Author: Bob Bowen, The Mandt System, Inc.

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 behaviors 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. Behavior Based Safety (7) puts forward 10 points in applying the principles of Applied Behavior 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 behavioral psychology, positive behavior 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:

  1. 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.
  2. 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.
  3. Cognitive Rehearsal – providing opportunities for people to mentally rehearse non-physical and physical skills in preparation for actual demonstration of the skill.
  4. 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.
  5. 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.

  1. “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.)
  2. “. . . 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
  3. “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



  1. Centers for Medicaid and Medicare Services (CMS), 42 CFR Part 482.13(f)(4)
  2. Jhpiego Strategy Paper on Competence Based Training, Rick Sullivan, Ph.D., U.S. Agency for International Development, September, 1995
  3. Heller, Karen, “From Management to Support: the Stress of Change”, presented at Tackling Restraint: Eliminating the Use of Restraint, April 4, 2007, Columbus, OH
  4. Jhpiego Strategy Paper on Competence Based Training, Rick Sullivan, Ph.D., U.S. Agency for International Development, September, 1995
  5. Jhpiego Strategy Paper on Competence Based Training, Rick Sullivan, Ph.D., U.S. Agency for International Development, September, 1995
  6. The Children’s Health Act of 2000, P.L. 106-310, Section 595, (b)(1)(B)
  7. Geller, E. Scott, How to Get More People Involved in Behavior Based Safety: Selling an Effective Process, retrieved from  April 4, 2003
  8. International Association for Continuing Education and Training (IACET) Application for Accreditation, Criterion 8
  9. 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
  10. Bandura, Albert (1986), The Social Foundations of Thought and Action: A Social Cognitive Theory, Englewood Cliffs, NJ: Prentice Hall
  11. Bandura, Albert (1969), Principles of Behavior Modification, New York, NY: Holt, Rinehart and Winston
  12. Mandt, D.H. and Hines, R.G., Advanced Technical Training: The Mandt System®, unpublished training manual, 2008, Dallas, TX
  13. Malloy, C. and Uman, G., (2005) Measuring Competency: Understanding the Tradeoffs of Different Assessment Strategies, retrieved from November 14, 2008
  14. Arnett, Betty, Module for Writing Tests, retrieved from November 14, 2008
  15. Unknown Author, Conscious Competence Learning Model, retrieved from April 4, 2003