Medical mechanical restraints are designed to restrain patients with the minimum of discomfort and pain and to prevent patients injuring themselves or others. There are many kinds of mild, safety-oriented medical restraints which are widely used. Medical restraints are generally used to prevent people with severe physical or mental disorders from harming themselves or others. A major goal of most medical restraints is to prevent injuries due to falls. Other medical restraints are intended to prevent a harmful behavior, such as hitting people. Ethically and legally, once a person is restrained, the safety and well being of the restrained person falls upon the restrainer, appropriate to the type and severity of the restraining method.

Although medical mechanical restraints, used properly, can help prevent injury, they can also be dangerous. The United States Food and Drug Administration (FDA) estimated in 1992 that at least 100 deaths occur annually in the U.S. from their improper use in nursing homes, hospitals and private homes. Most of the deaths are due to strangulation. The agency has also received reports of broken bones, burns and other injuries related to improper use of restraints.

Throughout the last decade or so, there has been an increasing amount of evidence and literature supporting the idea of a restraint free environment due to their contradictory and dangerous effects.[1] This is due to the adverse outcomes associated with restraint use, which include: falls and injuries, incontinence, circulation impairment, agitation, social isolation, and even death [2]

Use of physical restraints should be as a last resort; and only used when less restrictive mechanisms have been determined to be ineffective and risk of injury from intervening is less than that of not intervening. The use of restraint must be in accordance with a written modification to the patient’s plan of care. This primarily means setting up a therapeutic relationship with a patient, getting to know what environmental and emotional triggers could lead to aggressive or even violent behaviors. A plan to prevent a patient who is anxious or agitated from escalating into a full-blown, potentially dangerous situation should be in place.

If you would like to have The Mandt System to assist in setting up a patient plan of care or assist in establishing a therapeutic relationship with your patient or patients, please email us at Info@mandtsystem.com.

Sally Phipps – Mandt Faculty

1. ^ Evans; Wood & Lambert (2003). Journal of Advanced Nursing 3 (41).
2. ^ Huabin; Lin & Castle (2011). American Journal of Alzhiemer’s Disease &Other Dementias 1 (26).

In one of the activities in Chapter 1, we focus on the characteristics of healthy relationships identified by Julius Lundy. I will highlight the words that I think are important in the process we call teamwork. As we act, we need to act with Fidelity. Being true to the goal, the plan, the mission are necessary if we are to act in a way that not only builds healthy relationships but also achieves the goal.

Once we start to act, and do so with Fidelity, we need to make sure we act with Integrity. Integrity is defined as “Moral soundness; honesty; freedom from corrupting influence or motive; — used especially with reference to the fulfillment of contracts, the discharge of agencies, trusts, and the like; uprightness; rectitude”.

In the Liability and Legal Issues chapter of The Mandt System, we talk about the need to do what we should do, and not do what we should not do. In this way, we can limit the possibilities of being sued. Integrity leads to following through, so our “yes” is just that – yes, I will . . ., and the same is true when we say “no.”
Acting with Integrity and Fidelity will absolutely build up a team, and in the same way, acting without Integrity and Fidelity can tear a team apart. What we need to remember, though, is that we are all human. We will all make mistakes, and at times we may not follow through, and we may not stick to the plan.

The final word for the day, then, is Forgiveness. It will take a lot of courage (another of Lundy’s words) to act with forgiveness, and it is absolutely essential to a well running team. Self-righteous team members who expect perfection out of everyone (even themselves) can unwittingly destroy a team. We’ve all made mistakes, and as we say in Chapter 1 of The Mandt System, when we have trust in place, mistakes are just that: mistakes.

In April, Tim Geels wrote a blog about Performance Management and Strategic Goals. Forgiveness should be done when mistakes happen, unless the same mistake happens over and over again. In this case, performance management tools need to be used, with Integrity and Fidelity. We want to build healthy relationships in the workplace, and we need to get the job done in accordance with law, regulations, policies and procedures. There will come a time when judgment must be applied, and that is the subject of another blog!

Bob Bowen, CEO – The Mandt System, Inc.

For me, this particular point in Chapter 1 is always a gentle reminder (as is the way of Ubuntu) that I can recommit myself to a better way of thinking. That I can remember how each of us as a human being is interconnected with every other human being. That the way I treat other people affects not just that person but can have a ripple across all the people s/he will interact with and will, on a much larger scale, impact the whole world. I want to make a choice each day to interact with people in a way that will build them up instead of tearing them down.

Tutu further explained Ubuntu in 2008, “Ubuntu speaks particularly about the fact that you can’t exist as a human being in isolation. It speaks about our interconnectedness. You can’t be human all by yourself, and when you have this quality – Ubuntu – you are known for your generosity. We think of ourselves far too frequently as just individuals, separated from one another, whereas you are connected and what you do affects the whole World. When you do well, it spreads out; it is for the whole of humanity.”

At Mandt, we make a significant effort to help staff understand that treating others with dignity and respect is a vital component to building healthy relationships. In my workshops I also try to help new instructors recognize how difficult that might be for some of the staff they will be training. Some of the people we are offering services to do not treat us with dignity and respect. We sometimes have the attitude that we will only treat people with dignity and respect if they are treating us in a similar fashion. This can obviously be a vicious cycle (our clientele treats us with disrespect so we treat them with disrespect and in turn they continue to treat us with disrespect) and one that is our duty to break – as difficult as that may be. We are the paid professionals in this relationship. It is ultimately our responsibility. It is far too simple to fall into the “us vs. them” mentality and focus on the difference we have with the people we are providing services to – whatever the disease, disability, or diagnosis that has brought this person to our care. Instead, let us redirect our focus onto the similarities. The shared interests and the commonalities – the essence of our humanity.

Maybe today can be the start?

Nikki Wince – Mandt System Faculty

In some organizations this individual or Skills Coach naturally comes to the fore through undefined action and by the recognition of others. Sometimes this person is the Mandt certified trainer, but more often is a direct care or front line staff member. Hoping that this evolution naturally occurs may not be enough so helping may be a better approach for the organization that is serious about ‘bedding in’ the Mandt System approach and creating the sustainability that we have mentioned.

So finding your Mandt Champions or Skills Coach is the challenge. Every organization has a unique culture and operational personality and it is most likely that prospective candidates will already have embraced and be working toward that mission and goals. Additionally candidates are often characterized as those that somehow emit a calm and caring demeanor in all of their interactions. Often just being around this person can aid people to exhibit or work to their best whether staff or service user. Most staff teams if you ask them can identify one or two individuals in their teams for whom these behaviors are true.

What we have found is that these embodiments of the Mandt Philosophy will often expose an attitude not dissimilar to that of Mandt. They will often say, ‘I just try to always treat people the way I would like to be treated’ or ‘I always try and put myself in the other persons shoes and imagine how I might be feeling in the dame situation as then, and what would make me feel better’. These folks are a great staring point for consideration of your skills coach or Mandt champion. Having them share their approach or become co trainers is a great first step in achieving the sustainability goal.

Simon Kemp – The Mandt System
Director of Organizational Integrity

The first step in R.A.D.A.R is recognizing when the situation is out of whack; something is just a little off and not quite right. Knowing baseline data and having a clear understanding of the players will aid in accurately determining “normal”.

Another key factor to cultivating a better R.A.D.A.R is to not only have a complete picture of the individual through exploration of various assessments, and gathering of history, but to build a rapport before an incident occurs. Time after time, the person meant to diffuse a situation increases the anxiety, because he or she does not have a relationship or true picture of the individual’s needs.

Next utilize the gathered information to decide how to proceed. Teams should also take note of the old adage of “the best laid plans of mice and men often go astray” and make sure to have a “plan b”; then implement the plan.

Finally, after any incident, review the results with all the participants. Teams should explore what went well and what can be done better next time. Remembering that each one made the best choice with the available information for them at the time; therefore, the meeting needs to be about refining and improving not placing blame.

The bottom line is to refine our R.A.D.A.R to be more reliable, to increase our early intervention skills. The earlier you can intervene, the better chance you have of preventing interactions from becoming incidents, or incidents from becoming crisis.

Randel Goad – Mandt Faculty

Look: A good leader must look around and look ahead. They set the vision and the goals that guide the people they lead. They look up from their paper work and look around at the people and product.

Listen: Much has been discussed about a leader’s ability to listen to the people around them. One of the reasons for Management By Walking Around (MBWA) is to “listen to employees in an informal setting.”(Harris, 2002) They ask questions and then really listen to what is said and the way it is being said.

Liberate: A good leader gives their people freedom to work. “The goals and the values are like sidelines. The players have to know that as long as they follow the rules they can go anywhere within the lines.” (Blanchard & Bowles, 1998)

Learn: In 1992 I had the honor of spending 45 minutes with Howard Hendricks in his office at Dallas Theological Seminary. Howard Hendricks has mentored some of the great Christian leaders such as Chuck Swindoll and Tony Evans. During that meeting, Mr. Hendricks made two quotes that I have never forgotten and have implemented into my life. First, that “all leaders are first learners.” Second, that “all leaders are readers.” I have been a non-stop reader trying to learn all I can ever since that conversation. All leaders need to be in a constant state of learning all they can.

Labor: Leadership is work and a good leader leads by example. They role up their sleeves and jump in when necessary. Good leadership is first in and last out. You will not find the Great leader on the golf course while there is still work to be done.

Laugh: Good leaders know when and how to laugh. They understand that fun is a motivator. They also know how to celebrate victories both big and small. “It’s virtually impossible to dislike someone who makes you laugh, who helps us enjoy ourselves.” (Decker, 1991)

Love: Leaders love what they do and the people with whom they do it. As Kouzes and Posner (2007) say, “Leadership is an affair of the heart.”

Tim Geels
Director of Operational Instruction

Milieu therapy was coined by Bruno Bettelheim in 1948 and is more often used in relation to institutional treatment centers. Arguably the term can be applied to any health and human service setting, inpatient or outpatient. The relational training section of The Mandt System addresses this expectation and informs service providers of what must be in place to provide an environment in which healing/recovery can occur.

A therapeutic milieu provides a safe and trusting environment which allows the person receiving services to engage in their treatment and recovery effort. Often service providers complain that individuals in their service system are resistant and non-compliant with their individualized plan. This is less likely to occur if the individual themselves is instrumental in the development of the plan. To engage in that activity, the individual receiving services must feel safe and trust those involved in the provision of services. When an individual does not feel safe, their behavior will demonstrate that they do not feel safe. Part of the staff’s responsibility is to help the individual feel that with them and in that environment, the person receiving services is safe.

To enable trust to occur, individuals receiving services must be able to anticipate that they are going to be treated with respect and dignity and in a manner that is supportive of them. Individuals receiving services will be observing and testing the environment and staff to determine if they are safe with them and in the treatment environment. An important way of conveying trust is by the staff’s demonstration of respect, dignity and support to each other on a consistent basis. When the person receiving services perceive that the staff members do not trust each other, they will question why they should trust the staff.

It is important to recognize that each interaction with another person holds the potential for social learning and personal growth because an individual’s psychological difficulties are inevitably expressed in the context of human relationships. It is a strengths-based approach that focuses on teaching problem solving skills which can be applied to future events rather than using punishment to change behavior. This can be challenging when most service providers grow up with the notion that when someone does something wrong they should be punished, an attitude that accompanied them into their work environment.

It necessitates a change in attitude, the adoption of positive behavior supports and a movement away from control or punishment to shape the behavior of service recipients. These are perhaps the biggest barriers service providers face in developing a healing and therapeutic environment. It is challenging because it necessitates first looking at ourselves and other service providers to ensure that we are treating each other, as well as individuals being served, in a supportive, respectful and dignified manner.

However it is worth the work, because by doing so service providers actually model the behaviors they expect service recipients to exhibit.

Aaryce Hayes – COO & Faculty

The starting point is ensuring the appraisal systems are in line with the planning systems and tied directly into the budget system, which allows compensation to fuel the appraisal system. “The problem is these systems are not hooked together in most organizations.”(Hitchcock, 1992, p. 50) Too often organizations do not fully integrate appraisal systems directly into the strategic plan and tie it directly into the necessary budget components. The appraisal system then becomes a separate entity all together and dependent upon cash flow when available.

According to Hitchcock, an integrated performance management system should have the following: Link to strategy, employee involved performance goals, measurement, reporting, feedback, planning and links the rewards to the results. When all of these items are in place, it helps the organization to achieve its strategic goals. When appraisals and development put people into the wrong roles, this will have a negative effect on outcomes. It is also important for constant feedback along the way. “Periodic performance review repays the time and the effort involved.”(Macauly & Cook, 1994, p. 3)

Some questions to ask:
Does your strategic plan have appraisal systems tied in?
Are the employees aware of the strategic plan?
Is the strategic plan measurable with clear objectives?
Do employees understand their role in obtaining the measurable outcomes?
Do the employees understand how they ultimately benefit from successful outcomes of the strategic plan?
Are employees given feedback on their performance specific to the strategic goals?

Employees need to know if they are doing what they should be, know where they are lacking and how to correct it. (Benson, 1995) This feedback allows an organization to keep its employees focused and running at their most efficient means. “Ironically, in many organizations, continued employment-still having a job- is feedback (i.e., if you are not fired, you must be doing a satisfactory job).”(Harris, 2002, p. 233.) The lack of employee appraisal planning tied to strategy and vision disconnects employees from the organization. Employees who know their role in the organization and have a clear path on obtaining success have greater connection to the organization as a whole.

Tm Geels – Mandt Faculty

In light of the recent happenings in Boston where once again our country has been exposed to a terrible act of violence, it is important to have some simple reminders related to the impact that these occurrences can have on individuals in our care. Though individual’s receiving services or who need a greater level of care may not always or completely understand what is happening, their RADAR will be on. Individuals receiving services will be sensitive to the mood of the staff who are working with them. In the Mandt System we often use the phrase affirm your emotions but choose your behaviors. In times of national tragedy, this is not easy to do but is necessary. We need to be grounded ourselves to be emotionally present for those individuals in our care and help them feel safe. Here are some things to consider:

Turn off the Television-

Often times in group homes and in institutional care the television is on for background noise and is being watched by the staff. It might be a good idea to ensure the television is off during the upcoming days to help us avoid getting caught up in the media frenzy that goes on around these events. It will allow us as staff to focus on building safe relationships with out being sabotaged by a breaking event.

Be Honest-

It is the right of individuals receiving services to watch the television if they so desire. If they are watching the news, do your best to help them understand the events that are being discussed by processing with them. Use this time to build into your relationship and provide feelings of safety for the individual. Be honest about your feelings while showing concern for the individual’s feelings. If you do not know the answer to a question they may be pondering, be honest and say you do not know.

Watch for Changes in Behavior-

Keep your RADAR on and watch for signs of distress and changes in behavior that may indicate how an individual is being impacted. Post-traumatic stress is not uncommon following events such as the bombing at the Boston Marathon. Depending on the individual’s reaction, it may be necessary to make a referral to someone who can better assist the person in dealing with their reaction. It is important to watch out for fellow staff members as well. Many of us become quite emotional when these events occur and the increase in frequency we are experiencing recently can start to take its toll.

We must be aware that many people who have difficulty with expressive communication are very good at receptive communicate. Those individual may understand all that is going on around them from a self-preservation stand point. We must monitor our body language, facial expressions, and tones so as not to cause undo stress on those who depend on us to feel safe. Whenever possible we must use the team approach to help one another out and watch for signs of distress that may be passed on to our persons being served.

Though bad things will happen it is important to look for and focus on the good. The great Fred Rogers once said, “When I was a boy I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’” YOU are the helpers! In times of stress, you must help those whom you are responsible for feel safe. Thanks for all you do!

Tim Geels – Mandt Director of Operational Instruction

This is understandable. Challenging behavior is difficult and many teachers come out of higher education ill prepared to deal with the types of behaviors they are asked to face in a classroom. In addition, who can deny the importance of the topic of Autism as the numbers start to skyrocket into epidemic proportion? These are important subjects and need to be addressed. What has however dawned on me is that we could use these teachers to become more involved as advocates. I know…I know, one more thing to add to an already very heavy load. Nevertheless, one thing I know, teachers listen more to teachers then anyone else. Most other professional groups are the same way.

I am guilty of not being fully involved. For almost twenty years I worked in the field of disabilities before having my son Tyler who has Fragile X. Most of those years, I was involved with traumatic and acquired brain injury. I spoke at several support and advocacy groups but did not attend regularly nor get directly involved. I made all sorts of excuses. “I deal with it every day and need a break.” “I already give through my work.” “I want to keep a professional distance with the parents.” I regret to say I was wrong. I should have been more involved. I should have advocated better for my consumers. After Tyler’s diagnosis of fragile X, my wife and I have become very much involved in advocacy and support groups but they are mainly made up of parents like us. We are fortunate to have an amazing network with great professionals who trumpet the needs of our kids before their peers but we need more!

However, not only us, but also every disability group out there. I challenge all the professionals reading this to get more involved in your passion…whatever and whoever that may be. The parents need you in their meetings, at their fundraisers, at your conferences in front of your peers! After several years of not seeing one session on fragile X at the CEC conference there was one this year. Other syndromes also had one session representation. Down Syndrome had 5 sessions. We need professionals to become involved and share what you know to be working. Evidence based practices are important but so are practiced based evidences. Please share what is working for you in your classrooms and group homes. Please answer the call for papers when asked. Please become involved in the local chapter of one of your disability support groups. My fragile x family has become so important to me. As I have heard it said several times, It’s the best group you never wanted to be a part of! But, you do! You NEED it if you are a family member. Get involved in your local groups no matter what the diagnosis. If one does not exist, start one. However, professionals you want to tie into these as well. They need you more then you can ever know. Not only did I make many excuses for years why I could not or should not…I made a huge mistake not doing it. I see that now.

Tim Geels – Mandt Faculty