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The Six Core Strategies: Pitfall and Pragmatics to Successful Implementation

Janice LeBelGuest blogger, Dr Janice LeBel, gives us a sneak preview of her keynote presentation that will open October’s Restraint Reduction Conference.

The Six Core Strategies© (6CS) are a well-recognized organizational framework for producing practice change. The approach was developed in 2002 in the USA by a team of restraint/seclusion (R/S) experts – all with lived experience with either: using and reducing use or actually being restrained and secluded in care settings (Huckshorn, LeBel & Caldwell, 2016). Had national media attention, and public scrutiny and scorn not occurred in 1998/99 following an exposé on R/S deaths and injuries – it’s not clear if this evidence-based practice to prevent R/S would have been created. But federal leadership, funding, and an imperative to eliminate R/S resulted in 2003 when Charles Curie, the Substance Abuse Mental Health Services Administration Administrator, launched a national action plan and declared R/S as “disgraceful” procedures having no place in a treatment setting. This impetus fueled the development of the 6CS.

Since the inception of the national initiative and roll out of the 6CS, practice standards have advanced.  Requirements for R/S use are more stringent, reductions have been published, and alternatives to R/S have been created, most notably the use of sensory integration and sensory modulation interventions most often occurring in newly developed “Comfort Rooms” or “Sensory Rooms” for persons-served to learn and practice self-soothing and self-calming skills (LeBel & Champagne, 2010). In addition, the widespread scope of application of the 6CS has been demonstrated across settings, populations, regions, and countries. This translatability underscores the universality of the challenge of managing interpersonal conflict and violence in human service settings.

Adopting a framework, like the 6CS, to address a pernicious problem such as violence is just one step in a comprehensive, time-consuming implementation process to change not only R/S practice but the culture within the organization that has come to rely on R/S as tool for behavior management – rather than a life-saving measure of last resort. The steps and threats to successful implementation are many and varied.  Some of the more common threats to 6CS implementation involve the human equation: leadership and staff. Leaders who delegate R/S reduction/prevention without active participation run the risk of their effort not producing robust change. Leaders who fail to address organizational/operational obstacles (e.g. policy, funding, staff training, supervision, performance review) will not succeed. And leaders who fail to teach staff relevant skills and empower staff to use their judgement and creativity to prevent conflict and R/S will greatly limit the outcome and sustainability of this work (Huckshorn, LeBel & Caldwell, 2016).

Another significant threat to effective implementation is frank resistance from staff responsible for implementing the framework. A toxic culture can rapidly undermine the best model and training program. If staff are not actively included, along with persons-served, in this work unintended consequences can result (e.g., injuries, paradoxical rise in R/S use, alternatives not being used/misused) including a loss of trust from staff making any and all future change efforts much more challenging.

Sometimes threats can occur serendipitously and result in derailment of the work – or new inspiration – or both. In Louisiana, for example, devastating hurricanes resulted in two facilities participating in 6CS implementation having to immediately close and relocate with a loss of more than 50% staff, overnight (Huckshorn, LeBel & Caldwell, 2016). What resulted from this horrific experience was a redevelopment of these services with a decided focus on trauma/trauma-informed care and full consumer inclusion in care as well as new approach to workforce development: co-teaching/co-training by staff and persons-served together. This became a potent culture change tool and staff recruitment method. What has fueled the evolution and expansion of the 6CS over time has been this exceptional creativity by providers who have rethought what it means to deliver care that is intended to promote healing and recovery – from the vantage point of the customer/consumer and the staff who serve them.

Successful projects are those that: demonstrate sustainability, show continual drive toward quality/service improvement, and have leaders with courage who are not satisfied with the status quo and do not aspire to be part of the ‘new wave’ but rather aspire to be ahead – where the new wave will land. These leaders, don’t take ‘no’ for an answer, don’t accept R/S ‘reduction’ as the goal, and are focused on a level of excellence beyond industry standards and acceptable practice.

With successful implementation comes the capacity to apply innovations and new learning beyond the bounds of the organization. This is what has been demonstrated by ‘gen-next’ of 6CS implementation. Leaders have applied the framework beyond their organization, developed new technology and methods to support quality service and a strong culture of care, and applied the approach to other forms of service change.