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Six Core Strategies To Prevent Conflict and Violence: Reducing the Use of Seclusion and Restraint

Six Core Strategies To Prevent Conflict and Violence: Reducing the Use of Seclusion and Restraint (6CS) is a clinical model designed for use by institutions providing mental health treatment to children and adults admitted to inpatient or residential settings. The 6CS program works to change the way care is provided in these settings by focusing on the prevention of conflict and violence, the reduction in use of seclusion and restraint, the implementation of informed care principles, and the fullest possible inclusion of the client in his or her care.

The 6CS program is implemented at the institutional level, through the incorporation of the six program strategies: (1) leadership toward organizational change; (2) the use of data to inform practice; (3) workforce development; (4) full inclusion of individuals and families; (5) the use of seclusion and restraint reduction tools, which include the environment of care and use of sensory modulation; and (6) rigorous debriefing after events in which seclusion and restraint might have been used. In addition, items used as alternatives to seclusion and restraint (e.g., rocking chairs, weighted blankets) are placed in the clinical units, and their use is rehearsed. Once implemented, the 6CS program requires changes in organizational culture, such as the way in which staff meetings and debriefings are held; however, once these changes have been made, the program can be implemented by line staff with no special qualifications.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: March 2012
1: Seclusion rate
2: Seclusion time
3: Restraint use rate
4: Duration of seclusion per episode
5: Duration of restraint use per episode
Outcome Categories Mental health
Treatment/recovery
Ages 0-5 (Early childhood)
6-12 (Childhood)
13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
Race/ethnicity unspecified
Settings Inpatient
Residential
Geographic Locations Urban
Suburban
Implementation History The 6CS program was first implemented in January 2003 with seven State teams trained in Pembroke Pines, Florida. Since then, the program has been used by about 1,000 State and private hospitals and agencies across 31 States and the District of Columbia, with more than 10,000 individual staff members receiving training. The 6CS program also has been implemented in Australia, Canada, and Finland.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: No
Adaptations The 6CS program has been adapted for use in Australia, Canada, and Finland.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: March 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

National Technical Assistance Center for State Mental Health Planning & Human Services Research Institute. (2009). SAMHSA initiative to reduce and eliminate the use of restraint and seclusion. Coordinating Center: Alternatives to Restraint and Seclusion (ARS) State Infrastructure Grant (SIG) Program. First round of ARS SIG grantees. Evaluation report. Cambridge, MA: Author.

Study 2

Wale, J. B., Belkin, G. S., & Moon, R. (2011). Reducing the use of seclusion and restraint in psychiatric emergency and adult inpatient services--Improving patient-centered care. Permanente Journal, 15(2), 57-62.  Pub Med icon

Outcomes

Outcome 1: Seclusion rate
Description of Measures The seclusion rate was calculated by dividing the number of clients secluded in each facility by the total number of clients admitted to each facility during the study period. The data used in calculations were drawn from the facilities' electronic administrative records; incidents of seclusion were identified by floor staff at each clinical unit of the facilities. The facilities were classified on the basis of their degree of program implementation, as measured by the Inventory of Seclusion and Restraint Reduction Initiatives (ISRRI), which was developed for the study as an approach to tracking fidelity over time. Seclusion rates in 28 facilities that achieved stable implementation (defined as meeting at least 20% of the ISRRI objectives for a period of at least 4 months) were assessed for change from baseline to the end of the 4-year measurement period.
Key Findings A study assessed the effects of the implementation of the 6CS program within facilities providing psychiatric services to children and/or adults. The participating facilities ranged in size and setting and were located in seven States. From baseline to the end of the 4-year measurement period, facilities with stable implementation of the 6CS program had a reduction in the seclusion rates of clients (p = .002), after controlling for the proportions of clients who were Hispanic, were involuntarily committed, and had schizophrenia or another psychotic disorder.
Studies Measuring Outcome Study 1
Study Designs Preexperimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 2: Seclusion time
Description of Measures In one study, the seclusion time was calculated by dividing the number of hours of seclusion by the total number of treatment hours for all clients admitted to each facility during the study period, multiplied by 1,000. The data used in calculations were drawn from the facilities' electronic administrative records; incidents of seclusion and their durations were identified by floor staff at each clinical unit of the facilities. The facilities were classified on the basis of their degree of program implementation, as measured by the ISRRI, which was developed for the study as an approach to tracking fidelity over time. Seclusion times in 28 facilities that achieved stable implementation (defined as meeting at least 20% of the ISRRI objectives for a period of at least 4 months) were assessed for change from baseline to the end of the 4-year measurement period.

In another study, the seclusion time was calculated across facilities as the frequency of seclusion episodes per 1,000 patient-hours. The data used in calculations were drawn from the administrative records of facilities in a large municipal health care system; incidents of seclusion were identified by floor staff at each clinical unit of the facilities. The average seclusion times in the years before, during, and after implementation were compared.
Key Findings A study assessed the effects of the implementation of the 6CS program within facilities providing psychiatric services to children and/or adults. The participating facilities ranged in size and setting and were located in seven States. From baseline to the end of the 4-year measurement period, facilities with stable implementation of the 6CS program had a reduction in seclusion times as a proportion of treatment hours (p = .001), after controlling for the proportions of clients who were Hispanic and were involuntarily committed.

Another study assessed the effects of the implementation of the 6CS program within a large municipal health care system that included facilities providing psychiatric services to adult inpatients. In each successive year, from the year before implementation through the year after implementation, there was a reduction in seclusion time across facilities (p = .04).
Studies Measuring Outcome Study 1, Study 2
Study Designs Preexperimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 3: Restraint use rate
Description of Measures The restraint use rate was calculated by dividing the number of clients restrained by the total number of clients admitted to each facility during the study period. The data used in calculations were drawn from the facilities' electronic administrative records; incidents of restraint use were identified by floor staff at each clinical unit of the facilities. The facilities were classified on the basis of their degree of program implementation, as measured by the ISRRI, which was developed for the study as an approach to tracking fidelity over time. Restraint use rates in 28 facilities achieving stable implementation (defined as meeting at least 20% of the ISRRI objectives for a period of at least 4 months) were assessed for change from baseline to the end of the 4-year measurement period.
Key Findings A study assessed the effects of the implementation of the 6CS program within facilities providing psychiatric services to children and/or adults. The participating facilities ranged in size and setting and were located in seven States. From baseline to the end of the 4-year measurement period, facilities with stable implementation of the 6CS program had a reduction in restraint use rates (p = .027), after controlling for the proportions of clients who were male, were between the ages of 0 and 17, were involuntarily committed, had schizophrenia or another psychotic disorder, and had mood disorders.
Studies Measuring Outcome Study 1
Study Designs Preexperimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 4: Duration of seclusion per episode
Description of Measures The duration of seclusion per episode (in minutes) was derived from the administrative records of facilities in a large municipal health care system; incidents of seclusion and their durations were identified by floor staff at each clinical unit of the facilities. The average durations of seclusion per episode in the years before, during, and after implementation were compared.
Key Findings A study assessed the effects of the implementation of the 6CS program within a large municipal health care system that included facilities providing psychiatric services to adult inpatients. In each successive year, from the year before implementation through the year after implementation, there was a reduction in the duration of seclusion per episode across facilities (p = .04).
Studies Measuring Outcome Study 2
Study Designs Preexperimental
Quality of Research Rating 2.4 (0.0-4.0 scale)
Outcome 5: Duration of restraint use per episode
Description of Measures The duration of restraint use per episode (in minutes) was derived from the administrative records of facilities in a large municipal health care system; incidents of restraint use and their durations were identified by floor staff at each clinical unit of the facilities. The average durations of restraint use per episode in the years before, during, and after implementation were compared.
Key Findings A study assessed the effects of the implementation of the 6CS program within a large municipal health care system that included facilities providing psychiatric services to adult inpatients. In each successive year, from the year before implementation through the year after implementation, there was a reduction in the duration of restraint use per episode across facilities (p = .04).
Studies Measuring Outcome Study 2
Study Designs Preexperimental
Quality of Research Rating 2.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 0-5 (Early childhood)
6-12 (Childhood)
13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
55+ (Older adult) 		68.9% Male
31.1% Female 		62.7% Race/ethnicity unspecified
32.8% Black or African American
4.5% Hispanic or Latino
Study 2 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult) 		Data not reported/available Data not reported/available

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Seclusion rate 3.3 3.3 3.3 3.8 3.8 4.0 3.5
2: Seclusion time 2.4 2.5 3.5 3.5 2.6 3.8 3.0
3: Restraint use rate 3.3 3.3 3.3 3.8 3.8 4.0 3.5
4: Duration of seclusion per episode 1.5 2.3 2.8 2.8 1.5 3.5 2.4
5: Duration of restraint use per episode 1.5 2.3 2.8 2.8 1.5 3.5 2.4

Study Strengths

In both studies, the rates of seclusion and restraint use were measured directly and subject to review by external accrediting authorities, which provided the measures with evidence of reliability and validity. A study-specific questionnaire designed to assess intervention fidelity, the ISRRI, was used by all facilities participating in the studies; consultation and technical assistance also were provided to implementing sites. There was no attrition in either study. Careful efforts, including stratification and inclusion of relevant factors in regression models, were made in one study to address the possible confounding factors of variations in the degree of program implementation and secular changes unrelated to the program. One study used very sophisticated statistical techniques, including random-effects regression, and both studies used appropriate analytical methods.

Study Weaknesses

The reliability and validity of the outcomes measures, particularly those relating to the duration of events, were dependent on the strength of the data collection procedures at each facility and consistency across sites, which varied to some extent. The ISRRI was developed for the study and lacked external validation. One study did not adequately control for potential confounding factors.
Readiness for Dissemination
Review Date: March 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Cain, L., & Gross, D. (Directors). (2007). Behind closed doors--The story of four women struggling to reconcile violence within the psychiatric system [DVD]. Baltimore, MD: Maryland Disability Law Center, Gallery 144 Productions, and Sister Witness International.

Haimowitz, S., Urff, J., & Huckshorn, K. A. (2006). Restraint and seclusion: A risk management guide. Retrieved from http://www.nasmhpd.org/docs/publications/docs/2006/R-S%20RISK%20MGMT%2010-10-06.pdf

Huckshorn, K. A. (n.d.). Six Core Strategies for reducing seclusion and restraint use: Draft example policy and procedure on debriefing for seclusion and restraining reduction projects. Alexandria, VA: National Association of State Mental Health Program Directors.

Human Services Research Institute. (2005). Inventory of seclusion and restraint reduction interventions: Reviewer's guide and worksheets. Cambridge, MA: Author.

National Association of State Mental Health Program Directors. (2008). Paving new ground: A dialogue with peers and family members [DVD]. Alexandria, VA: Author.

National Association of State Mental Health Program Directors. (2009). Creating violence free and coercion free mental health treatment: Video training for the reduction of seclusion and restraint. [DVD]. Alexandria, VA: Author.

Substance Abuse and Mental Health Services Administration. (2010). Leaving the door open: Alternatives to seclusion and restraint [DVD]. Rockville, MD: Author.

Training materials [CD-ROM]:

  • National Association of State Mental Health Program Directors. (2009). Training curriculum for the reduction of seclusion and restraint. Alexandria, VA: Author.
  • Supplemental materials, including quality assurance tools
  • Training PowerPoint slides

Two-day training agenda template

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
2.3 2.8 3.5 2.8

Dissemination Strengths

The implementation materials are comprehensive and organized into step-by-step modules. Training materials are clear and straightforward, with well-defined learning objectives provided for each module. The content conveyed during training is supported by citations and materials to facilitate systemwide implementation. Extensive consultation and technical assistance are available to support implementation at new sites. The quality assurance tools are comprehensive and of high quality and promote both fidelity and outcome monitoring.

Dissemination Weaknesses

The written materials are not packaged in a manner that facilitates ease of use. It is unclear how new sites initiate access to program materials or training resources, and no standard written document outlines implementation requirements. Implementation materials lack a standardized format and organization, which may contribute to confusion among some users. The amount of information expected to be incorporated in the 2-day training may be daunting to some implementers. Written materials and the training provide very little guidance on implementing the available quality assurance system.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
6CS training curriculum manual (includes debriefing guidelines and planning guide) $24 per participant Yes
Paving New Ground, Leaving the Door Open, and Behind Closed Doors (3 DVDs) Free No
Sensory training materials $10 per participant Yes
6CS training videos (DVD set) Free No
1- or 2-day, on-site pretraining consultation $1,800 per consultant per day, plus travel expenses No
Pretraining consultation report $1,500 per site No
2-day, on-site training (includes Development of a Facility Action Plan Guide) $1,800 per trainer per day, plus travel expenses Yes
1- or 2-day, on-site posttraining consultation $1,800 per consultant per day, plus travel expenses No
On-site posttraining consultation report $1,500 per site No
Technical assistance via phone First 3 calls are free; $100 per hour for each subsequent call No
Quality assurance tools Free Yes

Additional Information

The numbers of trainers and consultants required to deliver the training and consultations, respectively, vary by the size and needs of the site.
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

* National Technical Assistance Center for State Mental Health Planning & Human Services Research Institute. (2009). SAMHSA initiative to reduce and eliminate the use of restraint and seclusion. Coordinating Center: Alternatives to Restraint and Seclusion (ARS) State Infrastructure Grant (SIG) Program. First round of ARS SIG grantees. Evaluation report. Cambridge, MA: Author.
Contact Information

To learn more about implementation or research, contact:
Kevin Ann Huckshorn, Ph.D., R.N., CADC
(302) 255-9398
kevin.huckshorn@state.de.us

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.