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Pediatric Psychiatry: More Rewards, Fewer Restraints

Child psychiatry staff members generally view restraints and seclusion as unpleasant—but sometimes necessary—tools to manage aggressive behavior among hospital patients, reduce their agitation, and prevent injuries to themselves and others. Professionals agree alternatives are needed, but there has been little research on specific, evidence-based behavioral interventions to reduce restrictive practices.

Now, modeling a proven prevention strategy that has been implemented in more than 7,500 schools nationwide to reduce disciplinary actions and suspensions and to improve academic performance, child psychologist Elizabeth Reynolds and colleagues were able to meaningfully reduce—from 543 events to 253 events—the use of restraints and seclusion on their inpatient unit. Other findings from the four-year prospective study published in 2016: The percentage of patients who were placed in seclusion or restraint markedly decreased, from 19.6 percent to 13.4 percent during the study period, and the mean duration of seclusion and restraint incidents decreased from 20.43 minutes to 8.18 minutes per episode.

Given the concern that a reduction in seclusion and restraint can lead to an increase in administering medications pro re nata (PRN)—or as needed—to treat acute agitation or aggression, the researchers also monitored the use of PRN medications. After implementing the model, there was a reduction in the use of PRNs from 1,705 to 1,014. The percentage of patients who received a PRN medication decreased from 41.6 percent to 29.4 percent.

“We were able to reduce the rates of seclusion and restraints, and the use of PRNs, significantly,” says Reynolds.

How? The Positive Behavioral Interventions and Supports model, Reynolds explains, employs positively worded behavioral expectations for patients—“be safe,” “be responsible” and “be respectful”—and a reward system that reinforces appropriate behavior by patients. In this program, staff members stamped patients’ passports with rewards that could be accumulated and reimbursed with physical products or privileges. Punitive actions were not included in the model.

“Rather than focusing on the behavior we don’t like, we focus on the behavior we want to see. When that behavior is demonstrated, we praise it and reward it,” says Reynolds.

The model also incorporated targeted problem-solving conversations with patients who demonstrated problem behavior on the unit and individualized behavior plans for patients who continued to have problematic behaviors after those problem-solving conversations. Key to success, Reynolds adds, is training for nursing staff that includes education and role-playing, and buy-in from staff members who are significantly challenged in managing high-risk patients.

The new strategy turned out to reward staff members as well as patients.

“Staff members enjoy this approach and have found through it a pleasant and positive therapeutic environment,” says Reynolds. “There’s less tension in the air when you’re not getting into power struggles all day, and it’s much easier for patients to engage in their treatment. We really see it as a positive and preventive environment.”