Additional Information

The Centers for Medicaid and Medicare Services (CMS) requires that staff who may be called upon to implement restraint in settings funded by CMS “demonstrate competence” (1)in the restraint methodology chosen by the organization. The Mandt System® has always thought of itself as a “competence based training program” and like many other programs, has not defined that term, until now.

Jhpiego (pronounced ja-pie-go, the word is not an acronym) is a non-profit organization associated with Johns Hopkins University. Located in Baltimore, they have offices and services in 30 countries and have worked with over 140 countries in the implementation of effective, low cost, hands-on solutions that strengthen the delivery of health care services, following the household-to-hospital continuum of care. In an on-line article published in 1995, they defined competency as “a skill performed to a specific standard under specific conditions.” (2)

When presenting information with the goal of utilizing it in a “real world setting,” great care must be used in designing the format for training. The goal of training is not to get a good grade; rather it is on developing competence in a set of skills, non-physical as well as physical, to maintain the psychological, emotional and physical safety needed in order for quality of life to be enhanced (3). Competence is defined as “a skill performed to a specific standard under specific conditions. “ (4)

In designing a training methodology designed to achieve competence, a specific format has been designed by Jhpiego to give physicians the competence needed to perform complex surgical procedures. The Mandt System, Inc. utilizes that format in the design of The Mandt System®. That format is:

• “Competencies are carefully selected.
• Supporting theory is integrated with skill practice. Essential knowledge is learned to support the performance of skills.
• Detailed training materials are keyed to the competencies to be achieved and are designed to support the acquisition of knowledge and skills.
• Methods of instruction involve mastery learning, the premise that all participants can master the required knowledge or skill, provided sufficient time and appropriate training methods are used.
• Participants’ knowledge and skills are assessed as they enter the program and those with satisfactory knowledge and skills may bypass training or competencies already attained.
• Learning should be self-paced.
• Flexible training approaches including large group methods, small group activities and individual study are essential components.
• A variety of support materials including print, audiovisual and simulations (models) keyed to the skills being mastered are used.” (5)

The competencies selected by The Mandt System, Inc. are derived from Public Law 106-310, Section 595, Parts H and I, commonly known as “The Children’s Health Act of 2000. A set of standards are presented in the law requiring training in “the prevention and use of restraint” in the following areas:

“the needs and behaviours of the population served, relationship building, alternatives to restraint and seclusion, de-escalation methods, avoiding power struggles, thresholds for restraints and seclusion, the physiological and psychological impact of restraint and seclusion, monitoring physical signs of distress and obtaining medical assistance, legal issues, position asphyxia, escape and evasion techniques, time limits, the process for obtaining approval for continued restraints, procedures to address problematic restraints, documentation, processing with children, and follow-up with staff, and investigation of injuries and complaints Satisfactory completion of training is based on achievement of all specified competencies.” (6)

Once competencies are selected, supporting theories are integrated with skill practice. Behaviour Based Safety (7) puts forward 10 points in applying the principles of Applied Behaviour Analysis in corporate and manufacturing settings to increase safety and decrease injuries. One of their points is to teach theories and principles before procedures are developed. This is a key component of The Mandt System®. The training manual is referenced using the APA format, and is theoretically based in cognitive behavioural psychology, positive behaviour support, trauma informed services, and a fundamental belief that all human beings are entitled to be treated with dignity and respect with no preconditions or contingent expectations.

After competencies are identified and theories are integrated with skill practice, training materials were developed by The Mandt System, Inc. that supported the acquisition of knowledge and skills to maintain the safety of all people. The Mandt System® is accredited by the International Association for Continuing Education and Training (IACET) which provides an internationally recognized set of standards that require organizations accredited by IACET develop “content and instructional methods . . . organized in a logical manner in support of learning outcomes and are consistent with learning outcomes regardless of delivery mode.” (8)

The methods of instruction in The Mandt System® then move to mastery of the material. Mastering any material or subject is a complex task, and the first step the curriculum designers of any course of instruction need to do is to establish the standards to which skill performance must be accomplished. Quoting from the definition of training earlier in this paper, training involves learning a “skill performed to specific standards under specific conditions.” The standards used in the prevention of workplace violence come from a public health model, postulating Primary Interventions, Secondary Interventions, and Tertiary Interventions. (9)

The corollary terms to these terms in the field of workplace violence are Prevention (Primary), De-Escalation (Secondary), and Intervention (Tertiary). The skills needed to prevent involve primarily non-physical interventions, although some physical interventions such as distance between individuals, body positioning to facilitate or prevent access to specific areas, and specific choices regarding how to stand, how to hold hands, etc. may be part of Prevention. De-escalation again will involve primarily non-physical interventions, although some skills and concepts regarding how the human body responds to threat, the impact of non-coercive interventions and specific relaxation strategies again may have physical components. Interventions are usually thought of as physical, but that is a misperception on the part of many people. Interventions to respond to violence may be physical, but they do not have to be. Identifying specific skills requiring mastery to prevent, de-escalate and intervene must be done prior to designing the course materials.

The idea of “self-efficacy” (10) which postulates that all people want to learn and can learn given adequate time and teaching methodologies is a core value of The Mandt System. This does not mean, however, that attendance at a learning event will automatically result in mastery of the material to the required level of competence.

In the evolution of The Mandt System®, training was initially accomplished in four days. As additional information as added to the program to respond to changes in federal, state, and provincial standards, additional time was added. The Mandt System® is taught in a 5 day, train the trainer course, with 7.5 contact hours per day (8:00 AM to 5:00 PM, with breaks discounted from time consideration). This time allocation is sufficient to facilitate mastery of the skill as measured by the testing done as part of the program.

The only part of the Jhpiego standards not incorporated into The Mandt System® is that “participants’ knowledge and skills are assessed as they enter the program and those with satisfactory knowledge and skills may bypass training or competencies already attained. “ Over 70% of the people who attend Mandt System® training have been certified in other programs, and while they have established competence in those programs, The Mandt System® is sufficiently different from other programs that pre-testing would take time away from instructional time.

Learning in The Mandt System® is self paced, with the instructor using different teaching methodologies geared to each participant. With this in mind, the authors of The Mandt System® developed a curriculum that consciously focuses on following principles that lead to competence in the utilization of skill. The first step in this design is to understand how people learn. The Skill Acquisition Process (11) is used by The Mandt System® as the framework for presenting the information.

The approach has five steps:

Attentional Skills– encouraging staff to attend to the material, by teaching using a wide variety of teaching modalities to include a wide variety of learning modalities.

Retentional Skills – creating a non-threatening environment in which people can retain information through repetition and the use of stories to empower participants to transfer cognitive knowledge into scenarios similar to those in which they work. “Escalation is an emotional process” (12), requiring that de-escalation techniques incorporate emotional, not just cognitive-behavioral approaches.

Cognitive Rehearsal – providing opportunities for people to mentally rehearse non-physical and physical skills in preparation for actual demonstration of the skill.

Motoric Reproduction– moving from “knowledge to implementation” in verbal interactions to prevent and/or de-escalate, and physical interaction to provide for safety. Motoric reproduction is an essential element in the acquisition of competency, which is why role play scenarios are incorporated into non-physical as well as physical skills.

Vicarious Social Learning – learning from watching others in addition to the instructor is a key element in The Mandt System® approach to skill development. By having different people in a train the trainer format do “practice teaching” under the supervision of the instructor, the prospective trainer is able to begin to develop the competencies necessary to teach, as well as observe other styles of teaching the material.

The approaches used by the Faculty of The Mandt System, Inc. to teach The Mandt System® are flexible involving large group lecture and discussion, small group activities, peer teaching, and individual study. Fidelity is geared to outcomes on the tests rather than to process in the presentation of the materials. Each of the 8 current members of the Training Faculty presenting The Mandt System® use their individual strengths in presenting the material, with a focus on ensuring fidelity in achieving mastery of the skills as measured by cognitive and performance examinations.

Learning objectives are identified in each chapter of The Mandt System®, and are the basis of the cognitive and performance tests. Competence is measured through written tests that require participants to complete multiple choice and “fill in the blank” questions. The Mandt System® uses a combination of “Structured Response, Constructed Response, and Performance Assessment” (13) testing methodologies in their training and testing materials. In using Structured Response questions, The Mandt System® avoids True-False questions as they are “not a good measurement of why a student selected a specific answer. The student has a 50-50 chance of guessing the right answer.” (14)

Physical skills taught by The Mandt System® are tested to a level of competence requiring the person to demonstrate core competencies three times in a row, correctly. A humorous line used by many trainers is “once you can be lucky, twice you can be real lucky, three times you’ve got it.” In measuring competence, the goal of Mandt System® training is to help participants achieve a conscious skill level in the skill. The four levels of skill acquisition (15) are:

Unconsciously Unskilled (You don’t know that you don’t know how to perform a specific skill to a specific standard)

Consciously Unskilled (You know you don’t know how to perform a specific skill to a specific standard)

Consciously Skilled (When you think about it, preferably with little stress, you can perform a specific skill to a specific standard)

Unconsciously Skilled (You can perform a specific skill to a specific standard, even under stress)

For much of the almost 35 years during which The Mandt System® has provided training, we “flew by the seat of our pants” in the provision of our training programs. Since 2002 we have focused on developing our own competencies, and with the advent of the CMS regulations requiring the demonstration of competence in the prevention and, if needed, use of restraint, we have built a training model that has empowered human service organizations throughout the United States and Canada to address issues of workplace violence. Competency Based Training models developed in other fields served as the basis for the development of our unique approach. The ultimate proof of competence can only be found in outcomes of increased safety and decreased injury to staff and individuals served in human service organizations.

“When staff are confident in their physical skills, they give non-physical skills the time it takes to either prevent or de-escalate. As a result, our restraints and injuries dropped by over 70%.” (Dennis Smithe, M.A., Lutheran Services of Iowa, Waverly, IA.)

“. . . we were able to reduce the number of restraints by at least 95% in our childrens’ programs. This reduction in restraints had nothing to do with the children coming to that building and everything to do with the teamwork and training that the staff enjoyed while that program operated.” Jerald Hogan, Northeast Occupational Exchange, Portland, ME

“By teaching staff concepts and principles, we were able to help them to respond to a variety of different ways in which aggression might take place. In training, staff almost always ask ‘what if’ questions. When we focused their attention on the principles, they could figure out the answers on their own.” (Tom , Trenton Psychiatric Hospital, Trenton, NJ)

Community Memorial Hospital in Menominee Falls, WI, experienced a reduction in Workers Compensation costs from $33,785.38 in 2005 to $293.94 in 2007. (Lynn Dunn, MSN, MBA, HCM, NE-BC

 

References

Centers for Medicaid and Medicare Services (CMS), 42 CFR Part 482.13(f)(4)

Jhpiego Strategy Paper on Competence Based Training, Rick Sullivan, Ph.D., U.S. Agency for International Development, September, 1995

Heller, Karen, “From Management to Support: the Stress of Change”, presented at Tackling Restraint: Eliminating the Use of Restraint, April 4, 2007, Columbus, OH

Jhpiego Strategy Paper on Competence Based Training, Rick Sullivan, Ph.D., U.S. Agency for International Development, September, 1995

Jhpiego Strategy Paper on Competence Based Training, Rick Sullivan, Ph.D., U.S. Agency for International Development, September, 1995

The Children’s Health Act of 2000, P.L. 106-310, Section 595, (b)(1)(B)

Geller, E. Scott, How to Get More People Involved in Behaviour Based Safety: Selling an Effective Process, retrieved from http://www.behaviour.org/group.php?id=16 April 4, 2003

International Association for Continuing Education and Training (IACET) Application for Accreditation, Criterion 8

Framework Guidelines for Addressing Workplace Violence in the Healthcare Sector, 2005, published jointly by the International Labour Organization, The International Council of Nurses, the World Health Organization, and Public Service International

Bandura, Albert (1986), The Social Foundations of Thought and Action: A Social Cognitive Theory, Englewood Cliffs, NJ: Prentice Hall

Bandura, Albert (1969), Principles of Behaviour Modification, New York, NY: Holt, Rinehart and Winston

Mandt, D.H. and Hines, R.G., Advanced Technical Training: The Mandt System®, unpublished training manual, 2008, Dallas, TX

Malloy, C. and Uman, G., (2005) Measuring Competency: Understanding the Tradeoffs of Different Assessment Strategies, retrieved from http://www.vitalresearch.com/pdf/VR_Measuring_Competency_Brief_February_2005.pdf November 14, 2008

Arnett, Betty, Module for Writing Tests, retrieved from http://www.ast.org/educators/documents/Module_for_Writing_Tests.pdf November 14, 2008

Unknown Author, Conscious Competence Learning Model, retrieved from http://www.businessballs.com/consciouscompetencelearningmodel.htm April 4, 2003

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Practice Based Evidence is an approach developed by Scott Miller, Ph.D., emphasizing outcome based evidence in “real world” settings.  Because human services is as much an “art” as a “science” it is important to understand that what works in one setting may not work in another.  However, the key principles upon which The Mandt System® is based are applicable in all settings.

All people have a right to be treated with dignity and respect at all times.  All people have a set of needs unique to them, and they will use behaviour to meet those needs.  All people want to be in relationship with at least one other person, and to have that relationship add meaning to their lives.  All people want to achieve, to succeed at something.

What we try to teach in The Mandt System® is an approach that “supports people, not just their behaviour™.”  We teach that people use behaviour, they do not “have behaviour” and we teach that a disability is not a definition of who a person is, a disability limits what a person does.  Evidence Based Practice (Miller et al, 2004) provides an approach that focuses on outcomes in each setting, then puts them together (aggregates) to look at larger trends to determine what works and what does not work in the field, not in the laboratory.

Many organizations have achieved significant reductions in the use of restraint in mental health settings.  By using The Mandt System® organizations have been able to focus on prevention instead of intervention in reducing the use of restraint.  The key to the success of The Mandt System®, in our opinion, is the relationships formed between and among all the stakeholders in the organization.

Reference:
Miller, Scott D.; Duncan, Barry L; Hubble, Mark A.; (2004) Beyond Integration:  The Triumph of Outcome Over Process In Clinical Practice, Psychotherapy in  Australia, Vol 10 No 2 February 2004

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Training staff in “the prevention and use of restraint” is a requirement in all human service sectors. When organizations seek a program to provide the minimum amount of training needed to satisfy regulatory expectations. The Mandt System® is almost never chosen. Our focus is on doing more than the minimum required to keep people safe. Our approach to training staff in The Mandt System® is based on relationships and therefore, we ask this question: “Would I have peace of mind if the people I am training were providing services to someone I love?” We seek, in our program, to help organizations to develop their staff, not just train them.

Staff development requires an initial investment of funds, both for the program and for the time to train staff. The question becomes “which program can provide our organization with the best “return on investment” for the training dollars we will spend. ” The following is a small sample of the many examples of organizations saving millions of dollars by making The Mandt System® the foundation of their relationship based approach to human services.

 

• Grafton Integrated Health Network, has sent us this in 2012:
”GIHN has achieved a 98 percent reduction in physical restraints and numerous positive sustainable outcomes including: improved client treatment, reduced employee and client injuries, significant savings in workers’ compensation costs and national and international recognition for clinical best practices. In fact, to date, our current total return on investment has exceeded 8 million dollars!“
• Independent Opportunities in Kentucky saved almost a million dollars during a 4 ½ year period, and in 2010 did only 3 restraints in their statewide operations.
• Schools in Texas that use The Mandt System® had a restraint rate that was 84% lower than the statewide average for schools. Not only did that save money for the schools, but the National Technical Assistance Center for the Education of Youth Who Are Neglected, Delinquent or at Risk has demonstrated that decreases in restraint use and behavioural referrals increases instructional time for students and decreases administrative time needed to deal with the aftermath of restraint
• Community Memorial Hospital in Menominee Falls, WI, reduced workers compensation costs for aggression-related injuries from $279,000 in 2004 to $239.94 in 2007, and has been at or near zero since
• The Dorothea Dix Psychiatric Center in Bangor, Maine reduced the use of restraint and staff related injuries by over 80% in 2009, and has maintained low levels of restraint and seclusion use
• Treasure Coast Forensic Treatment Center in Indiantown, Florida has significantly reduced the use of seclusion and restraint, and in 2010 had only 2 lost work days due to resident related aggression.
• Since 2000, Valley Mental Health Services in Morgantown, WV, has served over 1,000 people per year in a combination of in-patient, out-patient, and crisis response programs. During that time period, they did a total of 3 restraints

In their article “The Economic Cost of Using Restraint and the Value Added by Restraint Reduction or Elimination” Janice LeBel and Robert Goldstein calculated that in a psychiatric hospital, not doing just one physical (manual) restraint saved the hospital $302.03. While costs in less structured and regulated organizations will be less, saving even one-third of this cost adds up to significant savings per year. Not as evident, however, is the increased quality of life of individuals served and the increased feeling of safety for service users and service providers.

Developmental Services of Nebraska, in their 2009 newsletter, synopsized their experience in the following way:

“Dignity and respect are the cornerstone upon which DSN was founded, and The Mandt System helps us to identify how we will live that principle every day, in every interaction, in all that we do. . . . DSN is beginning to see the results of these efforts. Most remarkably, statistics show that the use of physical intervention of those we support has been reduced by 140% in the past two years. Along with the reduction in physical intervention, relation­ships are being strengthened, and people are gaining experience in self-management of their behaviour. The result is immeasurable for the people the agency supports and its employees. We continue to monitor use of physical interventions and strive to reach the goal of the provision of coercion-free supports. ”

At the heart of dry, dollar driven discussion regarding the work done in human service settings are clients, residents, patients, staff, families, and friends seeking the peace of mind that comes with the emotional, psychological and physical safety that all human beings need. It is this peace of mind that The Mandt System® can help you find and then give to everyone. This peace of mind comes from the fact that the instructional certification provided by The Mandt System® truly puts all people first by building healthy workplace relationships which result in:

◦                   Your service users will be safer

◦                   Your staff will be safer

◦                   Your work will meet or exceed your industry standards for safety

Our promise to you is that:

◦                   You will always be supported

◦                   Your staff development program will be tailored to you relevant to the

  needs of your service users and the staff who serve them

◦                   The materials provided to you will be thorough, research based because

Working with The Mandt System, Inc, 
you are working with the leader in the field

Organizations across the US and Canada have sent data to The Mandt System® demonstrating their ROI after implementing The Mandt System®. To get a copy of an Excel spreadsheet so you can report your data, click here. For more specific information, please contact Kevin Mandt at kevin@mandtsystem.com, and he can help you determine how using The Mandt System® as a staff development tool can enhance the quality of services in your organization and increase workplace safety.

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We designed the Relational Chapters for you if you interact on a daily basis with people who, for the most part, are cooperative. We feel that the Relational Chapters provide an adequate level of interpersonal interaction skills for use in most of these situations. The most important part of any crisis interaction training is having the proper attitude and philosophy. Therefore, we stress the importance of de-escalating and interacting with people – not controlling them. If you can manage and control yourself, you can better interact with other people.

In the first three chapters, Relational Chapters, you will review what it takes to build Healthy Relationships in the workplace. These three chapters are the most important ones we teach!

Chapter One: Building Healthy Relationships


This chapter is the basis not only for this section but the entire course. In a five-day train-the-trainer course, we will spend almost the entire first day on this chapter to highlight its importance and to ensure we lay down the foundation upon which this course is built. Chapter highlights include:

• Foundational Beliefs
• Working as a Team
• Understanding and Working with Emotions
• Behaviour Support and Supporting People
• Understanding Stress
• Crisis Cycle

Chapter Two: Building Healthy Communication


This chapter provides information on how communication takes place, and explores the different elements of communication. Communication is the key to resolving conflict and one of the keys to building healthy relationships. This chapter will provide information as well as opportunities to use this information in role-play and activities. Chapter highlights include:

• The Communication Process
• Nonverbal Elements in Communication
• Vocal Elements in Communication
• Verbal Elements in Communication: Strategies for De-Escalation

Chapter Three: Building Healthy Conflict Resolution

This chapter introduces basic approaches to conflict resolution. This chapter provides a definition for conflict and an approach, which ties conflict resolution into relationship building. We do not see the two as separate activities, but rather see conflict resolution as well as communication as two related tools to build healthy relationships. Chapter highlights include:

• The SODAS Method of Conflict Resolution
• Communication and Relationships
• Understanding Conflict Cycles
• Perceptions and Conflict
• Learning How to Resolve Conflicts

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We designed the Conceptual Chapters for you, if you interact on a daily basis with people who may become uncooperative. We feel that the Conceptual Chapters provide an adequate level of interpersonal interaction for use in most situations. We emphasize the use of a gradually progressive system of alternatives that involves the least restrictive means of interpersonal interaction.

Once healthy relationships have been established, there are four core competencies we want to give you so you can not only build healthy relationships but also use skills to address conflicts and meet unresolved needs. These next four chapters now focus on using skills and competencies.

Chapter Four: Trauma Informed Services


This chapter was written to help you work better with people who have experienced significant and in many cases ongoing trauma. There are people who may have experienced some type of traumatic event that was a “one time” occurrence, such as a natural disaster. Or they may have been victimized by other people: terms like abuse, exploitation, dehumanization, degradation can best describe what has happened to the person.

At a conceptual level, we want to give you the background information that may help you to become more aware of the effects of trauma on the people you serve, and provide a safer environment in which they can live, learn, work, and play with an increased feeling of safety. It may also give you the ability to support people and to respond to them in ways that do not retraumatize them.

• Two Models to Understanding Traumatic Stress
• Responding to Acute Episodic Trauma
• The Effects of Trauma – Betrayal Trauma

Chapter Five: Positive Behaviour Support

This chapter was written to help people implement behaviour support plans, not to write them. The more people know about positive behaviour support, the easier it will be to help the people writing those plans by giving them the information they need. and to implement the approaches within support plans. This chapter focuses on:

• Two Views of behaviour
• Antecedent – behaviour – Consequence Model
• Setting Events
• Relationships and behaviour
• Understanding Positive behaviour Intervention and Supports
• Assessments
• Intervention Strategies
• The Crisis Cycle and behaviour Support Interventions

Chapter Six: Liability and Legal Issues


This chapter provides an introduction to the legal issues surrounding the provision of services to people in educational, developmental disabilities, mental health and substance abuse, and other human services settings. Since none of us are attorneys, we cannot give legal advice, but we can give legal education by sharing the knowledge we have gained through the use of our skills and competencies as administrators, educators, social workers, expert witnesses, and direct support professionals. This chapter focuses on:

• Defining Liability
• Standards of Care
• Personal Liability and the Basis for Litigation
• Supervisory and Organizational Liability
• Reasonable Person Standard
• Reducing Exposure to Lawsuits

Chapter Seven: Medical Risk Factors


This chapter was written to provide an overview of the risks of physical restraint, using literature written by medical professionals. None of the authors of this chapter are licensed medical professionals. If you have any concerns about the health and welfare of people, whether people who receive services or people who give services, seek the advice of a licensed medical professional. This chapter focuses on:

• The Risks of Restraint Use
• CWLA Best Practice Guidelines
• Special Risks in Restraining Small Children
• Risk of Injury to Staff

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We designed the Technical Chapters for you, if you interact on a daily basis with people who may become uncooperative and/or confused. We present a system of gradual and graded alternatives for de-escalating and managing people, using a combination of interpersonal communication skills and physical interaction techniques designed to reduce injury to all the participants in an encounter. The interpersonal skills from the Relational and Conceptual Chapters are reviewed and practiced, but emphasis is placed on learning appropriate physical skills while maintaining a high level of dignity and respect.

That same criteria must be present as we consider the possibility of an incident becoming a crisis. Just because there is a crisis and an increased risk of harm does not mean that we no longer treat people with dignity and respect. In these next chapters, we will focus more on teaching concepts than on teaching techniques.

Chapter Eight: Assisting and Supporting


This chapter will focus on assisting and supporting people who may be confused or disoriented, or who may have difficulty maintaining their balance. They may also have difficulty with following directions and responding to requests due to changes in medication, seizure activity, or other personal issues. In this chapter, we will not be focusing on the possibility of aggression. This chapter includes:

• Implementation of Physical Interaction Skills
• Introduction to Assisting
• Stance and Balance
• Body Mechanics and Movements
• Body Positioning
• One – and Two-Person Assisting
• One – and Two-Person Supporting

Chapter Nine: Separating


This chapter addresses questions that arise when people may grab you, or other people, or objects. Not all such acts, though, are aggressive in nature, and we will provide you with a model to assess the act of being grabbed. This chapter includes:

• Physical Interaction Concepts
• Non-Physical Ways of Separating
• Physical Releases from Holds
• Biting
• Hair Pulling
• Clothing Holds
• Finger Holds
• Separating Two People Who Are Fighting

Chapter Ten: Restraint


This chapter will provide two ways to restrain adults and two ways to restrain children or people of relatively shorter stature. This chapter teaches the application of the principles discussed above for the purpose of limiting and redirecting movement, but not immobilizing a person. Restraint, even when properly applied, can result in physical or emotional and psychological harm. The risks and benefits of imposing a restraint must be balanced against the risks and benefits of not doing a restraint. This chapter includes:

• Restraint Usage and Associated Injuries
• Risk Factors Associated with Restraint
• Minimizing Risk and Injury
• Three Types of Asphyxiation Associated with Restraint
• Monitoring Restraint Usage
• Standing Restraints
• Restraints of persons of short stature
• Moving People During Restraint
• Time Limits When Restraint is Used

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