+

Restraint Reduction through Sensory Modulation

Caitlin Belvin MS, OTR/L

Colleen M. Glair PMHCNS-BC

+ Background The American Nurses Association promotes registered nurse

participation in reducing patient restraint and seclusion in

health care settings. Restraining or secluding patients either

directly or indirectly is viewed as contrary to the fundamental

goals and ethical traditions of the nursing profession, which

upholds the autonomy and inherent dignity of each patient

(ANA, 2012).

Regulatory standards from The Joint Commission require staff to

be able to demonstrate strategies to identify staff and patient

behaviors, events, and environmental factors that may trigger

circumstances that require the use of restraint or seclusion as

well as the use of nonphysical intervention skills (TJC, 2010).

Given the safety, ethical, professional, regulatory, and legal

standards related to reducing restraint, it is imperative that

alternative, evidence based strategies be employed throughout

our health care settings.

+ Seclusion and Restraint Reduction

through Sensory Modulation

This requires a culture shift!

National Executive Training Institute Seclusion and Restraint

Reduction Initiative (2003-present)

6 Core Strategies (EBP)

Trauma Informed Care

Recovery Model

Why Sensory Modulation?

MA State Initiatives

http://www.mass.gov/eohhs/gov/departments/dmh/restraintse

clusion-reduction-initiative.html

International Initiatives

http://www.tepou.co.nz/initiatives/sensory-modulation/103

+ 6 Core Strategies

Leadership toward organizational change

Use of data to inform practice

Workforce development

Use of seclusion and restraint prevention tools

Full inclusion of service users and families

Debriefing

(USDHHS, 2003; NASMHPD 2003-present).

+ The experience of being human is

embedded in the sensory events of our

everyday lives.

-Dunn, 2001

+ What is Sensory Modulation?

“The capacity to regulate and organize the degree, intensity,

and nature of responses to sensory input in a graded and

adaptive manner to achieve and maintain an optimal range of

performance and adapt to challenges in daily life”

(Miller, Reisman, McIntosh, and Simon, 2001, p. 57)

Ability to self-regulate or adapt one’s responses to sensory and

motor stimulation in an adaptive manner.

Self-regulation is the ability to attain, maintain, and change

one’s arousal level for a task or a situation.

It allows us to function and feel comfortable in different situations

and environments.

This approach involves providing sensory based therapy

tools or creating appropriate environments that engage the

user’s senses for emotional regulation to reduce the build up

of agitation and prevent the escalation of aggression.

+ The Sensory Connection to

Behavior

Our senses give us information about the physical experiences of our body and our environment. Activities that involve the senses can help us change our mood or state of being.

All of us have unique system tendencies and preferences we use to self-organize. This is why it is essential that we build engaging relationships with our patients to better understand their sensory needs.

A person may need to do something to “regulate” their level of alertness by introducing something that is perceived by that person as calming or alerting.

+ Sensory Systems

Vision

Hearing

Taste

Smell

Touch

Oral Motor

Vestibular (Balance)

It’s our personal GPS telling us

where we are in time and

space.

Proprioceptive (Kinesthesia)

A sense of one’s own body and

body movements provided by

the muscles and joints.

Deep Pressure Touch

External Senses Internal Senses

+ Sensory Input can be Calming or

Alerting

Helpful when we are

stressed, anxious, or

need to relax.

Slow

Soft

Familiar

Simple

Repetitive

Rhythmic

Positive Associations

Helps to energize us or

increase our ability to

pay attention.

Fast, quick paced

Loud

Novel

Complex

Unexpected

Non-rhythmic

Pronounced

Calming Alerting

+ Reviewing the Senses

Soothing scented candle

(vanilla, lavender)

Mild fragrances

Herbal teas

Scented bath powder or

shower gels

Scented Lotions

Cedar filled pillow

Positive associations

Candles with crisp strong scent

(lemon or peppermint)

Strong fragrances

Perfume

Noxious odors

Room fragrance spray

Citrus scents

Negative Associations

Calming Alerting

Olfaction

+ Reviewing the Senses

Mild

Sweet

Chocolate

Sweet fruits like apples and grapes

Pleasant tastes

Chicken noodle soup

Herbal teas

Oatmeal and brown sugar

Spicy

Sour candy

Bitter

Strong peppermints

Distasteful foods

Lemonade

Pickles

Coffee

Calming Alerting

Taste

+ Reviewing the Senses

Sucking or resistive

chewing

Hard candy

Thick liquid through a

straw

Sweet orange slices

Lollipops

Chewing gum

Crunchy

Popcorn

Pretzels

Raw vegetables

Cereal

Crushed Ice

Calming Alerting

Oral Motor

+ Reviewing the Senses

Soft colors

Dim lighting

Natural Lighting

Watching fish in an

aquarium

Bubble lamps

Serene paintings

Clean and sparsely

finished room

Bright Colors

Bright lighting

Flashing lights

Modern Art

Video games

Messy and cluttered room

Calming Alerting

Vision

+ Reviewing the Senses

Soft and slow music

Quiet

Familiar sounds

Humming

Singing quietly

Repetitive or rhythmic sounds

(drum beat)

Nature sounds

Meditation tapes

Loud noises

Rock music

Fast tempo or offbeat

Fire alarms

Thunder

Whistling

Changing sounds (city streets)

Hand held instruments

Calming Alerting

Auditory

+ Reviewing the Senses

Firm touch on shoulder

Using a heavy quilt or weighted blanket

Neutral warmth

Squeezing a stress ball

Foot roller

Use of hand lotions

Beanbag tapping

Massage

Unexpected touch

Light touch

Feeling something prickly

or squishy

Cool room

Use of “fidgets”

Snapping a rubber band on

wrist

Use of ice

Calming Alerting

Touch

+ Reviewing the Senses

Slow and rhythmic

Sustained

Joint compression or isometrics

Weight lifting or sports

Yoga, Tai Chi, or stretching

Walking

Gardening

Pushing heavy objects or adding

weight

Quick

Jarring

Jerky

Jogging

Aerobics

Boxing

Jumping Jacks

Calming Alerting

Proprioceptive

+ Reviewing the Senses

Rocking

Swinging

Stable

Slow

Using a glider chair or

rocker chair

Walking

Pacing

Jogging

Fast Dancing

Movement Activities

Spinning quickly

Bouncing

Jumping

Calming Alerting

Vestibular (Balance)

+ When is calming needed?

Physical Signs

Tense posture

Fidgeting

Increased

breathing

Increased heart

rate

Sweaty palms

Increased

energy

Hyperactivity

Sleeplessness

Emotional Signs

Anxiety

Agitation

Euphoria

Anger

Mania

Over excitation

Fear

Panic

Overwhelmed

Behavioral Signs

Hyper-vigilant

Intrusive

Noisy

Disruptive

Frustrated Easily

Over active

Distractible

Poorly self-

controlled

+ When is alerting needed?

Physical Signs

Low energy

Slouched posture

Lethargy

Sleepiness

Emotional Signs

Sadness

Hopelessness

Numbness

Discouragement

Feeling suicidal

Having flashbacks

Trouble with

disassociation

Behavioral Signs

Lack of interest

Withdrawal

Pre-occupation

Self-injurious

behaviors

Poor orientation

+ Sensory Diet

Menu of strategies that are strategically integrated into daily

routines to support health, wellness, and the recovery

process.

Includes prevention and de-escalation focused interventions

“Each person’s sensory diet is an important self-organizing

concept and needs to be considered in the identification of

individual crisis prevention strategies for use at critical

times” (Champagne, 2003).

For example, if an individual wishes to watch a relaxing video

tape at night to prepare for sleep but is prohibited from doing so

by institutional rules, he or she may experience increased

agitation or distress. If these needs are understood as part of the

individual’s sensory diet and as self-organizing activities, options

can be made available” (Champagne and Stromberg, 2004).

+ Individual Sensory Preferences

and Diet How do your own sensory preferences influence your actions

and relationships with others?

Self-awareness of our own patterns and habits helps us better

understand how we respond to people, life situations, and

our environment.

What is calming or alerting to you?

What is your ultimate work or home setting?

Quiet? Dark? Music?

What is a part of your personal “sensory diet” that you use

daily in response to stressful life situations and events?

+ Common Sensory Issues in Mental

Health Patients

People with mental illness may experience hyper or

hypo sensitivity to particular sensations including

touch, light, noise, and vestibular input.

How does this impact our patients?

Strong clothing preferences or avoidances.

Aversion to showers.

Discomfort with surprise touch (hugging, hand shaking).

Poor balance.

Sensitivity to visual stimuli like bright lights and contrast.

Distracted when other people are talking.

Sensitivity to loud noises or sounds.

Extreme food preferences.

Difficulty learning new skills.

Discomfort in crowded places.

Frequently feeling anxious/tense.

Need to maintain own space.

Avoiding routine medical procedures (shots, dentist).

+ Promoting Recovery

Building the capacity for:

Increased Resiliency

Development

Occupational Participation

Health and Wellness

Quality of Life

Gives patients a concrete strategy to help themselves in the

future, not just a temporary fix with PRN medication.

Allows staff to develop a therapeutic rapport and helps foster a

sense of safety and containment in the physical environment.

+ Trauma Informed Care

Collaborative care that recognizes the high prevalence and

pervasive impact of trauma and attachment-related

difficulties within their client population and provides care

that addresses the whole system (person, family,

organization) to help support the recovery process.

(Champagne, 2008, 2011a, 2011b, 2012)

Appreciation for the high prevalence of traumatic

experiences among consumers

An understanding of the profound neurological, biological,

and social effects of trauma and violence.

Care that recognizes and addresses trauma-related issues, is

collaborative, supportive, and skilled.

(NASMHPD, 2003-present)

+ Trauma Informed vs. Non-trauma

informed Care

Staff understands the

function of the behavior

(self-injury, rage,

compulsions)

Objective, neutral language

Recognition of culture and

practices that are re-

traumatizing

Power/control issues

minimized-constant

attention to culture of care

and individualized

approach

Most behavior seen as

intentionally provocative

(attention seeking)

Labeling language

(manipulative, needy,

attention-seeking)

“Tradition of toughness” or

primarily a behaviorist

approach valued as best

care approach

Rule enforcers- compliance

focused

Trauma Informed Non-Informed

+ Ourselves: the Caregivers

Identify our own sensory, trauma, and attachment

experiences.

Seek assistance as needed.

Create our own sensory supports and tool kits.

Consider your schedule (how many patients with

severe emotional disturbances, etc. do you see per

day/per hour, etc).

Find ways to embed sensory based strategies into your

daily routine.

Practice, practice, practice what we preach.

+ Implementation in Behavioral

Health• A sensory modulation

program was developed

and implemented on the

inpatient behavioral health

unit in 2016. The process

utilized a team

collaborative approach

with input from patients,

nursing, occupational

therapy, quality

management, infection

control, clinical practice

committee, employee

health, environmental

services, and the

department of facilities and

engineering.

+ Results

• Results suggest that the use of sensory modulation is an effective strategy for decreasing restraint and seclusion episodes on an inpatient psychiatric unit.

• Results suggest that the use of sensory modulation is an effective strategy as in decreasing employee workplace violence related injuries and lost or restricted work days due to injury.

• Sensory modulation provided an innovative approach that strengthened the therapeutic alliance between staff and patients. This approach assisted both the provider and the patient in the utilization of the patient’s preferred crisis prevention methods which decreased the need for seclusion and restraint.

2015 2016- ytd

# Staff Injured by Patients 7 3

Lost Work Days Due to

Injury35 0

Restricted Work Duty Due

to Injury27 0

05

10152025303540

Total Number

Staff Injuries

2015-Present

1Q

2015

2Q

2015

3Q

2015

4Q

2015

1Q

2016

2Q

2016

3Q

2016

4Q

2016

1Q

2017

2Q

2017

Seclusions 19 13 5 9 8 9 4 1 7 2

Restraints 6 10 7 13 0 1 0 0 0 1

0

2

4

6

8

10

12

14

16

18

20

Number

Seclusions and Restraints

2015-2017

+ References Adkinson, L. (2012) Understanding sensory stimulation.

ANA March 12, 2012, Reduction of Patient Restraint and Seclusion in Health Care Settings, Status: Revised Position Statement Originated by: Center for Ethics and Human Rights.

APNA 2014, Position Statement: The Use of Seclusion and Restraint.

AOTA 2014, Occupational Therapy’s Role with Restraint and Seclusion Reduction or Elimination, Fact Sheet.

Chalmers, A., S. Harrison, K. Mollison, N. Molloy, and K. Gray. "Establishing Sensory-based Approaches in Mental Health Inpatient Care: A Multidisciplinary Approach." Australasian Psychiatry 20.1 (2012): 35-39. Web.

Champagne, T. (2003). Sensory modulation and environment: Essential elements of occupation. Southhampton, MA: Champagne Conferences & Consultation.

Champagne, T. (2008). Sensory modulation & environment: Essential elements of occupation. Southampton, MA: Champagne Conferences.

Champagne, T. (2011). Sensory modulation & environment: Essential elements of occupation: Handbook & reference. Sydney, Australia: Pearson Australia Group.

Champagne, T. (2015, October). Sensory Processing, Trauma & Attachment Informed Care. Lecture presented at Course 1 Sensory Modulation & Trauma Informed Care: An Introduction in MA, Hadley.

Champagne, T., & Koomar, J. (2011, March). Expanding the Focus: Addressing Sensory Discrimination Concerns in Mental Health. Mental Health Special Interest Section Quarterly, 34(1), 1-4.

+ References continued Champagne, T., & Stromberg, N. (2004). Sensory Approaches in Inpatient

Psychiatric Settings: Innovative Alternatives to Seclusion and Restraint. Journal of Psychosocial Nursing, 42(9). Retrieved March 23, 2016.

Champagne, Tina, N. Stromberg, and R. Coyle. "Integrating Sensory and Trauma-Informed Interventions: A Massachusetts State Initiative, Part 1." American Occupational Therapy Association (2010). Web.

Dunn, W. (2001) The sensations of everyday life: Empirical, theoretical, and pragmatic considerations. American Journal of Occupational Therapy, 55(6), 608-620.

Masick, April, and Jennifer Landy. "Calming Rooms: A Sense-able Alternative." VA, Fairfax. 17 June 2015. Lecture.

Miller, L. J., Reisman, J. E., McIntosh, D. N., & Simon, J. (2001). An ecological model of sensory modulation. In S. Smith Roley, E. Blanche, & R. C. Schaaf (Eds.), Under- standing the nature of sensory integration with diverse popula- tions(pp. 57–82). San Antonio, TX: Therapy Skill Builders.

Moore, K. M. (2015). The Sensory Connection Program: Curriculum for Self-Regulation. Framingham, MA: Therapro.

NASMHPD (2006). Prevention Tools: A Core Strategy. Retrieved on March 28, 2016 from http://www.nasmhpd.org/sites/default/files/Consolidated%20Six%20Core%20Strategies%20Document.pdf

SAMSHA, (2006). Roadmap to Seclusion and Restraint Free Mental Health Services. Retrieved on March 28, 2016 from http://store.samhsa.gov/shin/content//SMA06-4055/SMA06-4055-F.pdf?

TJC 2010, The Hospital Accreditation Standards. Provision of Care, Treatment, and Services. Standards PC.03.05.01 through PC.03.05.19