The New York State Office of Mental Health Positive Alternatives to Restraint and Seclusion (PARS) Project

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, monitoring, 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.

NASMHPD provided two-day training, 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 interactions between staff members and patients from coercive to collaborative, proactive violence prevention, and use of sensory modulation (15) and comfort rooms (16,17). In addition, facility 2 staff received training in dialectical behavior therapy (18) and the sanctuary model (19). Staff members from all disciplines, including psychiatry, psychology, nursing, social work, and paraprofessional staff, were trained. Facilities started emphasizing the importance of hiring staff who demonstrated commitment to coercion-free care.

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 dysregulation. For each youth, individual calming plans were developed 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 child’s room to allow children to display whatever they wished, building an outdoor playground, and expanding its recreational and activity programs.

During the first two years, peer specialists worked with each site to develop programs that reflected input from the youths in care. In subsequent 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.

Episodes of restraint and seclusion 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 patient information, precipitating actions, and length of episode. 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 produced reports monthly for benchmarking and process improvement. In addition, the facilities displayed information about PARS progress in public spaces and in newsletters.

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.

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 realized, however, that they needed to examine their leadership styles and practices, the facility’s policies and practices, and the facility’s 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 project’s aims, leaders trusting staff to try out new interventions, and staff’s 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 stigmatizing and more supportive language.

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 implemented, actions had been effective, and culture had changed.

At facility 2, staff learned that the earlier the staff intervened, the more effective 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 resident’s unmet needs. In postincident debriefings, staff members shifted from looking at what happened immediately before the incident to looking back farther, to when there were earlier options to intervene effectively. From that perspective, they identified what could have been done differently. Debriefing time increased to one hour. Staff members shared responsibility for what happened and focused on how to respond more effectively in future situations. When the number of restraint and seclusion events was low, facility 2 analyzed situations in which crises were prevented by early intervention, to better understand how best to prevent escalation. Using data, the staff systematically reviewed factors that precipitated child distress and identified more effective staff interventions.

Facility 2 reported that culture change occurred 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 performance. Each staff member’s unique talents contributed to team-based problem solving.

Facility 3’s 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 individuals 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 privileges led facilities to better meet youths’ needs and minimize conflict by replacing the system with individualized planning. For example, a child who experienced a trigger would be placed on a modified 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 Council’s role to include making decisions regarding program expectations and behavioral norms. Facility 2 also involved youths in staff selection and found that they often raised insightful questions in interviews.

While the primary focus of the project was to implement change at the three participating facilities, the PARS steering committee implemented 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 seclusion. 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 facilities, persons served, parents, and advocates participated together in educational forums and discussed, planned, implemented, and tested changes to reduce use of restraint and seclusion. Finally, a Lessons Learned conference showcased progress at the three PARS facilities and included presentations 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 evaluation of staff and modification and even elimination of long-standing rules.