State of Texas Senate Bill 240: Workplace Violence Prevention Policy for Health Care

CPI Alignment

CPI recommends that all staff, at a minimum, receive annual de-escalation training. To be most effective, training should be conducted as an ongoing process that includes both the initial training and formal refresher training programs; and should also include other elements such as reviews, practices, policy reviews, drills, and situational application discussions to reinforce learning transfer and reduce training drift.

Additionally, each facility should evaluate how many staff may also need more training in the safe use of restraint and seclusion because of their roles or responsibilities within the organization. We recommend that all staff receive a formal refresher every six to 12 months to reduce training drift and to allow opportunities for problem solving and formal review. CPI also suggests that, in addition to formal content reviews, staff receive at least annually a review of the current policy on restraint and seclusion, as well as a review of Nonviolent Crisis Intervention^® (NCI^™).

The NCI^™ Training Program is grounded in the philosophy of providing for the Care, Welfare, Safety, and Security^SM of everyone involved in crisis moments. With training, staff can serve as a conduit to calm, versus chaos. However, staying calm and professional in the face of a crisis can be very challenging.

CPI training equips staff with strategies to effectively and professionally intervene both verbally and physically in a manner that protects an individual’s dignity. While the goal is to avoid the use of restraint and seclusion, it is also imperative that interventions used for physical restraint or seclusion provide for as much dignity as possible. CPI physical interventions are designed for safety and allow for a Therapeutic Rapport to be re-established with the individual who has lost control. Staying calm, professional, and rational in the face of escalating behavior is not always intuitive for people. Training staff in safe and effective strategies for recognizing potential crisis situations, as well as in developing de-escalation, Empathic Listening, limit setting, and debriefing skills, along with the safe use of personal safety and physical restraint skills, is imperative in creating a safe facility climate. With ongoing training and retraining, staff will be much more likely to respond with a trained response, versus a primal or an inappropriate response.

CPI Alignment

As part of a comprehensive violence prevention initiative, CPI recommends that organizations adopt policies and procedures that reflect the philosophy and strategies taught in the NCI^™ Training Program. CPI offers a variety of resources, tools and services that support organizations seeking to update their policies and procedures.

CPI Alignment

CPI recognizes and supports that training is an ongoing process, not a one-time event. CPI recommends that staff either be retrained in the NCI^™ Training Program— or that staff attend a formal refresher training—every 6-12 months. Further, CPI supports the implementation of regular drills, rehearsals, and practice sessions for staff; these are to include additional practice, and they are to apply both verbal and physical intervention skills to unique situations that may arise. CPI suggests that these sessions be recorded to help Certified Instructors keep track and assess which staff need additional training, as well as to assess staff competency in applying the skills learned in the NCI^™ Training Program.

CPI Alignment

The NCI^™ Training Program uses both verbal and physical interventions. We train that the least restrictive form of intervention should always be considered and utilized first, prior to the use of any physical restraint. Within this training, we also introduce a Decision-Making Matrix^SM or risk assessment matrix which helps staff to consider what level of intervention to consider based on the level of risk. The Decision-Making Matrix^SM and Physical Skills Review assist staff decision-making in the use of physical restraints. The physical restraints include lower-, medium-, and higher-level holding skills to safely manage risk behavior. Our NCI^™ With Advanced Physical Skills course also includes the use of Emergency Floor Holding which is designated as higher-level holding. Beyond physical restraints, CPI does not teach or speak to any other form of restraint (such as mechanical or chemical).

The use of physical (human-to-human) restraints is taught within our training program for use as a last resort when all lesser forms of intervention have been exhausted. The staff members involved as well as observers are trained to continually assess the use of physical restraints and may call for an end to the use of physical restraints at any time.

CPI teaches that any emergency intervention should be used as a last resort, when the individual is an immediate danger to self or others, and when less restrictive interventions have been tried and have failed or are deemed inappropriate.

Interventions taught by CPI have been designed to minimize the risk of injury to patients and staff. As such, interventions are meant to be free of pain and do not include the use of pressure points or joint locks. While no intervention is completely free from risk of injury to patients or staff, all of CPI’s interventions have been independently assessed for risk of psycho-social, soft tissue, joint, structural, neurological, cardio-vascular and respiratory injury to both patients and staff.

It is the core belief of CPI that every effort should be made to prevent the need for physical restraint. We teach that physical restraint should only be used as a very last resort when all nonphysical options have been exhausted. For last-resort circumstances, we teach safer, nonharmful restraint techniques that are the most adaptable in the industry.

CPI utilizes verbal and physical maneuvers to defuse and prevent violent behavior. Prevention is what CPI training is all about. We also teach verbal de-escalation and physical-disengagement skills to defuse any incidents that staff can’t successfully prevent.

CPI training teaches staff to consider the potential psychological, physiological and social-emotional effects that physical restraint or physical violence can have on an individual. In the training program, staff learn ways to minimize or eliminate these effects whenever possible throughout their prevention, intervention and post-intervention efforts.

CPI training involves personal disengagements skills to keep staff physically safe from strikes, grabs, and other injuries and assaults—without hurting others.

CPI trains that restraints should only be used when a person poses an immediate threat of harm. When a person no longer presents a potential for harm to themselves or others the restraint should be immediately discontinued.

CPI’s interventions are designed to allow an individual in crisis to breathe freely and without obstruction. CPI’s interventions do not utilize skills that apply pressure to the neck or torso, which can compromise the ability of the individual to breathe. Additionally, CPI does not teach or endorse the use of masks, covers, or any object the obstructs vision or breathing of an individual.

CPI’s interventions do not utilize skills that secure a person to a stationary object. However, CPI does teach emergency interventions which allow staff to respond to risk behavior while an individual is in a seated or a standing position.

CPI does not teach interventions designed to restrict of inhibit an individual’s ability to communicate. However, if a person's behavior is a risk to themselves or others, as a last resort, the staff might utilize emergency interventions that result in restriction of hands and arms. As a result, an individual whose primary method of communication requires the use of their hands could be impaired.

Strategies to prevent physical harm are incorporated into CPI training. This will involve training staff of personal disengagement skills to ensure that staff remain safe from strikes, grabs, and other injuries or assaults—without hurting others.

The NCI^™ Training Program curriculum provides disengagement strategies for staff that find themselves in a situation where they are confronted with physical violence.

CPI Alignment

CPI recommends documenting all incidents with all relevant information as part of a workplace violence prevention plan. The NCI^™ Training Program provides a model for assessing and gathering incident data to aid staff performing the important evaluation process. In addition, CPI offers a comprehensive means of documenting and recording staff training and provides verifiable certification records for each staff trained in CPI courses.

CPI Alignment

CPI recommends doing this with the individual involved and with all staff members involved as well. One step in our debriefing process is to look for patterns of behavior: patterns in the client’s behavior and patterns in the staff response to the behavior. It is then that we can identify alternative behaviors and intervention strategies and plan to prevent future occurrences of a similar situation or deescalate them more quickly and effectively.

Additionally, staff can use the CPI debriefing process to analyze each incident to assess their intervention strategies, identifying what worked well and what might be adapted to prevent future occurrences of the escalating behavior. This would also include debriefing with anyone else involved, with a focus on orienting to the basic precipitating factors that led up to the incident and how to remove or mitigate those factors in the future.