North Carolina Interventions Training Information:

NCI training is specifically designed for:
* Building positive relationships.
* Decision making and problem solving.
* Assessing risk for escalating behavior.
* Early crisis intervention.

North Carolina Intervention (NCI) Core:
* Prevention plus,
* Non-restraining blocks and releases

North Carolina Intervention (NCI) Core Plus:
* Approved optional restraining physical techniques such as therapeutic holds, carries and techniques for special populations.
NC Interventions© (NCI) is a standardized training program to prevent the use of restraints and seclusion, created and supported by DMH/DD/SAS and used in all DMH/DD/SAS state facilities.

The NCI Quality Assurance Committee oversees the integrity of the training program by training and monitoring Instructor Trainers and reviewing/ approving any changes or additions to the curriculum.

Other agencies may choose to use this curriculum. If so, they must use certified NCI© Instructors or Instructor Trainers.
ONLY certified Instructor Trainers are authorized to train Instructors.

ONLY certified Instructors are authorized to teach the curriculum.

Agencies may make individual arrangements with certified Instructors, or they may have someone on their staff trained as an Instructor (trains participants) or as an Instructor Trainer (trains Instructors as well as participants).

Information provided by:
North Carolina Interventions (NCI) REVIEW MATERIAL
North Carolina Intervention Training

The goal of this portion of North Carolina Interventions Training

is to teach skills that help you prevent the use of
personal restraint and time out. You are the key to reaching this goal. It is important to know
how to communicate to create positive relationships, how to treat others with respect, and
how to handle yourself when situations become difficult.
Good use of prevention techniques may eliminate the need to put your hands on a person to
control their behavior. No matter how skilled you become in physical interventions, there is
always the risk of injury to you or to the person you are intervening with when you attempt to
physically control his/her behavior.
Behavior Support Plans (BSP) spell out prevention techniques specific to the person for whom
the plan is written as well as any interventions that need to occur. The BSP is created to provide
staff with written instructions for supporting a particular individual so that everyone will treat
the person in a consistent manner. This consistency is critical to the success of the individual.
Without it the person may become confused by different expectations. This confusion may
prevent the person from learning to control his/her own behavior.

Behavior is anything you see a person do.
* Behavior is used to get something or to avoid something.
* Behavior is learned.
* Giving attention to a behavior will cause it to increase.
* Behavior is often used as a way to communicate.
* Inside and outside factors that affect behavior

Examples of inside factors:
* physical: lack of sleep, illness, hunger
* emotional: fear, anger, boredom, ability to communicate,
* medications, how you think

Examples of outside factors:
* time of day: early morning, late afternoon
* overcrowding
* days of rainy, cold weather
* temperature
* space
* noise level
* another upset person

Are you a factor?
What do you know about yourself?

Health may affect:
* energy level
* pain/illness
* hunger
* Reactions to stress:
* cutting back on outside activities
* being short-tempered
* feeling tired and worn out all the time

What do you know about others?
* Ways to get to know others:
* Spend time with that person.
* Read that person’s record.
* Talk to family, friends, other staff.

Dealing with anger and hostility. Anger is a natural emotion. Respect the right of a person
to be angry, but anger must be dealt with. If not, it becomes hostility, which can lead to

Understand the causes.
Offer choices besides aggression.

Ways to reinforce positive behavior:
social verbal praise (using specific reinforcement)
pat on the back
preferred items
favorite food
preferred activities

What a person thinks is happening is more important
than what might really be happening.

Working together with others is one of the most important aspects of your job.
In supporting people with developmental disabilities you need to develop therapeutic relationships.
Therapeutic relationships are goal oriented, have boundaries, and are based on needs of the

Good communication leads to a good relationship.
* We communicate through:
* Verbal messages: what you say and how you say it
* Body language: eye contact, posture, gestures, facial expressions
* Augmentative devices: use of machines to help people communicate
* Most of what people communicate is through body language.

Keys to effective communication:
Communication is a two-way street.
Feedback is what you say or do in response to what you heard or saw.

Three steps in giving feedback are:
* When giving feedback, describe exactly what you heard or saw.
* Give feedback as soon as possible.
* Sandwich any corrective feedback between positive statements.
* Say or sign positive statements. Train yourself to focus on good things
* and to respond to them.
* Use active listening.
* Give the person your undivided attention.
* Place yourself at the person’s level.
* Use good eye contact.
* Show respect.
* Learn about the culture of the person.
* Recognize their rights.
* Speak and act without prejudice.
* Value and focus on the strengths of the people you serve.

Why people communicate:
* for attention
* to get something you want
* to show what you like or don’t like
* to show distress
* to avoid things that cause problems

Loss of control over daily and long-range decisions can cause feelings of:
* fear
* panic
* frustration
* insecurity

These feelings can lead to:
* lack of cooperation
* aggression toward oneself or others
* withdrawal from others
* manipulative behavior
* negative attention seeking

You can assist people to have more control by:
* asking the person for input on treatment decisions
* encouraging the person to make decisions on selected items
* assisting the person to evaluate the effectiveness of the decisions
* Always consider the whole person when providing services and supports.
* how they think
* how they feel
* how they deal with the things that happen in their lives

Five Steps in Teaching Decision Making
1.State the problem.
2.List the options.
3.Evaluate the options.
4.Choose and do.
5. valuate the action.

Staff Attitudes and Behavior
What you do or say can help people remain calm, or it can contribute to escalating
* Examples of staff attitudes that tend to escalate behavior:
* ignoring people (except planned ignoring)
* not permitting people to make their own choices
* telling rather than asking
* giving unnecessary commands
* acting aggressively
* teasing or “picking”
* not following through – not keeping your promises
* Staff sometimes have their “buttons” pushed.

What should you do if you see a staff person acting inappropriately or in a way to cause
more problems?
* Trade off.
* Set up a buddy system.
* Suggest a break.
* Work as a team.

Make sure the supervisor knows.
All staff members are legally required to report
abusive behavior.
All staff members have a responsibility to make
sure persons being served are treated with respect
and without harm.

List of risk factors:
* mental illness
* health problems
* past history of violence
* poor communication skills
* poor support system

List of protective factors:
* good self-esteem
* good support system
* strong friends network
* good social/interpersonal skills
* problem-solving abilities

Some behavioral cues for escalating behavior:
* Physical
* turning red
* clenching fists
* pacing
* stomping feet
* crying
* poor eye contact
* excessive body movements
* angry facial expressions
* Verbal
* talking loudly
* cursing
* threatening
* withdrawing
* complaining
* Property abuse
* slamming doors
* breaking things
* throwing things

There are times when behaviors continue to get worse in spite of the efforts of staff.

Strategies that may assist in calming the person down
Verbal strategies
Use a low tone of voice.
Give reassurance.
Let the other person do most of the talking.
Ask what, when, how questions. Get the facts.
Physical strategies

* Use non-threatening body stance: relaxed, arms at sides, not crossed or
* on hips.
* Give the person space: 1.5 to 2 feet away.
* Touch the person only if you have to, and tell them what you are doing.
* Monitor yourself
* Are you making the situation better or worse by your actions?
* Positive reinforcement
* Reward people for not engaging in stressful or conflict-causing behavior.
* Scheduling
* Are the wrong people together at the wrong place at the wrong time?
* Arrange the environment
* Noise level, crowding, placement of furniture, level of light
* Redirection
* Interrupt the harmful behavior by asking the person to do something else.
* Reinforce the attempt at a new activity.
* Natural consequences
* Consequences must fit the act.

Behavior Support Plans are in place for people who have ongoing behavioral issues. It is
critical that Behavior Support Plans are followed as written when behavioral issues occur.
Interventions begin with less restrictive procedures and progress to more restrictive procedures.

Types of restrictions in order of least restrictive to most restrictive:
The first interventions deal with limiting someone’s space:

NETO – (non exclusionary time-out): Temporary removal of person
from ongoing activity but person remains in the activity area. If occurs
for more than 5 minutes then it is necessary to document on Restriction
of Rights form. (Can be used in an emergency.)
ETO – (exclusionary time-out), door not closed or held: Removal of a
person to a separate area or room from which exit is not barred for the
purpose of modifying behavior. (Can be used in an emergency.)
ETO, door held (requires written Behavior Support Plan): Removal of
a person to a separate area or room where the door is closed and held
for the purpose of modifying behavior. Staff should be able to visually
observe the person while he/she is in ETO. This must be a planned and
approved program prior to being used with the people who live here.
(Cannot be used in an emergency.)
ITO – (isolation time-out): Removal of a person to a separate room
from which exit is barred but which is not locked and where there is
continuous supervision by staff. ITO is used for the purpose of
modifying behavior. ITO must be a planned and approved program
prior to being used with the people who live here. (Cannot be used in
an emergency.)

The next interventions deal with limiting someone’s movement and are listed in order of less restrictive to most restrictive:
Benign Personal Restraint: Holding the person’s hands to the side
or front of person with staff member’s hands. If occurs for more
than 5 minutes then it is necessary to document on Restriction of
Rights form. Use no more force than would be required to assist a
person in a skill acquisition task. (Can be used in an emergency.)
Standing Personal Restraint: Holding the person’s arms in front of
him/her with arms crossed at the forearms and held at waist level.
Can also be used to assist the person in walking to another location.
May also be referred to as therapeutic hold. Health status must be
considered prior to implementation. CPR-trained observer must be
present during procedure and for 30 minutes following procedure.
(Can be used in an emergency.)
Prone Personal Restraint: (JIRDC technique. Not a part of NCI.
Requires at least 2 staff.) One staff member places the person in a
therapeutic hold. Second staff member assists by wrapping his/her arms
around the person’s (who is being held) legs. Person (being held) is lifted
and lowered to the floor (buttocks first) and then rolled over to his/her
stomach and held. Health status must be considered prior to
implementation. CPR-trained observer must be present during procedure
and for 30 minutes following procedure. (Prone personal restraint is
used only as part of an approved Behavior Support Plan. It cannot be
used in an emergency.)
A person should be checked for any signs of distress before, during, and after any
restrictive intervention.

When personal restraint is used (standing or prone):
Check breathing before beginning.
A CPR-trained person must be present during personal restraint and for 30 minutes
following the procedure.
A nurse must assess health status at the end of the procedure and document this

Restrictive procedures are documented on the:
* Restriction of Rights form
* Restraint Record (if indicated)
* Accident Incident Form (if indicated)

The person implementing the restrictive procedure is responsible for completing the
appropriate forms; notifying nurse, supervisor, and advocate as necessary; and for
making an entry in the person’s record. An entry should also be made in the log book.

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