Sensory Techniques to Manage Problem Behaviors and Prevent Seclusion and Restraint Use in Psychiatric Facilities

A Systematic Review By: Anthea Mourselas & Jessica Pierson

Key Terms
Seclusion involuntary confinement of a person alone in a room or

area from which the person is physically prevented from leaving. Restraint any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a person to freely move his or her arms, legs, body, or head.
(Sivak, 2010]

Multi-sensory environment dedicated room/space designed to

block out noise, with controlled temperature and lighting. Filled with equipment to stimulate the senses and promote pleasure and/or feelings of well-being. Promotes choice, interaction, and relationships through planned stimulation of the senses.
(Messenbauer, 2011)

Seclusion & Restraints (S/R) Risk Factors

Leads to psychological harm and physical injury for both

patients and staff Leads to life-long traumatization Approximately 150 people die each year due to S/R practices

Common causes include asphyxiation, cardiac arrest, missed medication doses.

(Lewis, Taylor, & Parks, 2009)

Retrieved from http://essentialeducator.org/?p=6106

S/R Reduction Initiatives

In 2001, the Joint Commission on Accreditation of

Healthcare Organizations revised S/R standards:

Only used as a last option and where there is imminent risk of injury to patients or others

National Seclusion and Restraint Reduction Initiative to

examine alternative methods for preventing, and eventually eliminating S/R use in psychiatric facilities Multi-sensory environments promote a culture for humane, client centered practice that engage patients senses to reduce build up of agitation and prevent escalation of aggression

Empower patients to self-manage

(Lewis, Taylor, & Parks, 2009)

Methods
Databases Used Additional Sources Search Terms Cochrane Library, PubMed, CINAHL, AJOT, and Google Scholar Reference lists of articles and textbooks Sensory strategies, sensory stimulation, multi-sensory, sensory integration, comfort rooms, Snoezelen rooms, comfort carts, sensory carts, mental health, mental illness, schizophrenia, restraint reduction, seclusion reduction, aggression, self-injurious behaviors, crisis prevention program, inpatient hospitals Articles in English, adult population, focused on an aspect of restraint, seclusion, aggression, or self-injurious behavior reduction, sensory treatment component

Inclusion Criteria

Exclusion Criteria
Grey Literature

Articles in languages other than English, child population, adults with dementia
One source included due to occupational therapy focus

Levels of Evidence Table

Level of Evidence I Randomized Controlled Trials (also systematic reviews, meta-analyses) II Two groups, non-randomized (cohort, case-control) Number of Articles 1 4

III one group, non-randomized (pre- and post-test, before and after)
IV Descriptive studies that include analysis of outcomes (single-subject design, case series)

4
3

V Case reports and expert opinion that include narrative literature reviews and consensus statements

Sensory Cart
Example Items
Stress balls CD player with

headphones Aromatherapy Art supplies Musical instruments Karaoke Games Journal writing supplies

(Lewis et al., 2009)

Retrieved from http://www.harloff.com/tag/universal-line-anesthesia-cart/

Sensory Cart Results

Decrease in Disruptive Behaviors & S/R
Crisis Prevention Management program at Johns Hopkins Hospital in Maryland: A significant decrease in the use of restraints on the 4 units A significant decrease in the use of seclusion on 3 of 4 units
(Lewis et al., 2009)

Study effectiveness of sensory assessment and sensory tools at The Alfred Hospital in Australia: 39% decrease in seclusion after completing the sensory assessment 81% of staff used some form of sensory resource with patients Time constraints, lack of education regarding proper sensory resource usage, and lack of standardized sensory cart protocol identified as clinical barriers
(Lee et al., 2010)

Snoezelen Room
Example Items
Multi-color bubble

tube Revolving mirror ball Projector and effect wheel Fibreoptic spray Magic glow panel Sound light wall unit Musical hopscotch pad Tactile pad Sensory ball Bean bag
Retrieved from http://keehnankonyha.com/journal/2011/3/24/a-ceremony-ofsenses-snoezelen-controlled-multisensory-envir.html

(Kwok, To, & Sung, 2003)

Snoezelen Room Results

Decrease in Disruptive Behaviors

Study effectiveness of Snoezelen Room at Kwai Chung Hospital in Hong Kong: 55.2% increase in relaxation/reduction of anxiety 58.1% reduction in self-injurious behaviors 21.4% reduction in aggression (Kwok et al., 2003) Study effectiveness of Snoezelen room in comparison to ADL skills training and Vocational skills training in residential treatment facility: Significant decreased levels of self-injury only before and after Snoezelen use. A decrease in both aggression and self-injury during Snoezelen room sessions when compared to ADL skills training and Vocational skills training
(Singh et al., 2004)

Weighted Blanket
Item Description
Deep pressure

stimulation (DPS) 30 lb

5 lb alone, 25 lb of weight (popcorn seeds) in nylon sleeves Evenly distributed

56 x 75 in

Retrieved from www.rompa.com

Weighted Blankets Results

Levels of Distress Decreased
First published research to explore the safety and effectiveness of the therapeutic use of the weighted blanket in adults. Quantitative: Safety Vital measurements including: pulse oximetry, pulse rate, and blood pressure indicated that the weighted blanket did not move participants into an unsafe physiological range. Qualitative: Effectiveness 63% rated their anxiety lower 78% reported they felt more relaxed

(Mullen, Champagne, Krishnamurty, Dickson, Gao, 2008)

Sensory/Comfort Room
Example Items

Rocking chairs Lava lamps Kaleidoscopes Colored glasses Calming music Wall images Squeeze balls Sand tables Weighted blankets Aromas Scented candles Candy
Retrieved from http://www.creativesupport.co.uk

Sensory Room Results

Levels of Distress Decreased, No S/R Change
Effectiveness in reducing S/R use & coping skills in New Hampshire: 89% of patients had improvement in self-rated distress after comfort room use
(Cummings, Grandfield, & Coldwell , 2010)

Effectiveness in reducing patient levels or distress, disruptive behaviors, and S/R use in Australia: Significant improvement in ratings of self-rated distress levels & clinician rating of behavior
(Novak, Scanlan, McCaul, MacDonald, & Clarke , 2012)

Reflection on implementation of sensory-based approaches in 2 different psychiatric units in Australia: Sensory Room Significant improvement in ratings of self-rated distress levels & clinician rating of behavior Sensory Connection Program Significant improvement in clinician rating of behavior

Future plans to turn a seclusion

(Chalmers, Harrison, Mollison, Molloy, Gray, 2012)

Sensory Room Results

Levels of Distress & S/R Decreased
Effectiveness in reducing patient levels or distress and S/R in MA: 98% of the participants reported a positive change in level of distress Restraint use decreased by 40% Effectiveness in reducing S/R use in DE: Elimination of S/R use after comfort room implementation Significant improvement in client assaults Self-injurious behaviors average increased by 12.1%

(Champagne & Sayer, 2003)

(Sivak ,2012)

Qualitative study to examine sensory-based approaches to prevent aggression in New Zealand: Staff & participant rating themes from semi-structured interview: Facilitating a calm state , enhancing a calm state, & supporting self management & managing distress & agitation

I remember being really, really emotional and going in there and sort of calming down.it made your mind feel at ease (Participant #12).
Your actually giving someone a concrete way of dealing with their problems (Staff Member #6).
(Sutton, Wilson, Van Kessel, & Vanderpyl, 2013)

Sensory Room Results

Traditional & Sensory Intervention Equally Effective
Determine if sensory interventions would be successful in reducing psychiatric symptoms within general & geriatric neuropsychiatric populations in MA: Both sensory & traditional were effective 7 symptoms demonstrated significant reduction: anxiety, tension, hostility, uncooperativeness, and conceptual organization
(Knight, Adkison, & Kovack, 2010)
Retrieved from work.chron.com

Summary of Positive Outcomes

Decreases
S/R 22%

Levels of Distress 45%

Disruptive Behaviors 33%

Clinical Importance
Method for preventing or

resolving distress & problematic behaviors that could lead to S/R use Treatment should be individualized to meet specific client sensory needs
(Champagne & Stromberg,, 2004)

Allows clients to be more

independent in selfmanagement Standardized protocol Staff training Staff to client engagement & collaboration
(Sivak, 2012)

Retrieved from www.stjamesmercy.org

Limitations
English articles only Weak study designs & methodological issues One study that didnt focus on individuals with a mental

illness One source of unpublished grey literature was included Over 50% of our studies looked exclusively at comfort/sensory rooms

Areas of Future Research

Specific psychiatric diagnoses in which

sensory interventions are more/less effective More RCT establishing a link between sensory interventions and reduced S/R Standardized protocol Length of time that patients would benefit most in multi-sensory environment Effect of Snoezelen room vs. comfort room Occupational therapy related studies Weighted blanket/DPS effectiveness on adults with psychiatric conditions

Retrieved from http://www.yellowad. co.uk/news.cfm?id=5013&headline=New

References
Chalmers, A., Harrison, S., Mollison, K., Molloy, N., & Gray, K. (2012). Establishing sensory based approaches in mental health inpatient care: A multidisciplinary approach. Australian Psychiatry 20(1) 35-39. doi: 10.1177/1039856211430146 Champagne, T. & Sayer, E. (2003). The effects of the use of sensory room in psychiatry. Retrieved from http://www.otinnovations.com/pdf_files/Q1_STUDY_ Sensory_Room.pdf Champagne, T. & Stromberg, N., 2004. Sensory approaches in inpatient psychiatric settings: Innovative alternatives to seclusion and restraint. Journal of Psychosocial Nursing, 4(9), 35-44. Retrieved from http://www.mass.gov/eohhs/docs/ dmh/rsri/sensory-article.pdf Cummings, K.S., Grandfield, S.A., & Coldwell, C.M. (2010). Caring with comfort rooms: Reducing seclusion and restraint use in psychiatric facilities. Journal of Psychosocial nursing, 48 (6), 26-30. doi: 10.3928/02793695-20100303-02 Knight, M., Adkison, L., & Kovach, J. S. (2010). A comparison of multisensory and traditional interventions on inpatient psychiatry and geriatric neuropsychiatry units. Journal of Psychosocial Nursing, 48(1), 24-31. doi: 10.3928/0279369520091204-03 Kwok, H., To, Y., & Sung, H. (2003). The application of a multisensory snoezelen room for people with learning disabilities Hong Kong experience. Hong Kong Med J, 9(2), 122-126. Retrived from http://www.hkmj.org/article _pdfs/ hkm0304p122.pdf Lee, S.J., Cox, A., Whitecross, F., Williams, P., & Hollander, Y. (2010). Sensory assessment and therapy to help reduce seclusion use with service users needing psychiatric intensive care. Journal of Psychiatric Intensive Care, 6(2), 83-90. doi: 10.1017/ S1742646410000014

References
Lewis, M., Taylor, K., & Parks, J. (2009). Crisis prevention management: A program to reduce the use of seclusion and restraint in an inpatient mental health setting. Issues in Mental Health Nursing, 30, 159-164. doi:10.1080/01612840802694171 Messbauer, L. (2011). What is a multi-sensory environment? Retrieved from http://lmessb auer.com/content/what-is-multi-sensory-environment Mullen, B., Champagne, T., Krishnamurty, S., Dickson, D., & Gao, R. X. (2008). Exploring the safety and therapeutic effect on deep pressure stimulation using a weighted blanket. Occupational Therapy in Mental Health, 24(1), 65-89. doi: 0.1300/J004v24 n01_05 Novak, T., Scanlan, J., McCaul, D., MacDonald, N., Clarke, T. (2012). Pilot study of a sensory room in an inpatient psychiatric unit. Australian Psychiatry 20(5) 401406. doi: 10.1177/1039856212459585 Sing, N. N., Lancioni, G.E., Winton, A.S., Molina, E. J., Sage, M., Brown, S., & Groeneweg, J. (2004). Effects on snozelen room, activities of daily living skills training, and vocational skills training on aggression and self-injury by adults with mental retardation and mental illness. Research in Developmental Disabilites 25(2004) 285-293. doi:10.1016/j.ridd.2003.08.003 Sivak, K. (2012). Implementation of comfort rooms to reduce seclusion, restraint use, and acting-out behaviors. Journal of Psychological Nursing, 50(2), 25-34. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22439145 Sutton, D., Wilson, M., Van Kessel, K., Vanderpyl, J., (2013). Optimizing arousal to manage aggression: A pilot study of sensory modulation. International Journal of Mental Health Nursing. 1-12. doi: 10.111/inm.12010