Health.
The authors report no financial relationships with commercial interests.
Received June 22, 2014; revisions received October 2 and November
24, 2014; accepted January 5, 2015; published online May 1, 2015.
FIGURE 1. Restraint and seclusion episodes at three youth
psychiatric facilities per 1,000 client-days for 20 quarters,
20072011
Facility 1
Facility 2
Facility 3
0
20
40
60
80
100
120
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20E
p
is
o
d
e
s
p
e
r
1,
0
0
0
c
lie
n
t-
d
a
y
s
E
p
is
o
d
e
s
p
e
r
1,
0
0
0
c
lie
n
t-
d
a
y
s
E
p
is
o
d
e
s
p
e
r
1,
0
0
0
c
lie
n
t-
d
a
y
s
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
0
50
100
150
200
250
300
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Time (quarters)
2007 2008 2009 2010 2011
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