Running head: PATIENT RESTRAINT PROTOCOLS Patient Restraint Protocols Patient restraints have been a hot issue within the past ten to fifteen years in nursing. There have been numerous studies done on the adverse affects restraints have on patients, physiologically and psychologically. Anger, fear, impaired mobility, bladder and bowel incontinence, eating difficulty, skin breakdown, and nosocomial infections have all been associated with the use of restraints (Weeks, 1997; Janelli, 1995). Therefore, there has been a move to limit the use of restraints and develop safer protocols for the times that they are used.
All hospitals, today, have restraint protocols that nursing staff should follow when implementing the use of restraints. However, the nursing staff does not always follow these protocols. Protocols often include making sure that the restraints have been tied safely, for easy removal, and doing frequent checks, at least every two hours, to assess for circulation and skin breakdown under and around restraints. This author has observed that the restraints are not always tied correctly. There have been times that restraints had to be cut off with scissors because they have been knotted very tightly to the beds. It has also been observed that some patients have not been assessed every two hours. However, it is frequently documented on restraint sheets that patients are being assessed every two hours when they really are not.
This clinical problem has been identified to be taking place on a 44 bed medical-surgical unit in an inner city hospital. It is a very busy unit with only 4-5 RNs, 1-2 LPNs and 2-3 PCAs working on the unit. The unit, for the most part, receives patients with neurological and respiratory problems. The patients can range in age from 18 to 100
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years old. Many of the patients are at risk for falls due to neurological problems. There are at least two to three patients restrained on the unit on a daily basis.
Some of the reasons nurses restrain patients are to prevent them from harming themselves or others, to help maintain treatment plans, and to control confused or agitated patients (Stratmann, Vinson, Magee and Hardin, 1997). The most frequently used restraints are vests, wrist, belts/ties, mitten and ankle, in that order (Stratmann et al., 1997). Many research studies currently taking place are focused towards discovering alternatives to restraints. Identifying successful alternatives to restraints and educating nurses about alternatives has helped in reducing the use of restraints (Winston, Morelli, Bramble, Friday and Sanders, 1999; Weeks, 1997). There are times, however, when restraints are needed to protect patients (Richman, 1998; Dibartolo, 1998). Restraints would be indicated for an intubated patient who keeps pulling out his endotracheal tube. In such cases, failing to use restraints could result in a claim or lawsuit being brought on for negligence (Richman, 1998).
In 1992, the Food and Drug Administration issued a warning on restraints because of the nearly 300 deaths and injuries related to restraint use occurring each year (Janelli, 1995). Problems identified by the FDA included inappropriate restraint selection, errors in applying devices, and inadequate monitoring of the restrained patient (Janelli, 1995).
Improperly tying restraints can turn into a serious safety issue. When a patient is in a medical emergency and needs to be quickly moved, not being able to remove the restraints quickly, can delay proper treatment. If the hospital or the unit experiences a situation,
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such as a fire, in which the health care team needs to move patients quickly out of harm, improperly tied restraints can become a serious threat to the life and safety of the restrained patient. Incorrect use of a restraint device has led to fractures, burns, and strangulations in the past (Janelli, 1995). The nurse is liable for any harm that can result from restraints that are inappropriately applied (Richman, 1998).
In all cases, in which restraints are used, monitoring of patient needs is critical. The frequency of their monitoring is defined by organizational policy. Documentation is necessary to demonstrate compliance (Kobs, 1997). However, no studies have investigated if the documentation truly demonstrates compliance. As a matter of fact, it hasn't been an issue that has been addressed in the studies done on restraints. In a search of the literature there were no published studies concerning the reliability of documentation regarding restraints.
Although the use of physical restraints has declined in nursing homes, the practice remains widespread in hospitals (Mion, 1996). Nursing staff (RNs, LPNs, and CNAs) from four hospitals completed a survey (Matthiesen, Lamb, McCann, Hollinger-Smith and Walton, 1996) regarding knowledge, practice, and attitudes about physical restraints. Nurses from both geriatric and geropsychiatric units reported significantly more educational activities about restraint use than did nurses on medical units.
Overall, there have been few studies that address hospital physical restraints. However, public awareness of the use of restraints in hospitals has been greatly heightened due to the recent debates about the needs for national standards in Congress (Annas, 1999). New federal regulations were announced in July 1999 which apply to all patients in hospitals that participate in the Medicare and Medicaid programs (Annas, 1999). With heightened
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public awareness, hospitals need to be much more aware of how their policies and protocols are being implemented if they wish to avoid being held liable for not following the federal regulations on restraints.
The goals for a planned change project should include improving nursing education among medical-surgical nursing staff; evaluating knowledge and practice; discovering other methods to check compliance of staff in following restraint protocols.
This author's goal is to improve compliance of restraint standards within the unit using Havelock's planned change model. Havelock's planned change model uses a problem solving process, in which the change agent can organize their work so that change can take place (Yoder-Wise, 1999). A change agent is an individual who leads a change process, in this case the nurse manager of the unit can takes the role of the change agent (Yoder-Wise, 1999). According to Havelock (1973), change can be planned, implemented, and evaluated in six sequential stages (Yoder-Wise, 1999). The six stages are building a relationship, diagnosing the problem, acquiring relevant resources, choosing the solution, gaining acceptance and stabilizing the innovation and generating self-renewal (Yoder-Wise, 1999).
In stage one, building a relationship, the nurse manager can use several strategies to facilitate the change process among the staff. The goal of this stage is to promote readiness for change among the staff. Communication and education about the improper documentation of restraints and improper tying of restraints can be attempted through staff meetings and informal discussions. Staff meetings and informal discussions are ways to promote awareness of the need to change, to keep people informed and to clarify change activities (Yoder-Wise, 1999). A vision is created and the nurse manager seeks input from the staff about ways to go about making the change. The nurse manager needs to be respected
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and trusted by the staff, posses excellent communication skills, and participate actively in the change process in order to be an effective change agent (Yoder-Wise, 1999).
After the nurse manager has build a relationship with the staff, he/she can go on to diagnose the problem. On this medical-surgical unit, a procedure was already in place to address management of the restrained patient, however this author identified areas for improvement in compliance. Feedback from the staff, obtained in stage one, could have identified other problems that the nurse manager wasn't aware of regarding restraints.
Acquirement of relevant resources and equipment is made in stage three. A review of literature on the clinical problem is made. The Standards Department of the Joint Commission can be consulted regarding the current standards on restraint use. Educational flyers about the proper use of restraints can be obtained to distribute among staff. Members from information services, nursing education and nursing administration can be asked to participate with clinical staff members to evaluate the situation and to better understand root causes of the problem. It would be helpful to ask staff from clinical areas caring for patients whom often require restraining measures, such as the psychiatric department to participate (Winston et al., 1999). A nurse researcher could be hired to study restraint issues on the unit, however this idea could be too costly for the institution (Stratmann et al., 1997).
In stage four, choosing the solution, it is vital that the staff participates in choosing the solutions because they most likely know best what would work on their unit. One solution is continuing education services on restraint documentation and how to tie restraints on properly. Another method of education can include periodic validation of competency in management of a patient in restraints (Winston et al., 1999). This can include a demonstration of being able to tie restraints on properly and an evaluation of knowledge of
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the restraint policy. New nursing employees should have to attend a restraint education class and demonstrate the ability to tie restraints on properly before working on the unit. It might be helpful to color code which patients are restrained on the unit, so that staff can easily remember which patients need to get assessments done every two hours (Winston et al., 1999). Perhaps, someone on the unit could be assigned the job of checking periodically that restraints are on properly and doing the assessments. The staff could alternate among themselves the assignment. The nurse manager will have to negotiate ideas with the staff on creating a solution to the problem.
In stage five, gaining acceptance, the nurse manager will present the solution he/she thinks will work. A thorough description and discussion of the plan is made with the staff on the unit.
In the final stage, stabilizing the innovation and generating self-renewal, the nurse manager performs daily monitoring of practice relating to the new standards on management of restrained patients. The monitoring helps reinforce standard requirements. Daily interaction between the nurse manager and the staff helps to clarify any uncertainties regarding the new standards (Winston et al., 1999). The nurse manager will slowly faze out of being the change agent and let the staff take over. Periodically, the nurse manager will perform monitoring of all restraint episodes to assure continued compliance with the new standards (Winston et al., 1999). The nurse manager will also be in charge of informing the staff when they need to attend continuing education classes on restraints and making sure that
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periodic validation of competencies on restraint use of staff members is done. Staff meeting discussions will be held to provide feedback from staff to the nurse manager and provide information on the need for any further changes.
Patient restraints are used to protect patients. However, when they are improperly used they can cause serious harm to patients. If restraints are being used improperly it is vitally important that an attempt is made towards change. Change can not be brought about abruptly; it takes time. It is necessary to recognize that sometimes the attempt towards change might not work. If the planned change does not work, the nurse manager can evaluate why the planned change did not work and attempt again until a solution to the problem is found.
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Annas, G. (1999). The last resort- the use of physical restraints in medical emergencies. The New England Journal of Medicine, 341(18), 1408-1412.
Dibartolo, V. (1998). 9 steps to effective restraint use. RN, 61 (12), 23-24.
Janelli, L. (1995). Physical restraint use in acute care settings. Journal of Nursing Care Quality, 9 (3), 86-92.
Kobs, A. (1997). Patient restraints. Nursing Management, 28 (1), 14-15.
Matthiesen, V., Lamb, K. V., McCann, J., Hollinger-Smith, L. & Walton, J. C. (1996). Hospital nurses' views about physical restraint use with older patients. Journal of Gerontological Nursing, 22 (6), 8-16.
Mion, L. C., Minnick, A., Palmer, R., Kapp, M. & Lamb, K. (1996). Physical restraint use in the hospital setting: unresolved issues and directions for research. Milbank Quarterly, 74 (3), 411-433.
Richman, D. (1998). To restrain or not to restrain? RN, 61 (7), 55-60.
Stratmann, M., Vinson, M. H., Magee, R. & Hardin, S. B. (1997). The effects of research on clinical practice: the use of restraints. Applied Nursing Research, 10 (1), 39-43.
Weeks, S. K. (1997). RAP: a restraint alternative protocol that works. Rehabilitation Nursing, 22 (3), 154-155.
Winston, P. A., Morelli, P., Bramble, J., Friday, A. & Sanders, J. B. (1999). Improving patient care through implementation of nurse-driven restraint protocols. Journal of Nursing Care Quality, 13 (6), 32-46.
Yoder-Wise, P. (1999). Leading and Managing in Nursing. Second Edition. Chapter 5, 74-88.