Evidence Based Approaches for Reducing Restrictive Practices Sharon

Evidence Based Approaches for Reducing Restrictive Practices Sharon Paley Manager, State Schools Operations (Behaviour) Queensland Department of Education

Risk associated with training staff in restraints • “The available research indicates that there is a risk of physical and psychological harm as a result of the use of any restrictive practice, including physical restraint. The most serious of which is death (Paterson et al 2003). ” • “The risk exists for both the person exposed to physical restraint, and also staff who implement the use. ” Duxbury 2015

Risk associated with training staff in restraints • “There can be no justification for the sustained and repeated use of the restraint of vulnerable people whilst services continue to neglect to embrace strategies, which can reduce the reactive and uncontrolled use of such approaches. ” Duxbury 2015

Risk associated with training staff in restraints • “Despite the growing evidence that physical restraint is potentially counter-therapeutic, traumatic, unnecessary and can be life threatening (Curran, 2007; Aiken et al. , 2011), nurses continue to rely upon this practice. ” • The use of restraint is seen as one of the few options clinicians view as effective in managing violence and aggression, in the absence of a real evidence base (Cutcliffe & Santos, 2012). ” Duxbury 2015

SO…………. Is it a good idea for us to reduce the use of restrictive practices? “Good ideas are not adopted automatically. They must be driven into practice with courageous patience. ’’ - Hyman G. Rickover

Barriers and resistance to reducing restrictive practices • Inconsistent definitions & lack of agreement about what is, or is not, a restrictive practices. • Lack of an ethical decision making process being applied, in the planned use of restrictive practices. • Policy and guidance that authorises the management of behaviour, rather than use of evidence based, proactive behaviour support responses; such as PBS. • Lack of investment in evidence based proactive behaviour support skills and knowledge for staff.

Barriers and resistance to reducing restrictive practices; practice myths Restrictive practices provide therapeutic benefit for people There is no evidence to support this idea, BUT there is evidence that they cause injury, psychological damage and trauma. Restrictive practices keep people safe Restrictive practices likely increase risk to staff and the people they support/students they teach. Reduction programmes have not seen an increase in assaults on staff. Restrictive practices prevent risky behaviour Use of restrictive practices increases feelings of anger resulting in an increase in risk behaviour. People who are subjected to restrictive practices view them as punitive and punishing.

Barriers and resistance to reducing restrictive practices; practice myths Staff can recognise potentially high risk situations This is not supported by evidence, that indicates staff use restrictive practices defensively and often without a good risk assessment. People with intellectual, cognitive or psychosocial difficulties are irrational and unpredictable Substantial evidence show's that people with additional needs are not more unpredictable or violent than the general population.

Barriers and resistance to reducing restrictive practices; practice myths There are circumstances in which the use of a restrictive practice is unavoidable Evidence supports that most circumstances when RP is deployed are avoidable. World Health Organisation 2017

Barriers and resistance to reducing restrictive practices; practice myths Alternatives will increase risk to everyone Alternative strategies are likely to reduce risk for everyone, significantly. Alternatives will require increased resources Evidence from restraint reduction programmes supports that resources are freed up, people are provided with better support/access to education, Concern there will be an increase in workover claims The evidence shows staff are at increased risk of injury when attending training in physical restraint and when implementing restraint than they might otherwise be.

What research tells us works

Individual service user level • Early intervention aimed at reducing the impact of the behaviour will reduce reliance on restrictive practices. • Encouraging a change in the approaches used by staff can reduce reliance on restrictive practices. • Fading the use of mechanical restraint can impact on reducing the use of mechanical restraint equipment used when a person self injures. • Long term follow up and audit in the use of individual restrictive practices. • Individualised approaches appear more effective than organisational strategies for reducing restrictive practices. (Luiselli 2009, Williams 2010, Allen 2011)

Checklist for Assessing Your Organization’s Readiness for Reducing Seclusion and Restraint Colton. D (2004, 2010) 1. Leadership. 2. Orientation and training of staff/caregiver. 3. Staffing; use of rostering, opportunities for training, rest leave. 4. Environmental factors. 5. Programmatic Structure. 6. Timely and responsive assessment. 7. Process after any event/incident. 8. Communication and user involvement. 9. System evaluation and quality improvements.

It is widely acknowledged that restraint reduction can be achieved by the adoption of what is referred to as the Six Core Strategies © (Huckshorn 2005): • • • Leadership. Use of data to inform practice. Workforce development. Use of specific restraint reduction tools. Involvement of service users. Implementation of debriefing strategies.

A basic organisation restraint reduction model Impact at an operational level Impact on organisational policy and practice Emphasise the importance of evidence based practice and research Has implemented a mandate for monitoring, audit and evaluation Paley- Wakefield 2013 Human Rights

Gradation Approach; developing workforce skills; Paley & Gilchrist 2016 Restrictive Practices Decreases reliance on aversive & high risk strategies Conflict management skills Increases proactive primary and secondary prevention skills De-escalations skills Skills of positive behavioural support Understanding challenging behaviour Understanding communication and basic communication skills

How do we do it, what does the action of restraint reduction/elimination look like? • • Create and publish an organisational plan. Create the imperative, set goals. Establish a leadership team. Increase staff skills and knowledge of evidence based proactive and preventative responses. Adopt an ethical decision making process. Developed individualised support approaches and planning. Adopt approaches that support risk assessment. Use your data!

Department of Education – Queensland Draft Framework Reducing Restrictive Practices in State Schools Policy Statement Guidelines & standards • • • Physical restraint Seclusion Mechanical restraint Clinical holding Focussed review Ethical decision making Capacity, knowledge & development • • • Fact sheet for principals Fact sheet for school staff Information for parents. Information for selecting a training provider De-escalation fact sheet Frequently asked questions

Strategy • Reviewed literature & developed a position paper. • Scanned other Australian and international jurisdictions. • Examined data (staff and student injuries). • Met with all current providers of training in restrictive practices used by Queensland state schools. • Consulted widely with experts and stakeholders, including teachers, parents and students.

Reducing Restrictive Practices in Queensland State Schools ‘The purpose of this policy is to reduce risk to students and staff and reduce reliance on restrictive practices ensuring that they are a strategy of last resort for responding to immediate risk. ’

Reducing Restrictive Practices in Queensland State Schools ‘This policy is written with consideration for the protection of everyone’s human rights, health, safety and welfare. It is not acceptable for any school employee to face physical harm in the workplace or to expect they might be harmed during the course of their work. ’

Policy statement - 6 principles 1. Regard for the human rights of students. 2. Safeguarding students, staff and others from harm. 3. Transparency and accountability. 4. Consultation and communication. 5. Maximises the opportunity for positive outcomes. 6. Aim to reduce or eliminate the use of restrictive practices.

In summary • The framework is based on current evidence aimed at reducing and eliminating restrictive practices. • It provides both a policy and procedural statement, as well as guidelines for Principals and teachers. • There are FAQ’s for Principals, teaching staff and also parents. • The framework encourages a collaborative planning approach that includes consultation with the student and their parents. • The policy statement prohibits the use of high risk physical restraint skills.

Can we reduce restrictive practices? Remember

References • Allen D (2001) Training Carers in Physical Interventions: Research Towards Evidence Based Practice. Kidderminster. U. K. BILD. • Allen D (2011) Reducing the use of restrictive practices with people who have intellectual disabilities. Kidderminster. U. K. BILD • American Psychological Association (2008) Are zero tolerance policies effective in schools? An evidentiary review and recommendations. American Psychological Association Zero Tolerance Task Force. American Psychologist. Vol 63, No 9. 852 -862 • Deveau. R. & Leitch S ( 2018) Person centred restraint reduction: planning and action. BILD. Birmingham. • Department of Education (2003) Guidance on the use of Restrictive Physical Interventions for pupils with severe behavioural difficulties (LEA/0264/ 2003). London. HMSO. • Huckshorn. K. A. (2006) Six Core Strategies to Reduce the Use of Seclusion and Restraint Planning Tool. National Association of State Mental Health Program Directors. Alexandria. VA • Huckshorn. K. A. Le. Bel. J. Harvey. J. E. (2014) An organisational approach to reducing and preventing restraint and seclusion use with people with acquired brain injury. Neurorehabilitation 34, p 671 -680. • James. S. & Freeze. R. (2006) One step forwards, two steps back: immanent critique of the practice of zero tolerance in inclusive schools. International Journal of Inclusive Education. Vol 10, No. 6. November 2006 p 581 – 594. • Mac. Intyre. D. (1999) One Man Four Lives. BBC Broadcasting. Media London. U. K.

References • Mc. Donnell. A. (2009) The Effectiveness of Training in Physical Intervention. In Ethical approaches to physical interventions. Ed Allen. D. BILD. Kidderminster. U. KMenon K. Baburaj R. Bernard S (2012) Use of restraint for the management of challenging behaviour in children with intellectual disabilities. Advances in Mental Health and Intellectual Disabilities. 6. 2. p 62 -75 • Menon. K. Raghavendra. B. Bernard. S. (2012) "Use of restraint for the management of challenging behaviour in children with intellectual disabilities", Advances in Mental Health and Intellectual Disabilities, Vol. 6 Issue: 2, pp. 62 -75, https: //doi. org/10. 1108/20441281211208428 • Nunno. M. A. Day. D. M. Bullard. L. B. (2007)Violence Restraints and International Standards. In For Our Own Safety: examining the safety of high risk interventions for children and young people. CWLA. Arlington. VA. • Paterson. B. Bradley. P. Stark. C. Saddler. D. Leadbetter. D. Allen. D. (2003) Deaths Associated with Restraint Use in Health and Social Care in the United Kingdom. The results of a preliminary survey. Journal of Psychiatric Mental Health Nursing. 10. 3 -15 • Paterson. B. & Leadbetter. D. (2004) Learning the right lessons, Reflecting on the David Bennet inquiry recommendations with particular reference to violence management training. Mental Health Practice. 7, 7, 12 -14

References • Paley-Wakefield. S. (2013) Framework for reducing restrictive practices. Kidderminster. U. K. BILD. • Paley S & Gilchrist M (2016) Barriers and Enablers for Reducing Restrictive Practices: IASSID World Congress 14 -19 August. Melbourne. Australia • Rogers. P. Miller. G. Paterson. B. Bonnett. C. Turner. P. Brett. S. Flynn. K. & Noak. J. (2007) Is breakaway training effective? Examining the evidence and the reality, Journal of Mental Health, Training, Education and Practice, 2 (2), pp. 5 -12. • Sugai. G. & Horner. R. H. (2009) Defining and describing schoolwide positive behavior support. In W. Sailor, G. Dunlop, G. Sugai, & R. Horner (Eds. ), Issues in clinical child psychology. Handbook of positive behavior support (pp. 307 -326). New York, NY, US: Springer Publishing Co. • Skiba. R. & Peterson. R. (2006) The dark side of zero tolerance: can punishment lead to safe schools? Retrieved 31 August 2018 http: //www. pdkintl. org/kappan/kski 9901. htm • Skiba R. J. & Knesting. K. (2001) Zero tolerance, zero evidence: an analysis of school disciplinary practice. New Directions for Youth Development. No 92. 17 - 43 • Zarolla. A. & Leather. P. ( 2006) Violence and aggression management training for trainers and managers. A national evaluation of the training provision in healthcare settings. HSE. London. U. K • World Health Orgnsiation (2017) Strategies to end the use of seclusion, restraint and other coercive practices - WHO Quality. Rights training to act, unite and empower for mental health (pilot version). Geneva: World Health Organization; 2017 (WHO/MSD/MHP/17. 9). Licence: CC BY-NC-SA 3. 0 IGO.