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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Comfort Rooms

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A Preventative Tool Used to Reduce the Use of Restraint and
Seclusion in Facilities that Serve Individuals With Mental Illness

Ideas & Instructions for Implementation

February 2009

Megan MacDaniel
2008 Fellow on Women in Public Policy
Through the Center for Women in Government and Civil Society

Office of Quality Management
Jayne Van Bramer, Director

New York State Office of Mental Health
Michael F. Hogan, Commissioner

Please Note:
While this guide was prepared with child and adolescent treatment sites in mind, this information can be applied to adult and geriatric units as well. Many of these sites have successfully utilized comfort rooms.

Table of Contents

Acknowledgments

We extend our appreciation and gratitude to the Directors, Staff and Consumers at the sites below who provided valuable assistance in the development of this guidebook.

South Beach Psychiatric Center, Staten Island, NY
Hutchings Psychiatric Center, Syracuse, NY
St. Lawrence Psychiatric Center, Ogdensburg, NY
Greater Binghamton Health Center, Binghamton, NY
Woman’s Christian Association of Jamestown at WCA Hospital

We also acknowledge with appreciation the contributions of Paula T. Hennessy, Susan Callaghan, Walter Boppert and Elizabeth Chura in editing and producing this guide.

Introduction and Overview

Background:

The Positive Alternatives to Restraint and Seclusion (PARS) grant was awarded to the New York State Office of Mental Health in August of 2007. The grant provides three years of funding, from the Substance Abuse and Mental Health Services Administration (SAMHSA) through the Office of Mental Health, for the development of strategies to reduce the use of restraint and seclusion in three diverse mental health facilities serving children and adolescents in New York State.

The PARS project will promote efforts to create a therapeutic, trauma-informed culture of healing and recovery that meets the goals of significantly reducing the use of restraint and seclusion; providing mental health services that support recovery and incorporate trauma-informed care; and determining strategies that assist organizations in establishing comprehensive, positive, system-wide alternatives to restraint and seclusion. Part of the strategy towards implementing these changes is providing funding for the development of comfort rooms and calming environments.

This information on calming and comfort rooms was compiled through an extensive literature review, visits to calming and comfort rooms across New York State, attendance at conferences, and interviews with experts in the field. The resulting information has been compiled in this binder for use by the grant recipient sites, as well as other interested facilities, to guide an informed process for the development of calming and comfort rooms.

The purpose of this binder:

This binder provides information to service providers that are interested in developing comfort rooms and calming spaces. It has been compiled to assist in the planning and implementation process.

As you will quickly come to realize, the development of a comfort room (i.e., deciding where to put the room, what to put in it, and developing policies and procedures around its use, etc.) requires an agency wide commitment and an agency specific plan. The location and content of your room and how it will be used should be determined based on the individuals you serve and the resources you have. Learning more about comfort rooms and reflecting on your own population and environment will help you to develop a successful plan.

The information included in this binder should help to get you started; references have been included to help initiate your research if you find it necessary to gather more information. The information has been presented in a three-ring binder so that you can add articles, ideas, sketches, and notes. This binder is meant to stimulate creative thinking. Please do not hesitate to share your ideas with others.

Contents:

Section I provides an overview of what comfort rooms are and how they are used. Part II includes written interviews that were conducted with facilities that have comfort, multi-sensory, and Snoezelen® rooms. Interviewees provided information about the processes their sites used in developing the room. They offered suggestions to take into consideration when beginning the process of developing a calming space. Informative, quick, and easy to read articles have been included in Part III to provide further explanation and background information on comfort, multi-sensory, and Snoezelen® rooms.

Section II can be used to help stimulate creative thinking about what items you might want to consider including in your comfort room. Images, lists and suggestions for the use of specific items have been included. Items have been categorized by the sense (touch, sight, sound, scent) they stimulate. As you browse through these items, begin to think about what you would like to include in your comfort room.

In Section III the process of developing your comfort room is discussed. The first document provides a list of questions to consider as you begin to develop your room. The second is a document developed by Tina Champagne, which can be found in the Sensory Modulation and Environment handbook, and can be used to consider what type of environmental changes you will make in your facility in order to create a more calming and comforting atmosphere. The second part of Section III provides examples of policies that have been developed by facilities in New York State that use comfort, multi-sensory, and Snoezelen® rooms.

Section IV discusses evaluation plans. Participating facilities in the PARS grant initiative will receive funding for the planning, development and evaluation of a comfort room at each of the three sites. This will provide an opportunity to contribute to the field of knowledge about the use of comfort rooms by collecting information at each site. Through the use of evaluation we can document the process of developing policy and shaping opinions about use of the room. This information can then be used by other facilities to develop comfort rooms in the future. Additionally, plans are being made to collect data to show the correlation between use of the comfort room and episodes of restraint and seclusion. It is anticipated that an increase in the use of the comfort room will correlate with a decrease in the use of restraint and seclusion.

Section V includes several additional resources and a copy of the Power Point presentation that can be used to introduce comfort rooms to facilities beginning the implementation process. The Power Point slides are followed by information gathered from articles read. It can be used as a quick reference handout. Additional references have also been included.

We hope this guide will be helpful to facilities by sparking enthusiasm for creating comfort rooms. There is no "right or wrong" way to design a comfort room. The process will be agency specific The only underlying rule for creating a comfort room is that it should be designed in a way that is safe and effective for the individuals using it.

Best of Luck!

Please feel free to contact Paula Hennessy, PARS Project Coordinator, with feedback, suggestions, or any questions you might have.
Phone: (518) 474-0884

This manual was compiled and produced by:
Megan MacDaniel
2008 Fellow on Women in Public Policy, through the Center for Women in Government and Civil Society
January-June 2008

New York State Office of Mental Health, Office of Quality Management
Jayne Van Bramer, Director

Section I What is a Comfort Room?

A comfort room is a designated space that is designed in a way that is calming to the senses and where the user can experience visual, auditory, olfactory, and tactile stimuli. A comfort room is furnished with items that are physically comfortable and pleasing to the senses in order to provide a sanctuary from stress.

A comfort room is used as a tool to teach individuals calming techniques in order to decrease agitation and aggressive behavior. The goal in using the comfort room is to develop practical skills that can be used in inpatient settings and after being discharged from care.

South Beach Psychiatric Center, Staten Island
South Beach Psychiatric Center, Staten Island

A Comfort Room Is:

A Comfort Room is Not:

Where is the Best Location for a Comfort Room?

Comfort rooms are often developed in available spaces, such as a room that had previously been used for seclusion or in an unoccupied bedroom.

It is important that the room is located in an area of the facility that is easily accessible to those who will be using it. Often times the comfort room is located near the nurses’ station to afford increased supervision. Some comfort rooms are adjacent to the nurses’ station and connected with a window to allow for supervision.

Sometimes, facilities do not have extra space for a comfort room. They might then develop "comfort kits" and/or "comfort carts" that incorporate similar calming items, but are mobile. These comfort alternatives can also be utilized in addition to your comfort room.

Hutchings Psychiatric Center
Hutchings Psychiatric Center, Syracuse, New York

How are items chosen for the comfort room?

Individuals who will be using the comfort space and the staff assisting them should participate in planning the room and selecting the items that will be placed in the room. This encourages ownership and ensures that the room meets the needs of the facility’s population. Rooms developed without the participation of staff and consumers often go unused.

Calming techniques and strategies from patients’ individual calming plans should also be taken into consideration when developing the comfort room.

The type of supervision required for those using the comfort room depends on what type of equipment is in the room. For example, a room filled with specialized equipment may often only be used under the supervision of trained facilitators. Selection of advanced, specialized equipment necessitates that adequate training and staff resources be devoted to comfort room use.

Encouraging direct care staff and residents to use the comfort room:

Approval and support from upper management is important for securing funding and adequate resources for implementation of comfort rooms. It is also important that direct care staff, supervisors and users receive training on the benefits of the comfort room. If direct care staff and residents do not believe in the benefits of using the comfort room, it will not be used. The following information about the use of comfort rooms should be discussed with direct care staff and users:

Benefits of using comfort rooms:

Suggestions for gaining the support of direct care staff and comfort room users:

Incorporate use of the comfort room and equipment into individual calming plans.

Create a schedule that allows for the room to be accessed 24/7 (whenever it is needed).

Carry out as many activities as possible in the comfort room (i.e. new patient orientation, one-on-one sessions with psychiatrist and social worker, self-awareness activities, etc.).

Include users and staff as part of the steering committee when developing the room.

Make information available that highlights positive outcomes associated with use of comfort rooms.

Incorporate knowledge and practices into staff orientation and ongoing training.

Develop policies that support the use of comfort rooms.

Reinforce why, when, how comfort rooms are used.

Interviews with facilities in New York State that use comfort rooms:

The following section includes interviews with individuals who successfully championed the development of a comfort room in their facility. The interviews were conducted at five facilities across New York State. These facilities serve children and adolescents and have a comfort room, multi-sensory room, or Snoezelen® room on site. The interviews share experiences and insights that will assist others in creating their own comfort spaces. Their stories highlight the positive outcomes they have seen. Illustrations and a brief description of each room are included, along with an overview of other initiatives the facilities have adopted to reduce the use of restraint and seclusion.

Interviewees have generously agreed to share their contact information. Please do not hesitate to take advantage of this valuable resource. They are willing to answer questions via phone or email and might even be willing to host visitors for a tour of their comfort room. This is an invaluable opportunity for gathering first hand information.

The excitement and enthusiasm that is produced during discussions about the use of the comfort room is contagious. Staff members, as well as the youth that use the rooms, recognize positive changes in behavior and have data to support their belief that use of comfort rooms helps to reduce restraint and seclusion in facilities that serve youth with mental illness.

Contact Information:

South Beach Psychiatric Center
Staten Island, NY
Bill Langford, Treatment Team Leader (Adolescent Unit)
Phone Number: (718) 667-2585

Hutching Psychiatric Center
Syracuse, NY
Annette Sierak, Occupational Therapist

St. Lawrence Psychiatric Center
Ogdensburg, NY
Joette Holgado, Director of Quality Management
Phone Number: (315) 541-2202
Carol Brew, Child and Youth Chief of Services
Phone Number: (315) 541-2590
Ashleigh King, Occupational Therapy Assistant
Phone Number: (315) 541-2533

Greater Binghamton Health Center
Binghamton, NY
Karen Witbeck, Treatment Team Leader
Phone Number: (607) 773-4044
Barbara Vartanian, Supervisor of Rehabilitation Services
Phone: (607) 773-4262

Interviews not included but feel free to contact:

Woman's Christian Association of Jamestown at WCA Hospital
Trish Mclennan, Counselor III
Phone Number: (716) 664-8687
Mary ann Wilcox, RN, MSN , Nurse Manager
Phone Number: (716) 664-8658

South Beach Psychiatric Center
Staten Island, NY

Comfort Room Visit with Bill Langford and Diane Disavow
March 19, 2008

comfort room at South Beach comfort room at South Beach
Comfort room at South Beach

The comfort room at South Beach was created to look like a bedroom that could be found at home or in a typical college dorm. This facility purposely did not use state issued furniture in order to create a space that felt separate from the youths’ typical living space in the facility. This room has been in use for two years and has suffered no significant damage.

South Beach Psychiatric Center (SBPC) was one of the first facilities in New York State to implement a comfort room. It has been operational since the Spring of 2006. Although the facility has included other creative initiatives to reduce the use of restraint and seclusion, South Beach claims that their successful reduction program has been most influenced by the use of their comfort room.

Over the course of six months, SBPC saw a 66% reduction in the use of restraint and seclusion. Restraint and seclusion rates had been unusually high the previous quarter due to the aggressive activity of a high risk child. This child had been in acute care where she required multiple 4-point restraints daily. When she came to the facility she often lost the ability to control her behavior, necessitating locked seclusion multiple times a day. Over the course of several months and through the use of the comfort room, she was able to learn the skills necessary to recognize when she was beginning to feel agitated and aggressive. Developing increased self-awareness provided her with the skills to calm and control her behavior on her own while the facility provided her with the tools to do so. Before leaving care, she was able to go from being restrained and secluded several times a day to going four months without a single episode of restraint or seclusion. After seven months of treatment, she was discharged from South Beach and had developed the skills necessary to allow her to become a less frequent consumer of care.

The following interview with Bill Langford, Treatment Team Leader, and Diane Disavow, Chief of Child and Youth Services, highlights the importance of gaining the support of upper management, direct care staff, and the youth served. They emphasize the importance of allowing for a slow implementation process, and explain the importance of being willing to learn from what isn’t working and to then make the appropriate changes.

Population: Children and youth Ages 12-18 with a wide range of disorders

Size of the facility: 10 bed unit with an average length of stay is 116 days

Client to staff ratio: 2:1

How long have you had the comfort room? 2 years

How much did you budget for the comfort room? $3,000 - $3,500. They were very "cost­conscious" when choosing items for the room including:

What kind of planning did you do? The idea of implementing a comfort room was presented at a facility meeting, encouraged by the leadership and OMH Central Office. Bill Langford was the champion for the comfort room and was able to elicit support from direct care staff and youth by sharing information and getting them involved. With the support of upper management, supervisors, direct care staff and residents, they were able to transform one of their two seclusion rooms into a comfort room. Most importantly, they allowed implementation to be an incremental process to gain staff support and to ensure that staff "owned the project".

Based on what you went through, do you have any suggestions for facilities trying to implement comfort rooms?

Suggestion #1: Allow for a slow implementation process

Suggestion #2: Emphasize need for upper management support

Suggestion #3: Be open to learn from what isn’t working and be willing to make changes

Suggestion #4: Emphasize that it is a room for the youth, not for the staff to use whenever they want.

Suggestion #5: Don’t get hung up on "What if’s"

Suggestion #6: Operate under the assumption that, "The more you give to kids the more you get back from them."

Description of the comfort room:

Youth have also created comfort boxes to keep in their rooms. These are shoe boxes that are decorated as a group activity and then filled with items to promote self-soothing behavior. Youth choose what they want to keep in their comfort box. Items might include a family photograph, a stress ball, or CD. These boxes can be taken home with them when they are discharged from care or visiting their family for the weekend.

The room is used as a place for youth to emotionally regulate, which in turn reduces episodes of restraint and seclusion. For youth, the room has become associated with calm (brain patterns are changed and child’s auto-response is to become calm when using the room).

Items the youth use most? Computer, music

How did you decide what to put in the room? Bill presented magazines and ideas, but ultimately youth and staff picked items out. They purposely put non-state furniture into the room– to make it feel like an escape or a setting you would see in a home or college dorm .

Conditions of use:

Can a child use the room when ever they choose? Yes, however when they are in group or at school they are expected to stay, but they are welcome to use the room if need be during those times.

How many residents can be in the room at a time? 1 (several if staff provide supervision)

Does the room stay unlocked? No, the room is locked and is opened by staff member when youth requests use of the room.

Can youth use room unsupervised? Yes, most of the time

The comfort room is also used for:

Suggestion: "Find ways to use the room as much as possible".

What kind of results have you seen based on use of the comfort room? Over six months SBPC saw a 66% decrease in R/S (had been high the previous quarter due to a high risk individual)

Individual Success Story:
Girl, who had previously been in and out of care, came into the facility needing to be R/S multiple times a day. An individualized treatment plan was developed including use of the comfort room, and three months later she gained control of her behavior. Eventually she went four months without R/S and was discharged from care.

Besides the comfort room, what additional efforts has the facility made to reduce the use of restraint and seclusion? South Beach Psychiatric Center uses a combination of DBT and PEM .

The facility looks at trends in episodes of restraint and seclusion, noting when rates are lowest and highest and evaluating why those trends exist. In response, programs have been implemented.

For example, rates appear lowest on days when youth go to the PEM "rewards store", so an additional rewards day was added on a day of the week when R/S rates were highest.

Rates are highest on the weekends so SBPC created additional programming:

St. Lawrence Psychiatric Center
Ogdensburg, NY

Comfort Room Visit with Joette Holgado, Director of Quality Management Peggy Roddy, Adult Services OT & Champion of the Adult Comfort Room Carol Brew, Child and Youth Chief of Services Ashleigh King, Champion of the C/Y Comfort Room
March 5, 2008

St. Lawrence Psychiatric Center comfort room St. Lawrence Psychiatric Center comfort room
This side rocker was made as a gift by adult in-patients for the comfort room on the children’s unit.

Population: Acute care for child and adolescents, average length of stay: 21 days

Size of facility: There are three separate halls: one for children (with an average of 8 living on the hall at a time), one for female adolescents (average of 10 at a time), and one for male adolescents (average 10)

Client to staff ratio: On average the client to staff ratio is 2.5:1 for day and evening shifts

How long have you had the comfort room? About a year

How much did you budget for the comfort room? On average, each room cost about $1,000 with a total of three rooms (one on each hall).

What kind of planning did you do?

With the support of Joette Holgado and Carol Brew, Ashleigh King, Occupational Therapy Assistant, was the champion for implementation of the comfort room. She worked with Peg Roddy in researching the process of developing a comfort room, got the youth who would be using the room involved (by having them vote on themes, pick items, and help paint the walls), and made pillows and other items for the rooms. She persevered and made sure that the comfort room was implemented.

Based on what you experienced, do you have any suggestions for facilities trying to implement comfort rooms?

Suggestion #1: To make sure that your comfort room does not go unused

Suggestion #2: Decorating

Description of the comfort room:

Young children’s room:

Adolescent girls’ room:

Adolescent boys’ room:

Items used most?

Do you use any assessment tools? St. Lawrence Psychiatric Center keeps a "Comfort Room Log Sheet" to track which individuals use the room and for how long. This information is used to compare frequency of use of the comfort room to the number of episodes of restraint and seclusion. Data collected has shown a correlation between increased use of the comfort room and decreased use of restraint.

A feedback form is kept in the comfort room for youth to fill out after use. It lists what they liked and didn’t like about the room and what changes could be made to make the room more effective.

(See Section IV, "Evaluation", for a copy of St. Lawrence Psychiatric Center’s assessment tools)

Conditions of use:

(See Section III for a copy of St. Lawrence’s policy for use of the comfort room)

What kind of results have you seen? As a result of the use of the comfort room, St. Lawrence Psychiatric Center has seen a decreased use of restraint and seclusion, as backed by the data they have been collecting.

Youth are able to the use self-soothing skills when discharged home. Youth develop a "comfort kit" to use while in the comfort room and take with them when they leave care. They also use the comfort room as part of the DBT program.

(See Section II for more information on developing comfort kits.)

Besides the comfort room, what additional efforts has the facility made to reduce the use of restraint and seclusion?

Hutchings Psychiatric Center
Syracuse, NY

Comfort Room Visit with Annette Sierak
March 4, 2008

"The Peaceful Place"

Hutchings Psychiatric Center Multi-Sensory Room Hutchings Psychiatric Center Multi-Sensory Room
Multi-Sensory Room

Population: Acute care children and adolescents, ages 5-12- average length of stay is several months

Size of facility: 11 bed unit How many youth? Hutchings serves on average 11 youth

Client to staff ratio? Varies, some require 1:1, but in general there is a 3:1 ratio

How long have you had the comfort room? The comfort room became operational in the summer of 2007.

How much did you budget for the comfort room? $8,000 Items for the room were selected under the guidance of the facility’s occupational therapist, Annette Sierak. "The Peaceful Place" is a multi-sensory room, rather than a comfort room. Items were chosen that could be used by youth with little guidance. They provide youth with an opportunity to practice self-directed behavior.

What kind of planning did you do? The idea of implementing a comfort/multi-sensory room was initially proposed before the current OT was on staff, and funds were denied. The motivation to give the proposal a second try was sparked after staff (including the COO and CYS-TTL ) attended a conference. At the conference a speaker presented on the benefits of implementing a comfort room in teaching individuals self-soothing techniques. All were responsive and motivated, so Hutchings’ Occupational Therapist, Annette Sierak, took this as an opportunity to re-propose the plan. She pulled information together and, using data from the first time the idea was proposed, she compiled a new equipment list and attached supporting articles. This was re-presented and approval for the purchase was granted by the CEO/Executive Committee. As an occupational therapist, Annette Sierak used her knowledge of multi-sensory integration to choose what items to put in the room in order to create an environment that would provide youth with an opportunity to practice self-directed behavior and practice self-soothing skills.

Based on what you went through, do you have any suggestions for facilities in the beginning stages of implementing a comfort room?

Suggestion #1: Annette suggests contacting an occupational therapist to help decide what items to choose.

Description of the comfort room:

The Peaceful Place is located in a room next to the cafeteria, not on the halls where youth sleep. Individuals use the comfort room by appointment with the occupational therapist and trained staff members. In addition to the multi-sensory room, there is a small, square-carpeted room on one of the resident halls, known as the "quiet room". Each has a small and large weighted blanket and a ball blanket in it for comfort.

Items the youth use most? Bubble tube, CD player, cloud chair, ball blanket, weighted blanket, kid garage, aromatherapy (rub on arms before bed), chewy tubes, color morph molecule ball, slinky pop tubes, Simon Says game, and Roundabout.

Do you use any assessment tools? Some of the children are evaluated by the occupational therapist using a "Sensory Profile" developed by Dr. Winnie Dunn (published by the Psychological Corporation, 1999). This information is then used when interacting with youth in The Peaceful Place. It is not required. A brief safety assessment is necessary to avoid the potential for property destruction, to preserve the room over time. Typically, a child who has been unable to remain calm or been unable to use the room to calm before a "crisis", or has PEM related "frownies", is required to earn back "smilies" before entering the room. One child is allowed in the room at a time.

Annette Sierak is also in the process of developing an evaluation plan as part of a Performance Improvement Project on CYS. The PI Project aims to have all CYS staff trained in the use of the room, and to adopt a way to measure the impact of room use on the staff. Information on perceived levels of agitation, near misses, and number of restraints, will also be collected and used to establish room routines.

Conditions of use:

Initially the Peaceful Place stayed locked and was only used under the supervision of the facility’s occupational therapist. Youth were and are scheduled to meet with the therapist for 15-20 minute intervals, one at a time, one after another. When an individual seems to be nearing a state of distress they are given precedence. The occupational therapist trains all direct care staff on how to use the room. The occupational therapist first demonstrates to the staff how to use the equipment and then they must each perform an accurate "teach back".

Written Policy: The policy that guides use of the Peaceful Place was developed by Annette Sierak.

What kind of results have you seen? Initially the room was only used under the supervision of the OT , but as staff began to see positive results associated with use of the multi-sensory room, floor and clinical staff asked that certain youth be taken into the room more often. Now, most of the regular day staff have been trained and have access to the room. They are using the room at their liberty while the OT still uses the room two evenings per week.

Individual Success Story:

A seven year-old child with Conduct Disorder, PDD , and an average IQ uses the multi-sensory room as part of his regularly scheduled behavioral management program. He is directed towards objects in the room that facilitate fine-motor skill development, an area of delay that is addressed by his OT in treatments as well. Due to the calming effects of the room, he is able to learn these skills without getting frustrated and, as a result, his episodes of restraint have also decreased due in part to the use of the room.

Besides the comfort room, what additional efforts has the facility made to reduce the use of restraint and seclusion? Hutchings implemented a "restraint reduction strategic plan" last year. In response to the frequency of restraints on the children’s unit, the focus of this strategic plan is to reduce restraint. This implementation group had its first meeting in Spring , 2008. There has been ongoing training throughout the campus on client centered care. On the children’s unit there are weekly unit community meetings where the child and adolescent population provides feedback about programming. The adult units have set up a "world cafe" forum that is now being used to inform and direct programming changes.

Greater Binghamton Health Center
Binghamton, NY

Snoezelen® Room visit with Karen Witbeck, Treatment Team Leader, CSE Chair, February 29th, 2008
with Barbara Vartanian, Supervisor of Rehabilitation Services, May 27, 2008

Snoezelen® Room
Snoezelen® Room

Population: Children and adolescents, ages: 5-17; Primarily mood disorders (90% +/-), sensory integration D/O, conduct D/O, aggression, anxiety, mood, bi-polar, high risk, self-injurious behavior, PDD ; average length of stay is 30 days (+/-)

Client to staff ratio: In the Snoezelen® Room, 1:1

How long have you had the Snoezelen® room? The Snoezelen® room in the Child and Adolescent Unit has been in use since December 2006. The Child and Adolescent unit is a new service provided by Greater Binghamton Health Center that opened in August of 2006. The Snoezelen® Room was built into the new facility. Initial training was provided to staff in September of 2006 by Linda Messbauer, who is one of the leading experts in creating multi-sensory environments, with over 30 years of experience (http://www.lmessbauer.com/index.php Leaving OMH site ), on how to use the equipment and the room. However, technical difficulties with the installation of equipment delayed the use of the Snoezelen® room until December of 2006. Staff training with Linda was repeated again in the spring of 2007 and has been carried out several times since.

How much did you budget for the Snoezelen® room? Due the specialized Snoezelen® brand equipment that has been selected for use in this room the budget was high. Barbara Vartanian feels that some of the equipment used could have been purchased at a lower cost (such as the "squishy balls", disco ball, bean bag chairs, etc.), while some items needed to be bought through the Snoezelen® vendor (ball pit, bubble tube, etc.).

What kind of planning did you do? Greater Binghamton Health Center began by researching recreational therapy equipment. Eventually, one staff member suggested they look into using Snoezelen® brand equipment for anxiety reduction and relaxation, and it seemed a perfect fit.

Barbara Vartanian became the champion for the Snoezelen® Room, eliciting support from Karen Witbeck, treatment team leader, and Margaret Dugan, Executive Director. After gaining their support, Barbara was able to contact Linda Messbauer. Linda helped with the selection of items for the room and explained which items work best for specific populations. Barbara found Linda’s guidance to be particularly helpful.

The first year was one of trial and error, ultimately resulting in great success. Over the course of the year, staff members learned how to use the specialized equipment in a way that would be most effective for the youth in care, and developed an evaluation plan for collecting data on use of the room.

The room is currently used 4 to 5 times a day resulting in significant improvement in the behavior of the children. Use of the room helps youth with self-regulation, increased awareness of the environment and how it affects their behavior, and promotes decreased anxiety and anger.

Based on what you went through, do you have any suggestions for facilities trying to implement comfort/Snoezelen® rooms?

Suggestion #1: Barbara would suggest contacting a consultant with expertise in multi-sensory environments and would highly recommend eliciting the services of:

Linda Messbauer
http://www.lmessbauer.com/index.php Leaving OMH site
(718) 776-3015).

Suggestion #2: Participate in continued education; attend conferences, contact and interact with experts in the field, research, get involved with organizations that promote multi-sensory environments

Such experts and organizations include (as suggested by Barbara Vartanian):

Linda Messbauer
http://www.lmessbauer.com/index.php Leaving OMH site
(718) 776-3015

American Association of Multi-Sensory Environments
http://www.aamse.us/ Leaving OMH site

The Hidden Angel Foundation
http://www.cdhaf.org/ Leaving OMH site

Suggestions #3: Evaluate! Share what you have learned. Collecting data on the use of the room is a way to determine the effectiveness of the room and to gain insight on what is working and what improvements could be made.

Feel free to contact Barbara Vartanian as a resource:
Phone: (607) 773-4262)

Description of the Snoezelen® Room:

Items the youth use most? The padded ball pit (sit in the ball pit while the pit vibrates with the music that is being played through the sound system)

The large bean bag (sit on the bed sized bean bag chair with the weighted blanket on their lap, next to the bubble tube or viewing images projected onto the wall, as the chair vibrates with the bass of the music)

The bubble tube (provides visual stimulation, as well as an opportunity to practice self-directed behavior since youth can control the color of light that is projected though the tube)

Music (youth can select which CD to listen to, from calming instrumentals to alternating tribal drum beats)

Do you use any assessment tools? Greater Binghamton Health Center uses two different assessment tools to evaluate use of the room. One of the tools, a "Multi-Sensory Data Collection Sheet", is used to collect quantitative data on when the room is used and what items the individual used while in the room. The other assessment tool is used to determine if use of the Snoezelen® Room is effective in changing mood.

(See Section IV, "Evaluation", for a copy of Greater Binghamton Health Center’s assessment tools)

Conditions of use:

The Snoezelen® Room is used by youth under supervision. They have scheduled sessions to use the room, but can also use it by request.

What kind of results have you seen? Do you have data to back it up? Greater Binghamton Health Center recognizes the importance of collecting data in order to prove the effectiveness of the use of their Snoezelen® room. The Center has developed and adapted evaluation tools and has found a statistically significant difference in anger levels before and after use of the Snoezelen® room. They have also been able to illustrate a strong correlation between use of the room and a decrease in the number of episodes of restraint. (See Section IV, "Evaluation")

bar graph

To the left is a bar graph comparing the frequency of Snoezelen® Room use and episodes of restraint over a fifteen month period. As use of the Snoezelen® room increased there was a sharp decrease in use of restraints. In March of 2008, GBHC went restraint free.

References

Articles of Interest:

Articles on comfort rooms by Gayle Bluebird:
https://www.cwla.org/programs/groupcare/rgcqspring2005.pdf and http://download.ncadi.samhsa.gov/ken/pdf/SMA06-4055/Manual_Module5.pdf

Articles on Multi-Sensory Rooms by Tina Champagne:
Sensory Modulation & Environment: Essential Elements of Occupation, Handbook & Reference, 3rd Edition. This book can purchased from: http://www.ot-innovations.com/index.php?option=com_ezstore&Itemid=28&func=viewcategory&catid=1 Leaving OMH site

The article on Snoezelen® Rooms, "History of Snoezelen®" http://www.peicod.pe.ca/sno-history.htm Leaving OMH site

For further information search the following websites: Coping, Calming, Comfort Room (CCC): For Adults in Mental Health Settings (Sensory Room) by Sensory Connection Program, from: www.sensoryconnectionprogram.com Leaving OMH site

Coping, Calming and Comfort Room Development: Ideas for Creating and Furnishing a Sensory Room by Sensory Connection Program, from: www.sensoryconnectionprogram.com Leaving OMH site

Building Bridges to Function in the Community by Sensory Connection Program, from: www.sensoryconnectionprogram.com Leaving OMH site

Pictures, Stories, and Studies on Coping, Calming, and Comfort Rooms from a Variety of Mental Health Settings Sharing Ideas on Sensory Rooms by Sensory Connection Program, from: www.sensoryconnectionprogram.com Leaving OMH site

History of the Snoezelen® Room from: http://www.peicod.pe.ca/sno-history.htm Leaving OMH site

The effects of the use of the sensory room in psychiatry by Tina Champagne, M.Ed. , OTR/L from: http://www.ot-innovations.com/images/stories/PDF_Files/qi_study_sensory_room.pdf Leaving OMH site  (PDF)

For general information on Multi-Sensory Rooms: http://www.ot-innovations.com/content/view/49/46/ Leaving OMH site http://www.sensoryconnectionprogram.com/index.php Leaving OMH site

Section II Brain-Storming Items for Your Comfort Room

Section II is meant to stimulate thinking as you begin to consider what items to put in your room. The first part contains images of items that have been used in comfort rooms in the past. The images are accompanied by commentary on how certain items can be used. The images are followed by a list of items. Both the images and lists are broken down by the senses (touch, sight, sound, scent, taste) that each object is meant to stimulate or calm.

Is it the items you choose that determine your policy or the policy that determines the type of items you choose? Materials for the room and policy development go hand-in-hand, one influencing and building upon the other. It is important to keep in mind that the decisions you make (about what type of room you will create, what items you plan to put in the room, and the development of policy around room usage) should all be made with the best interest of the user in mind. The decisions should be specific to the population you care for. Also, when choosing specialized equipment it is best to consult with an occupational therapist or expert in the field.

As a suggestion, look though Section II to get some ideas about possible items. Be sure to get users involved with this process. The lists in this binder are by no means complete. Add to the lists or create new lists. Include materials that stimulate the senses in a way that is calming and encourages self-directed behavior. Choose items that are safe to use.

In order to make the right choices, try brainstorming with staff, users and parents about what the comfort room will look like, items to be included and activities that will take place in the room. Make a sketch of the room. Cut out images from magazines that you want to see as part of the room.

Photographs provided by Flaghouse at http://www.flaghouse.com/bring_AL.asp Leaving OMH site

Visual Stimulation

Visual Stimulation

Use black lights, different colored lighting, and various tinted sunglasses to provide visual stimulation that can impact mood and behavior.

The Bubble Tube is a Snoezelen® brand product that is very common in multi-sensory rooms. The color control pad provides youth with an opportunity to control their environment as they select the color of bubbles.

To maintain a safe environment, items with long cords can be placed behind Plexi glass on a shelf. Consult your maintenance staff.

If you are thinking about including a fish tank you must be sure to find someone who will volunteer to maintain it.

Sleeping masks can be used to block out all visual stimulation, if that is what the individual prefers.

Soft, alternative lighting is suggested to replace harsh florescent lights that are typical of institutionalized settings. Florescent lights can be covered. A dimmer switch provides a variety of lighting effects.

Ideas for the Walls

Ideas for the Walls

Wall decals and safety mirrors are a quick and easy way to provide visual stimulation.

Life size posters or murals can be added, Youth should be involved with selecting themes and images.

Installation of a white board gives staff and youth a space to record items borrowed from the room, to take notes during group activities, and provide a large space for drawing. As an alternative, chalkboard paint can be applied to the walls and used for the same purpose.

Cover overhead florescent lights with calming clouds or other pictures.

Please be advised that flashing lights and projected images may result in confusion and disorientation for some individuals with acute mental illness. Adjust use of these items accordingly.

Sound

sound

It is important to consider what types of music to allow in your comfort room. While selection can provide an opportunity to practice self-directed behavior, the choices should be calming and not promote aggression.

Seating products are available (i.e. Snoezelen® Cloud Chair or Ball Pit; see "seating" page) with the technology to incorporate a sound system. Once connected, the seat vibrates in sync with the music that is playing. Adding a weighted blanket or lap pad creates a soothing experience.

Drums and other musical instruments are used for self expression. The facilitator plays a rhythm, which youth must carefully listen to and play it back. A drumming group is a good way for youth to practice their listening skills together.

Suggestion: See if you have a staff member who has the ability to teach musical instruments. Think creatively about your resources and use them!

Sound machines provide options for nature sounds as well as white noise, which can be used to drown out other sounds.

The rhythmic sound and feel of passing a slinky back and forth between your hands can be soothing.

Scent

scent

Various essential oils can be used in an oil diffuser. Scents elicit different reactions. For example:

Warning: Aromas and scents can act as triggers for traumatic memories. If an individual is having an adverse reaction to an olfactory item, be sure to remove it immediately. Consult with an individual certified in aroma therapy.

Scented lotion can be used for a soothing hand or foot self-massage. Bring volunteer students in from local massage schools to run a session on self-soothing techniques or therapeutic touch.

Put a dab of scented oil on an individual’s wrist before bedtime to promote relaxation and sleep.

A scented room can create a multi-sensory, therapeutic environment.

"Follow Your Nose" is an aroma-therapeutic game that can be found where Snoezelen® brand items are sold.

touch

Touch

Fiber optic lighting is not only aesthetically pleasing, but provides individuals with a new form of tactile stimulation.

The Multi-Sensory Path consists of blocks that are different textures and can be walked on and touched.

Stress balls can be used to squeeze and squish away frustrations. Having a variety of shapes, sizes, and textures provides individuals with an opportunity for choice and self-directed behavior.

One way to encourage respectful treatment of the items in the room is to encourage "ownership" by involving youth in selection of those items, suggesting themes for the room and, developing policy around use of the room.

Fine Motor Skills

Fine Motor Skills

Beading, sewing and knitting are activities that can be done as a group in the comfort room.

Completing puzzles is an activity that requires concentration and use of fine motor skills.

In a study done at McFarland Mental Health Center in Illinois, individuals reported decreased levels of stress after using the comfort room which contained inexpensive items, such as markers, paper, beads, pillows, music, and stress balls.

Utilizing fine motor skills requires individuals to stay focused on the task at hand, which may result in de-escalating aggressive behavior and helping the individual to move beyond the trigger event. Providing individuals with a creative outlet can also lead to increased confidence and personal growth as they find new ways to express themselves.

Journaling is one way for individuals to express themselves.

Textures

Textures

Include as many different textures as possible to add to the opportunities for tactile stimulation.

You can use different textures and fabrics when choosing:

Youth can make a "tactile book" by cutting out and pasting different textured papers and fabrics into a book that is then kept in the comfort room.

Textured materials can include various colors and patterns to be visually pleasing as well as stimulating to touch.

Weighted Modalities

Weighted Modalities

A weighted exercise ball can be used as a therapeutic tool. The rhythm of tossing the weighted ball back and forth between the individual and therapist can have a soothing effect.

Weighted stuffed animals work in a similar way to a weighted lap pad, but are soft and cuddly like a pet. Weighted stuffed animals can be purchased or made by staff and youth.

Weighted blankets and lap pads have proven to be an effective tool for people with mood disorders, autism, trauma histories, substance abuse histories, and those who engage in self-injurious behaviors. Individuals have reported positive effects when using weighted items to produce a grounding effect.

If possible, consider offering weighted items in different materials; such as, fleece, cotton, velour, etc.

A weighted neck wrap can also include aroma-therapy features and options for heat or cold.

Blankets designed to allow modification and placement of weights are particularly effective in meeting individual needs.

Seating

seating

Bean bag chairs are a youth friendly option. If you have space for several, they can be used for tunneling or building.

If your budget allows for it, you might want to consider including a vibrating massage chair in your comfort room.

The Snoezelen® brand bean bag, ball pit, and "Cloud Chair" can be hooked up to a stereo system and vibrate with the music.

A less expensive seating option is a rocking chair.

It is important to make sure that youth have access to comfortable seating during group sessions that are held in the comfort room. Yoga mats or small rugs are a space and money saving option.

Seating that allows for swinging and rocking can create a very calming effect.

Other Items to Consider

other items

Fountains not only add to the aesthetic of the room but also provide soothing auditory stimulation.

A microwave and mini refrigerator provides access to a quick snack, as well as the ability to heat and cool items, such as eye masks and aromatherapy neck wraps.

In addition to brightening your space, plants create an opportunity for youth to take the responsibility of caring for them.

Puzzle books (such as word searches, mazes, & sudoku) and puzzles are good items to stimulate the brain.

Books shelves are an ideal space for the storage of books, miscellaneous items, and individualized comfort kits. Any items that must be used under supervision can be kept in a locked cabinet to ensure safety.

Having a supply of current news, books and magazines is an ideal resource to keep youth updated on current events. Included in a collection of self-help books should be literature written by recovered individuals.

Suggested Items for your Comfort Room

Keep in mind that the listed items are only suggestions. Take note of which items would be appropriate for your facility and be sure to add to the list, and don’t forget to… Be Creative!!

On a tight budget?
Think: What kind of resources does your facility have? Do staff members or volunteers have special skills to make or help acquire items? Where are some places you could look for safe, inexpensive or donated items?

Touch:

Sight:

Sound:

Scent:

Comfort:

Seating:

Intellectual stimulation:

  • Self-help books
  • Books written by recovered individuals
  • Art supplies
  • Paper, colored pencils, sketch books, coloring books
  • Additional Items:

    Comfort Room Policy and Procedure

    1. Purpose:

      The Comfort Room is a supportive therapeutic environment which assists patients in their self-calming efforts by affording them an environment conducive to relaxation. When people are in distress, a crisis could occur that results in a restraint or seclusion. At St. Lawrence we are committed to reducing these interventions and believe the Comfort Room is one tool that can assist in this effort. Comfort Rooms are located in close proximity to staff work stations. They are designed and furnished to provide an area of low stimulus and an absence of peer interpersonal interactions for the purpose of tension reduction. The entire room from the color of the wall to its furnishings has been designed to facilitate the process of self calming and soothing. The purpose of this policy directive is to set forth conditions and procedures for use of the Comfort Room at the St. Lawrence Psychiatric Center.

    2. Relevant Statutes and Standards:
      • Mental Hygiene Law, Section 33.04
      • New York Code, Rules and Regulations (NYCRR), Title 14, Section 27.7
      • Office of Mental Health (OMH) Official Policy Manual, Section PC-701 (11/7/95)
      • Accreditation Manuals for Hospitals (JCAHO)
      • SLPC Strategic Planning Framework
    3. Policy Overview

      The SLPC mission, vision, and values statements reflect the guiding principles used to develop the Comfort Room: respect, safety, recovery, hope, teamwork. The Comfort Room is a supportive therapeutic environment in which patients can use self help techniques to manage their behavior and emotional state in a safe environment. Staff are trained in facilitating patient use of the Comfort Room via this policy. Patients are made aware of the Comfort Room on admission and via the ongoing Recipient Council/Recipient Town Hall process. Using the principle of continuous quality improvement, a survey of patient responses regarding what they found helpful/unhelpful about the Comfort Room is collected and analyzed so that further modification/enhancements may be made.

    4. Definition:

      At the St. Lawrence Psychiatric Center the Comfort Room is defined as an enclosed room where the door is not locked when a patient is present, and which is located in close proximity to the staff work station. It is designed and furnished to provide an area of low stimulus and an absence of peer interpersonal interactions for the purpose of tension reduction. The Comfort Room will contain furniture which is free from sharp corners and cannot be easily picked up or thrown; it shall be free of dangerous objects, long cords, hooks, and non-breakaway window coverings and any other item that might be used for suicide or inflicting self-harm. Items conducive to a reduction in tension such as bean bag chairs, cots, music, pillows, dimmer for light regulation, mural, books and magazines are to furnish the Comfort Room. All objects will meet infection control requirements.

    5. Procedure

      The Comfort Room is always to be used on a voluntary basis. The Comfort Room is never to be used as a containment intervention. The patient must continue to demonstrate self control to use the Comfort Room, and must be using the Comfort Room to assist with tension reduction as an objective towards the goal of maintaining self control. The Comfort Room may be used along with other available therapeutic modalities clinically determined to be appropriate in assisting an individual patient with tension reduction/de­escalation. To the extent possible, according to the clinical status of a patient, other calming areas or activities on the ward may be used to assist a patient in gaining time alone or tension reduction. This becomes most pertinent when more than one patient is requesting use of the Comfort Room.

    6. Indications for Using the Comfort Room

      The Comfort Room is a supportive intervention which can be used for any of the following conditions:

      1. Upon patient request, and when it is clear the patient desires time alone (personal time/space), away from noise or other environmental distractions.
      2. Upon patient request, and it is clear to ward staff that any agitation which is exhibited by the patient is safely within control of the patient, him or herself.
      3. Upon suggestion from staff as a means of assisting a patient to increase or maintain self control, and the patient is agreeable and capable of maintaining self control. This would be considered an early stage de-escalation intervention.
      4. For C/Y: only one individual at a time may use the Comfort Room.
        For Adult Services: Since the Comfort Room is also used as a TV/Quiet Room in some areas, more than one individual at a time may occupy the Room. In some cases, when TV may be too loud or distracting and, depending on another individual’s need for calming, use of the Room by the patient seeking relaxation/calming will take precedence over use of the room by someone watching TV. The RN’s clinical judgment will be used in these cases.
    7. Implementation of Comfort Room Use
      1. When a patient requests to use the Comfort Room it should be available immediately and as long as the patient is able to maintain his/her self control.
      2. Ward Staff can suggest to a patient that they use the Comfort Room. Should the patient choose not to use this therapeutic tool, staff can offer other therapeutic interventions to assist in tension reduction. Should the patient choose not to use other tension reduction interventions, and in the opinion of the staff the patient presents a risk of escalation of agitation to the point of loss of self control, the nurse will request evaluation of the patient by the ward psychiatrist or MD on call.
      3. The patient will inform staff of their use of the Comfort Room.
    8. Monitoring
      1. While a patient is in the Comfort Room, an assigned staff member will monitor the patient at least every 15 minutes in the C/Y Services Comfort Room and every 30 minutes in the Adult Services Comfort Room by direct visual observation, or more often if clinically indicated.
    9. Terminating Use of the Comfort Room
      1. The patient may choose to leave the Comfort Room at any time.
      2. Ward movement (i.e., mealtimes, fire drill) will dictate leaving the Comfort Room. If another individual (in C/Y) is waiting to use the Comfort Room, then a limit of 30 minutes is expected.
      3. If no one is waiting to use the Room, there is no time limit for its use for a specific intervention. However, if it becomes clear that a patient is isolating him or herself through excessive use of the Comfort Room, the Treatment Team will address this as a clinical issue.
    10. Documentation of Comfort Room Use
      1. Comfort Room use will be documented on a log sheet kept at the Nurses Station.
      2. As with any noteworthy clinical observation, any significant issue or observation which occurs while the patient is in the Comfort Room shall be documented in the Progress Note Section of the medical record by ward staff.
      3. Patient will be asked to voluntarily complete a feedback form on what was helpful or unhelpful about their time in the Comfort Room.

    Comfort Room Voluntary Feedback Form

    Your answers to the following questions will help the staff to consider ways of making the Comfort Room more useful. Please answer the following questions:

    1. The Comfort Room (Select One):
      Helped me Did not help me
    2. What I liked about the Comfort Room was
    3. What I did not like about the Comfort Room was
    4. The Comfort Room would be more helpful to me if
    5. Comments/Suggestions:

    Name(Optional):

    Ward:

    Date:

    Thank you for completing this form.

    If staff assistance was provided to help the patient complete this form:

    Staff Name:

    Title:

    Signature: __________________________________________ Date:

    Comfort Room Log Sheet Ward:

    Name of User Time In Time Out Staff Initial
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           

    Section III Developing the Comfort Room and Policy Around Its Use

    In Section III, the process of developing your comfort room is discussed. The first document provides a list of questions to consider as you begin to develop your room. The second is a document developed by Tina Champagne, expert in the field of sensory modulation, which can be found in the Sensory Modulation and Environment handbook. This document should help you to consider what type of environmental changes you will make in your facility in order to create a more calming and comforting atmosphere.

    St. Lawrence Psychiatric Center has developed policy and procedure for use of their comfort rooms. In addition, they have created informational flyers and promotional posters to inform staff and youth about the purpose of the comfort room and to promote its use.

    Hutchings Psychiatric Center has developed guidelines for use of the multi-sensory room by outlining how each item in the room should be used. A competency checklist is used when direct care staff members are trained to use the room and equipment by the occupational therapist. Staff are required to perform a "teach back" to ensure that they understand what they have been taught.

    South Beach Psychiatric Center has shared their room use protocol.

    Cayuga Medical Center, Adult Behavioral Services is a hospital that has created a comfort room for the use of the adults they serve and has provided another example of policy and procedure that govern the use of the comfort room.

    Sample Policy for the use of a Sensory Modulation Room: The final example that has been included in this part is a sample policy developed by Tina Champagne. In her policy, she highlights the various aspects of policy development that should be touched upon: defining purpose, giving an overview of the policy, discussing who it will apply to, and outlining the procedure for use of the room.

    Questions to Ask When Developing a Comfort Room and Room Use Policy:

    These are critical questions to explore in order to provide guidance through the development process.

    Developing a mission and vision:

    1. What is the main purpose of the room?
      1. What do you hope to accomplish through use of the room?
        1. Restraint and seclusion reduction?
        2. Improved staff/patient relationships?
        3. Less punitive environment?
        4. Teaching self regulating behaviors?

    Defining the population served:

    1. Who will be allowed to use the room?
      1. Should staff be allowed to visit the room when they have free time?
      2. Children and parents?
      3. When will the room be available?
        1. 24/7?
        2. During group sessions? Meal time? School hours?

    Safety:

    1. Who will supervise the environment?
      1. How will personal safety be maintained?
      2. Who will inspect items before they are placed in the room?
      3. Are you selecting items that are washable and fire proof?
      4. Who will supervise users of the room?
      5. Will users of the room be allowed in alone?
      6. How often will staff check in?
      7. How will equipment be cleaned and stored?
      8. Will you include items that can only be used under supervision?

    Space:

    1. What space is actually available and how can it be adapted to fit therapeutic goals?
      1. Do you have permanent space available in your facility for a comfort room?
      2. Do you have the resources to develop a comfort room?
        1. Monetary
        2. Staff leadership and involvement
        3. Enthusiastic residents
      3. Are there any other factors that can be changed in your facility to create a more calming environment in or outside of the comfort room?

    Section IV Evaluation

    Your opportunity to contribute to the field

    Participating sites in the PARS grant initiative will be given assistance in planning and developing comfort space at each of the three sites. In addition, evaluation forms will be completed following the implementation and through out use of the comfort room. This will document the room’s effectiveness in reducing restraint and seclusion. This information can then be used by other facilities to develop comfort rooms in the future. Data collection will demonstrate the correlation between use of a comfort room and episodes of restraint and seclusion. It is our anticipation that an increase in the use of the comfort room will result in a decrease in the use of restraint and seclusion. Greater Binghamton Health Center has already initiated an evaluation plan and has collected data that reflects positive results.

    bar graph

    To the left is a bar graph that was compiled using data collected on use of the Snoezelen® Room at GBHC and episodes of restraint. As use of the Snoezelen® Room has increased, beginning in October ’07, there has been a sharp decrease in the episodes of restraint.

    In March of 2008, GBHC was restraint free.

    This data was collected by simply recording the name of the youth who used the room, and the date and time the user signed-in and out of the room. Greater Binghamton Health Center has developed a single sided evaluation sheet to record pre and post-session anger and mood levels, as well as to document which items were used by the youth while in the Snoezelen® room. The evaluation form at Greater Binghamton Health Center is filled out by the supervising staff members.

    St. Lawrence Psychiatric Center also tracks when the room is used most frequently and by whom. Youth fill out a feedback form, which provides them with an opportunity to express what they liked most and what could be added to the room to improve effectiveness.

    This section also includes a sample "Comfort Room Guest Book". This can be filled out by youth who use the room. When developing an evaluation plan for your facility be sure that the data collection method is user friendly and not a deterrent to the use of the comfort room.

    Evaluation Survey
    Date:

    The following is a brief survey to gauge your knowledge and perception about comfort rooms. Please answer questions to the best of your knowledge, using the back of this form if you run out room in the space provided. If you do not know the answer to a question, simply respond "N/A". Please check all that apply:

    Position:
    Administrator
    Clinician
    Direct care staff
    Other, Specify
    Full-time
    Part-time

    Shift:
    Day
    Evening
    Night
    Other

    How would you describe the concept of a comfort room to someone who has never heard of it before (i.e. explain the purpose of the room, what it would look like, how it is used)?

    What kind of changes do you anticipate seeing as a result of use of a comfort room?

    1. Do you believe that use of a comfort room in your facility will help to decrease the use of restraint and seclusion in your facility?
                    

    2. Do you believe that use of a comfort room in your facility will help to improve staff/consumer relationships?
                    

    3. Do you believe that use of a comfort room in your facility will help to improve staff moral?
                    

    4. Do you believe that use of a comfort room will help to decrease stress levels for individuals who are recipients of care in your facility?
                    

    5. Do you believe that use of a comfort room will help to decrease stress levels for individuals who are employed by your facility?
                    

    6. Do you believe that use of a comfort room will be an effective tool for helping to teach individuals the skills necessary to control aggressive behavior?
                    

    Thank you! Please add additional comments on the back of this form!

    Guest Book front coverComfort Room Guest Book

    Welcome to the Comfort Room!

    The purpose of this "Guest Book" is to give you a way to tell us about your experience in the room. We encourage all users of the comfort room to make suggestions on what can make the room as useful as possible. Staff members are also asked to fill out a survey based on their observations.

    Guest Book inside cover

    Instructions for filling out the guest book:

    Please include comments about what items you found most useful in helping to destress, as well as items you would like to see in the room that have not yet been included.

    Complete the scale on the right hand side of the page to rate your mood before you use the room and then again after you use the com­fort room. Circling number 1 indicates distress, while 10 indicates joy and happiness.

    Don’t forget to include your name, date, and times you checked in and out of the room.

    Enjoy!

    Comfort Room Guest Book

    Name:
    Date:  

    Check in time:

    How are you feeling before the comfort room?

    unhappy so so happy

    Check out time:

    How are you feeling after the comfort room?

    unhappy so so happy

    Items you used while in the comfort room:

    Other:

    Comments/Suggestions:

    Staff perspective:

    1. Please check to see that the individual’s name, time, and date have been included on the reverse side of this form.
    2. Please answer the questions below.
    3. Upon completion, remove this page from the "Comfort Room Guest Book" and file with the other comfort room evaluation forms. Thank you.

    From your perspective, please rate individual’s level of escalation before the use of the comfort room?

    unhappy so so happy

    From your perspective, please rate individual’s level escalation after their use of the comfort room?

    unhappy so so happy

    Please include comments on the individual’s use of the comfort room, as well as any suggestions to make use of the comfort room more effective:

    What items did the individual use to most successfully gain control of his or her behavior?

    Thank you for visiting.
    Come back soon!

    Section V Additional Resources

    Power point, research notes, and references

    Included in Section V is a copy of the Power Point presentation created and presented at each of the grant sites and for the PARS steering committee by Fellow Megan McDaniel. The power point slides are followed by notes developed from her research. References have also been included.

    Comfort Rooms
    Positive Alternatives to
    Restraint and Seclusion

    Megan MacDaniel

    Agenda:

    • Describe comfort rooms and how they fit into the PARS project
    • Process for implementation
    • Evaluation Plan

    My Role in the PARS Project

    • Gather information that will be used to support the implementation of comfort rooms in the three facilities that are working with the PARS team
    • Ensure that our plans to develop comfort rooms follow guidelines that reflect evidence based best practices
      • "…service design and delivery are based on the best research and evidence available and best practice guidelines are incorporated into treatment practices." OMH Mission, Vision, & Values

    How have I been doing this?

    • Literature Review
      • Evidence based best practice
    • Conferences and Training
      • Baltimore: Training for the reduction of s/r
      • PMCS (Preventing and Managing Crisis Situations)
    • Field Visits
      • NYS psychiatric hospitals and residential treatment facilities that have already developed comfort rooms
        • Greater Binghamton, Hutchings, St. Lawrence, South Beach, Women’s Christian Hospital

    How is this information relevant to other OMH licensed facilities?

    • Information gained through this pilot program will be used to endorse the implementation of comfort rooms in OMH facilities across NYS
    • We hope to:
      • Provide you with an additional tool to reduce the use of R/S
      • Learn from your experience about the process of implementing comfort rooms and developing policy around use of the rooms
      • Record findings to provide new data driven research to determine if use of comfort rooms is best practice in reducing the use of restraint and seclusion
        Evaluation

    Why is this important?

    • Comfort Rooms are a tool that can be used to reduce the use of restraint and seclusion by preventing aggressive behavior

    Comfort Rooms are Not:

    • An alternative to restraint and seclusion
      • Should not be used after the child has lost control of their behavior
      • Should be used as a preventative tool
    • To be used as a punishment or reward
      • Should be used when necessary to avoid episodes of R/S

    Comfort Rooms are:

    • Are to be used at will
    • To be used as necessary to avoid episodes of restraint and seclusion
    • To be used be for the onset of aggressive behavior

    What is a Comfort Room?

    • Comfort Room:
      • A designated space that is designed in a way that calms an individual when they recognize they are beginning to lose control of their behavior
    • Multi-Sensory Room:
      • A room that is designed in a way that therapeutically stimulates all the senses
        • (may be alerting or calming)
    • Snoezelen Room:
      • Multi-sensory room with Snoezelen brand equipment

    Positive Findings (in the literature)

    • Studies show a strong correlation between the reduction of restraint and seclusion and the use of comfort rooms
    • Residents who have access to comfort rooms have shown decreased "rebellious, aggressive, and depressive behavior"
    • Snoezelen has been used successfully with multiple populations
    • Trend towards the use of comfort rooms
      • 500-600 Snoezelen rooms alone have opened in the US

    The Purpose of using Comfort Room

    • Provide staff with an additional tool to proactively reduce the use of R/S
    • Create an environment that is failure free
    • Empower through providing choices
    • Increase self-awareness (identify stressors)
    • Resiliency
      • Develop skills to adapt/cope with triggers
      • Self-nurture
      • Self-care
    • Decrease burn out (staff see improvements)
      • Improve staff and youth relationships
        • Staff see youth as individuals
        • Youth see that staff really care
    • Provide a space for youth that is supportive rather than depredating
    • Develop skills youth can use outside of treatment
      • Explore new activities in a new environment to self-regulate

    A client-centered, strength-based, recovery-oriented approach!

    Responses from field visits

    • Staff see positive changes "They Love it"
    • Youth see that staff care
    • Parents see improvements in their children’s behavior when they are home
    • "Comfort Plans" have been incorporated into youths’ discharge plan
    • Successful creation of a less punitive environment

    Comfort Rooms as a tool to prevent aggressive behavior

    • What is behavior?
      • Manner of conducting one’s self
      • Action and response to stimuli
      • The response of an individual to the environment
      • Outward action to denote inward emotion
    • Three factors that influence behavior:
      • Biological (underlying medical conditions, mood D/O, effects of chemical substances, trauma, etc)
      • Psychological (Anger, frustration, guilt, aggression, lack of choices)
      • Environmental

    Activity:

    • Make a list environmental factors that might cause a person to become agitated or aggressive

    Environmental Factors:

    • Temperature
    • Noise
    • Lighting
    • Color
    • Food
    • Privacy policy
    • Overcrowding
    • Staff interactions with youth and each other
    • Scheduling-do they have time to do things they want to do? Are they under stimulated
    • Witnessing other youth in crisis

    Discussion: What factors have you listed that might effect the youth in your facility?

    Items that could be added in a comfort room to improve environment

    • Temperature:
      • Too hot? Space heater, blanket, neck warmer, heating pad
      • Too cold? Fan, ice pack, water cooler, ice packs
    • Lighting:
      • Dimmer switch, non-florescent lighting, lava lamps, black light
    • Food:
      • Mini refrigerator, microwave, snack food

    McFarland Mental Health Ctr., IL
    Self reported survey

    • Conducted a survey of persons served to rate their stress levels following use of the comfort room
      • Stress Level pre use: 5 – 10
      • Stress Level post use
        • Average decrease: -4 points
        • Avg. time in room: 38 minutes
        • Activities: markers, coloring paper, music, bead pillow, watching videos, stress balls

    Cooley-Dickinson Hospital, MA
    Tina Champagne and Ed Sayer

    25 bed community hospital

    • Avg. length of stay: 9 days
    • Ages 17-93 with 26 different diagnosis (n= 47)
    • 10 point scale after 96 tx sessions
    • 89% reported positive changes
    • 74% R/S reduction over 2 year period

    Greater Binghamton Health Center
    Binghamton, NY

    bar graph

    *Increase in use of the Snoezelen Room by 110%

    24.8 sessions–>52 –>11h10m23h45m

    *Decrease in use of restraint by 70%

    25 episodes/m –> 7.3

    Examples of Comfort Rooms (in New York State)

    Comfort Room South Beach Psychiatric Center
    Staten Island, NY

    Comfort Room South Beach Psychiatric Center

    St. Lawrence Psychiatric Center
    Ogdensburg, NY

    Saint Lawrence Psychiatric Center

    Comfort Room Women’s Christian Hospital
    (Jamestown, NY)

    Women’s Christian Hospital

    Multi-Sensory Room Hutchings Psychiatric Center
    Multi-Sensory Room Hutchings Psychiatric Center

    Greater Binghamton Health Center Snoezelen Room
    Greater Binghamton Health Center Snoezelen Room

    Greater Binghamton Health Center Snoezelen Room in Use:
    Greater Binghamton Health Center Snoezelen Room

    Examples of Items that can be used in the Room

    Items for the Room

    Sight
    sight
    Scent
    scent
    Sound
    sound

    Items for the Room
    Touch
    touch

    Texture
    Texture

    Items for the room (Fine Motor Skills)
    Fine Motor Skills

    Items for the room
    other Items for the room

    Items for the room (Weighted Modalities)
    Weighted Modalities

    Evaluation

    • The PARS project gives us an opportunity to contribute to the field and help other NYS facilities as they go through the process of implementing comfort rooms

    Limitations for Generalizabiltiy and Validity of Research on the use of Comfort Rooms

    • Small sample sizes
    • Lack of objective observers to gather info
    • Lack of control groups
    • Subjects as volunteers (no random sampling)
    • Conclusions are drawn based on very few sessions
    • Terms are left undefined (ex. "challenging beh.")
    • Lack of sample diversity

    Assessment Tools
    Adding to the bank of data driven research

    • Pre/post assessment
      • 10 point scale with emoticons
    • Feed back from residents and staff
      • Items to add to the room, what they found most useful
    • Sign-in/Sign-out book
      • When is room used the most
    • Create a pre and post implementation qualitative evaluation tool
    • Collect quantitative data around episodes of use of the room and R/S (time, date, length, who)

    NIMRS Data
    NIMRS Data

    Positive Findings

    • While there is a scarcity of data driven research that supports the use of the rooms there is plenty of information available on how to implement and develop the rooms:
      • Policy Development
      • Assessment tools
      • Who should be involved in the decision making process
      • Ideas for other activities that can be carried out in comfort room and items to put in the rooms

    Comfort Room Policy Development
    Policy should include:

    • Brief description of the purpose of the room
    • Policy Overview
      • (time frames, how items are to be used, supervision, assessment)
    • Scope: who the policy applies to
    • Definition of terms
    • Outline of procedure for use of the room
    • General precautions
    • Reviewed and approved by
      • (Tina Champagne)

    Policy Development (continued)

    • Policy content will vary from site to site based on ideas around how the room should be used
    • Factors:
      • What type of items are in the room
      • Proximity to nurses’ station
      • Individuals served
        • Length of stay
        • Severity of illness
        • Age

    What have we learned from facilities with comfort rooms about implementation?
    Allow for slow implementation

    "How do you eat a 1,000 pound elephant"

    • Introduce one new item at a time
    • Allow for a slow process so that staff won’t feel forced
    • Share information
      • bring in journal articles and magazines

    What have we learned from facilities with comfort rooms?

    Leadership: The importance of gaining support

    On All Levels of Care

    • Upper management
    • Direct care staff
    • Youth
    • Families
    • Jamestown: families notice the difference in their children’s behavior and want to set up mini comfort rooms at home
    • Binghamton Day Tx: Call families when kids do good things, not just when they are in trouble

    A Blueprint for Managing Change
    Adapted from © PeopleWork

    Final Tips for Change Leaders
    Adapted from © PeopleWork

    • Find ways to gain support
    • Remember that change is not linear – expect bumps and set backs
    • Change always takes longer than you expect
    • Be persistent

    Quick Reference List

    Creating Multi-Sensory Environments:

    The following is a brief and general overview of an extensive literature review done on the purpose, effectiveness, implementation process, and policy development related to comfort rooms, multi-sensory rooms and Snoezelen® rooms.

    Purpose of the Comfort/Multi-Sensory Room:

    Multi Sensory:

    Other uses for Comfort/Sensory Space:

    Alternative activities to de-escalate:

    List of Objects in various Comfort Rooms:

    To Calm:

    To Arouse:

    Data collection methods in Comfort Rooms:

    Sensory Modulation-Related Assessment Tools (Tina Champagne):

    Incorporate Individual Treatment plan:

    Developing the Room:

    Developing the Room: Questions to ask (Champagne):

    Guidelines for use of the room:

    Research shows that:

    Implementation, Staff and Community Involvement:

    Use of Comfort Rooms is endorsed by:

    On data driven research findings about comfort rooms:

    Website References

    Web Based Search:

    You might want to try entering some of the following Key Words for Research:

    For general information on Multi-Sensory Rooms:

    Good place to start:

    http://www.ot-innovations.com/content/view/49/46/ Leaving OMH site
    http://www.sensoryconnectionprogram.com/index.php Leaving OMH site

    Good articles to read:

    http://www.ot-innovations.com/images/stories/PDF_Files/qi_study_sensory_room.pdf Leaving OMH site  (PDF)The Effects of the Use of the Sensory Room in Psychiatry by Tina Champagne, M.Ed. , OTR/L

    Websites for general information about Comfort Items and Snoezelen® Brand Products:

    http://www.ot-innovations.com/component/option,com_weblinks/catid,28/Itemid,23/ Leaving OMH site * This websites provides links to multiples resources

    http://www.snoezeleninfo.com/products.asp Leaving OMH site

    http://www.flaghouse.com/bring_AL.asp Leaving OMH site

    http://www.somatron.com/ Leaving OMH site

    http://www.rompa.com/cgi-bin/Rompa.storefront Leaving OMH site

    http://www.store.schoolspecialty.com Leaving OMH site

    http://www.specialneedstoys.com/mse/viewcontent.asp?section=MSE Leaving OMH site

    http://www.abilitations.com/sportime-shared/activityGuidesAB.jsp Leaving OMH site

    http://www.changingimages.org Leaving OMH site

    http://www.designerlightpanels.com Leaving OMH site

    References:

    Baillon, S., van Diepen, E., and Prettyman, R., (2002). Multi-sensory therapy in psychiatric care. Advances in Psychiatric Treatment. 8. 444-452.

    Bluebird, G. (2002). Comfort and communication help minimize conflicts National Technical Assistance Center. Summer/Fall, Special Edition. 18-19.

    Bluebird, G. (2005). Comfort rooms: reducing the need for seclusion and restraint. Residential Group Care Quarterly. 5(4). 5-6.

    Bluebird, G., (2004). Redefining consumer roles: changing culture and practice in mental health settings. Journal of Psychological Nursing. 42(9). 46-53.

    Bluebird, G. (2000). Using the arts to recover mental health. Mental Health Recovery Newsletter. 1(3).

    Cantu, C. (2004). White space and sensory rooms. Advance for Occupational Therapy Practitioners. 20(19). 12.

    Centers for Medicare and Medicaid Services (CMS), (April 11, 2008). "State Operations Manual: Advance Copy" Department of Health and Human Services, Centers for Medicare and Medicaid Services. Issued, April 11, 2008.

    Champagne, T. (2008). Sensory rooms in mental health. Accessed on January 29, 2008 from: http://www.ot-innovations.com/content/view/49/46/ Leaving OMH site

    Champagne, T., and Sayer, E., (N/A). The effects of the use of the sensory room in psychiatry. Copyright by Tina Champagne.

    Champagne, T., and Stromburg, N., (2004). Sensory approaches in inpatient psychiatric settings. Journal of Psychosocial Nursing. 42(9). 1-8.

    Crisis Consultant Group, LLC (2005). Comparison: Pennsylvania regulation comparison to: CCG’s facing emergencies and reacting crisis intervention training. Crisis Consultant Group, LLC. Accessed February, 2008 from http://www.crisisconsultantgroup.com/ Leaving OMH site

    Curie, C. (2005). SAMHSA’s commitment to eliminating the use of seclusion and restraint. Psychiatric Services. 59(9). 1139-1141.

    Donat, D., (2003). An analysis of successful effort to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Services. 54(8). 1119-1123.

    Donat, D., (2005). Encouraging alternatives to seclusion, restraint, and reliance on PRN drugs in a public psychiatric hospital. Psychiatric Services. 56(9). 1105­1108.

    Donovan, A., Siegel, L., Zera, G., Plant, R., and Martin, A., (2003) Seclusion and restraint reform: an initiative by a child and adolescent psychiatric hospital. Psychiatric Services.54(7). 958-959.

    Donovan, A., Plant, R., Peller, A., Siegel, L., and Martin, A., (2003). Two-year trends in the use of seclusion and restraint among psychiatric hospitalized youth.

    Glick, J., (2006). "Excited delirium" cited in deaths. ABC News Associated Press. Accessed on March 30, 2008 from: http://www.policeone.com/edp/articles/1179873-Excited-Delirium-cited-in-deaths/ Leaving OMH site

    Harmon, T. (2005). Restraint and seclusion: New York state practices receive national attention. CQC. Accessed February, 2008 from http://www.cqcapd.state.ny.us/advocacy/publications/pubvoice.htm

    Hogg, J., Cavet, J., Lambe, L., and Smeddle, M., (2001). The use of Snoezelen® as multi-sensory stimulation with people with intellectual disabilities: a review of the research. Pergamon, Research in Developmental Disabilities. 22. (353­372).

    Huckshorn, K. (n/a). 6 core strategies for reducing seclusion and restraint use©, draft example: policy and procedure on debriefing for seclusion and restraint reduction projects. National Association of State Mental Health Program Directors, National Technical Assistance Center. Accessed on April 24, 2008 from: http://www.nasmhpd.org/nasmhpd_collections/collection5/publications/ntac_pubs/Debriefing%20p%20and%20p%20with%20cover%207-05.pdf Leaving OMH site  (PDF)

    Hudson, J., (2006). Sample S&R reduction priorities of P&As – 2006 TASC skills building conference. Written in association with the National Disabilities Rights Network.

    Joint Commission on Accreditation of Healthcare Organizations (JCAHO), (2004). System analysis: assess early and often avoid unnecessary use of restraint and seclusion. Joint Commission Perspectives on Patient Safety. 4(5). (5-6). Accessed on June 17, 2008 from: http://www.jcipatientsafety.org/fpdf/psp/PatientSafetyArticles/S3-PS-05-04.pdf Leaving OMH site  (PDF)

    Jonikas, J., Cook, J., Rosen, C., Laris, A., and Kim, J., (2004). A program to reduce the use of physical restraint in psychiatric inpatient facilities. Psychiatric Services. 55(7). 818-820.

    Kinkead, G., (2003). A room comes alive with color and sounds. The New York Times. December 23, 2003.

    LeBel, J., (2006). Rediscovering pathways to compassionate care. American Academy of Child and Adolescent Psychiatry News. Accessed in February, 2008 from http://www.aacap.org/cs/root/member_information/practice_information/jan/feb_2006_aacap_news_seclusion_restraint_rediscovering_pathways_to_compassionate_care Leaving OMH site  (PDF)

    LeBel, J., Stromburg, N., Duckworth, K., Kerzner, J., Goldstein, R., Weeks, M., Harper, G., LeFlair, L., and Sudders, M., (2004). Child and adolescent inpatient restraint reduction: a state initiative to promote strength-based care. Journal of the American Academy of Child and Adolescent Psychiatry. 43(1). 1-20.

    Long, A., and Haig, L., (1992). How do clients benefit from Snoezelen®? An exploratory study. British Journal of Occupational Therapy. 55(3). 103-106.

    Matson, J., Bamburg, J., and Smalls, Y., (2003). An analysis of Snoezelen® equipment reinforces persons with severe or profound mental retardation. Science Direct, Research in Developmental Disabilities. 25. (89-95).

    Mawson, A. (1999). Stimulation-induced behavior inhibition: a new model for understanding physical violence. Integrative Physiological and Behavior Science. 33(3). 177-197.

    McLoughlin, K. (2002). Following the yellow brick road: a story about a sensory awareness group. Social Work with Groups. 25(4). 21-35.

    Minner, D., Hoffstetter, P., Casey, L., and Jones, D., (2004). Snoezelen® activity: the good shepherd nursing home experience. J Nurs Care Qual. 19(4). 343-348.

    Moore, K. (2007) "Coping, calming, comfort room (CCC) for adults in mental health settings" Accessed February, 2008 from: www.sensoryconnectionprogram.com Leaving OMH site

    Morrison, L., Duryea, P., Moore, C., and Nathanson-Shinn, A., (Date N/A). Investigations Unit -Staff on Prone Restraint. Protection and Advocacy, INC. California.

    National Association of State Mental Health Program Directories (NASMHPD), (2005). NTAC National Technical Assistance website. Last updated July, 2005.

    New York State Mental Hygiene Laws, Chapter II, Article 27.7: Restraint and Seclusion. Issued March, 31, 1997.

    OMH Of.cial Policy Manual, issued May 29, 2007 by the State of New York Office of Mental Health. Section: Patient Care-Patient Management. Directive: Seclusion and Restraint

    OMH, (2007). "Strategic Plan Framework, 2007" as accessed in February, 2008 from: http://www.omh.state.ny.us/omhweb/budget/2007-2008/strategic_framework.html

    Reddon, J., Hoang, T., Sehgal, S., and Marjanovic, Z., (2004). Immediate effects of Snoezelen® treatment on adult psychiatric patients and community controls. Current Psychology: Developmental, Learning, Personality, and Social. 23(3). 225-237.

    Singh, N., Lancioni, G., Winton, A., Molina, E., Sage, M., Brown, S., Groenweg, J., (2004). Effects of Snoezelen® room, activities on daily living skills training, and vocational skills training on aggression and self-injury by adults with mental retardation and mental illness" Science Direct, Research in Developmental Disabilities. 25. 285-293.

    Smith, G., Davis, R., Bixler, E., Lin, H., Altenor, A., Altenor, R., Hardenstine, B., and Kopchick, G., (2005). Pennsylvania state hospital system’s seclusion and restraint reduction program. Psychiatric Services. 56(9). 1115-1122.

    State of Minnesota: Office of the Ombudsman for Mental Health and Mental Retardation (2002). Current issues in seclusion and restraint. Office of Ombudsman for Mental Health and Mental Retardation. Published December 12, 2002.

    Substance Abuse and Mental Health Services Administration (2006). SAMHSA releases training guide to reduce seclusion and restraint use. CMHS Consumer Affairs E-New. 6(61). Accessed February 22, 2008 from http://mentalhealth.samhsa.gov/consumersurvivor/listserv/060206b.asp Leaving OMH site

    Van Weert, J., van Dulmen, A., Spreewenberg, P., Bensing, J., and Ribbe, M., (2005). The effects of the implementation of Snoezelen® on the quality of working life in psycho geriatric care. International Psychogeriatrics. 17(3). 407-427.

    Weiss, E., Altimari, D., Blint, D., Megan, K., (1998). Deadly restraint: a Hartford Courant investigative report. Hartford Courant. October 11-15.

    Withers, P., (1995). Successful treatment of severe self injury incorporating the use of DRO, a Snoezelen® room and orientation cues. British Journal of Learning Disabilities. 23. 164-167.

    World, H., (2007). Mental health care’s new model shuns restraint and seclusion: the nursing spectrum. Mental Hope News Blog. Accessed in February, 2008 from: http://mentalhopenews.blogspot.com/2007/08/mental-health-cares-new-model-shuns.html Leaving OMH site