Multisite study of an evidence-based practice to reduce seclusion and restraint in psychiatric inpatient facilities.

OBJECTIVE: This federally funded study examined implementation and outcomes of the Six Core Strategies for Reduction of Seclusion and Restraint (6CS) in 43 inpatient psychiatric facilities. METHODS: A prototype Inventory of Seclusion and Restraint Reduction Interventions (ISRRI) tracked fidelity over time. Outcome measures--seclusion and restraint events as percentages of total inpatient population and seclusion and restraint hours as percentages of total inpatient hours--conformed to licensed Behavioral Health Performance Measurement System specifications. Independent variables were facility and patient characteristics. Facilities were classified into five implementation types based on ISRRI scores: stabilized (N=28), continued (N=7), decreased (N=5), discontinued (N=1), or never implemented (N=2). For the stabilized group, linear modeling and random-effects meta-analysis compared the contribution of individual facilities to an overall effect. Subgroup analyses explored relationships between facility characteristics and outcomes. Dose-effect analysis tested the hypothesis that the stabilized group would have more positive outcomes. RESULTS: Overall, the stabilized group reduced the percentage secluded by 17% (p=.002), seclusion hours by 19% (p=.001), and proportion restrained by 30% (p=.03). The reduction in restraint hours was 55% but nonsignificant (p=.08). Individual facility effect sizes varied; some rates increased for some facilities. The dose-effect hypothesis was supported for two outcomes, seclusion hours and percentage restrained. The order of implementation group effects in relation to each outcome varied unpredictably. CONCLUSIONS: The 6CS was feasible to implement and effective in diverse facility types. Fidelity over time was nonlinear and varied among facilities. Further research on relationships between facility characteristics, fidelity patterns, and outcomes is needed.

Effects of job development and job support on competitive employment of persons with severe mental illness.

OBJECTIVES: Few studies have sought to determine which specific supported employment services improve employment outcomes for people with pyschiatric disabilities. This study examined the effects of job development and job support among other services on acquisition and retention of competitive employment. METHODS: Data used in the analysis came from seven sites of the Employment Intervention Demonstration Program. Employment data were collected weekly for a period up to 24 months for 1,340 participants. A random-effects meta-analysis was conducted. RESULTS: Job development increased the probability of obtaining competitive employment. The effects of job development on job acquisition remained after the effects of other factors were controlled for. Job support was associated with more months in the first competitive job but not total hours worked. However, no evidence for the causal role of job support was found in analyses that tested the effects of job support after the job support was provided. The causal role of job support alone was also cast in doubt by the fact that a substantial overlap existed between individuals who received job support and vocational counseling. CONCLUSIONS: Job development is a very effective service when the goal is job acquisition. Job support is associated with retention of a first competitive job, but its causal role is questionable.