1. Peer Debriefing: An Essential Strategy For Reducing Seclusion & Restraint. Fiona Wilson & Sarah Moir Patient & Family Collaborative Support Services April 27 th 2016

2. Objectives Implementation and development of SJHH Least Restraint Initiative SJHH post seclusion Peer debriefing program Benefits/Challenges for Peer Debriefing roles and increase opportunity for advocacy and empowerment Improved conditions for the individuals served Anything else?

3. The Evidence History of S/R use. Clear lack of rigorous, scientific evidence to support the use of S/R as an effective intervention. Growing qualitative evidence to support the negative and deleterious effects of S/R on service users and providers. Growing body of literature and studies to support alternative interventions, including trauma- informed care.

4. There is little, if any, empirical evidence to determine the safety &/or effectiveness of the use of seclusion & restraint Nelstrop et al, 2006

5. Increased call for… Scientific studies that show evidence of both the benefit and harm related to S/R (raises ethical issues). Scientific studies that show the evidence to support alternative interventions as best practice. Further acknowledgement of individual stories and experiences that relay history of trauma preceding &/or caused by S/R interventions.

6. The Experience of Seclusion & Restraint Patient Emotional – stigma, powerlessness, loss of dignity, humiliation, disempowerment Physical – sensory deprivation, isolation, loss of contact with others, positional asphyxia, increased risk for injury &/or death Staff Interruption of therapeutic relationship Lost opportunities for health teaching, problem-solving Increased assaults & injury

7. The Experience of Seclusion & Restraint

8. How Do We Justify Still Using S/R? It’s a treatment intervention to keep individuals served safe. Used to keep staff safe. Not used as, or meant to be punishment. Therapeutic interventions based on clinical knowledge. The literature suggests use of S/R is a treatment failure. Injuries Deaths Trauma Hinders Therapeutic rapport Assumptions Reality

9. The Start of the S/R Reduction Journey Recommendations from Coroner’s Inquest Elimination vs. Reduction Patient Bill of Rights Whose Involved Intensive Training 6 Core Strategies

10. 2009-10 * Senior Leadership adopted Kevin Huckshorn’s Six Core Strategies * Panel discussion by people with lived experience at launch * Mandatory training for all staff 2010-11 * Forms and process developed with input and feedback from Peer and Family Council * Education staff - Trauma Informed Care, best practices in reducing S/R * First Pilot 2012-14 * Process refined * Forms revised * Policy reviewed * Training for Peer Support Providers 2014 - present * Revised process implemented using phased approach * Education for all staff, peer support providers * Forms reviewed six months post- launch * Policy informed by the findings Restraint Reduction Journey

11. 6 Core Strategies for Restraint Reduction Senior Leadership Peer Support Debriefing Prevention Data/ Evaluation Workforce Development Post-Acute Debriefing Peer Debriefing Family Debriefing Formal Debriefing

12. 6 Core Strategies for Restraint Reduction Senior Leadership Peer Support Debriefing Prevention Data/ Evaluation Workforce Development Post-Acute Debriefing Family Debriefing Formal Debriefing Peer Debriefing

13. “Involving patients, other mental health consumers, family members, and external advocates in a variety of roles in the organization can have a powerful impact, particularly as a primary prevention strategy to reduce the use of restraint and seclusion. The presence of these stakeholders in an inpatient environment sends a strong message to both patients and staff that recovery is real, that recovery happens, and that living with a psychiatric disability need not be perceived as a reason to accept anything less than pursuing one’s hopes and aspirations.” Kevin Huckshorn

14. Why use peer support providers? A robust and growing research evidence base shows peer support is associated with: Reductions in hospitalizations for mental health problems, Reductions in ‘symptom’ distress, Improvements in social support, and Improvements in people’s quality of life Research has highlighted that patients may be distressed with the staff directly involved in their seclusion or restraint. Service users have expressed a desire for debriefing following seclusion or restraint, including opportunities to understand and change their behavioural responses to distress, anger or frustration. Bonner et al., 2002; Faschingbauer, et al, 2013

15. Debriefing provides Peer Support Providers the Opportunity to: Inform and play an active role in an innovative and valued SJHH initiative; Improve sense of satisfaction via connection with peers and opportunities to advocate for change ; Experience professional and personal growth through increased interactions with clinical teams; Reduce misconceptions of peer support role and sense of “us vs. them” between clinical staff and peer support.

16. Keys to building a Peer Debriefing Team Use Peer Staff who were not directly involved in the S/R event and with no specific details of the event ( safety issues addressed ) Avoid Blame/Shame – our peer debriefers conduct the interviews. A peer manager acts as an advocate for the individual at the Formal Debrief.

17. Peer Debriefing Provides an Individual the Opportunity to: Be heard & their feelings validated. Drive change at a system level by sharing their experience. Foster improved relationships with clinicians by providing them with tips on improving their therapeutic relationship with individuals. Increase connection with peer support and others with personal lived experience. Know that it’s okay to share their view on an experience and/or treatment. Feel valued and listened to Have conflicts/concerns resolved and/or addressed

19. Forms Comfort Plan -> Prevention Seclusion/Restraint Debriefing Tool & Guide Seclusion/restraints family Debriefing Debriefing of Individual Sample Questions: Why do you think the S/R happened? Were you made aware of what is expected from you to end the S/R In the future, is there anything that staff could do differently to help or support you better?

21. Learnings and Impact Individual/service user perspective Basic Needs What Comfort Plan? Trauma Histories Self-identified opportunities for growth or change. Individual/service user perception of what happened is as important as what may have actually happened. Individuals have more awareness than clinical staff give them credit for. Individuals want to be listened to. “I’m glad I had the opportunity to talk about this”. Connected people to peer support and advocacy.

22. Learnings and Impact Clinical perspective “Initially staff felt somewhat defensive…..” “Allows for some dedicated time to review the clinical need of some folks who are often needed complex supports. Having peer support participate in those clinical planning discussions provides valuable insight and opportunities for more partnerships with peer support.” “The greatest value of peer debriefing in my mind is the opportunity to reflect on the patient’s perspective on the experience, especially when it differs from the staff perspective”. “…what has been interesting to watch as a byproduct is the growing respect for the peer role…the clinicians value the input and feedback…..keeps a focus on the amount of time someone spends in seclusion. Now was a standard part of the review, we focus on the amount of time spent in and opportunities to end seclusion sooner.” “At times it is surprising to hear how much insight the patient had, even in the state of intoxication or crisis”. “The negative is the delay sometimes in the form being completed because it can take a week and by then the patient is off ward or involved in groups and does not want to take the time to give feedback.”

23. Learnings & Impact Peer Provider Perspective Inform and play an active role in an innovative and valued SJHH initiative; Improve sense of satisfaction via connection with peers and opportunities to advocate for change ; Experience professional and personal growth through increased interactions with clinical teams; Reduce misconceptions of peer support role and sense of “us vs. them” between clinical staff and peer support

25. References http://diversityrules.typepad.com/my_weblog/2009/08/restraint-by-any-other-name.html Nude Schizophrenic in Restraints While Bored Nurse Looks On... pamelaspirowagner.com3000 × 3000Search by image Nude Schizophrenic in Restraints While Bored Nurse Looks On | WAGblog: Dum Spiro Spero pamelaspirowagner.com3000 × 3000Search by image encounter in Seclusion Room | WAGblog: Dum Spiro Spero pamelaspirowagner.com1936 × 1936Search by image pamelaspirowagner.com1936 × 1936Search by image READ THIS, Michael Edward Balkunas, MD of Hospital of Central Connecticut in New Britain, CT, Before You Throw Another Psychiatric Patient Into Your Supermax Seclusion Cells! | WAGblog: Dum Spiro Spero READ THIS, Michael Edward Balkunas, MD of Hospital of Central Connecticut in New Britain, CT, Before You Throw Another Psychiatric Patient Into Your Supermax Seclusion Cells! | WAGblog: Dum Spiro Spero pamelaspirowagner.com1762 × 1878Search by image pamelaspirowagner.com1762 × 1878Search by image Davidson L, Bellamy C, Guy K, Miller R. (2012, June). Peer Support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry. 2012 Jun; 11(2): 123–128. Huckshorn, K.A. (2004, October). Creating violence free and coercion free mental health treatment environments for the reduction of seclusion and restrain: the emerging science of trauma informed care. Presented to NASMHPD Medical Directors and NRI, Inc. 2004 Best Practices Symposium, Atlanta, Georgia. Retrieved March 20, 2009, from www.oregon.gov/DHS/addiction/trauma-policy/reducing-use.pptwww.oregon.gov/DHS/addiction/trauma-policy/reducing-use.ppt Meehan et al., 2004Meehan, T., Bergen, H., Fjeldsoe, K. Staff and patient perceptions of seclusion: Has anything changed?. Journal of Advanced Nursing. 2004;47:33–38. Nelstrop et al (2006). A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments.Worldviews Evid. Based Nurs 2006;3(1):8-18.