VERTROUWELIJK COERCIVE MEASURES IN CARE FOR THE ELDERLY WITH DEMENTIA AND CARE FOR MENTALLY RETARDED PEOPLE: WHAT DOES THE DUTCH SUPERVISORY BODY DO? M.E.W.(Thijs) Melchior, RN, PhD coordinating/specialized senior inspector

VERTROUWELIJK PRESENTATION OUTLINE Short history about the role Dutch inspectorate in reducing coercive measures Reducing belts and seclusion project Purpose and method Results What is (in my opinion) important for supervisory bodies in their contribution to reduce coercive methods in a responsible way? Discussion & questions

VERTROUWELIJK HISTORY Examining coercive measures has always been important for health care inspectorate One to legal reasons (law in psychiatric care) Complaints from citizens Report from health care organizations e.g. accidents (quality law) Several reports see (summary in English) Risks in using the Swedish belt in care for mentally retarded people, 2002 Care for freedom; a reduction in the use of restrictive measures is both possible and necessary, Culture shift: reduction in the use of restrictive measures in longterm care is work in progress (2010).

VERTROUWELIJK WHAT IS A (SWEDISH) BELT?

VERTROUWELIJK WHAT IS SECLUSION? 5

VERTROUWELIJK DECLARATION OF INTENT ( November 2008) Achieving a marked reduction in the use of physical restraints within three years Alternatives for the restraints may not be other coercive measures If restraints were used, this was only possible under strict quality conditions and only in exceptional circumstances such as: Second opinion from an expert not involved in the care of the client A multidisciplinary approach A structured search for alternatives for the belt or the seclusion Clear instructions in the care plan The health care inspectorate added seclusion in the care of mentally retarded people because of the high impact on the quality of life for the client when seclusion is used.

VERTROUWELIJK WHY FOCUS ON RESTRAINTS WITH BELT AND SECLUSION? Use and reduction of other coercive measures are also important Risks There are alternatives (next speaker) Focus, narrowing down the options Spin-off: if you don’t use coercive methods you must look at the client: why does he show that behavior? What is the best way for the nurse to deal with that behavior?

VERTROUWELIJK METHOD Random selection of organizations (n=101) Investigating the care of the individual client Speaking with care givers (nurse, medical doctor, psychologist) Speaking with client or his representative (most family) Investigation of care plans Using assessment scales (what is good/wrong) Writing reports of each client Health care organization management receives a report and need to take measures to improve the care quality

VERTROUWELIJK SOME RESULTS Why was a belt used? Reducing fall incidents (care elderly, automutilation (mentally retarded) Why seclusion? aggression (mentally retarded) Culture change reduction of coercive measures on agenda Very few belts in bed 72% of coercive measures stopped in a responsible way, 24% had some remarks A second opinion not always given (69%) Too little focus on reducing coercive measures in individual client Important information in care plans such as instructions were not always available No standard system to measure coercive measures are being used at the moment, so we can not say if they are reduced in the Netherlands. Report available in December 2012.

VERTROUWELIJK SUCCESS FACTORS IN REDUCING BELTS AND SECLUSION (from care givers) Involvement client, family (fear for alternatives) Multidisciplinary approach Experts advice Take little steps Support from the entire organization (financial dept; e.g. extra personnel) Focus on understanding the behaviour of the client, not on the use of coercive measures

VERTROUWELIJK WHAT CAN SUPERVISORY BODIES DO IN THEIR CONTRIBUTION TO REDUCE COERCIVE MEASURES IN A RESPONSIBLE WAY? Involvement boards (client/patient, nurse, medical doctor boards) Declaration of intent Communication, information with health care organizations Focus on some coercive methods e.g. belts, seclusion, psychotropic medication. Last but not least. Continue inspections! Reduction of coercive measures must remain on the agenda.

VERTROUWELIJK DISCUSSION & QUESTIONS