Promoting a Restraint-Free Culture Through Sensory Modulation

The American Nurses Association (ANA) 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). The American Psychological Nurses’ Association (APNA) supports the psychiatric-mental health nurses’, critical role in the provision effective treatment and milieu leadership to maximize the individual’s ability to effectively manage potentially dangerous behaviors in the psychiatric setting (APNA 2014). The profession of occupational therapy emerged from some of the earliest restraint and seclusion efforts, realizing the need for more humane and nurturing interventions for people with mental health and rehabilitation needs (AOTA, 2014). Sensory modulation is a client centered approach used by occupational therapists to help individuals who are distressed and agitated regain a sense of calm by using a range of tools to moderate sensory input (Champagne, 2004 and 2011) 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, evidenced based strategies be employed throughout our health care settings.

Sensory Modulation teaches patient’s self-regulation skills and improves the rapport between staff and patients by giving them additional opportunities for therapeutic communication, prevention of escalation and aggression, and tangible alternatives to PRN medications. Trauma informed care is patient strength based approach to care, as a least ninety per cent of public mental health consumers have been exposed to trauma (Felitti V. J. & Anda R. F. 2010). Instead of talk based therapies sensory approaches provide experiential opportunities to help individuals recognize and regulate their unique sensory experiences. By using sensory modulation strategies in combination with a trauma informed approach to care, patients can feel empowered by identifying their own individual preferences and can feel more secure knowing that staff will work with them during times of crisis to prevent seclusion and restraint episodes. Patients can also identify their own signs of escalation and aggression and alternative methods for coping during times of stress which can translate beyond the inpatient setting and can be used at home after discharge. Additionally, is that nursing staff can feel empowered with the knowledge provided by patients and suggest patient identified methods of calming during times of stress instead of blindly offering cookie cutter suggestions and care based on tradition instead of evidenced based care.

A sensory modulation program was developed and implemented on the inpatient behavioral health unit at Virginia Hospital Center 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. A designated sensory space was created on the unit; equipped with a glider chair, beanbag chairs, a large mural, and a multitude of sensory supplies. The development of online training modules on sensory modulation and trauma informed care augmented the initial implementation of personalized safety and crisis prevention forms completed collaboratively by both the patients and staff. Individual sensory modulation competencies were completed by nursing and therapy staff. Trained staff, in collaboration with occupational therapy, presently provides bi-weekly recovery plan review groups with the patients to emphasize the use of sensory modulation in recovery.

Data was collected on restraint usage on the behavioral health unit from January 2015, through June 2016. Following institution of the program in January 2016, there has been a decrease in total numbers of restraints on the unit. Data was also collected on the number of behavioral health staff injured due to workplace violence injuries involving patients and the number of restricted and lost work days as a result of injuries from January 2015, to the present.

Results suggest that the use of sensory modulation is an effective strategy in decreasing patient agitation; employee workplace violence related injuries and lost or restricted workdays due to injury. This has allowed for proper staffing in order to provide safe and high quality patient-centered care. Additionally, the application of sensory modulation could reach beyond the inpatient behavioral health setting and be implemented for patients on acute care units throughout the hospital in the future using sensory carts. Furthermore, there are additional implications for utilizing sensory modulation, as a self-care strategy to decrease provider stress is also an avenue, which holds promise.