Running head: A SYSTEMATIC REVIEW

Sensory Techniques to Manage Problematic Behaviors and Prevent Seclusion and Restraint Use in Psychiatric Facilities: A Systematic Review Anthea Mourselas & Jessica Pierson Touro University Nevada

A SYSTEMATIC REVIEW Objectives and Statement of Problem Today less and less occupational therapists (OTs) are working in acute psychiatric facilities which may be attributed to funding changes and a lack of available jobs opportunities. The occupational therapy profession was founded on ideas, such as moral treatment and work cure that were used as more humane options for clients with mental illness (Champagne, 2011).

Unfortunately, seclusion and restraint (S/R) use have been common practices used with mentally ill individuals for centuries. It is currently still used in psychiatric facilities as a method for controlling problematic behaviors commonly displayed by this population. Tina Champagne, an OT that supports sensory strategies as a more humane alternative to S/R stated, The knowledge base of OTs justifies the role of OTs as one of the primary and qualified professionals to help supervise the development and implementation of sensory approaches within mental health care settings (Champagne, 2008, p. 1). Unfortunately, there has been limited published research done on OTs using sensory strategies with patients who suffer from mental illness in psychiatric facilities. An evidencebased review of sensory strategies used with this population to reduce problematic behaviors and S/R use, can help justify the need for OTs to be more involved in these types of interventions. Therefore, this review seeks to synthesize the existing evidence available regarding specific types of sensory strategies such as, Snoezelen rooms, sensory rooms, sensory carts, and weighted blankets. The purpose of this systematic review is to look at a variety of programs which have implemented sensory techniques into the plan of care for their psychiatric patients and evaluate these sensory-based strategies are effective in reducing problematic behaviors such as distress, aggression to others, and self-injury, which ultimately would decrease, or eliminate S/R practices. Effective sensory treatment alternatives could positively influence the quality of life

A SYSTEMATIC REVIEW for psychiatric patients and help to further justify the need for more occupational therapy involvement in psychiatric settings. Background Literature S/R continues to be used throughout mental health facilities despite negative outcomes including deaths and injuries to both clients and staff members (Sivak, 2012). Approximately 150 people die each year due to S/R practices used in psychiatric facilities (Sivak, 2012). The risk of death increases for secluded patients because of missed medication, cardiac arrests, or

other medical emergencies (Lewis et al., 2009). Asphyxiation was noted as the number one cause of death related to restraints use (Stefan & Phil, 2002). Physical injuries to staff and patients can result from placing someone in S/R due to aggression and resistance (Lewis et al., 2009). In addition, S/R can cause long-lasting psychological distress, as well as retraumatization for those mentally ill individuals that have had experienced a traumatic and violent past (Sivak, 2012). In an attempt to decrease S/R use the Joint Commission on Accreditation of Healthcare Organizations revised their S/R standards in 2001 calling for these practices to be used only when there is imminent threat of physical injury to the patient or others (Lewis, Taylor, & Parks, 2009). As a result of this accreditation change, as well as the number of deaths and injuries associated with S/R practices, the National Seclusion and Restraint Reduction Initiative was created to advocate for alternative methods for managing problematic behaviors in the mentally ill (Champagne, 2011). One such sensory alternative that has become widely used is psychiatric facilities is the creation of multi-sensory environments. These environments are designated spaces or rooms filled with sensory equipment that is designed to stimulate the senses and create feelings of pleasure and well-being (Champagne, 2011). It is thought that by providing mentally ill patients with a sensory stimulating environment that there will be a decrease in aggressive

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incidents that commonly result in S/R use (Champagne, 2011). Proponents of these environments also believe that they empower clients to manage their own problematic psychiatric symptoms and make them less dependent on psychotropic medications (Sivak, 2012). The current research should be examined to identify which sensory strategies are most beneficial in decreasing problematic behaviors, if there is a standardized protocol for multi-sensory environment use, and how involved OTs are in creating and implementing these interventions. Methods for Conducting the Systematic Review A literature search was done to identify articles relating to sensory strategies to reduce seclusion and restraint use in mental health facilities from 2000 to 2013. The electronic databases Cochrane Library, PubMed, CINAHL, AJOT, and Google Scholar were searched. Search terms included sensory strategies, sensory stimulation, multi-sensory, sensory integration, sensory rooms, Snoezelen rooms, comfort carts, mental health, mental illness, schizophrenia, restraint reduction, seclusion reduction, aggression, self-injurious behaviors, crisis prevention program, inpatient hospitals. These search terms were used in varying combinations. The reference lists of retrieved articles were examined to identify other potential research articles not located in previous searches. Articles were selected based on designated inclusion and exclusion criteria developed for this review. Only articles written in English, focused on an adult population, addressed some aspect of restraint, seclusion, aggression, or self-injurious behavior reduction, and had a sensory component were included. Articles were excluded if they were not written in English, focused on children, or concentrated exclusively on treatments for adults with dementia. Decisions to include a specific publication were made by the two members of the systematic review team following evaluation of all full text articles. All articles were critically appraised using the McMasters Critical Review - Quantitative Form (Law et al. 1998).

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Author/ Year Mullen, Champagne, Krishnamurty, Dickson, & Gao (2008)

Study Objectives

Level/Design/ Subjects Level 1 RCT design 32 non-hospitalized, adult volunteers with no apparent medical conditions or physical injuries between the ages of 18 & 64.

Intervention

Outcome Measures

Results -All persons vitals stayed consistent. except1 person was out of the safe range for systolic BP -There was not a significant difference between using the blanket, not using the blanket & between the orders in which the blanket was applied. -STAI-10 survey responses showed that 63% of the participants rated their anxiety lower with the use of the weighted blanket. -Exit survey responses showed that 78% reported a lower anxiety after using the blanket. -Significant difference in decreased levels of before & after Snoezelen use for self-injury but not for aggression. -Decrease in both aggression & self-injury during Snoezelen room sessions when compared to ADL skills training & Vocational skills training.

Study Limitations

To present the details of the first clinical study exploring both the safety & effectiveness of the use of a 30 lb weighted blanket, the heaviest available at the time of the study.

Weighted blanket -All persons participated in 2 test sessions, 1session with the treatment (the 30 lb weighted blanket) & one session without the treatment. -Each persons assigned code determined whether the treatment (30 lb blanket) was given during the 1st or 2nd testing session.

-The quantitative measurements for both safety & effectiveness included a pre & post measurement before & after treatment sessions. -Data collectors used a standardized data-recording protocol to document & practice sessions. -Blood pressure, pulse oximetry, pulse rate, & skin conductance (SC) data were collected . -State Trait Anxiety Inventory-10 (STAI-10): Exit survey

-5-minute time frame was used in each of the test sessions. -Participants were all required to use the full 30 lb despite varying body weight. - Not all participants pulse oximetry, pulse rate, & SC data were obtained due to pulse oximetry & SC sensors not always staying in place.

Singh, Lancioni, Winton, Molina, Sage, Brown, & Groeneweg (2004)

To understand the effects of Snoezelen rooms on individuals with mental retardation & mental illness in comparison to activities of daily living (ADL) training & Vocational skills training.

Level II Cohort design N=45 -Residents in a residential facility for people with developmental disabilities. -All participants had severe or profound mental retardation & Axis 1 disorders, on psychotropic medication & displayed aggression

Snoezelen room -Participants assigned to 3 groups of 15. -3 groups spent 1 hour in each of the following conditions: A=ADL skills training B=Snoezelen room C=Vocational Skills training. -Staff members were trained to observe & track aggressive & self-injurious behaviors during that

1 minute sequence of observation by trained staff member to record occurrence or nonoccurrence of target behaviors (aggression & self-injury) for the entire 1 hour session & before & after.

-Does not take into account aggression & self-injurious behaviors as escape, avoidance, & sensory seeking behaviors. -No full sensory evaluations were conducted on residents. -Snoezelen rooms were not customized to fit resident specific sensory needs.

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& self-injurious behaviors.

time.

Knight, Adkison, & Kovach (2010)

To determine whether sensory interventions would be successful reducing acute psychiatric symptoms in general psychiatry inpatient & geriatric neuropsychiatry populations.

Level II Cohort Design Traditional group: (N =36) Geriatric: (N=20) General: (N=16) Sensory group: (N=24) Geriatric (N=11) General: (N=13) -The sample was taken from McLean Hospital in Belmont, MA. The participants were all inpatient.

Sensory room Pre & post measurement only once after the implementation of a traditional or sensory intervention.

-The Brief Psychiatric Rating Scale (BPRS) was used for measurement. -Included items such as anxiety, tension, hostility, uncooperativeness, & conceptual disorganization.

-There was a significant difference in pre & post BRPS scores for both the traditional & sensory intervention groups (p=0.000) -Both interventions were effective in managing psychiatric symptoms, yet neither was more effective. -Of the 18 symptoms evaluated, 7 demonstrated significant reduction for intervention: anxiety, excitement, tension, uncooperativeness, hostility, conceptual disorganization & depression.

-Small sample One-time intervention -One measure of change per individual -The use of as needed drug administration if the nurse or individual determined the need. -Contribution of the patient-staff relationship not addressed.

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

To reflect upon the implementation of sensory-based approaches introduced at the Mercy Mental Health Psychiatric Unit

Level II Cohort Design N = 109 Acute adult psychiatric inpatient unit in Australia Included low dependency unit (LDU) & high dependency (HDU)with 2 seclusion rooms

Sensory room -Team: Unit manager, 2 psychiatric nurses & an OT for needs analysis -Staff training -HDU-Sensory connection program -LDU-sensory room -Staff members supervised participants during use

-Log sheet completed by participants in LDU including distress/anxiety level pre & post entry of room. -The Fremantle Acute Arousal Scale: staff member rates arousal level a six-point scale (0 = asleep or unconscious, 5 = highly aroused, violent towards self, others or property) -Pre & post entry for both LDU & HDU

-The most common type of distress reported by participants was anxiety, restless, agitation, & distress. -LDU: Sensory Room: Reduction in distress scores from entry to exit of the sensory room was statistically significant (p < 0.0005) -Patient rating: decreased from 5.98 to 3.09 Clinician rating: decreased from 2.69 to 1.42 -HDU: Sensory

-The sensory room is a small room & not as close to HDU as would be preferred. -Having it closer to the HDU would allow more unwell patients access. -Limited information on time spent in sensory room.

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Connection Program: pre to post arousal score was statistically significant decreasing from mean score of 2.17 to 1.6 Sivak (2012) To examine the positive impact on clients & nursing staff when comfort rooms are implemented at one small, rural, tertiary mental health hospital in Delaware. Level II Cohort design N=70 -Patients from a small, rural tertiary mental health hospital Sensory room -Before implementation, nursing care staff & participants collaborated on different aspects of the comfort room. -After, clients were recommended to use comfort room for up to 30-min when they first felt anxious or angry. -Feedback forms given to participants, pre & post use of comfort room. -Staff tracked participants: -Levels of distress, -Clientto-client assaults (CTCA), Client-to-staff assaults (CTSA), Self-injurious behaviors -4 months before implementation of sensory room & 4 months after -Since the initiation of the comfort rooms, there has been no use of seclusion or restraints. -Average rates of incidents after comfort room implementation over 4 months decreased including: CTCA (23.4%), CTSA (-48.1%). Self-injurious behaviors average increased (+12.1%). -Other clients actions during the treatment could significantly alter the outcome. -The data was limited to only 4 months prior to implementation & 4 months during the implementation. -Some clients may have not understood the survey.

Novak, Scanlan, McCaul, MacDonald, & Clarke (2012)

To find out if use of a sensory room would : (1) reduce distress reported by consumers who used the room; (2) reduce disruptive & disturbed behaviors demonstrated by consumers who used the room; (3) reduce rates of seclusion & aggression on the psychiatric facility Sensory room to help clients reducing their level of self-perceived distress as well as help reduce &/or prevent the need for seclusion

Level III Before-After design N =75 -Patients all had psychiatric disorders with predominantly schizophrenia or other psychoses. -Recruited from an acute inpatient psychiatric hospital in Sydney, Australia.

Sensory room -Sensory room implemented -Staff education & training -Staff offered time in comfort room to participants at the first sign of distress or agitation.

-Consumers assessed their own level of distress before & after sensory room use. -Clinicians rated behaviors including: physical aggression, pacing, loud, irritable, intrusive, paranoid, elevated, anxious, settled, calm, & withdrawn before & after sensory room use. -Rates of seclusion use & incidents of aggression were analyzed. -Self-rating level of distress before & after sensory room sessions. -Rate of restraints use

-There was a significant improvement in in ratings of self-rated distress levels before & after the use of the sensory room -Significant improvement in clinician rating of behavior. -There no significant changes in rates of seclusion or aggression.

- The measure was created for the study & was not proven to be reliable or valid. -Lack of masked evaluation

Champagne, & Sayer (2003)

Level III Before-After design -47 clients an in-patient psychiatric unit in a hospital in

Sensory room Data collected over 96 treatment sessions conducted by 4 staff OTs in sensory room

-98% of the participants reported a positive change -10% reported no change -1% reported a negative change

-Contribution of the patient-staff relationship not addressed -Staff assistance provided to complete

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or restraint.

Massachusetts

sessions -Included exploration of sensory environment mindfulness & selfsoothing exercises, deep breathing, sensorimotor activities, & stretching. Snoezelen room -1 hour Snoezelen session provided by multidisciplinary staff in Snoezelen room. -Staff then rated the effectiveness of room after client usage. -Effectiveness of Snoezelen room on patients in 8 areas: -Relaxation/reduction in anxiety -Increased motivation for learning -Increased self-confidence -Improvement in rapport/ communication with carer -Leisure/enjoyment -Increased attention/ concentration -Decreased aggression -Decreased self-injurious behavior

in self-perceived levels of distress. -Restraint use decreased by 40%

client self-evaluations when clients not able to do so independently.

Kwok, To, & Sung (2003)

Examining the effectiveness of Snoezelen room use at reducing problem behaviors & increasing socialization & learning in patients with intellectual disabilities.

Level III Before-After design -96 patients in the Psychiatric Unit for Learning Disabilities at Kwai Chung Hospital

-55.2% increase in relaxation/reduction of anxiety -30.2% increase in motivation for learning 18.8% increase in selfconfidence -51.0% increase in improvement of rapport -62.5% increase in participation in leisure -51% increase in improved rapport -36.5% increase in attention/concentration -58.1% reduction in selfinjurious behaviors -21.4% reduction in aggression. -89% of patients reported decreased distress after comfort room use -No significant changes between experimental and control units in seclusion and restraint use with addition of comfort room -11 high-utilizer patients identified accounting for 14% of

Co-intervention was not avoided -Lack of masked evaluation -Rating form used not reliable or valid

Cummings, Assess the effectiveness Grandfield, & of a comfort room to Coldwell (2010) reduce seclusion and restraint use and to promote positive coping skills.

Level III Before & After Design N=105 -Patients in acute inpatient psychiatric unit at New Hampshire Hospital in Concord, NH.

Sensory room -Patients were able to enter the room 1 at a time after asking nursing staff to unlock the door. -Patients were able to leave the room independently when they were no longer feeling distressed. -Staff able to monitor

-Patients subjectively rated level of distress with 5point Likert scale before and after comfort room use. -Frequency and duration of seclusion and restraint use analyzed between experimental unit (before and after room implementation) and control unit during 9 month period.

-No standardized protocol in terms of time allowed for patients to be in comfort room.

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the room by video camera and enter the room if client displayed unsafe behavior. Lee, Cox, Whitecross, Williams, & Hollander (2010) Describe a pilot study on the use of sensory assessment & resources to reduce the use of seclusion. Level IV Case study design N=43 -Patients in a psychiatric unit at The Alfred Hospital in Melbourne, Australia Sensory cart -Dissemination of sensory resources in the form of sensory cart -Development of the Alfred Psychiatry Safety Tool (interview form) -Education for inpatient staff on the use of the Safety Tool & sensory resources. -Past seclusion rates compared to seclusion episodes occurring after the Safety Tool interview date -Staff feedback collected through anonymous survey.

seclusion hours and 56% of restraint hours -Comfort room not an effective intervention for high-utilizer patients. -65% of patients had been secluded in previous admission or in the current admission before completing the Safety Tool -Only 26% were secluded after completing the Safety Tool -Sensory resources were used by 81% of staff & were found to be somewhat useful in deescalating aggressive behaviors. Decrease in restraint use ranging from 20-97% on 4 units -Decrease in seclusion use ranging from 30-63% on 3/4 units -Decrease in hours spent in both seclusion or restraints -Only 2 moderate injuries but increase in minor injuries for both patients & staff. -Study was observational in nature rather than RCT -Pharmacological cointervention was not avoided -Multiple program variables that could impact effectiveness of sensory cart.

Lewis, Taylor, & Parks (2009)

Describe a crisis prevention management program at Henry Phipps Psychiatric Clinic at Johns Hopkins Hospital.

Level IV Case study design -All patients in 4 psychiatric units at Henry Phipps Psychiatric Clinic from 2004-2006.

Sensory cart Primary interventions: use of Phipps Aggression Screening tool, Personal Safety Plans, Daily Safety Focused Community Meetings, Milieu Rounds, increased staff education & visibility on units Secondary: Personal Safety Plan, Patient Support Sheet, Comfort Cart Tertiary: Witnessing Program

-Number of times seclusion or restraint use was initiated from 2004-2006 -Hours of seclusion or restraint use from 20042006 -Incidents of staff & patient injuries.

-Multiple program variables that could impact effectiveness of Comfort Cart

A SYSTEMATIC REVIEW Results The results were organized according to the sensory-based treatment used during the research study. The four categories included weighted blanket, sensory cart, sensory/comfort room, and Snoezelen room. The sensory/comfort room section included seven articles. Subcategories were created for this section that focused on outcomes. These subcategories included, levels of distress and S/R use decreased, levels of distress decreased but not S/R use, and tradition versus sensory interventions both equally effective. Weighted Blanket Of the 12 articles reviewed, only one article was a RCT. Mullen, Champagne,

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Krishnamurty, Dickson, and Gao, (2008) explored the safety and effectiveness of using weighted blankets to reduce levels of distress. The study specifically examined the use of a 30 pound blanket, the heaviest available blanket at the time. Anecdotal evidence supports the positive effects of the weighted blanket including, individuals feeling safe, grounded, and comforted; however, there is a lack of published research on the safety and effectiveness of the therapeutic use. Participants included non-hospitalized, medically stable, consenting adults who volunteered for participation. The participants were diverse; however, the majority of them were college students, which could be considered a bias favoring the treatment. There were quantitative measures for both the safety and effectiveness of the weighted blanket. Participants were divided into two-test sessions. Both groups received the treatment, but the order of the treatment was determined through random assignment and a cross over design. The study was conducted in a university were nursing resource rooms were set up to replicate an inpatient

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setting. This created a more controlled environment, allowing for future comparisons performed in an acute mental health hospital. The safety component included a quantitative measure of vital signs included, blood pressure, pulse oximetry, pulse rate, and SC. The results from all three vital sign measures indicated that the weighted blanket did not move participants into an unsafe physiological range. The purpose of the SC testing was to show there was a difference in the order of the treatment session. Both a z-test and a t-test were conducted; both resulting with an alpha of 0.05 indicating there was no significant difference in the order in which the blanket was applied. The qualitative measure included the STAI-10, which is a self-rated 10 question survey to measure anxiety, and an exit survey. The results indicated the blanket attributes to a larger decrease in anxiety ratings than without the blanket. The exit survey determined that participants showed a significant increase in relaxation with the blanket than without the blanket (Mullen, Champagne, Krishnamurty, Dickson, & Gao 2008) Snoezelen Rooms Snoezelen rooms were the focus of two of the reviewed articles. Both studies included adult participants with intellectual disabilities, as well as a variety of comorbid mental illnesses. Self-injurious behavior and aggression towards others were common problems for participants in both studies. The results of both studies indicated a significant reduction in self-injurious behaviors in clients, but not in aggression towards others. Kwok, To and Sung (2003) looked at the effectiveness of Snoezelen room sessions at increasing positive behaviors and reducing problematic behaviors in clients that displayed aggression or self-injury in the Psychiatric Unit for Learning Disabilities at Kwai Chung Hospital in Hong Kong. Clients participated in one hour Snoezelen room sessions provided by multidisciplinary staff members. Staff were asked to rate

A SYSTEMATIC REVIEW clients on targeted behaviors before and after Snoezelen room sessions. The most significant changes occurred in a 62% perceived increase in leisure, a 55% increase in relaxation, 55.2%

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increase in improved rapport/communication, and 58.1% decrease in the self-injurious behaviors of self-biting, skin picking, and head banging. There was a 21% decrease in aggression towards others after Snoezelen room usage, but the authors did not feel this was a significant change. Kwok et al. (2003) hypothesized that there may not have been a significant decrease in aggression towards others because it is a more complicated behavior that involves numerous psychological and environmental factors that cannot be easily alleviated by Snoezelen alone. However, bias may have been present due the lack of masked evaluation by staff. This factor may have impacted the results of the study (Kwok, To, & Sung, 2003). Sing et al. (2004) focused on the decrease of aggression towards others and self-injurious behaviors during Snoezelen rooms sessions, ADL skills training, and Vocational skills training in a residential facility for adults with developmental disabilities. All participants received all three conditions during different times throughout the day. Trained staff were assigned to observe participants and record occurrence and nonoccurrence of targets behaviors for one minute intervals during each treatment condition. Levels of behavior were also analyzed before and after Snoezelen room use to see if it had a proactive effect on behavior. The authors concluded that there was a significant difference in levels of before and after Snoezelen use for self-injury but not for aggression. However, there was a decrease in both aggression and self-injury during Snoezelen room sessions when compared to ADL skills training and Vocational skills training. The main limitation of this study was that the authors did not consider that aggression may have occurred as an escape based behavior to avoid work-related tasks in ADL and vocational skills training. No demands were placed on clients during Snoezelen room sessions and could have

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accounted for the decrease in self-injurious and aggressive incidents during those times (Sing et al., 2004). Sensory/Comfort Rooms Levels of Distress and S/R Use Decreased. Three of the studies reviewed resulted in the reduction of patient levels of distress and/or disruptive behaviors as well as reducing or eliminating the use of S/R by incorporating a sensory/comfort room into a psychiatric inpatient facility. Sivak (2012) examined the impact of comfort rooms on mental health patients and staff in Delaware. In this particular study the staff collaborated with the patients regarding the comfort rooms. The patients got to vote on items they wanted to include in the room such as, music, murals, and comfortable chairs. This increased patient pride and ownership of the rooms (Sivak, 2012). Clients used the rooms for up to 30 minutes when they first began to feel anxious or upset (Sivak, 2012). The clients levels of distress were self-rated on a Likert scale before and after the use of the comfort room. The staff rated the clients behavior by keeping track of CTCA, CTSA, and self-injurious behaviors before and four months after treatment was implemented. The results showed that since the implementation of the comfort room, S/R use was eliminated. The rate of incidences of CTCA and CTSA significantly decreased, however, self-injurious behaviors actually increased. The main limitation of the study is that there were different clients admitted and discharged throughout the eight months of study which could have affected the results (Sivak, 2012). Champagne & Sayer (2003) provided results on a quality improvement study at a community hospital in Massachusetts. In this study OTs created a sensory room and sensorybased treatment protocols, educated staff on room use, and created the assessment tool used to measure sensory room effectiveness. This was the only source of grey literature included due to

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the occupational therapy focus. The room contained bubble lamps, rocking chairs, and posters of nature scenes and a variety of other materials designed to promote relaxation. Four OTs alternated providing treatment sessions at different times inside the sensory room. Some of the treatment sessions included exploration of the sensory materials, mindfulness, deep breathing, and stretching. Patients rated their levels of distress before and after sensory room sessions. Results of this study indicated a significant decrease in self-perceived levels of distress after sensory room use. Also the number of restraint use decreased 40% during the year the study was conducted. The results of this study certainly indicate that the implementation of the room was successful. However, the results may be biased. After sensory room use, the therapists helped clients that had low Allen Cognitive Level scores fill out the self-assessment form. The therapists may have skewed the patients results to reflect more positive findings (Champagne & Sayer, 2003). Sutton, Wilson, Van Kessel, and Vanderpyl (2013), did a qualitative research studying to examine the potential of using sensory-based strategies to prevent or manage aggression in a mental health hospital in New Zealand. Semi-structured interviews of the staff and discharged patients were conducted in order to access acceptability, implementation, and impact of the intervention. The results were very positive toward the sensory-based treatment and three main themes emerged. In the first theme, facilitating a calm state, the agreement among most of the participants was that the sensory room reduced arousal and induced a calm state of mind. The patients discussed how they were able to think more clearly, regulate their emotions, control their environment, and control negative behaviors. In the second theme, enhancing interpersonal connection, the sensory intervention was perceived as developing meaningful connections with the staff and the patients. Both the patients and staff agreed that having staff members present in

A SYSTEMATIC REVIEW a soothing and supportive manner developed trust and rapport, and made patients feel safer. In

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the third theme, supporting self-management, it was discussed that staff were able to support the patients to increase self-awareness to their own triggers and sensitivities. This allowed patients to be more independent and develop their own strategies for self-management. The main limitation of this study is that only discharged patients were able to give interviews. This prevented getting an overall perspective of the treatment including patients whom may still be admitted. Levels of Distress Decrease with No S/R Reduction. There were three studies that found that the use of sensory/comfort rooms reduced the patients level of distress and/or disruptive behaviors, however, they did not reduce use of S/R. Chalmers, Harrison, Mollison, Molloy, and Gray (2012) reflected upon the effectiveness of the implementation of sensorybased approaches at Mercy Mental Health Psychiatric Unit in Australia. The study included two different units, one involving patients with more severe mental illness than the other unit. This was a multidisciplinary approach including psychiatric nurses and an occupational therapist. The staff had education and training regarding sensory modulation, sensory assessments, and sensory rooms. A sensory room was built in the unit with the less severe patients. It included items such as a massage chair, bean bags, music, a variety of lighting, self-help books, stress balls, a water feature, and a yoga ball. A log sheet was developed and completed each time the patient used the sensory room. The staff documented which sensory items the patient used while in the room and the patients report of his or her distress levels (on a scale of one to ten) pre and post entry of the room. The most common types of distress reported by patients were anxiety, restless, agitation, and distress. The reduction in these distresses rated by the patients before and after entry into the comfort room was statistically significant. The unit with the patients who were more severe participated in an engagement program, which is based off the Sensory Connection Program

A SYSTEMATIC REVIEW developed by Moore. It includes sensory strategies for stress reduction, coping, and self-

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regulation. In both units the patients were assessed using the Fremantle Acute Arousal Scale-12. It is a six point scale ranging from zero, meaning asleep or unconscious, to five, meaning highly aroused, violent towards self, and others. The clinicians rated clients behavior on the scale before and after the treatments. Patients in both units showed a statistically significant decrease on the scale. Although it was mentioned that there a recent development to turn one of the seclusion rooms in the unit with the more severe patients into a sensory, during the time of the study, there was not a documented reduction of S/R (Chalmers, Harrison, Mollison, Molloy, & Gray, 2012). There was limited information on the time spent in the sensory room; therefore, there was uncertainty of a standardized protocol. Novak, Scanlan, McCaul, MacDonald, and Clarke (2012), researched the effectiveness of the implementation a sensory room on distress and problematic behaviors that result in seclusion and/or aggression in a psychiatric hospital in Australia. The patient self-rated their levels of distress on a 10-point scale and clinicians rated behavioral disturbances before and after sensory room use. There was a significant decrease in both patient and clinician ratings. However, S/R use did not change significantly. The items that were most frequently used in the sensory room included the weighted blanket, music, reading, and rocking chair. However, the measures used to rate improvement were created for the study and not proven to reliable or valid which could have altered the results (Novak, Scanlan, McCaul, MacDonald, & Clarke, 2012). Cummings, Grandfield, and Coldwell (2010) found S/R rates did not decline after implementation of a comfort room in an acute inpatient facility in New Hampshire Hospital. Comfort room use was considered to be effective if patients did not progress to needing S/R after time in the comfort room and if their perceived levels of distress decreased. It was determined

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that 12% of the sensory room interventions were followed by S/R. Upon further examination of the data and a thorough chart review, 11 high S/R utilizer patients, a total of approximately 2% of the total hospital admissions, were identified. They accounted for 54% of restraint hours and 14% of seclusion hours. These patients were characterized as usually males with traumatic brain injuries, intellectual disabilities, severe psychosis, or personality disorders with assaultive tendencies. It was determined that sensory interventions were not appropriate for these patients and that alternative treatment options needed to be explored. However, 89% of patients that used the comfort room reported that it decreased their levels of distress. Traditional and Sensory Intervention Equally Effective. One article specifically looked at comparing a traditional intervention with a sensory room intervention. Knight, Adkison, and Kovack (2010), sought to determine if sensory interventions would be successful in reducing problematic behaviors in both general and geriatric neuropsychiatric patients in a hospital in Massachusetts. In addition, they also measured traditional interventions to find out if one was more effective than the other. Both groups included geriatric and general psychiatric patients, and were both groups were composed of different individuals. The traditional interventions included, alone or quiet time, increased supervision, one on one staff time, pacing, space restrictions, removal from situation, and room schedules. The sensory intervention included items such as, aromas, candy, kaleidoscopes, lava lamps, rocking chairs, calming sounds and music, weighted blanket, etc. A limitation within both groups included pharmacological co-intervention, which could have altered the results of the interventions. The BPRS was used by the nurses to rate the patients psychiatric symptoms on a seven-point scale from not present to extremely severe. The nurses assessed both intervention groups before and after treatment. The results indicated that both the traditional and sensory interventions had a

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significant difference in the pre and post BPRS scale, and of the 18 symptoms, the most managed were anxiety, tension, excitement, uncooperativeness, hostility, conceptual disorganization, and depression. Three additional significant changes were shown in the sensory group including: blunted affect, emotional withdrawal, and somatic concerns (Knight, Adkison, & Kovack 2010). Sensory Carts Sensory carts were the main sensory intervention discussed in two of the reviewed articles. Both studies were quality improvement studies that discussed the implementation of comprehensive S/R reduction programs that included primary and secondary intervention strategies. Lewis, Taylor, & Parks (2009) discussed in detail the implementation of the Crisis Prevention Management program at Henry Phipps Psychiatric Clinic at John Hopkins Hospital. The program included staff and client education opportunities, as well as culture change aspects such as increased staff visibility and daily patient meeting to discuss levels of safety and comfort on the unit. Assessment tools to identify early warning signs for aggressive behavior and client specific sensory coping strategies were also utilized. The sensory carts were made available to clients during times of distress in an attempt to prevent further escalation of problematic behaviors. Data was recorded from 2004 through 2006 on the incidents of seclusion and restraint. A significant decrease in the use of restraints on the four units was reported, as well as a decrease in the use seclusion on three of the four units. Sensory carts were a part of the Crisis Prevention Management Program; however, they were not the main focus of the program. Thus, it is difficult to ascertain whether this sensory intervention played a key role in the reduction of S/R usage at this facility (Lewis, Taylor & Parks, 2009).

A SYSTEMATIC REVIEW Lee, Cox, Whitecross, Williams, & Hollander (2010) described a pilot study aimed at reducing seclusion rates through the use of a sensory cart and a sensory assessment tool. The program was implemented on the acute psychiatric inpatient unit at Alfred Hospital in Melbourne, Australia. An assessment tool was created that identified patient stress triggers,

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calming sensory strategies, and seclusion history. This tool was used upon patient admission to the unit. Sensory resources were stored on the cart and made available to distressed patients by nursing staff. Seclusion rates were analyzed after implementation of the assessment tool. Results showed that 65% of patients had been previously secluded before completing the assessment, while only 26% had been secluded after completing the same tool. Staff feedback about the frequency of use and effectiveness of the sensory interventions was also gathered through anonymous questionnaires. Questionnaire results indicated that 81% of staff used some form of sensory resource with patients and most of the staff found them to be somewhat-moderately helpful in managing escalating patient behaviors. However, staff identified multiple barriers to sensory cart use such as time constraints, lack of education on how to appropriately use the materials with clients, and a lack of protocol on how to assess and store materials after use. Again, a limitation of this study was that the sensory cart was not the main focus of the program. It may be surmised that the sensory cart played a part in calming behaviors, therefore reducing the need for seclusion. However, due to other program variables like early identification of behavioral triggers it is impossible to make such a statement with absolute certainty (Lee, Cox, Whitecross, Williams, & Hollander, 2010).

A SYSTEMATIC REVIEW Discussion and Implication for Practice, Education, and Research Further Research

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It is clear that sensory strategies were effective in reducing patients levels of distress and in some instances did help to reduce S/R use. However, further research needs to be conducted on diagnoses specific sensory strategies that are effective. A patient with a history of anxiety or depression may appreciate calming music more than a client with borderline personality disorder and a history of self-mutilation (Knight et al, 2010). That client may benefit more from more sensory arousing activities like holding ice or sucking on sour candy (Knight et al, 2010). This also speaks to the benefit of individualizing sensory interventions based on client specific sensory needs. Further research should also be conducted to determine if certain multi-sensory environments are more beneficial. This is particularly true in the case of Snoezelen rooms versus sensory rooms. Snoezelen rooms are much more expensive to implement than sensory rooms. For the sake of cost-effectiveness in clinical settings this should be investigated in more detail. More studies should also be conducted by OTs to validate the need for occupational therapy in acute psychiatric facilities. More RCTs also need to be conducted on this topic to provide stronger, more reliable evidence related to sensory strategy use in psychiatry. Limitations A limitation of this systematic review was the inclusion of only one RCT that was not conducted on patients with mental illness. The majority of the studies included were of a weaker level of evidence. However, it is difficult to conduct RCTs in a clinical setting with this vulnerable population due to ethical issues. Also many of the studies included had various methodical issues such as, pharmacological co-intervention, small sample sizes, use of unreliable assessment measures, and a lack of blind evaluation. Additionally, over 50% of the included

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articles were focused exclusively on sensory/comfort rooms. It would be more advantageous to examine each multi-sensory environment separately and in more depth. In addition, available evidence was excluded if it was not written in English. Implications for Occupational Therapy Practice Out of the 12 articles reviewed only two included interventions being created or implemented by OTs. This is troubling given OTs background in conducting sensory assessments and individualizing treatment to meet client specific sensory needs. Knight et al. (2010) suggested that OTs run sensory intervention groups to introduce sensory tools to patients in a psychiatric setting. Patients could safely explore sensory tools and identify specific sensory strategies that would be beneficial during these groups (Knight et al., 2010). Cummings et al. (2010) identified staff training as an essential element to effective sensory based treatment. Lack of education related to sensory material use was a clinical barrier identified by staff in one study. OTs could play an integral role in the staff education process. Even if they were not a part of the facility staff, they could act as consultants to educate staff and even help create the multi-sensory environments to make sensory based treatments more effective. All of the studies reviewed used a different protocol for sensory based treatment. This was particularly true for the studies that focused on sensory rooms and Snoezelen rooms. There was no designated times that the clients were able to stay in the rooms. In one study patients were in the room for an hour, whereas in a different study patients were able to stay in the room until they felt sufficiently calm. Also, there was no standardization about whether the patients used the sensory resources alone or with staff members. Moreover, there was a lack of standardized assessments used to test the effectiveness of the multi-sensory environments in decreasing distress and problematic behaviors. A standardized protocol needs to be developed to

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make the practice of sensory resource use in psychiatric facilities more valid and reliable. Further research needs to be conducted in this area.

A SYSTEMATIC REVIEW References

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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. (2008). The seclusion and restraint reduction initiative. Retrieved from http://www.ot-innovations.com/content/view/44/1/ Champagne, T. (2011). Sensory modulation and environment: Essential elements of occupation. (3 rd ed.). Sydney, AUS: PsychCorp. 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), 3544. 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: 10.3928/02793695-20091204-03
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

Law, M., Stewart, D., Letts, L., Pollock, N., Bosch, J., & Westmoreland, M. (1998). Critical review formquantitative studies. Retrieved from https://bb-

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tun.touro.edu/bbcswebdav/pid-1778091-dt-content-rid-1387925_1/courses/OCCT-643---2013-AA-TUN-OT/Critical%20Review%20Form%20quantitative%20review.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 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

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/J004v24n01_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) 401-406. 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 Disabilities, 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

A SYSTEMATIC REVIEW Stefan, S., & Phil, M. (2002). Legal and regulatory aspects of seclusion and restraint in mental

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health settings. Networks, 3-4. Retrieved from http://www.nasmhpd.org/docs/publications/ archiveDocs/2002/SummerFall2002.pdf 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