Clinical Best Practice Guidelines
FEBRUARY 2012
Promoting Safety: Alternative Approaches to the Use of Restraints
BEST PRACTICE GUIDELINES • www.rnao.org 1 Promoting Safety: Alternative Approaches to the Use of Restraints
Disclaimer These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of this work.
Copyright With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from the Registered Nurses’ Association of Ontario. Appropriate credit or citation must appear on all copied materials as follows:
Registered Nurses’ Association of Ontario. (2012). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, ON: Registered Nurses’ Association of Ontario.
This Program is funded by the Ontario Ministry of Health and Long-Term Care.
Contact Information Registered Nurses’ Association of Ontario 158 Pearl Street, Toronto, Ontario M5H 1L3 Website: www.rnao.org/bestpractices
REGISTERED NURSES’ ASSOCIATION OF ONTARIO Promoting Safety: Alternative Approaches to the Use of Restraints
Greetings from Doris Grinspun, Executive Director Registered Nurses’ Association of Ontario
It is with great excitement that the Registered Nurses’ Association of Ontario (RNAO) presents this guideline, Promoting Safety: Alternative Approaches to the Use of Restraints, to the health-care community. Evidence-based practice supports the excellence in service that nurses are committed to delivering in our day-to-day practice. The RNAO is delighted to provide this key resource to you.
The RNAO offers its heartfelt thanks to the many individuals and institutions who are making our vision for Nursing Best Practice Guidelines (BPGs) a reality: the government of Ontario for recognizing our ability to lead the program, and providing multi-year funding; Irmajean Bajnok, Director, RNAO Interna- tional Affairs and Best Practice Guidelines (IABPG) Program, for her expertise and leadership in advancing the production of the BPGs; each and every Team Leader involved, and for this BPG in particular – Laura Wagner and Athina Perivolaris – for their superb stewardship, commitment and expertise. Also thanks to Brenda Dusek, RNAO’s IABPG Program Manager, for her intense work to see that this BPG moved from concept to reality. Special thanks to the BPG Panel – we respect and value your expertise and volunteer work. To all, we could not have done this without you!
The nursing community, with its commitment to and passion for excellence in nursing care, has provided the knowl- edge and countless hours essential to the development, implementation, evaluation and revision of each guideline. Employers have responded enthusiastically by nominating best practice champions, implementing and evaluating the guidelines and working towards a culture of evidence-based practice.
Successful uptake of these guidelines requires a concerted effort from nurse clinicians and their health-care colleagues from other disciplines, and from nurse educators in academic and practice settings and from employers. After lodging these guidelines into their minds and hearts, knowledgeable and skillful nurses and nursing students need healthy and supportive work environments to help bring these guidelines to practice actions.
We ask that you share this guideline with members of your interprofessional team, as there is much to learn from one another. Together, we can ensure that the public receives the best possible care each and every time they come in contact with us. Let’s make them the real winners in this important effort!
Doris Grinspun, RN, MSN, PhD, LLD(Hon), O.ONT. Executive Director Registered Nurses’ Association of Ontario
BEST PRACTICE GUIDELINES • www.rnao.org 1 Promoting Safety: Alternative Approaches to the Use of Restraints
Table of Contents
How to use this Document...... 4
Summary of Recommendations...... 5-7
Interpretation of Evidence...... 8
Development Panel Members...... 9-10
Stakeholder Acknowledgements...... 11-16
BACKGROUND Purpose and Scope...... 17
Responsibility for Development...... 18
Background Context...... 19-21
Practice Recommendations...... 22-43
Education Recommendations...... 44-45
Organization and Policy Recommendations...... 46-50
Research Gaps and Future Implications...... 51
Evaluation/Monitoring of Guideline...... 52-55
RECOMMENDATIONS Implementation Strategies...... 56
Process for Updating and Reviewing Guideline...... 57
References List...... 58-67
Bibliography...... 68-82 REFERENCES
Appendix A: Glossary of Terms...... 83-87
Appendix B: Guideline Development Process...... 88
APPENDICES Appendix C: Process for Systematic Review...... 89-92
2 REGISTERED NURSES’ ASSOCIATION OF ONTARIO Promoting Safety: Alternative Approaches to the Use of Restraints
Appendix D: Description of the Toolkit...... 93
Appendix E: Example: Experience of Being Restrained (SEBR) Interview Tool...... 94-96
Appendix F: Example: Short-Term Assessment of Risk and Treatability Tool (START)...... 97-98
Appendix G: Example: Broset Violence Checklist Tool...... 99-100
Appendix H: Example: Historical-Clinical-Risk Management: 20 (HCR-20)...... 101
Appendix I: Example: Coping Agreement Questionnaire (CAQ)...... 102-103
Appendix J: Example: Alternative Approaches List...... 104-107
Appendix K: Example: Caregivers Perceptions of Restraint Use Questionnaire (PRUQ)...... 108-112
Appendix L: Example: ABC (Antecedent-Behavior-Consequence) Charting Template...... 113
Appendix M: Example: Behaviour Monitoring Log...... 114-115 APPENDICES Appendix N: Example: Alternative to Restraints Decision Tree...... 116
Appendix O: Example: Mutual Action Plan Behaviour Profile...... 117-118
Appendix P: Example: Safety Plan Interventions...... 119-120
Appendix Q: Example: Siderail and Alternative Equipment Intervention Decision Tree...... 121
Appendix R: Example: Personal De-escalation Plan...... 122-123
Appendix S: Example: Safety Plan Women’s Program...... 124
Appendix T: Example: Comfort Plan Mental Health and Addiction Program...... 125
Appendix U: Example: De-escalation Tips and Interventions to Assist Patients Cope...... 126-127
Appendix V: Resource List of Websites...... 128-130
Appendix W : Example: Observation & Documentation Record: 12-Hour Emergency Use of Chemical Restraint, Seclusion & Mechanical Restraint Record...... 131-138
Appendix X: Example: Debriefing Form: Patient Debriefing Tool following Restraint/Seclusion...... 139
Appendix Y: Example: Organization Audit Form: Least Restraint Last Resort (LRLR) Program: Unit-based Data Collection Form for the Least Restraint Last Resort (LRLR) Program Adherence...... 140-144
BEST PRACTICE GUIDELINES • www.rnao.org 3 Promoting Safety: Alternative Approaches to the Use of Restraints
How To Use this Document This nursing best practice guideline is a comprehensive document, which provides resources necessary for the support of evidence-based nursing practice. The document must be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. This guideline should not be applied in a “cookbook” fashion, but rather as a tool to enhance decision-making in the provision of individualized care. In addition, the guideline provides an overview of appropriate structures and supports necessary for the provision of best possible care. BACKGROUND Nurses, other health-care professionals and administrators who lead and facilitate practice changes will find this document invaluable for the development of policies, procedures, protocols, educational programs, and assessment and documentation tools. It is recommended that this nursing best practice guideline be used as a resource tool. Nurses providing direct care will benefit from reviewing the recommendations, the evidence in support of the recommendations and the process that was used to develop the guidelines. However, it is highly recommended that practice settings/environments adapt these guidelines in formats that would be user-friendly for daily use. This guideline has some suggested formats for local adaptation and tailoring.
Organizations wishing to use the guideline may do so in a number of ways: a) Assess current nursing and health-care practices using the recommendations in the guideline. b) Identify recommendations that will address identified needs or gaps in services. c) Develop a plan to implement the recommendations systematically, using associated tools and resources.
The Registered Nurses’ Association of Ontario is interested in hearing how you have implemented this guideline. Please contact us to share your story. Implementation resources will be made available at our website (www.rnao.org) to assist individuals and organizations in implementing best practice guidelines.
4 REGISTERED NURSES’ ASSOCIATION OF ONTARIO Promoting Safety: Alternative Approaches to the Use of Restraints
Summary of Recommendations BACKGROUND Practice Recommendations
Level of RECOMMENDATION Evidence
Nurses establish a therapeutic relationship with the client who is at risk of harm to self/ 1 IV others to help prevent the use of restraints.
Nurses should assess the client on admission and on an ongoing basis to identify any 2 IIb risk factors that may result in the use of restraints.
Nurses should utilize clinical judgment and validated assessment tools to assess clients 3 IIb at risk for restraint use.
Nurses in partnership with the interprofessional team and client/family/substitute 4 decision-makers (SDM) should create an individualized plan of care that focuses on IIb alternative approaches to the use of restraints.
Nurses in partnership with the interprofessional team should continuously monitor and 5 re-evaluate the client’s plan of care based on observation and/or concerns expressed by IV the client and/or family/SDM.
Nurses in partnership with the interprofessional team should implement multi- 6 IIa component strategies to prevent the use of restraints for clients identified at risk.
Nurses in partnership with the interprofessional team should implement de-escalation and 7 crisis management techniques and mobilize the appropriate resources to promote safety IIb and mitigate risk of harm for all in the presence of escalating responsive behaviours.
Nurses in partnership with the interprofessional team should engage in care practices 8 that minimize any risk to the client’s safety and well-being throughout the duration of IV any restraining process.
BEST PRACTICE GUIDELINES • www.rnao.org 5 BACKGROUND 6
Education Recommendations Promoting Alternative Safety: Approaches to theUse Restraints of 9 REGISTERED NURSES’ASSOCIATION OFONTARIO
opportunities withspecificemphasison: in allentrytopracticenursingcurriculaaswellongoingprofessional development Education onworkingwithclientsatriskfortheuseofrestraints shouldbeincluded RECOMMENDATION ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Therapeuticnurseclientrelationships; client-centred care andclientrights; Monitoringanddocumentationresponsibilities; Interprofessional collaboration; Ethicaldecision-making; Educationonnursingresponsibilities fortheproper applicationofrestraints; Approaches tocare: (e.g.traumainformedcare); of restraints. Understanding ofthelegalandlegislativerequirements theuse governing the potentialcomplicationsfrom theuseofrestraints; and Types ofrestraints (leasttomostrestrictive) andassociatedsafetyrisks, human rights; beliefs surrounding theuseofrestraints andthreats toclientautonomyand Nurses’ responsibilities regarding self-reflection andexploringtheirvalues management; Knowledge ofbasicprevention,approaches, alternative de-escalationandcrisis behaviours puttingclientsatriskfortheuseofrestraints; Knowledge ofdiagnosesandcommontriggersassociatedwithresponsive of debriefing; Communication andeducationofclient/family/SDMkeycomponents Evidence Level of Ib BACKGROUND 7 III Ib IV
Level of of Level Evidence
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Organizations may wish to develop a plan for implementation that includes: planning, resources, organizational and administrative support, as well as appropriate organizational and administrative support, as well as appropriate planning, resources, Opportunities for reflection on personal and organizational experience in on personal Opportunities for reflection implementing guidelines. Ongoing opportunities for discussion and education to reinforce the importance Ongoing opportunities for discussion and education to reinforce of best practices. the support needed for the Dedication of a qualified individual to provide education and implementation process. An assessment of organizational readiness and barriers to education, taking into An assessment of organizational readiness account local circumstances. supportive function) or indirect Involvement of all members (whether in a direct who will contribute to the implementation process. Establishing communication responsibilities and debriefing procedures for client/ and debriefing procedures Establishing communication responsibilities team; and family/SDM and the interprofessional use, the uptake to monitor the rate of restraint Establishing evaluation programs client/family/ and the impact on of restraints, of alternative to the use approaches team safety. SDM and interprofessional Establishing monitoring protocols for clients and the documentation requirements requirements for clients and the documentation Establishing monitoring protocols episode; for the duration of any restraining Establishing a restraint reduction/prevention policy; reduction/prevention Establishing a restraint of clients at risk of harm that allow for early identification Developing structures them at risk for the use of restraints; to self/others placing use and risks of restraint about the associated Educating the client/family/SDM exploring their concepts of safety; education on alternative including staff Establishing a multi-component program strategies to the use of restraints; Establishing a definition of what is a restraint; of what is a Establishing a definition Using alternative approaches, de-escalation and crisis management as the first andUsing alternative de-escalation approaches, measure as a safety prior to the use of restraints second line intervention strategies of last resort; Ongoing opportunities for discussion and education to reinforce the importance of Ongoing opportunities for discussion and education to reinforce best practices. Developing a philosophy that promotes alternative approaches to the use of restraints; of use the to alternative approaches promotes that philosophy a Developing
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ RECOMMENDATION facilitation. Health-care organizations should implement risk management and quality improvement and quality improvement should implement risk management organizations Health-care to the use of alternative approaches that promotes a culture strategies to enable by: safety of client rights and staff in support restraints
Nursing best practice guidelines can be successfully implemented only where there are ad- are there be successfully implemented only where Nursing best practice guidelines can equate
The organization’s model of care should promote an interprofessional team approach in team approach an interprofessional should promote model of care The organization’s that supports the use of alternativecollaboration with the client/family/SDM approaches the use of restraints. and prevents
10 12 11 Organization & Policy Recommendations & Policy Organization Promoting Safety: Alternative Approaches to the Use of Restraints
Interpretation of Evidence
Types of Evidence
Levels of Evidence
Ia Evidence obtained from systematic review and meta-analysis of randomized controlled trials. BACKGROUND
Ib Evidence obtained from at least one well-designed randomized controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomization.
Evidence obtained from at least one other type of well-designed quasi-experimental study, without IIb randomization.
Evidence obtained from well-designed non-experimental descriptive studies, such as comparative III studies, correlation studies and case studies.
Evidence obtained from expert committee reports or opinions and/or clinical experiences of IV respected authorities.
Source: SIGN 50. Levels of Evidence. Available at: http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html
8 REGISTERED NURSES’ ASSOCIATION OF ONTARIO BACKGROUND 9
www.rnao.org RN, BHK, BScN, MSc
RN, MScN RN, BScN, BHSc, MN RN, BScN, MEd RN, BScN, MScN, MEd RN, BScN, MScN, RN, BScN, MHSc, CHE RN, BN, MScN, GNC(C) RN, BScN, MSN BEST PRACTICE GUIDELINES • Clinical Nurse Specialist, Medical Psychiatry Program Psychiatry Medical Specialist, Nurse Clinical Department of Psychiatry Children Sick for Hospital Ontario Toronto, Advanced Practice Nurse, Geriatrics Nurse, Practice Advanced Hospital The Ottawa Ontario Ottawa, Michelle A. Peralta Paula Raggiunti Dianne Rossy Sanaz Riahi Mary Anne Lamothe Mary Anne Ibo Barbacsy-MacDonald Coordinator Best Practice Care Long-Term Integration Network Health Local East, South ofAssociation Ontario Nurses’ Registered Ontario Eastern South Mary-Lou Martin Catherine Morash Director, Infection Prevention & Control Prevention Infection Director, System Health Valley Rouge Ontario Scarborough, Clinical Nurse Specialist, St Joseph’s Healthcare St Joseph’s Specialist, Nurse Clinical University McMaster Professor, Associate Ontario Hamilton, Clinical Education Leader Education Clinical Practice Professional Sciences Health Mental for Centre Ontario Shores Ontario Whitby, Advanced Practice Nurse, Trauma, Emergency & Critical & Care Emergency Trauma, Nurse, Practice Advanced Centre Sciences Health Sunnybrook Ontario Toronto, Coordinator Clinical Practice & Standards & Standards Practice Clinical Coordinator Centre Health Regional Bay North Ontario Bay, North Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting RN, BScN, MN RN, PhD RN, BScN RN, BScN, MN, GNC(C) BSc, BSW, MSW, RSW MSW, BSc, BSW,
RN, BScN, MN, CNN(C), CRN(C) RN, BScN, MN, GNC(C)
Team Leader Team Nurse Practice Advanced and Addiction for Centre Health/Gerontology, Mental Health Mental Ontario Toronto, Mental Health Commission of Commission 2011) (July Canada Health Mental Associates and Lisa Casselman Alberta Calgary, Corporate Nursing Consultant Nursing/Retirement Homes Nursing/Retirement Consultant Nursing Corporate (Corporate) Homes Nursing Care Caressant Ontario Woodstock, Jeanette Kuntz Susan Edgar Louise Carreau Lisa Casselman Nancy Boaro Athina Perivolaris
Laura M. Wagner Laura Development Panel Members Panel Development Advanced Practice Leader, Neuro Program Neuro Leader, Practice Advanced Institute Rehabilitation Toronto Ontario Toronto, Team Leader Team Scientist Adjunct Unit Research & Evaluative Applied Lunenfeld Kunin System Geriatric Care Health Baycrest Ontario Toronto, Professor Assistant of College Nursing University York New Geriatric for Nursing Institute Hartford USA NY, York, New Advanced Practice Nurse Nurse Practice Advanced Care Continuing Bruyère Ontario Ottawa, Clinical Nurse Specialist, Geriatrics Specialist, Nurse Clinical Hospital, Grand River Ontario Kitchener/Waterloo, BACKGROUND 10
literature and the preparation of evidence tables. evidence literature andthepreparation of Sangster BA, M.CL.SC.(Candidate), Research the Assistant for their contribution of to appraisal thequality RNAOThe would like to acknowledge Tang Mary RN, BScN, MN, ENC(C), Lead Research Assistant, andLaura Molly Westland Anne Stephens Promoting Alternative Safety: Approaches to theUse Restraints of Peterborough, Ontario Fleming College Education HealthSchool and of Wellness Academic Chair
Toronto, Ontario Toronto Community Care Central Access Centre Clinical Nurse -Seniors Care Specialist Further detailsare available from theRegistered Nurses’ Ontario. Association of interest andconfidentiality of Declarations were theguideline development made memberspanel.by all of REGISTERED NURSES’ASSOCIATION OFONTARIO RN,BScN,MEd,GNC(C) RN,BScN,MN Toronto, Ontario Registered Nurses’ Ontario Association of International Affairs Practice andBest Guidelines Program Facilitator, Program Manager Glynis Vales Brenda Dusek, Toronto, Ontario Registered Nurses’ Ontario Association of International Affairs Practice andBest Guidelines Program Program Assistant BA RN, BN,MN BACKGROUND 11
www.rnao.org BEST PRACTICE GUIDELINES •
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Coordinator Empowerment Council Empowerment Health and Mental Addiction for Centre Ontario Toronto, Educator Regional Authority Health Regional Winnipeg Manitoba Winnipeg, Medicine President Vice Associate Hospital Grand River Ontario Kitchener, Consultant Nursing Corporate Inc. AON Ontario Omemee, Health Mental Inpatient Leader Team Hospital Orillia Memorial Soldiers Ontario Orillia, Client Services Client Manager Program Care Enhanced Seniors Centre, Access Central Care Community Toronto Ontario Toronto, Principal Consulting Ashton Territories West North Yellowknife, Coordinator Guideline BestPractice Care Long-Term Integration Network Health Local Central, OntarioAssociation Nurses’ Registered Ontario Toronto, Clinical SpecialistClinical Health Ontario Information Mental Health for Institute Canadian System Reporting Ontario Toronto, ofDirector Nursing & Innovation Research Knowledge Centre Sciences Health Sunnybrook Ontario Toronto,
Jennifer Chambers BSc Margaret Blastorah RN, PhD Joy Bevan RN, BHSc(Nurs), MHSM Susan Bernjak BA, RN, CACE, GNC(C) Jennifer Berger RN, BScN, MSc, CPMHN(C) Shawna Belcher RN, BScN, CPMHN(C) Linda Bayly RN, BScN, GNC(C) Susan Bailey RN, BA, MHScN Susan Ashton RN, BScN, PHN Susan Ashton RN, Jamie Arthur BSc, BScPT Jamie Arthur BSc, Stakeholder Acknowledgement Stakeholder Stakeholders representing diverse perspectives were solicited for their feedback and Association the ofRegistered Nurses’ Guideline: BestPractice reviewing in contribution their following the for acknowledge this Nursing to like Ontario would BACKGROUND 12
Michele DurrantRN,MSc Deborah DuncanRN Lynda DunalMSc,BScOT, OTReg.(Ont) Nicole DidykMD,FRCP(C) Sylvia DavidsonMSc,DipGer, OTReg.(Ont.) Michelle DaGloriaRN,BScN Kathy CulhaneRN Yvonne CraigBScN,BN,RN,CPMHN(C) Debora CowieRPN Michelle Court,RN Theresa Claxon-Wali, CPS Uppala ChandrasekeraMSW, RSW Promoting Alternative Safety: Approaches to theUse Restraints of
REGISTERED NURSES’ASSOCIATION OFONTARIO
Toronto, Ontario HospitalThe for Sick Children Advanced Nursing Practice Educator Penetanguishene, Ontario Waypoint Centre for Mental Health Care Vice President Regional Programs Toronto, Ontario Toronto Rehabilitation Institute –University Centre Advanced Practice Leader –Geriatrics Toronto, Ontario Canadian Mental Health Association Ontario Planning andPolicy Analyst Toronto, Ontario Mental Health PatientOntario Association of Councils, Centre for Addiction and Chair Guelph, Ontario Guelph Hospital General Clinical Educator, Professional Practice Lead Medicine Hamilton, Ontario St. Joseph’s Hospital Mountain Site NurseStaff (Mental Health) Waterloo, Ontario Michael G. Groote De Medicine School McMaster of University Waterloo Regional Campus St. Mary’s Hospital/Grand River Hospital Geriatrician Whitby, Ontario ShoresOntario Centre for Mental Health Sciences andBereavementGrief Educator Toronto, Ontario Baycrest Health Care Geriatric System Occupational Therapist Ottawa, Ontario Professional Development, Prevention Crisis Instructor Royal Ottawa Mental Health Centre Nurse Clinician Wawa, Ontario Lady Health Dunn Centre Nurse Educator BACKGROUND 13
www.rnao.org
BEST PRACTICE GUIDELINES •
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Nurse Practitioner – Geriatrics Practitioner Nurse General Hospital Mary’s St. Ontario Waterloo, Staff Nurse Park West Campus, Birchmount The Scarborough Hospital, Centre Healthcare Ontario Scarborough, Instructor Clinical Staff Nurse, Centre Sciences Health London College Fanshawe Ontario London, Practice Nursing Manager Lakeview Manor Ontario Beaverton, Programs Clinical Manager Senior Children Sick for The Hospital Ontario Toronto, Coordinator Guideline BestPractice Care Long-Term Projects Provincial OntarioAssociation Nurses’ Registered Ontario Toronto, Clinical Nurse Specialist/Adult-Nurse Practitioner Geriatric Practitioner Services Specialist/Adult-Nurse Nurse Clinical University McMaster Professor, Clinical Assistant Healthcare Joseph’s St. Ontario Hamilton, Extendicare, E.O. Extendicare, Consultant, Care Long-Term Office Corporate Canada Extendicare Ontario Markham, Product Development Specialist Development Product Canada Accreditation Ontario Ottawa, Educator Nurse & Health Mental Hamilton Healthcare Joseph’s St. Program Addiction Ontario Hamilton, Clinical Nurse Specialist Nurse Clinical Hospital Children’s McMaster Unit Health Mental Youth and Child Ontario Hamilton,
Stephanie Laivenieks RN, BScN Karen J. Kieley MHSA Hellen Jarman RN(EC), NP-PHC, BScN Laurie Horricks MN, RN Carol Holmes RN, BScN, MN, GNC(C) Kathy-Lynn Greig RPN, BScN Student Kathy-Lynn Leslie Green RN Bettyann Goertz RN, BScN, CPMHNC Ainsley Gillespie RN, MScN Ainsley Gillespie Lisebeth Gatkowski RN, BScN, CPMHN(C) Lisebeth Gatkowski Patricia A. Ford RN(EC), BA(N), MHSc, GNC(C) Ford RN(EC), BA(N), Patricia A. BACKGROUND 14
Susan PhillipsRN,MScN,GNC(C) Emily ParsonsRN,BScN,MN,GNC(C) BScN, MN,GNC(C) Rola MoghabghabNP-Adult, OT Reg.(Ont.) B. McGibbonLammiMScBHSc(OT), Peggy McDougallRN,MSc(A) Sandra MairsRN,BScN,MHSc(N),GNC(C) Tina MahBScOT, MBA Steve LurieBA,MSW, MMGT Elena LukRN,BScN,CNCC(C) Arlette LefebvreMD,FRCP(C) Sandra LawRN,MA Frances Lankin Promoting Alternative Safety: Approaches to theUse Restraints of
REGISTERED NURSES’ASSOCIATION OFONTARIO
Ottawa, Ontario OttawaThe Hospital, NurseGeriatric Specialist Toronto, Ontario Social Assistance inOntario Services,Community andSocial Commission for theReview of Commissioner Oshawa, Ontario College/UniversityDurham Technology Institute Ontario of of Professor, Collaborative BScNProgram Toronto, Ontario Hospital for Sick Children PsychiatristStaff Toronto, Ontario St. Michael’s Hospital Ottawa, Ontario Canadian Occupational Therapist Association of Ottawa, Ontario Bruyère Continuing Care NurseStaff Kitchener, Ontario Grand River Hospital Vice President, PlanningandPerformance Management Kitchener, Ontario Grand River Hospital Clinical Nurse Emergency Management –Geriatric Specialist Nurse Nurse Emergency Management Practitioner -Geriatric Toronto, Ontario NurseGeriatric Practitioner (U.S.) Clinical NurseGeriatric Specialist, Toronto, Ontario University Toronto of Lawrence S. Nursing of Bloomberg Faculty PhD Student Policy Analyst Toronto, Ontario CanadianThe Mental Health Association, Toronto Branch Executive Director
BACKGROUND 15
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Medicine – Geriatrics, Nurse Practice Advanced Hospital Brant Memorial Joseph Ontario Burlington, Geriatric Emergency Management Nurse Nurse Geriatric Management Emergency Central Hospital York Ontario Hill, Richmond Critical Care Manager, Research Hospital Michael’s St. Ontario Toronto, Emergency/Trauma Nurse Practice Advanced Staff Nurse Forensic Secure Hamilton Healthcare St.Josephs’ Ontario Hamilton, Coordinator Education Authority Health Regional Interlake Manitoba Selkirk, Manager Program Office Advocate Patient Psychiatric Ontario Toronto, Staff Lawyer Centre Disability Law ARCH Ontario Toronto, Center Sciences Health Sunnybrook Ontario Toronto, Leader Practice Clinical System Health Valley Rouge Ontario Ajax, Coordinator Advocacy and Policy Society ofSchizophrenia Ontario Ontario Toronto, Manager Project Safety Institute Patient Canadian Alberta Edmonton, Chief Officer Practice Central Hospital York Ontario Hill, Richmond Educator Nurse Healthcare Joseph’s St. Ontario Hamilton,
Fran Szypula RN, BScN, CPMHN(C) Irina Sytcheva MSW, RSW Irina Sytcheva MSW, Susanne Swayze RPN Stanley Stylianos BS, BA Lily Spanjevic RN, BScN, MN, GNC(C), CRN(C) Lily Spanjevic RN, BScN, MN, GNC(C), Denise Sorel RN, BScN, CIC Orla Smith RN, BScN, MN, CNCC(C) Judy Smith RN, BScN, MDE, ENC(C) Tess Sheldon MSc, JD, LLM Tess Dorene Rosmus RN, BN, GNC(C) Dorene Rosmus RN, Tiziana Rivera RN, BScN, MSc, GNC(C) Rivera RN, BScN, Tiziana Ping Rau RN, MSc, CPMHN(C) Ping Rau RN, MSc, Sharon Ramagnano RN, BScN(E), Sharon Ramagnano ENC(C) MSN/MHA, BACKGROUND 16
Luana WhitbreadRN,BSc,BN,MN,GNC(c) Natalie Warner RN,MN Dania Versailles RN,BScN,MScN,CVAA(C) Andrea Trainor RN,BSc(N),MSc(A) Heather ThompsonRN Promoting Alternative Safety: Approaches to theUse Restraints of
REGISTERED NURSES’ASSOCIATION OFONTARIO
Ottawa, Ontario Bruyère Continuing Care Advanced Practice Nurse Toronto, Ontario Registered Nurses’ Association Ontario North East, Local Health Network Integration Long-Term Care Practice Best Guideline Coordinator Toronto, Ontario Registered Nurses’ Association Ontario East,Central Local Health Network Integration Long-Term Care Practice Best Guideline Coordinator Ottawa, Ontario Hopital Montfort Clinical Nurse Specialist Winnipeg, Manitoba Winnipeg Regional Health Authority Personal Care Home Program Clinical Nurse Specialist Promoting Safety: Alternative Approaches to the Use of Restraints
Purpose and Scope
Best practice guidelines are systematically developed statements to assist practitioners’ and clients’ decisions about appropriate BACKGROUND health care (Field & Lohr, 1990).
This guideline provides evidence-based recommendations for Registered Nurses (RNs) and Registered Practical Nurses (RPNs) related to the care of individuals who are at risk for behaviours that may result in harm to self/others and lead to the possible use of restraints (physical, chemical, environmental). Unless otherwise indicated in the guideline, the discussion focus is on physical restraint.
It is the intent of this document to assist RNs and RPNs to focus on evidence-based best practices within the context of the nurse-client relationship and on strategies for assessment, prevention and use of alternative practices (including de-escalation and crisis management techniques) to prevent the use of restraints, and move towards restraint-free care in diverse settings such as acute, long-term and home health-care.
The Appendices included at the end of this guideline are provided as examples of the types of tools in use from various orga- nizations. The content of these documents may or may not align with the terminology or definitions of terms (see Appendix A) used within this document. The examples can assist interprofessional team members and organizations to understand the application of the concepts presented within the discussion of evidence, and to explore what type of tools would be required.
The movement towards the use of alternative practices for restraint-free care cannot apply to all organizational setting (e.g. Policing and Corrections), as these settings are beyond the scope of this guideline.
Nurses play a significant role in client safety through implementation of alternative strategies to prevent the use of restraints and to avoid the potential harmful outcomes associated with the use of restraints. It is acknowledged that this guideline cannot encompass all organizational settings and populations due to lack of research in some practice areas. This guideline seeks to bring forth the best available research findings in the form of recommendations. However, we do support the review of Promoting Safety: Alternative Approaches to the Use of Restraints by nurses to identify the best practice recommendations most appropriate for implementation within any institution that pertains to the practice of nursing and within the context of any Federal and Provincial regulations governing the setting and populations served.
An attempt has been made throughout this document to identify to the reader the research population and health sector where the research was conducted. However, lack of research studies in some health-care sectors such as home health-care, specialty areas such as procedure/treatment and operating rooms, and special populations such as paediatrics, have resulted in some limitations. Nurses working within these areas should review each recommendation and supporting discussion of evidence for applicability to the setting and population to ensure the promotion of safety within the context of that environment.
Nurses working in any health care setting must be aware of the legislation that pertains to their geographic location, health care sector type and client population as they move towards the implementation of best practices to support restraint-free environments.
It is intended that this guideline will be applicable to all domains of nursing including clinical, administration and education to assist nurses’ to become more comfortable, confident and competent when caring for individuals at risk for harm to self/others.
BEST PRACTICE GUIDELINES • www.rnao.org 17 BACKGROUND 18
of time when prevention, when time of have management de-escalation strategies andcrisis to failed keep and/or theindividual others safe. This guideline can provide support for nurses who are considering the use restraints of as a last resort, for the shortest duration
conducted. See andoutcomes. thesearchAppendix strategy B& Cfor detailsof was evidence of types other and studies research relevant reviews, systematic guidelines, practice clinical for literature of restraints. alternativeSubsequently,guideline,and practice of approaches use best clientsafety tothe the scopeof searcha the on consensus to came and work their of purpose RNAO.the the discussed panel of The auspices the convenedunder was sectors and research practice,and healthcaresettings fromin education multiple expertise Inwith 2010,April panel a To access theCoroner’s verdict thefull of Jury, http://www.sse.gov.on.ca/mohltc/PPAO/en/Documents/sys-inq-jam.pdf visit Registered Nurses’AssociationofOntario(RNAO) were restraints: recommendations aguideline thefollowing on thetopic thecreation of associatedof with report the in Contained embolism. pulmonary acute as identified death of cause with died, subsequently who restraints September 18th to October 10, 2008. The inquest was to review the death an of individual who had just been released from Health Long-Termand of recommendations fromresultCareCoroner’s a of the as Inquest, Ontario,in from held Canada Promoting Safety: Alternative Approaches to the Use of Restraints guideline development was funded by the Ontario Ministry Responsibility forDevelopment guideline focusesonThis three areas: Promoting Alternative Safety: Approaches to theUse Restraints of
communication between health-care professionals and clients/families andsubstitute decision-makers (SDM). ongoingcoordinated incorporates interprofessionala approachthat on depends care effectivehealth that acknowledged is It must inplace be are restraints when used. identify what is a restraint versus a Personal Assistance Service Device (PASD), and what monitoring and observation practices last resort. Nurses working within organizations must be aware of the organization specificpolicies and procedures in order to needed, optionclient toa the restraint as best used tothe be workand if identifyand alternatives restraints with to of use the interprofessionalthe team, client’sknownurses,with their that collaboration in(trauma/preferences) important history is It
iii. ii. i. 62. atoolkit. provided guideline shouldbe practice thebest That to theuseof nurses with 61. for all clients who are routines. restraint restrained of who andmonitoring for clients all toused related be totype thebest appropriate recommendations specific of was foundNo to guidethedevelopment research evidence orbest
REGISTERED NURSES’ASSOCIATION OFONTARIO consultation relevant stakeholders with Nurses’ such astheOntario Association. clients,psychiatric in restraints RNAOin the That of use forthe guideline practice developnursing should best a Restraint Use Focused on Client Safety. De-escalation InterventionsDe-escalation Management; andCrisis and Assessment, Prevention and Alternative Approaches;
BACKGROUND 19
. . Evans, Evans,
www.rnao.org (Dickson & Pollanen, 2009) (Dickson & Pollanen, . Short-termhas use restraint . BEST PRACTICE GUIDELINES • Patient Restraints 2001 Patient Minimization Act, (Bill 85) (available (Pellfolk, Gustafson, Bucht, & Karlsson, 2010) Karlsson, & Bucht, Gustafson, (Pellfolk, Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting (Huckshorn, 2004; Mental Health Commission of Canada, 2009; Schrank & Slade, 2007) & Slade, Schrank 2009; Mental Health Commission of Canada, 2004; (Huckshorn, . (Johnson, Ostaszkiewics, & O’Connell, 2009; Livingston, Verdun-Jones, Brink, Lussier, & Nicholls, 2010; Nay & Koch, Nay & Koch, 2010; & Nicholls, Lussier, Brink, Verdun-Jones, Livingston, 2009; & O’Connell, Ostaszkiewics, (Johnson, include a table fixed to achair a or Physical include table arestraints fixed bed rail that cannot beopenedby the client. . Despite the enactment of the Patient Restraints Minimization Act, 2001 and a plethora of Act, the Despite enactmentorga- of Minimization Restraints . the Patient
. . The prevention of behaviours such as aggression, wandering and treatment interference has been are any Chemical form restraints are any of medication used psychoactive not but to treat to intentionally illness, inhibit a
). Since ). health-care then, facilities have http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_01p16_e.htm
been associated with sudden death arising from deep vein thrombosis and pulmonary thrombosis embolism vein deep withbeen associated arising death from sudden The use of physical restraints to prevent falls and injuries has not been and proven might even increase risk of falls ( Seclusion, with or without restraint, is a measure used as an intervention to manage clients that remains poorly documented documented poorly remains that clients manage to intervention an as used measure a is restraint, without or with Seclusion, in health-care settings. Feng et al. (2009) undertook a cross-national study on restraint use and antipsychotic use in long term care homes and identified theprevalence of physical restraint use31% to over beand variedFinland, in 28% more thanKong, five-fold acrossHong in the20% study States, United the in 9% Switzerland, in 6% average an from – countries restraint physical of prevalence the outlined (2007) Leipzig & Catrambone, Johnson, Mion, Minnick, by study A Canada. in use in hospitals in the United States of America as 50 per 1,000 patient A days. recent study by Dumais, Larue, Drapeau, Allard (2010) & on Giguere 2,721 psychiatric patients in Menard, Canadian mental health care facilities found that 23.2% of and that 17.5% of restraint. in seclusion had been placed with clients had been them secluded (physical) particular movement. behaviour or Restraints Restraints as definedby theCollege of Nurses of Ontario (CNO), (rev. 2009c) arephysical, environmental or chemical measures used to control the physical or behavioural activity of a person or a portion of Physical restraints his/her body. movement. limit a client’s Environmental restraints control a client’s mobility. Examples include a secure unit or garden, seclusion or a time-out room. reported to be associated with several harmful physical, psychological and social effects to the client such as impaired mobility, mobility, impaired as such client the to effects social and psychological physical, harmful several with associated be to reported behaviouralsocialfunctionand and symptoms cognition 2006; Ralphs-Thibodeau et al.; Ryan & Bowers, 2006) & Bowers, Ryan et al.; Ralphs-Thibodeau 2006; The guideline development panel believes that a move towards a restraint-free environment is demonstrated in the model, model, the in demonstrated is environment restraint-free a towards move a that believes panel development guideline The predominately is focus first The 1. Figure in represented of Restraints Use the to Approaches Safety:Alternative Promoting on prevention, alternative approaches and assessment; the second focus on implementation including use ofof de-escalation interventions alternative and crisis approaches management; the last focus of care is restraint use as that culture restraint-free a a paradigma adopting towards shift thus last ineffective, resort proven have alternatives allother after only rather minimizing restraints. than just restraint, to alternatives focuses on It It was the consensus of the guideline development panel that the use of a model in tandem with guiding principles was a critical starting point in the development of the guideline for nurses in order to promote a move restraint-free towards individuals at risk for of environments demonstrating of behaviours self/others. harm to nizational policies and procedures, nizational front policies line health and care procedures, providers continue to strong regarding voice concerns the use of restraints. Reports of injury and death even methodscontinue “less to when such restrictive” occur, as seat belts are used as restraints. In mental health, the use of restraint is not consistent with a recovery model that focuses on client control, in their own care and involvement empowerment
at: at: ofuse the alternatives encourage and restraints chemical and ofuse the physical minimize to practices and policies created 2006) et al., (Ralphs-Thibodeau Background Context Context Background the In 2001, June province of Ontario in Canada enacted the Wood, Wood, & Lambert, 2002) Front line Front health care providers continue to apply voicing restraints, concerns that restraint-free or least restraint policies staff), (including workload others and riskincreasing whileofthe clients increase harmto would of lack a and alternatives and the risk organizations to BACKGROUND 20
the UseofRestraints Promoting Safety:AlternativeApproachesto Figure 1: Model Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO Approaches &Assessment Prevention, Alternative De-escalation &Crisis Management Restraint Use • •Organization: •Debriefing • • • •RN/RPNScope of Restraint Use as aLastResort: •Harm Reduction &EvaluationObservation Practices •Post-Crisis •Understanding EscalationProcess theCrisis • • • Prevention, Alternative Approaches & Assessment:
• •Communication: ManagementCrisis Interventions: &De-escalation • Quality improvementQuality program Verbal/Non-verbal Skills Diffusing strategies Assessment: When Prevention Strategies: tapering use; anddiscontinuationtapering Ethics Safe Use of non-emergency psychological impacts Cultural Contest, Client Safety: Techniques:De-escalation School/Curriculum &education programs ■ ■ ■ ■ ■ Understanding behaviourre needs unmet Care Individualized Planof BehaviourSupport Sensory teaching, Sensory stratgies self-soothing Culture, philosophy, policy Other All Restraints: Activities: algorithms/tool; myths&truths; Alternatives Have Proven ineffective Harm Reduction Philosophy, cognitive impairment Practice debriefing application; emergency vs. prevention &safety factors; risk monitoring;
Promoting Safety: Alternative Approaches to the Use of Restraints
The guiding principles used to assist in the development of the Promoting Safety: Alternative Approaches to the Use of Restraints guideline are as follows: BACKGROUND
Guiding Principles/Assumptions in Promoting Safety: Alternative Approaches to the Use of Restraints
• Clients – patient, resident, consumer, family, significant others, substitute decision-maker (SDM) – are active partners in care to the extent of their capacity and in collaboration with the interprofessional health-care team. • The philosophy of individualized care is foundational to the therapeutic nurse patient relationship. • All client behaviour has meaning that is contributing to the underlying cause. • Prevention of the use of restraints starts with assessment and use of alternative approaches. • De-escalation techniques for crisis management can be used as a prevention strategy to avoid the use of restraints. • Leadership is required across all organizational and health care sector levels to create a move towards restraint free environments. • When restraint use is unavoidable, the least restrictive form of restraint is used for the shortest duration of time for avoidance of harm to self/others; restraint use is temporary and alternatives must continue to be considered.
BEST PRACTICE GUIDELINES • www.rnao.org 21 BACKGROUND 22
clients. health mental for restraint physical of experience subjective the explored (2002) Wellman& Rawcliffe,Lowe,Bonner, therapeutic the is nursing (rev. coreCNO the of at The Nurse that Relationship identifies StandardClientTherapeutic 2009d) therapeutic The 2005). [NCCNSC], Care Supportive and Nursing for Centre Collaborating (National behaviour aggressive disturbed/ decreased to contributes staff and clients between developed relationship therapeutic the that exists Evidence Discussion ofEvidence Use ofRestraints Prevention andAlternativeApproachestothe Practice RecommendationsforAssessment, Promoting Alternative Safety: Approaches to theUse Restraints of insight on episodes. restraining insight clientstogain nursesand between discussionsfacilitate can that tool a of example an is that guide interview structured E) Science, University of Pennsylvania School of Nursing has a or illness) (e.g. factors internal consider external factors or to(e.g. environment) seek that could team contributeto to emerging clientdisturbed and/or interprofessional aggressive behaviour.the and Pennwith Nursing collaboration nurse facilitate the and client assist the know would to come clients with time Spending andduringthe process. before restraining staff the with of time duration more from have benefited would they perceived clients that identified Findings match theclient’s needs. the client’s behaviour in the context the of situation and the nurse-client interaction to identify the interventionsright that of meaning the understand to important is it indicate (2001) Hauser & Johnsonwell-being. and client’s the safety ensure to effectiveplanned that be so interventionscan reasonsbehaviour or the for triggers tothe determine important is it and ventions that help prevent and manage behaviours that may put the client at risk for restraint use. All behaviour has meaning interclient’sindividualize the to and behaviour of meaning the understandorder to in cues or triggers for observe nurse the client from harm and ensure the relationship is psychotherapeutic. Knowing the client as a unique individual helps the inherentthe power nursethe careof health a in professional’s role. (rev.CNO the identifies that 2009d) nurseis to protect be must awarenessthe empathy,byand on professional relationship based intimacy requires whichappropriate of knowledge trust and respect This well-being. and health client’s the supports that relationship key a relationship, nurse-client for use.restraint risk the increase that behaviours the minimize or prevent help to strategies management crisis and de-escalation of communication and calming techniques when situations arise. Understanding the client’s experience facilitates the success behavioursminimize whichor increaseprevent the torisk for restraint needed use.is Oftende-escalation when trustwhere is established,interventions clientsof areimplementation more forreceptive allows to that therapeutic care of plan a of development the in assist to client the with behaviour contentand emotions,explorethought totechniques communication therapeutic utilize effectively to nurse the of ability (RNAO,the relationship,does the so in rev.develops trust 2006b).As relationship is foundational for trust, therapeutic communication and understanding the meaning the of client’s behaviours help preventtheuseofrestraints. Nurses establishatherapeuticrelationshipwiththeclientwhoisatriskofharmtoself/others RECOMMENDATION 1 REGISTERED NURSES’ASSOCIATION OFONTARIO Subjective Experience Subjective of Experience Being Restrained (SEBR) (see Appendix Level ofEvidence=IV -
BACKGROUND 23
www.rnao.org Level of Evidence = IIb BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting .
(Kontos & Naglie; RNAO, rev.2010a) RNAO, & Naglie; (Kontos Nurses should assess the client on admission and on an ongoing basis to identify any risk factors admission and on an ongoing basis to identify any risk factors Nurses should assess the client on that may result in the use of restraints. RECOMMENDATION 2 RECOMMENDATION but but also factors associated with certain client populations that are known to result in the use of need Nurses restraints. to alternative approach strategies to the use of restraints. Nurses should take into consideration not only the client characteristics client the only not consideration into take should Nurses restraints. of use the to strategies approach alternative Understanding Understanding a client’s history, the circumstances leading to the client’s admission and and prevention incorporates the that care of potential plan a of influencesdevelopment the of for assessment initial on important the very is environment Client admission processes must include the nurse’s understanding of the client’s diagnoses and conducting an assessment assessment an diagnosesconducting and of understanding client’s the nurse’s the include must processes admission Client risk. at client the place would that factors precipitating known characteristics or predisposing any history for ofclient’s the a is There team. interprofessional the to communicated and documented clearly be should they identified are factors When andall possiblepredisposing anticipate and understand helpnurse settings the all to health-care of lack from studies robust precipitating factors that could be associated with the risk of restraint use. Client characteristics and precipitating factors - consid special are there and care) community and long-term[LTC] acute, (e.g. sectors health-care and ranges age all affect erations for some populations such as geriatric, mental health, trauma and paediatrics. The majority of studies focus on or the acute A care older settings. those quantitative study adult, by in Strumpf, Evans, Bourbonniere, mental LTC health, & Maislin (2003) found that the following client characteristics may be overlooked as variables in the use severely impaired of mental state; English as restraints: a second language; use of sedation; and sensory-perceptual loss that affects the ability communicate. to Nurses must assess on admission the potential for the presence of predisposing and precipitating factors that put the client client the put that factors precipitating and of predisposing presence the for potential the admission on assess must Nurses at risk for the use of restraints. There are multiple predisposing and precipitating factors (see Figures 2 and 3) identified individualthe Recognizing restraintswhencaringclients. use for to decision nurse’s the to contributing as literature the in who may be at risk of the need for restraint use and implementing strategiesalternative to prevent the use of restraints is one goal of client Predisposing and safety. precipitating factors can be influencedby the ageclient’s aswell as other- situ ational factors which individually or combined result in behaviours that may influencedecision a tonurse’s consider the use of restraints to prevent harm to the client and/or others. Some predisposing risk factors may also act as precipitating risk factors. When clients with predisposing risk factors experience a new than previously experienced. emphasized more situation, become or increase the predisposing risk factors may Discussion of Evidence A therapeutic A nurse-client & relationship study qualitative enhances by Naglie (2007) effective communication. Kontos explored personhood and communication as a means to enhance dementia person-centered gradually dementia lose the care. ability to Clients maintain their living social roles. Recognizing with this social role to be a partial component of the individual which is outwardly expressed and understanding the internal notion of a true client’s self by seeking to learn about true the personhood client’s would allow nurses to connect with clients on a deeper level (e.g. individual was to This helps as a hobby). planting flowers shift and enjoyed evening worked at a whoschool always previously a caretaker agitation as such behaviours responsive managing when care nursing of delivery the in interaction nurse-client the enhance and aggression A study by Holmes, Kennedy, & Perron (2004) demonstrated that nurse-client contact was important in crisis management. importantcrisismanagement. was in contact nurse-client that demonstrated (2004) Perron & Kennedy, Holmes, by study A emo- and perception negative the on impacted seclusion during contact nurse-client of lack a that suggested findings Their oftional experience clients. RECOMMENDATIONS 24
Figure 2 health. that may include pre-existing behaviours or dementia (diagnosed/not diagnosed) that may the be characteristics client’sof towards the potential increase of restraint contributeuse. Figurecan 2 summarizes that some predisposing characteristics risk factors predisposing and associated examples of evidence for clients assess should nurses suggests evidence Emerging Predisposing RiskFactors restraints for theuseof that put atrisk theindividual behaviours client challenging trigger may facility the at changes staffing or ratios staffing and attitude activity, staff social and/or music to exposure of lack facility,or exposureor home new facility,to relocationthe in levels noise time, meal at understand environmental or non-clinical precipitating factors such as congestion in hallways, waiting time for an elevator Promoting Alternative Safety: Approaches to theUse Restraints of •Blind or low-vision impairment •Deafened or hard of Impairments 9. Sensory •Risk of •Restlessness, •Challenging/Disruptive behaviours • • 8. Responsive Behaviours 7. Psychiatric Conditions •Increasing dependence of for activities •Decline inmobility 6. Increasing Dependence Falls/ Falls5. Fear of of History 4. Fecal Incontinence &Urinary • 3. to Decreased/Inability Communicate •Trauma •Moderate-severe dementia 2. Cognitive Changes 1. Advancing Chronological Age Examples ofPredisposing RiskFactors forRestraint Use REGISTERED NURSES’ASSOCIATION OFONTARIO Anxiety Aggression, Aphasia to self injury of history wandering hearing or others violence, to self injury daily living (Shah, Chiu, Ames, Harrigan, &McKenzie, 2000) or others . RECOMMENDATIONS 25
www.rnao.org http://www.alzheimer.ca/english/ . BEST PRACTICE GUIDELINES • . Engberg et al. (2008) found that falls, or an increase increase an or falls, that found (2008) al. et Engberg . (Becker et al., 2005) et al., (Becker Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting . The nurse must also assess whether the client would attempt to ambulate independently independently ambulate to attempt would client the whether assess also must nurse The . (RNAO, rev. 2011; Safer Healthcare Now! [SHN], 2010) [SHN], Now! Healthcare Safer 2011; rev. (RNAO,
(Putman & Wang, 2007) Wang, & (Putman Assess the chosen anotherAssess strategy strategy Should work. it did/did not be why tried? and analyze Analyze what the client is tryingAnalyze Identifycontributing communicate. to trigger factors may the response. behaviour. taking a moment on the by Identifyclient’s reflect to the problem d. List strategies the issue. Choose List implementone to appropriate the most resolve possibly to . c. a. b. suggest it is important suggest care/ethics-restraints.htm to: Nurses Nurses should be aware that certain clients (e.g. Stroke survivors with aphasia, Alzheimer’s disease) may not be able to communicate their needs. The Canadian Coalition for Senior’s Mental Health (CCSMH) (2006) identifies that all behaviour client’s has meaning and often is associated with unmet needs. Understanding the reasons for some of the strategies care developing towards step first a is communicate inabilityto withclient’s a associated behaviouralchanges restraint in communicate to inability to related research limited is There restraints. of use the to alternatives provide that expertise clinical the importancesubstantiate ofwould identifying in factor client this predisposing however, literature assessment. The Alzheimer Care: Ethical Guidelines, Restraints (2011) available at: an Interprofessional Psychogeriatric Team (IPT) an for Interprofessional Psychogeriatric Team clients in long-term care homes who screened positive for psychiatric and assessment for behaviours that are a result of cognitive functional decline is vital to implementing strategies that would would strategiesthat implementing vitalto is decline functional of cognitive result a are that behaviours for assessment and prevent the use of restraints. Kotynia-English, McGowan, & Almeida (2005) examined the implementation and efficacy of and early referral to the IPT did not significantlychange the use theof studyprocess allowedrestraints,for however, early appear factor predisposing a as cognition altered with Clients use. restraint for risk at clients for admission on identification risk also act as a precipitating factor. a higher impairment may risk Cognitive of have to restraint use. Concerns about Concerns the safety of clients can result in restraint use when risk factors Nurses for falls been with have identified. other members of the interprofessional team must assess clients for risk factors for falls on admission and implement in the plan of care individualized multifactoral interventions that would the prevent use of including restraints, physical the siderails ofrestrictive use 5) History of of Falls Falls/Fear Nurses’ awareness of Nurses’ the ability client’s to be independent and to ambulate for toileting is key for the for risksafety in of increase an ofthe client. aware be should Nurses restraints. for risk at client a place can toileting in independence Decreased agitation or behaviours aggressive in clients whose precipitating factor is the fear of not being able to toilet and/or fear of incontinence 4) Fecal and Urinary and Incontinence 4) Fecal
3) Decreased/Inability to Communicate 3) Decreased/Inability to 1. morbidity (depression, dementia etc.) and health outcomes. One health outcome variable observed was restraint use. Screening use. restraint was observed variable outcome health One outcomes. health and etc.) dementia (depression, morbidity 2) Cognitive Changes 2) Cognitive awareness Nurses’ use. restraint for factors risk all are wandering without or with confusion and depression dementia, Delirium, 1) Advancing Chronological Age Chronological Advancing 1) Nurses should be aware that age in combination with Engberg, by other study predisposing A characteristics restraints. of such use the as consider cognitive to decline nurse might the influence may which wandering, as such behaviours in result characteristicof have a who is individuals years 80 than age greater an that identified (2008) McCaffrey & Castle, Nicholas, been restrained. in falls post admission was to associated LTC, with the introduction of a restraint. Rask et al. (2007) studied the of effects a quality improvement falls management program that included education for nurses on the following eight-step fall paradigm:response to avoid incontinence, which may result in a fall. Cognitive performance, incontinence and visual impairment are identified identified are impairment visual and incontinence performance, Cognitive fall. a in result may which incontinence, avoid to further investigation restraint use that requires for as risk indicators RECOMMENDATIONS 26
seclusion includes that restraints of use the for risk increased at clients place diagnosis psychiatric a of presence the with characteristics behaviour of combinations certain that reflects literature emerging The 7) Psychiatric Conditions 6) Increasing Dependence long-term care homes. intheparticipating thisresponse paradigm and documentation on based theuse of Rask et al. was able to demonstrate a substantial reduction in the use of restraints and falls from the improved care processes Promoting Alternative Safety: Approaches to theUse Restraints of Lehtinen, 2003)
• schizophrenia. •Older persons with • •Personality disorder; •Psychiatric illness; organic • Rachlin, & Walker, 2002; Hellerstein, Staub, &Lequesne, 2007) resident related characteristics restraints. to thatresulted mobility intheuseof range of motion, use of nine or more medications, no discharge potential, and presence of pressure ulcers as common in bedridden, independence in ADLs,decline being of loss the identified al.residents.(2007) et non-restrained Rask than dependence walking more and ADLs low performance, cognitive low exhibited restrained were who residents those found and homes care term long in residents studied (2008) al. et Engberg use. restraint and risk fall higher a LTCsafety.in residentsclient that experienced independentlynotesal. (2005) transfer Becker et to wereunable who ensureto nurse the by assessed be should that characteristic key a is independently mobilize use.to Ability restraint Wandering, dependency on others for ambulation, falls history of and high risk for falls are all factors associated with b. Decline inMobility falls, andlowof cognitive scores aphysical were of restraint. theinitiation associated with performing ADL, low independence in history that lowal.confirmed performance. et (2008) ADL with Engberg use restraint of correlationindependent strong a found (2004) homes.careKirkevoldlong-termEngedal in & restraints Clients who are unable to independently perform their ADLs have been shown to be at an increased risk for the use of (ADLs)Performancea. DailyLiving of Activities Within one to seven days: Within aresident falling: of 24hours Characteristics of restrained adults in mental health settings include settings health mental in adults restrained of Characteristics Adult: REGISTERED NURSES’ASSOCIATION OFONTARIO 8. 7. care; Develop aresident-specific and plan of 6. Conduct assessment on afalls theresident; 5. Initiate immediate interventions; 4. Care to Fax Physician; thePrimary analert 3. Record circumstances, resident response outcome to theevent; andthestaff 2. Investigate thecircumstances surrounding thefall; 1. Evaluate andmonitor theresident; Violence asaresult of Agitation; Alcohol intoxification anddrug or withdrawal; resident’s response. Post (one to fall sixmonths) continue interventions to specific andthe monitor theimplementation of . and self poisoning;
: (Downes, Healy, Page, Bryant, & Isbister,Flannery,2009;Healy,(Downes,Page,& Bryant, (Kaltiala-Heino, Tuohimaki, Korkeila, & Korkeila,(Kaltiala-Heino,Tuohimaki, RECOMMENDATIONS 27
.
www.rnao.org : Services; and Family Children . These clients were more often immobile, immobile, often more were These clients . . (National Institute for Clinical Excellence [NICE], 2004) (National Institute for Clinical Excellence [NICE], BEST PRACTICE GUIDELINES • (Delaney & Fogg, 2005) Fogg, (Delaney &
the Department of and (Choi & Song, 2003) (Choi & Song, others: or .
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
. Self-injury or harm can also be accidental and non-intentional such as those Self-injury such and non-intentional harm or . can also be accidental injury self to . (de Jonghe-Rouleau, Pot, & de Jonghe, 2005) & de Jonghe, Pot, (de Jonghe-Rouleau, of in custody or care in foster risk of
violence, (de Jonghe-Rouleau et al.)
behaviours. agitated assaultive or (Kirkevold & Engedal, 2004) & Engedal, (Kirkevold disorder; a psychotic suicide; and attempting ideation suicidal voicing
history of Self-injury: Challenging/Disruptive behaviours:
(Lee, Hui, Chan, Chi, & Woo, 2008; Putman & Wang, 2007) Wang, Putman & 2008; Woo, & Chi, Chan, Hui, (Lee, History of restrained in bed and had been prescribed benzodiazepines. Self-injurious behaviours included head banging, biting and head Self-injurious banging, included behaviours restrained in bed had and been prescribed benzodiazepines. ofscratching oneself Restlessness/Wandering: Nurses should be aware that client restlessness may trigger behaviours such as wandering or treatment interference trigger interference as wandering treatment or such behaviours may restlessness that client should be aware Nurses and is a discriminating restraint application for factor Nurses should identify predisposing factors that may raise the concern for client potential to self injure. In long-term care care long-term In self to potential client for injure. raise the concern that may factors predisposing should identify Nurses in 22% of found with self-injurious with the use of were behaviours the clients correlated and dementia ben- homes, the use of and/or zodiazepine restraints carried out during dissociative states found in psychiatric populations populations psychiatric in carried found states during out dissociative Nurses should be aware of the client’s safety and potential for harm to self/others when the client exhibits aggressive aggressive exhibits when the client self/others safety harm for to and potential of the client’s should be aware Nurses characteristics with client associated are behaviours the and aggressive dementia and severe Moderate behaviours. use of restraints Aggression, Nurses need to help clients recognize their internal emotional states and identify any precipitating factors in order in order factors precipitating any and identify states emotional internal their recognize help clients need to Nurses of the use of responses. strategies increase in the development would that self-control appropriate assist the client to strategies that challenging- (2007) outline should be behaviours managed by that pre & Scott George, Duke, Dean, engaging in the use least restraints) the client and include the use of (e.g. minimize or interventions restrictive vent behaviour options. responsive of appropriate other Anxiety, Characteristics of settingsin psychiatric include restrained youth Youth: • restraints 9) Sensory Impairments Hearing and vision impairments in clients are concerns that should be assessed by the nurse and interprofessional team to help keep the client safe. Hearing and vision impairments have been strongly associated with falls and initiation of 8) Responsive Behaviours 8) Responsive •
• • hospitalization; psychiatric • Previous in special • Enrolled education, gender; • Male the facility; to admissions • Multiple hospitalizations; • Longer • Diagnosis of • Threatening, • History of RECOMMENDATIONS 28
Figure 3 to cope. use may have previously been predisposing factors but the change in settings and client situation threatens the client’s ability (predisposing and/or precipitating), the greater the risk for restraint use. Many the of precipitating risk factors for restraint development behaviours at of forrisk restraint use. It is generally acknowledged that the greaterthe the factorsnumberrisk of potentiate could that setting health-care a to admission as, such situation client normal the to changes of result a as maythat factors(Figureoccurmonitor3) clientany for and the precipitating torisk assess additional need nursewill The Precipitating RiskFactors Promoting Alternative Safety: Approaches to theUse Restraints of •Toileting •Thirst •Pain •Hunger •Fear • Unmet needs: ProceduralSurgery/ Interruptions Multiple Admissions •Unanticipated side effects •Psychoactive agents •Polypharmacy •New medications •Benzodiazepines • Medications Influences: Falls •Unfamiliar environment •Temperature •Noise •Music Environmental Factors: •Lack of •Bedridden Mobility: Decreased •Unable to remember instructions •Sundowning •Dementia •Delirium Cognitive Changes: Examples ofPrecipitating RiskFactors forRestraint Use REGISTERED NURSES’ASSOCIATION OFONTARIO Anxiety Alcohol andsubstance abuse assistive devices RECOMMENDATIONS 29
with
www.rnao.org (Engberg et al., 2008; Möhler, Richter, Köpke, &, &, Köpke, Richter, Möhler, 2008; al., et (Engberg . BEST PRACTICE GUIDELINES • (RNAO, rev. 2010a,b) rev. (RNAO, Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting . (RNAO, rev. 2011) rev. (RNAO, . Falls
Meyer, 2011; Putman & Wang, 2007) Wang, Putman & 2011; Meyer, the interprofessional team to prevent or minimize these influences and prevent the use of restraints. Putman and Wang (2007) Wang and Putman restraints. of use the prevent and influences these minimize or prevent to team interprofessional the be- resident to related environments home nursing in factors contributing any of importance understanding the identified of tradi - to use (ASCU) Units Care Special hospitalization, Alzheimer ofcompared (2008) al. rates et Nobili lower anxiety. or withagitation associated haviours had ASCU to admitted dementia with clients that found and homes care term long tional (physicians, interprofessional was staff ASCU The use. agent antipsychotic from withdrawal higher a and restraints physical nurses, psychologists, rehabilitation and occupational therapists) and trained in the assessment of behavioural problems and the stimulation of residual cognitive and functional performance renewal a ASCU implement specifically had to designed Each program onenvironmental therapy and individualized care. through use of various activities, occupational which included the creation of wandering separate areas, areas for structured activities, minimization of noxious stimuli, doors exit magnetic-locked secured colours, neutral wall identification, facilitate railsto doors/hand room brightcoloured routes). and areas different identify residents to help cues and wayfinding open to with release for digital codes risk for restraint. Upon client admission and on a routine basis nurses must assess the impact of the medication client’s use on behaviour that places the client at risk for the use of associated medication While with is 2011). often a restraints. initiated previous fall rev. and The use of medication psychoactive (RNAO, initiation of restraint use the on dependency was or abuse and/or found medication the of use to the from be occur may that effects side the effects, therapeutic its for withof use associated the behaviours restraints responsive in result can medication See Predisposing Factor # 7 Psychiatric Conditions. # 7 Psychiatric Factor See Predisposing Multiple Admissions Multiple Medication Influences Influences Medication client’s a increase alcohol, including abuse, substance and antidepressants as such agents psychoactive and Benzodiazepines Nurses should be aware of agitation or anxiety in clients that may be triggered by environmental factors and create strategies create and factors environmental by triggered be may that clients in anxiety or agitation of aware be should Nurses Environmental Factors Environmental Decreased Mobility, In addition to the information outlined in the predisposing risk factor section it for impaired is mobility, very important for nurses to know what devices are used as essential components for the safety of the client and not intended to work as a restraining An example devices. would be the use of siderails to harmprevent in the transportation of clients or the use of siderails in specialty areas such care as and intensive operatingpaediatricroom, recovery or rooms, settings. procedure restraint but a under should not these Siderails physical bemay becircumstances reviewedconsidered the ensure use to is the understanding on focus a supports literature Current client. the ofsafety the for component essential an and protective, cause of behaviour client’s and the promotion of alternative individualized multifactorial strategies for clients at risk for falls rather than trying to control behaviour through the use of A restraints. systematic & review Heng by Ng, McMaster, settings. hospital care acute in falls prevents use siderail restrictive that support to evidence no is there demonstrated (2008) in injury fallswith a decrease ofin rate restraints demonstrate and from no change to fallswhen physical continue Studies not used siderails are restrictive Cognitive Changes: Cognitive will to neednurse the changes, cognitive sectionfor riskfactor predisposing the in outlined information the to addition In pre-existing a on superimposed delirium ofa onset the as such changes, cognitive new for ofclients monitoring the continue restraint use. for the potential lead to can then which dementia, RECOMMENDATIONS 30
accompanied by makes triggers,andwhat pictures signs to thechild warning better. identify feel help interview clients that help identify predisposing/precipitating factors and plan for client preferred approaches. The children’s tools are adult or children, adolescentfor tools interviewing age-appropriate of examples some gives and Initiative Safety duction website Health Mental of Department to manage responsive behaviours leading up to and during a crisis event to prevent the use restraints.of The Massachusetts and coping for strategies preferreddevelop to client the with work then can teaminterprofessional the of members other interprofessional team.the bywith interventionsnurse The of planning and referral further facilitate can and risk highest at clients identify to help will factor(s) client specific of identification the to targeted available) (if tools screening of use toessential self/othersis by safeclient evaluation care. further of to harm with clinical judgment Overall combinationa of Nurses’ ability to identify on admission and throughout an episode of care those clients at risk for behaviours that may lead Discussion ofEvidence result client inchallenging behaviours (aggression, to restraints harm self/others) thatresult intheuseof and the presence anyof predisposing factors such as anxiety, fear or the need to toilet may be actual precipitating factors that Nurses need to be aware that clients decliningwith ADLs may not be able to meet their basic needs (e.g. hunger, pain, thirst) Unmet Needs • nurse asto why must andencourages therestraint assoonsafely used therestraint be possible. discontinuation of that certain circumstances require the appropriateoutlines restraints use butof that the clientCNO should receivebreathing). explanations fromin the assist to inserted tube endotracheal (e.g. intervention an of necessity the understanding of The CNO (rev.2009c) identifies that there are circumstanceswhere the nurse may need to restrain a clientwho is not capable preoperatively. restraints andtheuseof daily living of dependency inactivities the presence of preoperative risk factors such as younger age (less than 85 years), confusion, dementia, requiring assistance/ Sullivan-Marx, Kurlowicz, Maislin, & Carson (2001) identified that physical userestraint post operatively was predicted by and lead to treatment suchinterruptions as preventing the or insertion discontinuation intravenous of therapy. A study by can create an environment that places the client at risk of developing responsive behaviours such as aggression or confusion as operating/recovery rooms and intensive care units can often trigger fear, confusion and anxiety in clients. This experience procedure to ensure the client is safe and protected from harm. Treatment processes that occur in health-care suchsettings the of component essential an is what regarding decision-making appropriate require environments health-care Certain Surgical/Procedural Interventions Promoting Alternative Safety: Approaches to theUse Restraints of restraint use. Nurses shouldutilizeclinicaljudgmentandvalidatedassessmenttoolstoassessclientsatrisk for RECOMMENDATION 3 interruption of a medical device. amedical of interruption care applied for arestraint unitandhad restlessness were exhibiting behaviours thatnurses’ to lead the felt might (Ludwick, Meehan, Zeller, &O’Toole, 2008) would interfere interventions medical/therapeutic such asintravenous with or indwelling therapies catheters Nurses were more perceived they likely to if userestraints aclient’s exhibiting behaviourthat of wasatrisk safety Treatment Interruption REGISTERED NURSES’ASSOCIATION OFONTARIO has a Restraint/Seclusion Re- Restraint/Seclusion a has http://www.mass.gov/eohhs/gov/departments/dmh/ . Choi &Song (2003) identified that who clients wereadmitted to anintensive Level ofEvidence=IIb (Engberg etal., 2008) . RECOMMENDATIONS 31
threats,
(Swauger (Swauger & verbal
for aggression; for ; www.rnao.org Level of Evidence = IIb boisterousness,
; and ; (Cohen-Mansfield,1989) irritability,
(RNAO, rev. 2010b; RNAO, rev. 2011; SHN, 2010). RNAO 2010). SHN, 2011; rev. RNAO, 2010b; rev. (RNAO, BEST PRACTICE GUIDELINES • agitation [RNAO, rev 2010b]) [RNAO, confusion, . The use of validated tools is helpful in identifying specificidentifying in helpful is tools of validated use The . assess (Tenneij, Goedhard, Stolker, Nijman, & Koot, 2009) & Koot, Nijman, Stolker, Goedhard, (Tenneij, . to G) Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting . (RNAO, rev. 2006b) rev. (RNAO, Appendix and depression dementia (see (RNAO, rev. 2007a) rev. (RNAO, (BVC) pain Scale-Revised (SOAS-R) Aggression of assessment (CMAI) for Inventory Agitation Checklist
(Engberg et al., 2008; Yamamoto, Izumi, & Usui, 2006) Usui, & Izumi, Yamamoto, 2008; al., et (Engberg Violence Observation . Nurses in Nurses . collaboration with the interprofessional team and client/family/SDM should focus the plan of care outlines that the best use of any assessment tool is to first identify the specific risk factors so that prevention can prevention specific the identify that so first risk factors to is tool bestofthe use that assessment outlines any attacks on objects; or Historical-Clinical-Risk Management: 20 (HCR-20) (see Appendix H) Appendix (see to attacks assess on the 20 objects; historical (HCR-20) or Management: Historical-Clinical-Risk settings; forensic or corrections riskand current violence in psychiatric, for Broset Staff Short-Term Assessment Short-Term of Risk and (see (START) Treatability Appendix F) for historical and current assessment of and victimization); use, substance unauthorized absence, self-neglect, self-harm, suicide, risk (violence, domains seven Nurses in partnership with the interprofessional team and client/family/substitute decision-makers Nurses in partnership with the interprofessional team and client/family/substitute on alternative approaches to the (SDM) should create an individualized plan of care that focuses use of restraints. RECOMMENDATION 4 RECOMMENDATION cognition (delirium, altered for • Tools client needs when planning care as the tools facilitate the specific factor assessment. Some examples include: Some the specificassessment. factor facilitate as the tools needs when care planning client • Cohen-Mansfield Tomlin, 2000) Tomlin, Aggressive Aggressive behaviour can lead to increased use of restraints. Assessment helps to identify clients who may demonstrate aggressive behaviour as well identify any precipitating factors that contribute to aggressive episodes crisis or behaviour management intervention requiring ongoing Flannery et al. (2002) identifies that clients with a previous history of violence and or assault have an increased risk for restraint for risk increased an have assault or and violence of history previous a with clients that identifies (2002) al. et Flannery use. Hellerstein et al. (2007) describe a hospital-wide effort to decrease restraint and seclusion facilities with initial that decreasing interventions timeinclude was a of in hours new four restrainttwo before to order from clients in psychiatric education of required, staff identificationof concerning clients at riskof restraintavoid earlyto intervention or seclusion, crisis and use of a Coping Agreement Questionnaire (CAQ) (see Appendix I) to assess client for preferences dealing with prefer theywould how and upset; when responded theyhave how upset; them whatmakes clients asks CAQ The agitation. to be treated while on the ward as well as obtaining family/substitute decision-maker (SDM) input on effective methods for coping. The use of a tool such as the CAQ may assist nurses with the interprofessional team to identify client specific and skills. own strengths strategies the client’s that incorporate and alternative prevention • Collaboration among interprofessional colleagues is considered an essential strategy for ensuring client safety Discussion of Evidence • - determin in important is basis ongoing an on and admission on client/family/SDM the from history thorough a Obtaining ing risk the for individual’s injury due to falls and/or impairment cognitive of assessment for • Tools (rev. 2010b) (rev. on on interventions that demonstrate an understanding needs ofand wishesthe client’s in and/or to prevent minimize order behavioural symptoms that may be a reflectionof unmet needs (CCSMH, 2006).Implementing alternative strategies in Assessment Assessment tools to are available assist in nurses explore depth the identifiedclient risk factors that places them at risk for ofrestraints use the be tailored to the identified risks.Furthermore, thecomprehensive assessment should include a focused physical history, examination, medication cognitive, functional review, and environmental assessments to link any assessment findingsto evidence-based interventions. • RECOMMENDATIONS 32
older adult (see Figure 4) and paediatric critical care settings (see Figure care(see 5). settings critical older Figure adult (see 4)andpaediatric the in interference treatment prevent to approaches practice best identified Snyder(2004) and interference.(2000) Happ treatment preventto strategies non-restraint in principles key as persistence re-evaluation,and frequent and strategies of restraint use. Happ (2000) identified ascertaining the meaning ofbehaviour, be can staff continuity and presence, interventions individualization individualized identified, are planned behaviour and used to the assist the nurse, for interprofessional team cause(s) and client to or resolve issues reason(s) that may lead the to the considerationWhen of needs. unmet of The focus of nursing care management should be on identifying the factors that contribute to the behavioural presentations Figure 4 orientation, physical andenvironment ability andfunctional factors of client’slevel the include should that characteristics client individual of assessment thorough a follows care of plan the Promoting Alternative Safety: Approaches to theUse Restraints of •Massage/touch therapies • • • •Tube stabilizer •Repositioning/specialty mattress andPositioningComfort •Tubing out of • •Commercial device-protective, •Generous tape, •Long sleeved gowns Camouflage •Television •Music tubing/packaging •Empty • •Photo albums •Gadgets •Reading material • •Occupational therapy consult • andDiversionDistraction • •Guided of visualization •Frequent verbal explanation andRemindersExplanation Non to Prevent Restraint Strategies Treatment Interference in Adults REGISTERED NURSES’ASSOCIATION OFONTARIO Aromatherapy Analgesia/sedation Augmentative communication Abdominal binder Washcloths Writing tools Activity apron Written reminder field visual or dressings atsite ace wrap device cushioned sleeve, or IVsite guard (Dunn, 2001; Snyder, 2004) (Happ, 2000) .
RECOMMENDATIONS 33 .
(Crock et al.) www.rnao.org
BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Surgical/Procedural Surgical/Procedural Interventions ). After the procedure there should be
Visualization comfort that maintains devices in a way Attach camera Video with • Insert natural devices movements body not interfere in locations that do that is lightweight camouflage and comfortable • Use tape judiciously • Use procedures stressful for adequately child • Prepare while • Engage carrying child procedures out choices child the • Offer exploration guided • Use care family-centered • Embrace carefully interference treatment prevent that may interventions • Choose distraction during procedures stressful • Use (Snyder, 2004) (Snyder, rapport • Establish with and family child with and family child pertinent information • Provide and stimulating activities with child creative • Provide • Nursing Intervention Strategies to Prevent Treatment Interference in Children Interference Treatment Strategies Intervention Prevent to Nursing Environment • Maximize • reduction • Noise presence • Family • Sitter/companion Technologic Reduction Technologic devices nonessential • Discontinue adaptor • Intravenous device with intrusive less restrictive/less • Replace In In order to fully understand the meaning of address behaviour, the unmet needs of clients and accurately determine the best client specificprevention and alternative approach strategies (seeAppendix J - a sample must: the nurse limit the use of or restraints, list prevent that would behaviours) presenting based on suggestions of alternate approach an evaluation with the client about the level of discomfort experienced to assist the nurse and interprofessional team in with associated behaviours interference treatment responsive help minimize to procedures future planning for Crock Crock et al. (2003) identified thatchildren canexperience distress and pain nurse the during assist assessments repeat procedural Pre-procedure interventionstests. of puncture lumbar and a marrow bone as such nature treatment or diagnostic evaluate to and procedure the undergoing about is child the upset or frightened how evaluate to team interprofessional and approaches to care that can help minimize the risk of harm agitation from behaviours responsive or anxiety, such as fear, aggression (see Recommendation # 2, subsection: Permission granted Copyright Clearnace Center Figure 5 Figure Permission granted Copyright Clearnace Center Permission granted Copyright RECOMMENDATIONS 34
and negotiation of strategies that the nurse and interprofessional team can apply to prevent and de-escalate responsivebehaviours or such aggression as agitation de-escalate and prevent to apply can team interprofessional and nurse the that strategies of negotiation and crisis prevention plan. This process should help to identify the triggers and early warning signs and facilitate the discussion and trauma of substance abuse history so that risk,nurses can violence work in for partnership with the possible interprofessional team as and client/family/SDM soon to developas a assessed be should facility a to admitted individuals all that providers on what to do when clients get agitated or the health-care treatment and direct support they preferand in indicate a crisis.to O’Hagan behaviours et responsiveal. exhibiting outline not are clients while completed be to instructions as to lead may that care. developing usewhen restraint theplanof O’Hagan,behaviours Divis,responsive advance &Long (2008)describe directives plans andcrisis for risk at clients of care and assessment the approach to ways many are There Nurse •Primary Questionnaire (PNQ) • • • Promoting Alternative Safety: Approaches to theUse Restraints of • •P.I.E.C.E.S. • such as: clients/family/SDM with work to interprofessionalteam the and nurses assist may that care of models multiple are There The underlying principle of any type of model or approach to care is to prevent and extinguish or minimize behaviours minimize or extinguish and prevent to is care to approach or model of type any of principle underlying The •Tidal Model –http://www.tidal-model.com/. • • • Wellness Recovery for whichmay arestraint considered be Recommendations (see #2and3); Assess the client for predisposing or precipitating factors that may result in unmet needs demonstrated in behaviours upenn.edu/cisa/Pages/Research.aspx questionnaires: which hasthefollowing example An use.website is the Penn Nursingrestraint Science, University with Pennsylvania of NursingSchool of associated available at: values own their evaluate providers’ health-care assist to available are questionnaires and resources,tools evidence-based of Examples use. restraint toward attitudes their and decisions relationship. Karlsson, Bucht, Eriksson, & therapeutic Sandman the (2001) found of values there professional was the a and significantcontrol maintain relationship to between nurses’ goal nurses’ the was conflict of source primary a found and restraint physical of nurses’experience health mental examined (2008) Crowe & Bigwood client. the of needs the meet to self of use therapeutic use and calm remainto wereable responses emotional and values own interactions and implement effective strategies. Johnson & Hauser (2001) found that nurses who were aware of their the highlight importance self- of awareness and self-management in influencing a nurse’s ability to have therapeutic f am o efohr ta cud eut n osdrn te s of use the considering in result could that andknowrestraints Recommendation behaviourhasmeaning(see all #2); self/others to harm of behaviours to lead that factors Understand Develop Be work for best theclientmight on based thepresenting problem, to prevent restraints; or limittheuseof changes to the plan of care and interventions. It may take several attempts to determine the alternative strategies that Continuouslyclient’sa assess response to prevention alternativeand approach strategies restraints; the useof containspreventionthe alternativepreferencesde-escalationand and approach strategies considered to be toavoid which care of plan the of awareness an ensure to team interprofessional the with communicate and Collaborate to harm self/others; andlong-term for goals thepreventionshort- behaviours of or minimizationof or attributes which interfere with what the nursethe knows interfereclient’swhat which the to attributes or be with choices valuesand REGISTERED NURSES’ASSOCIATION OFONTARIO aware Chart Perceptions a of client-specific TM
their –http://www.piecescanada.com/; of
Restraint own Action –http://www.mentalhealthrecovery.com/aboutwrap.php Plan ®(WRAP®) ; personal individualized Use Questionnaire values (O’Hagan etal.) and plan knowledge (PRUQ) of
. care to meet a client’s therapeutic needs and wishes as indicated by (see of
Appendix the clinical K), to mitigate their own personal values personal own their mitigate to issues
with Matrix of
Behaviours and evaluatemakeand (CNO,rev. 2009b) http://www.nursing. and Interventions .Studies
RECOMMENDATIONS 35 (Dean (RNAO, (RNAO,
(RNAO, rev. 2006b; (RNAO, www.rnao.org Level of Evidence = IV . The continuous monitoring will allow for the for willallow monitoring continuous The . BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting (CCSMH, 2006; RNAO, rev. 2010a) rev. RNAO, 2006; (CCSMH, . The plan . of should care ongoing direct assessment and and promote evaluation of clinical
. . Routines established to monitor and reassess the effectiveness of interventions in the plan of care could be . . The . use of targeted client-specific interventions helpsto minimize the riskof escalating behaviours responsive and nurses should be aware of this type of mandated The requirement. findings from screening should trigger (CCSMH) Nurses in partnership with the interprofessional team should continuously monitor and team should continuously monitor with the interprofessional Nurses in partnership by the and/or concerns expressed plan of care based on observation client’s re-evaluate the client and/or family/SDM. RECOMMENDATION 5 RECOMMENDATION et al., et 2007) al., improvements the by of care identify plan of review the and assessment to the trigger should and outcomes members clinical of unexpected identification early team and nurses allow also can assessment continual Alternatively, team. interprofessional in client conditions indicating the client risk restraint use. is in a decreased for resulting responding to treatment modalities and/or individualized interventions RNAO, rev. 2010a; RNAO, rev. 2010b) rev. RNAO, 2010a; rev. RNAO, guided by legislation pertaining to the type of organization and/or client population (e.g. Ministry of Health and Long-Term Long-Term and Health of Ministry (e.g. population client and/or organization oftype the to pertaining legislation by guided is very be aware importantIt to nurses for 1990). Act, Health 2007 and Ontario Mental Act, Homes Care Long-Term Care: monitoring these guide and establish to helps that population legislationclient of and organization pertaining their to any and reassessment A routines. structured or standardized approach to screening (e.g. use of protocols to assess for factors that place the client at risk for the use of restraints) is often helpful because tools and can protocols guide the nurses and interprofessional team to review more than one measure (e.g. self-report, proxy report and observation) and consideration take other factors into such as type of client, the unique client’s history and diagnosis, specific triggers and setting. based Again, on setting and client population some assessment tools are mandated (e.g. Assessment Resident Instrument [RAI] Minimum Data Set [MDS] or the Functional Independence Measure [FIM] used in rehabilitation settings) caused from precipitating factors and/or the demonstration of responsive behaviours that may not be appropriate. Use of multiple strategies in an individualized plan of care that takes into consideration client preferred strategies is the best approach to prevent the use of restraints. This plan developed prior to the client demonstrating identify ofto examples Some how supportneedsofcrisis. the in when to client respected the and acknowledged be responsive should behaviours Appendix in seen be can preferences preferred client effective and behaviours in trends factors, precipitating document and Log. Monitoring the Behaviour M, Appendix (ABC) charting and tool and Consequence Behaviour Antecedent, the L, rev. 2010a) rev. (CCSMH, (CCSMH, 2006) client’s the in change significant a to response in or intervals regular at done be should assessment repeat a that recommended is It behaviour or functional status. The purpose of continual assessment is to identify symptoms that would require further investigation and allow the team to respond to changing needs and adjust prevention and management interventions Discussion of Evidence that could be potentially harmful while reinforcing appropriate responsive behaviours in support of the client in crisis in client the ofsupport in behaviours responsive appropriate reinforcing while harmful potentially be could that outcomes outcomes and treatment effectiveness. This is critical for monitoring goals client-centered withaligned changes are objectives in the client and ensuring intervention Ongoing Ongoing assessment of client behaviours would alert the nurse and interprofessional team as to the immediate need to implement alternative strategies for prevention and/or de-escalation and crisis management techniques the use of a decision-making algorithm (see Appendix N) or use of a behaviour profile documentation form (see Appendix Appendix (see form documentation profile behaviour ofa use or N) Appendix (see algorithm decision-making ofa use the O) to guide nurses and the interprofessional team to implement a targeted assessment, initiate specific treatmentfor the identified symptoms and circumstances andensure that thechanges appropriate to interventions are made in the planof care RECOMMENDATIONS 36
Some different suggested by strategies studies to prevent •Individualized plansof useare: restraint •Group programming; •Reinforcement of detection •Early andidentification of appropriate •Consultation with interprofessional team members; minimize the use of restraints is growing is restraints of use the minimize or prevent to strategies alternative and prevention multi-component of implementation and knowledge The restraints. may include relatives and caregivers, who can accurately identify changes in the client’s behaviour client’s the in changes identify accurately can who caregivers, and relatives include may which informants, reliable from history collateral a client, the of consent the with and appropriate where obtain should supports communication theinterprofessionalsupports with team. and relationship nurse-client therapeutic the within applied is client’s care the perspective, that reflects which wishes and client’s needs meet to therapeutic care of plan individualized an client’sthe of needs,identification of assessment nursing •Education of •Review of of •Support prevention: restraint of aspects • Consultation Studies Discussion ofEvidence restraints physical of use the prevent to and care client quality safe,to mood, behaviour and functioning and that the communication and documentation of the results of the assessment is critical It is important for nurses to recognize that the process of screening and assessment is ongoing to detect changes in cognition, Promoting Alternative Safety: Approaches to theUse Restraints of Salter, & Mion, 2006; Dean et al., 2007; Donat, 2003; McCue, Urcuyo, Lilu, Tobias, & Chambers, 2004) An individualized approach to the plan of care is foundational to achieve the goal of restraint prevention.Studies restraint of goal the achieve to foundational is care of plan the to approach individualized An J andP)requires safe andleastrestrictive care environments, assessment, early care. intervention andindividualized plansof Documentation Standard Documentation strategies topreventtheuseofrestraintsforclientsidentifiedatrisk. Nurses inpartnershipwiththeinterprofessionalteamshouldimplementmulti-component RECOMMENDATION 6 during episodes of escalating client escalating behaviours. episodes of during alternative theuseof approaches inadvance restraints thatsupport andpractices policy or to theuseof nation of providing clinical andfacilitate good clients while decision-making thedevelopment skills atrisk thedissemi- of care canresult andconsultation educationmodeling to nurses atthepointof inprovision identify with of the intricacies of thedecision-making process of relatedthe intricacies to restraints asresources used canbe NP andCNSspecialists to organizations androle assistnurses within through models Nurse (NP)andClinical Nurse Practitioners (CNS) Specialists (Ludwick et al., 2008; Vance,2008;2003) al., et (Ludwick REGISTERED NURSES’ASSOCIATION OFONTARIO seclusion/restraint incidents; andleadership; administration staff, theclient’s appropriate responsive behaviours; client/family/SDM; (CNO,rev. 2008) and care.
outline the complexities of decision-making that influence nurses’ decision to use to decision nurses’ influence that decision-making of complexities the outline supports nursing standards of practice and documentation that demonstrate the demonstrate that documentation and practice of standards nursing supports (Evans et al., 2002) al., et (Evans clients’
risks; . The implementation of alternative strategies (see Appendices (see strategies alternative of implementation The .
(RNAO,rev.2010a) (Evans etal., 2002; Möhleretal., 2011) identify the following multi-component . It is recommended that the nurse the that recommended is It. Level ofEvidence=IIa (RNAO,2010b) rev. . NP/CNSrole (Amato, . The The .
RECOMMENDATIONS 37
www.rnao.org
suggest use of response teams to assist with use of suggest to teams response BEST PRACTICE GUIDELINES • during sleep time; procedures avoid
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting applicable;
hospitalization; for and reason place ulcers. and pressure skin breakdown prevent to immobile are clients date, and day,
time of
. all clients;
(McCue et al., 2004; Prescott, Madden, Dennis, Tisher, & Wingate, 2007) Wingate, & Tisher, Dennis, Madden, Prescott, 2004; (McCue et al., room; in each and calendars clocks (Putman & Wang) (Putman & Teams Crisis or Response Response Rapid Studies de-escalation of client responsive behaviours to prevent or minimize the duration of minimize or restraintconsultation use and prevent to behaviours ofde-escalation responsive client setting of that the use care psychiatric acute in an found et al. of Prescott prevention further for restraint episodes. restraintperiod. intervention hadreductions in a six-week use significant in mechanical team a rapid response fluid therapy; continuous Avoid position every if • Change hours three Recreational Activity Recreational Putman & Wang (2007) used a multi-component group of interventions to understand the factors contributing to resident’s agitationthe and anxiety including decrease can the interventions of impact group multi-component ofa of part the as activities recreational nursing resident-driven home Offering environment behaviour. as it related to the responsive agitation and anxiety while increasing socialization resulting in a decrease in restraint use and the medication use of antipsychotic Vidan et(2009) Vidan outlined al. the following intervention strategiesmulti-component to manage deliriumand/or prevent in in the use of with result seniors agitation associated restraints: that may • Orientation of Orientation Tools should be used to assist nurses to identify alternative multi-component strategies to siderail use in the provision of care. care. of provision the in use siderail to strategies multi-component alternative restrictive identify of to nurses use assist the to used be prevent should to Tools nurse the by considered be can that strategies provides that algorithm example an is Q Appendix Decision-Making Algorithms and Tools Algorithms Decision-Making associated the and clients many in behaviours Behaviour Programs Management aggressive reducing for effective are programs management behaviour Systematic when use restraint and behaviours aggressive in decrease a demonstrated (2007) al. et Dean by study A use. ofriskrestraint staff oftraining, individualized care and reinforcement behaviour early appropriate management and plans, intervention, the least restrictive form of restraint intervention was used in and children adolescents eton a al. psychiatric McCue unit. (2004) identified thatuse of stress/anger management groupsfor clients assisted inreducing aggressive behaviours and the subsequent use of restraints. It is important for nurses to collaborate with the interprofessional team and client when effectiveness for strategies the evaluate continually to and programs management behaviour implementing and developing behaviours. responsive in reducing facility-wide conduct and residents individual in use siderail restrictive evaluate to APNs used (2007) al. et Capezuti siderails. education in four long term care homes. The findingsFall subsection: 2, # concluded Recommendation (see injuries serious that or falls recurrent falls, restrictive bed-related in increase an without sidereduced rail useon residents can be safely (2002). Evans & Strumpf, Maislin, Capezuti, by Risk/History of a earlierstudy from findings confirms which Falls) • • of clients to • Reminders glasses wear and hearing to aids if • Reminders day; each • Mobilization of • Use sleep; before tea • Sleep preservation chamomile -- hot milk or RECOMMENDATIONS 38
overcrowding, noise, or confusion or overcrowding,noise, from agitation than differently approached are delirium and infection as such stresses,physiological or hunger,pain and patterns.client’stodetect the prehensivePhysicalsource stress,the of todeterminetry assessment and suchas behaviours com- a complete and situations de-escalating in components psychological and physiological the consider should Nurses management de-escalationtechniques andcrisis various of effectiveness the environment.on treatment However, evidence restrictive researchand less limited a is to there signed as- be should risk low with admissions al. new months).et two that concluded Beck first in incidents (>6 clients risk high than characteristics demographic and diagnostic different had and incidents or injury of perpetrators the be to likely less facility and found that low risk clients (>.15 seclusion or restraint incidents per month over course hospitalization) of were considering the use of restraints. A study by Beck et al. while (2008) providing a investigatedsafe space for the nurses to patterns employ de-escalation strategies of to manage restraint the client’sand escalating seclusionbehaviours before in a psychiatric at risk of harm to self/others. Environmental modifications can help decrease thepotential for escalating harmfulbehaviours considering any modifications to the environment based on the client’spotential for demonstrating responsivebehaviours about organization’sleadership the and members team interprofessional with collaborate to when know to need Nurses #3) thatevaluatecomplex to client deal risk with situations. Recommendation munication(see 1),Recommendations# toolsassessment(See includingappropriateand the2 # of use com- therapeutic/interpersonal of use the in competence demonstrate to able be should nurse The care.centered family client/ and persuasion, gentle care, informed trauma management, crisis and de-escalation in abilities their of awareness client responsive behaviours and implement client-preferred interventions to assist them to cope. Nurses should have a self- situations. effectivecrisis in performance by nursesused to Appendix de-escalate be providescan U that suggestions some It is essential for nurses to have knowledge of a broad range of de-escalation and behaviour management strategies to ensure de-escalating their behaviours may mosteffective. be care by all health-care providers. Specific interventions identified by the client to be effectivestrategies in the early stages in of client’splan the behavioural individualized of consistent implementation the in important prevention,is and of aspect important an is behaviours responsive escalating of signs early of Knowledge behaviours. responsive escalating of signs behaviour.of Tools (see Appendices S and areT) available to assist the clientthe nursewith to identify or be aware early of client’sthe topattern applies it as agitation increasing of signs early the awareof being R).PreventionAppendixincludes is a prevention strategy and key principle in personalizing a specific de-escalation planwith client identifiedtechniques (see such as crowding, noise or lack of privacy. Awareness of client-specifictriggers clients in or agitation factorsincreased and thatbehaviours escalating influenceto lead thecan that client’sfactorsenvironmental of aware behaviour be should Nurses Discussion ofEvidence Promoting Alternative Safety: Approaches to theUse Restraints of • includes to: action theability of model This have tonursesappropriatelyforwho Figure 6) skills (see the client’s de-escalate a action of pattern a for model behaviour. •Take into consideration theenvironmental factors thatmay contributing to be theclient’s behaviours; risk ofharmforallinthepresenceescalatingresponsivebehaviours. mitigate and safety promote to resources appropriate the mobilize and techniques management crisis and de-escalation implement should team interprofessional the with partnership in Nurses RECOMMENDATION 7 Appropriately andunderstand observe of theneeds REGISTERED NURSES’ASSOCIATION OFONTARIO (NCCNSC, 2005; Park, Hsiao-Chen Tang, & Ledford, 2005) Ledford, Tang,& Hsiao-Chen Park, 2005; (NCCNSC, (Möhler etal., 2011) theclient; . . Johnson & Hauser (2001) identify a identify (2001) Hauser & Johnson . Level ofEvidence=IIb RECOMMENDATIONS 39
.
(Mamun &
(Snyder, 2004) (Snyder, . www.rnao.org suggests that if a restraint Level of Evidence = IV patient needs Knowing what the Reading the patient (Johnson & Hauser, 2001) (Johnson & Hauser, BEST PRACTICE GUIDELINES • Matching the Intervention and Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting of the behaviour Noticing the Patient Understanding the meaning . The literature related to the management of responsive, aggressive or Theharmful to aggressive the related literature . management of responsive, Connecting with the Patient behaviours; demonstrated the client’s Reading the Situation
Patient on the continuum Patient (Choi & Song; 2009c; rev., CNO, Maccioli et al., 2003; Mamun & Lim; Muralidharan & Fenton, 2008) Knowing where the patient is of the meaning Assess Nurses in partnership with the interprofessional team should engage in care practices that Nurses in partnership with the interprofessional team should engage safety and well-being throughout the duration of any minimize any risk to the client’s restraining process. RECOMMENDATION 8 RECOMMENDATION Discussion of Evidence prevention the focusfirst where onof assessment, a ispredominately philosophy care require environments Restraint-free and use of alternative approaches. The second focus of care is on the implementation of alternative strategies, including use of de-escalation interventions and crisis management techniques; with the use of restraints as a last resort only after all other alternatives have proven ineffective (see Figure 1). Choi and Song (2003) outline decision-makers that in nurses the are use the of primary restraints for client safety. There is insufficient evidence including to seclusion supportfor short-term the management of use disturbed/aggressive of behaviour in restraints adult psychiatric settings Reprinted with permission from Mental Health Nursing. Reprinted with permission from Mental Health Figure 6: Patterns of Action for De-escalating Client Behaviour of Patterns 6: Figure and de-escalation to approach standardized organization’s their consider should team, interprofessional the needs. with that will identified intervention(s) hopefully meet the client’s most appropriate the employing by nurse, • Intervene The crisis management when individual creating plan a ofclient’s approaches can Alternative include providing care. comfort to the client, providing meaningful activities for the client and providing the client with a safe environment • Treatment approaches Treatment for agitated behaviours must be utilized within the context of the situation, the the pathology, age ofclients’ - psycho the client, and the degree of anxiety and agitation demonstrated by the client on the continuum of aggression) physical or agitation verbal to anxiety, escalating (from behaviours Lim, 2005; McCue et al., 2004; Nelstrop 2006) et McCue 2004; al., et al., 2005; Lim, behaviours RECOMMENDATIONS 40
aromatherapy •Initiate aphysician’s order limited, --time • • •Identify theclient’s responsive behaviour; •Review client-specific precipitating andpredisposing criteria; (including seclusion) isdeemed necessary, thenurse should: Promoting Alternative Safety: Approaches to theUse Restraints of vary depending on the organizational setting (e.g. correctional facilities have clientele that are always restrained by the by restrained always are that clientele have facilities correctional (e.g. setting organizational the on depending vary (see Appendix V, ResourceWebsites) of List .CNO, The (rev. mayconsidered restraint is a what acknowledgesthat 2009c) population client and sector health-care on based legislation specific by guided are resort) last a consideredas is restraint a when followed be (toprocedures and restraint) a not is or is, what (on policies organizational if aware be must Nurses the with client’s identified preferences.fit should restraints chemical of use the in increase an avoid to initiated strategies Alternativespace. personal and privacy their of violation of result a as clientscognitively impaired responsivein use) escalatedbehaviours actually factors (restraint physical and (visitation) social of use the that identified al., Voyerbehaviours. et responsive with clients Reduction in the use of physical restraints may result in an increase in use of chemical restraints use of sleep aids and sleep hygiene strategies considered. Alternative strategies such as music as such considered. strategies Alternative strategies hygiene sleep and aids sleep of use the and assessed be should disturbances Sleep problems. sleep and behaviours disruptive for medications neuroleptic of chemical as used being not are these ensure restraint to in medication the needed”clinical “as setting. of Voyer administration and et use al. the (2005) suggest review the to use team of alternative solutions to reduce unnecessary administration the loss client’sof and can rights have legal implications. There should be a process for the nurse the with interprofessional for potential a is there coerciveas administration resulting in inappropriate medications use. needed”Overuse of “as“as needed of medications” use in clinical practice can result the in recommend not does (2003) al. et Thapa possibility, this •Debrief useandmonitoring restraint •Document of • • •Initiate aplanof •Review consent theclient/family/SDM; with •Continue to explore new alternative strategies; • ■ ■ ■ Advocate for theleastrestrictive of form eliminate the risk factorseliminate have therisk successful notbeen isrequired; andarestraint theinterprofessionalConsult with team andclient/family/SDM andinitiate only after attempts to or modify tocoping; client help with strategies thatinclude client andinitiateDocument strategies preferences for useof to explore use of new alternative strategies and trial earliest safe release of theclient from safe release earliest to restraints; new alternativeof explore andtrial useof strategies required for client safety, theclient response to process, therestraining any comfort measures given andtheprocess Provide of ongoing thatoutlines monitoring policy thefrequency organization asper andtype them to removed be from therestraints; explanations asto their rights, why to are needs andwhat happen they (behaviour)inorder restrained being for awareBe thatclients are who notsure unsafe feel andensure why are theclient will they restrained being isgiven strengtheningrelationship The thetherapeutic from or re-establishment theclient’s of perspective; and procedures staff. andeducation of incidents may harmful prevented be review, of further restraints, with policies use of asthesetypes of adjustment any client of complicationsA review concerns or safety surrounding event therestraining the or asdirect result of care; and of didandnotwork, what considerations subsequent to adjustments of andanevaluation with theclient’s plan the prevention, restraints, to prior used theuseof including environment strategies de-escalationpractice andbest perspective. risk episode from therestraint shouldfocuson ananalysis of review of The amitigation of A review REGISTERED NURSES’ASSOCIATION OFONTARIO interprofessional with team andclient/family/SDM to support: (Friedman,Kates,Mendelson,Bingham,& 2009) theinterprofessional care incollaborationwith team andclient/family/SDM; for thesafe removal andfor restraint trial theearliest of of to specific thetype theclient on astandardized form; restraint have been identified as producing a calming effect on unrestrained unrestrained on effect calming a producing as identified have been andproduct restraint used; alternative approaches andde-escalation (Beaulieu et al., 2008) and (Janelli, Kanski, & (Janelli,Kanski,Wu,2002)
monitoring therestraint; . To minimize
and RECOMMENDATIONS 41
(Chaves, (Chaves, Cooper, www.rnao.org . Nurses must have knowledge of the possible the of knowledge have must Nurses . BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
urine and stool Decrease muscle mass, tone and strength, stiffness and strength, tone mass, muscle Decrease Contractures osteopaenia Bone demineralization, Nosocomial infections resulting from immobility (e.g. pneumonia) immobility (e.g. from infections resulting Nosocomial causing injury Falls Dehydration from lack of access to fluid of lack to from access Dehydration of Loss appetite Deconditioning dependency Increased Venous stasis (blood clot, pulmonary emboli), lower extremity edema extremity lower pulmonary emboli), stasis (blood clot, Venous Asphyxia Aspiration Strangulation Increased agitation Increased frustration Increased and basal metabolic rate volume in blood pressure, Change stress Cardiac ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
• Injury alterations • Musculoskeletal of • Incontinence and nutritional alterations status • Hydration • Infection impaction • Fecal
• Death functional status • Decreased
alterations system • Cardiovascular
• Behaviour alterations Medical Collins, Karmarkar, & Cooper, 2007; Maccioli et al., 2003; Mamun & Lim, 2005; Nelstrop et al., 2006) al., et Nelstrop 2005; Lim, & Mamun 2003; al., et Maccioli 2007; Cooper, & Karmarkar, Collins, Figure 7: Possible Complications of Restraint Use Complications Possible 7: Figure Clients Clients must be monitored frequently by the nurse for the development of complications from restraints environment and paediatric settings have cribs for infants which are not viewed as restraints). The Long-Term Care Homes Homes Care Long-Term The restraints). as viewed not are which infants for cribs have settingspaediatric and environment Act (2007) in Ontario, Canada outlines the Assistance Personal Service Devices that (PASD) are approved for use by the ofpurpose intended the for used be can ofcare plan the in documented and client/family/SDM and team interprofessional assisting bythe theclient in legislationactivitiesunder long-term care this definition, governing of daily The living. PASD been considered. have the use of a restraint if to the PASD alternatives is not considered Canada in Ontario, homes multiple multiple medical, psychological and functional complications (see Figure 7) resulting from the use of restraints and up. and follow monitoring be in observation, diligent RECOMMENDATIONS 42
• •Clients thatare restrained, responsibilities: •Organization •Consent : Figure 7: Possible ComplicationsofRestraintUse(continued) Promoting Alternative Safety: Approaches to theUse Restraints of of •Definition or to others”.patient to herself himself/ The Act outlines: toand other facilities to usealternative prevent whenever itisnecessary by when possible harm bodily a strategies serious PatientThe Restraints Minimization Act (2001)(see Appendix inOntario, waspassed V) Canada to encourage “hospitals • Perceptions of • Pain •Disordered alterations sleep integrity • Skin •Increased confusion • Psychological Authorization requirements to or restrain confine aclient on: orbased useamonitoring device ■ ■ ■ ■ ■ ■ ■ REGISTERED NURSES’ASSOCIATION OFONTARIO Education of staff. Education of Physician order requirements; and (patient/others); Prevention harm bodily serious of freedom, Enhancement of Documentation andrecordDocumentation keeping, to Monitor:Duty policies, andprocedures policy Establishment of thatencourage alternative on compliance andreporting methods to ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Development of pressure Development of ulcers Bruising Abrasion site atrestraint Trauma/ retraumatization deprivation Sensory Fear Depression Anxiety Anger Guilt image Changes inself autonomy Loss of anddignity Self alternative method, patient, confined or have amonitoring device, restrain;
RECOMMENDATIONS 43
www.rnao.org continue to cite a lack of lack a cite to continue . Appendix X provides an example example an provides X Appendix . (Wynn, 2004) (Wynn, BEST PRACTICE GUIDELINES • . Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting (Choi & Song, 2003) (Choi & Song, . Nurses should Nurses . be supported in the documentation of care for the duration of restraint a client’s
(Akansel, 2007; Forrester, McCabe-Bender, Walsh, & Bell-Bowe, 2000; Kirkevold & Engedal, 2004) Engedal, & Kirkevold 2000; Bell-Bowe, & Walsh, McCabe-Bender, Forrester, 2007; (Akansel, (Maccioli et 2003) al., A rangeofA studies Nurses must know any restraint legislation based on their jurisdiction and health-care sectors and understand how it applies applies it how understand and sectors health-care and jurisdiction their on based legislation restraint any know must Nurses to their work settings. The 2009a) CNO identifies(rev. thatnurses must policy know their andorganization’s procedures regarding the use of restraints and the informed consent requirements when restraints are considered as an intervention to deal with the responsive behaviours. It client’s is very important that nurses use only the type of restraints authorized for use within their organization and know the practice the and (2001) Act Minimization Restraints Patient The required procedures. and policy monitoring, organization’s their by outlined as observation and documentation responsibilities limited in except used be cannot form any in restraints that outlines 2009c) (rev. CNO, by restraints on document standard with nurse the that and emergency situations where there is risk ofcare 2009a; harm without to self/others, CNO their the (rev. client/family/SDM consent. regarding decisions make to right a have client/family/SDM the that outlines also rev.2009c) the interprofessional team must inform the client/family/SDM of any alternative measures/interventions being proposed and the risks and The care andbenefits Office of treatment. ofavailable thatchoices thefor Chief the are client’s Coroner, whenever services advocacy to access automatic have should clients that recommended (2008) Canada Ontario, of Province they are placed in physical restraint or seclusion or given a chemical restraint. Nurses should client rights and be support when as policyrestraints a to advocacy, related are considered and last processes resort to ensure aware of organization informed of are clients the process. throughout options oftool. a debriefing - chal a as observation and ofcare duringprocess restraint the client the application, the regarding documentation nursing ofmotion range passive repositioning, frequent to limited be not but include should care Nursing practice. in issue lenging of of head the elevation the needs, toileting/elimination care, mouth intake, fluid and food adequate ensuring turning, and - appro as ambulation and limb of affected the rotation and removal restraint otherwise unless indicated, degrees 30 to bed priate episode by a standard form (see Appendix W) identified for use within the organization for tracking and recording assess- W) use for identified recording organizationfor within the tracking and Appendix form (see a standard by episode provided observations care and the nursing ments, All orders for restraints should be time limited in duration. The potential to discontinue or reduce restraints should be of The restraints process a should debriefing include discontinuing process team. the health-care by frequently considered with the team and interprofessional the client/family/SDM to that to ensure restraint alternatives use are discussed and to future the in again indicated be restraints of should plan a care to contribute RECOMMENDATIONS 44
et al., 2010; Smith,2010;al., et Timms,Parker, 2003) Hamlin,Reimels, & et al., 2003; Testad etal., 2005) ers, de Jonge, Candel, & Berger, 2007; Huizing, Hamers, Gulpers, & Berger, 2008; Huizing, Hammers, Gulpers, & Berger, 2009; Pellfolk et al., 2010; Smith nurses in caring for clients with responsive behaviours that put clients at risk for the use restraints of assist to tool a as used be and restraints physical of use the reduceto attitudes knowledge,change increase can Education Discussion ofEvidence Education Recommendations Promoting Alternative Safety: Approaches to theUse Restraints of Testad, Ballard, Bronnick, & Aarsland, 2010) Studies point to the need for education related to the risks of restraint use and use of alternative strategies andon violence components to clientand management safety. thatpertain of would assist organizations to train on some of the key elements across programs such as the theoretical aspects of prevention restraints restraints in acute care settings Nay & Wilson, 2006; Kontio et al., 2009; Smith et al., 2003; Sung, Chang, Lee & Lee, 2006; Testad et al., 2010) show promise in decreasing restraint use, increasing positive client outcomes and greater nurse job satisfaction behaviours,responsive manage to alternatives and use restraint of impacts negative the psychological), and physiological (physical,processes,environmental, restraints toalternativesuse,decision-making restraint about facts and myths the on •Understandingofthelegalandlegislativerequirementsgoverninguserestraints. • •Therapeuticnurseclientrelationships;client-centredcareandrights; • •Monitoringanddocumentationresponsibilities; • •Interprofessionalcollaboration; • •Ethicaldecision-making; •Educationonnursingresponsibilitiesfortheproperapplicationofrestraints; •Communicationandeducationofclient/family/SDMkeycomponentsdebriefing; •Approachestocare:(e.g.traumainformedcare); emphasis on: specific with opportunities development professional ongoing as well as curricula nursing practice Education on working with clients at risk for the use of restraints should be included in all entry to RECOMMENDATION 9 REGISTERED NURSES’ASSOCIATION OFONTARIO complications fromtheuseofrestraints;and Types ofrestraints(leasttomostrestrictive)andassociatedsafetyrisksthepotential surrounding theuseofrestraintsandthreatstoclientautonomyhumanrights; Nurses responsibilitiesregardingself-reflectionandexploringtheirvaluesbeliefs management; Knowledge ofbasicprevention,alternativeapproaches,de-escalationandcrisis putting clientsatriskfortheuseofrestraints; Knowledge ofdiagnosesandcommontriggersassociatedwithresponsivebehaviours . (Smith et al., 2003) . Lee et al. (2001) reviewed training curriculums and suggest that course standardization and in persons with dementia . Education programs have been associated with reductions in the use of of use the in reductions with associated been have programs Education . (Pellfolk et al., 2010; Testad, Aasland, & Aarsland, 2005; . Educational programs that focus Level ofEvidence=Ib (Evans et al., 2002; Pellfolk (Akansel, 2007; Koch, (Huizing, Ham- RECOMMENDATIONS 45 and
ensuring clients; for . www.rnao.org restraint. expectations and restraints
. Hamers et al. (2009) suggest that eta para al. - Hamers . of use the BEST PRACTICE GUIDELINES •
rights; human to and beliefs values related from (Möhler et al., 2011) (Möhler et al., restraint; cultural/language influences; restraints including Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting complications
all forms of avoid to action (culturally sensitive) suggest continuing education for nurses should include, but not necessarily not but include, should nurses for education continuing suggest own their autonomy, the use of (Kontio et al., 2009; Ludwick et al., 2008; Turgay, Sari, & Genc, 2009) & Genc, Sari, Turgay, 2008; Ludwick et al., 2009; et al., (Kontio alternatives, forms of the different on education
of modes or approaches alternative restraint use; to related considerations ethicalclinical and (Chuang and Huang, 2005; Hamers, Gulpers, & (Chuang Hamers 2004; Strik, Gulpers, and et Hamers, 2005; Huang, Huizing 2009; al., et et Koch 2007; al., et Kontio 2006; al., 2009; al., Client/family/SDM safety from harm to all; all; harmsafety to from with the restraint of cope feelings regarding to how including components and emotional Psychological be limited, to the following: to be limited, and safety; autonomy • Client clients; psychotic or interaction with demonstrating case scenarios aggressive effective • Client characteristics possible risk • Client for of • Studies Studies digm shift must concurrently occur at the organization level in addition to a staff education program that coincides with the implementation of health-care policies that support the use of alternative approaches. These systems and processes the use of staff reduce to or restraints. support be available to the policyneed expectations to and prevent Saarnio, Isola, & Laukkala, 2008; Werner & Mendelsson, 2001) Mendelsson, & Werner 2008; Laukkala, & Isola, Saarnio, Although there are studies that indicate staff education is effective in reducing restraint other use, studies noted have that education alone is not enough affectto the rate of restraint use of • Use Nurses should be educated to deal with clients who are exhibiting A alternatives. deeper aggressive understanding behaviour of clinical and decision-making can implement also help safe, nurses effective in implementing policies and safe practices in regards to clients at risk and enable the development of knowledge and skills to serve as restraint use prevent to role team interprofessional models on an • Decision-making; of • Definition understanding and • Legal, and misconceptions; • Myths of self-reflection • Opportunity nurse’s for • RECOMMENDATIONS 46
the use of restraints.the useof prevent to culture and philosophyapproach alternative an creating for important is leadership senior from commitment transition in this facility was a culture that supported collaborative relationships and a the focus to on key safety. the that identified Several Chandler studies model. care trauma-informed a to transitioning was that hospital a of experience the described (2008) Chandler use. restraint in reduction the with associated component key a is culture Organizational Philosophy andCulture the shiftto alternative anorganization. approaches within restraints to theuseof straint philosophy. Koch et al. (2006) found that adopting a universalre- least definition helpeda alleviate the tensionand associatedwith restraints of use the to approaches alternative embracing in stress experience staff policies, organizational internal within restraint of definition no there is if that identified consitutesrestraint.(2007) a what Lai of understanding a is what common includesthat definition of a restraints howon clearpolicy a to of use minimizeneed the Organizations Definition Discussion ofEvidence Organization &PolicyRecommendations Promoting Alternative Safety: Approaches to theUse Restraints of et al., 2006; Chandler; Donat, 2003; Pollard, Yanasak, Rogers, & Tapp, 2006; Rask et al., 2007) al., et Rask Tapp,2006;Pollard,& Yanasak,Rogers, 2003; Donat, Chandler; 2006; al., et • • • • • • • •Establishingarestraintreduction/preventionpolicy; •Developingaphilosophythatpromotesalternativeapproachestotheuseofrestraints; •Establishingadefinitionofwhatisrestraint; client rightsandstaff safetyby: to enableaculturethatpromotesalternativeapproachestheuseofrestraintsinsupport Health-care organizationshouldimplementriskmanagementandqualityimprovementstrategies RECOMMENDATION 10 REGISTERED NURSES’ASSOCIATION OFONTARIO interprofessional teamsafety. alternative approachestotheuseofrestraintsandimpactonclient/family/SDM Establishing evaluationprogramstomonitortherateofrestraintuse,uptake SDM andtheinterprofessionalteam; Establishing communicationresponsibilitiesanddebriefingproceduresforclient/family/ duration ofanyrestrainingepisode; Establishing monitoringprotocolsforclientsandthedocumentationrequirements line interventionstrategiespriortotheuseofrestraintsasasafetymeasurelastresort; Using alternativeapproaches,de-escalationandcrisismanagementasthefirstsecond to theuseofrestraints; Establishing amulti-componentprogramincludingstaff educationonalternativestrategies opportunities toexploreclient/family/SDMconceptsofsafety; Educating theclient/family/SDMaboutassociatedrisksofrestraintuseandproviding others placingthematriskfortheuseofrestraints; Developing structuresthatallowforearlyidentificationofclientsatriskharmtoself/ suggests that administrative support and support administrative that suggests Level ofEvidence=Ib (Amato RECOMMENDATIONS 47
(Amato
and include the include and (Hellerstein et al., 2007; 2007; (Hellerstein et al., www.rnao.org and when possible, should possible, when and . Educating the client/family/ . . One study supported the need for for need the supported study One . (Coussement et al., 2009; (Coussement Maccioli et 2009; et 2003; al., al., Other studies have shown no significant - interprofes the between discussion key A . . The current research supports that programs supportsthat research current The . BEST PRACTICE GUIDELINES • (Huizing et al., 2007; (Huizing Huizing et Huizing 2007; et 2008; al., et 2009; al., al., (McCue et al.; Pellfolk et al.) Pellfolk (McCue et al.; . (Amato et al.; Gillies et al., 2005) al., et Gillies al.; et (Amato Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting . Behavioural. treatment plans been have successful in decreasing the (Donat, 2003) (Donat, (Capezuti et al., 2007; Ludwick et al., 2008; Vance, 2003; Wagner et al., 2007) al., et Wagner 2003; Vance, 2008; al., et Ludwick 2007; al., et (Capezuti (Gallinagh, Nevin, McAleese, & Campbell, 2001) Campbell, & McAleese, Nevin, (Gallinagh, (Dean et 2007) al.,
. As part of a behaviour management program in a psychiatric hospital, adolescents withfamily/ their adolescents hospital, psychiatric a in partprogram ofmanagement As behaviour a . (Amato et al., 2006; Dunbar & Neufeld, 2000; Evans & Fitzgerald, 2002; Forrester et al., 2000; Gillies et al., 2005; Lai et al., 2006; 2006; al., et Lai 2005; al., et Gillies 2000; al., et Forrester 2002; Fitzgerald, & Evans 2000; Neufeld, & Dunbar 2006; al., et (Amato . Studies support . education the to client/family/SDM . (Happ, 2000) (Happ, et al., 2006; Baier, Butterfield, Harris, & Gravenstein, 2008; Evans & Fitzgerald, 2002; Lebel & Goldstein; Werner, 2002) Werner, Goldstein; & Lebel 2002; Fitzgerald, & Evans 2008; Gravenstein, & Harris, Butterfield, Baier, 2006; al., et McCue et al., 2004) McCue et al., establishment of a committee to address the use ofrestraints use the address to committee ofa establishment Often family members/SDM and health-care providers think of restraints as providing protection to clients (e.g. prevention prevention (e.g. clients to protection providing as restraints of think providers health-care and members/SDM family Often of falls or wandering) and therefore are not only supportive but expect that the staff will use restraints to safeguard their family The member. results of education of health-care providers as a strategy to reduce the use of restraints are mixed. whileuse restraint to regard in experience and knowledge their increase of education support to for strong is nurses There prevent to strategies of alternative use and risks associated the characteristics, client about learning by attitudes influencing restraints of use the sional team and client/family/SDM needs to address information on the potential risks the potential with information on associated address the use of needs type to and client/family/SDM team sional any strategies be considered. of approach to restraint the possible and alternative Möhler et al., 2011) Möhler et al., cognition Alternative approaches should approaches Alternative focus on the client and an individualized to approach care regardless oflevel of the client’s Alternative Approaches Alternative The implementation The ofimplementation a formal restraint programreduction is important restraint use decreasing for Programs Multi-component Early Identification for of at risk clients identification early enable to technology and supporttools provide to organizations important for is It translation support can knowledge of trees use strategiesas Organizationdecision or ofalgorithmssuch use the restraints. into clinical practice. The adoption of standardized assessment tools can assist nurses in screening, early identificationof strategies ofalternative development the enabling by ofcare philosophy organization’s the willfacilitate This risk. at clients to manage emergingany behaviours client withoutresponsive the use of restraints SDM collaborated with providers in the development of an individualized management plan that addressed goals ofgoals - treat addressed that plan ofmanagement individualized an development the in with providers collaborated SDM ment and management of aggression McCue et al., 2004; Pellfolk et al., 2010; Smith et Sung al., 2003; et Testad et al., 2005). al., 2006; effects from education of health-care on providers restraint reduction an interprofessional team approach that team approach the includes an client/family/SDM in interprofessional and care decision-making the regarding use of rails side as such restraints environmental to to prevent or minimize restraint use must include an interprofessional and approach consultative to planning care Kratz, 2008; Lai et al., 2006; Lebel & Goldstein, 2005; McCue et al., 2004; Pollard et al., 2006) al., et Pollard 2004; al., et McCue 2005; Goldstein, & Lebel 2006; al., et Lai 2008; Kratz, consider the use of advanced practice nurses nurses practice advanced of use the consider use of studies in restraints in seclusion and hours Organizations will need to evaluate all strategies implemented to ensure health-care practices are moving towards the use of use the towards moving are practices health-care ensure to implemented strategies all evaluate to need will Organizations TMF as such Websites outcomes. client positive in resulting ofrestraints, use the in reduction a with approaches alternative Commitment Organization as such resources provide to available are Institute Quality Health Foundation) Medical (Texas chart Environment for long-term to care help to Restraint-Free organizations evaluate their to restraint-free commitment care as well as other resources for comprehensive assessment and evaluation of programs. . TMF http://nursinghomes.tmf.org/Restraints/RestraintToolkit/tabid/548/Default.aspx at: available restraint resources are SDM will help to build knowledge and trust surrounding the use of alternative approach strategies. strategies. trustSDM will and approach use of the knowledge build surrounding help to alternative RECOMMENDATIONS 48
monitoring varies within the literature from daily from literature the within varies monitoring basis.frequencyof ongoing The an on use restraint of types all review to is monitoring componentin important Another assist in debriefing scenarios.assist indebriefing can episodes restraint of documentation and assessment for technology of use or tools standardized outcome.Useof the what went anyan well explorationwith of harmful incidents to determine what actions could have of improved or preventedreview a and restraints of use the to up led events what of exploration the in assist to approach standardized a utilize must non-punitive environment and a within implemented be to needs client.Debriefing the from feedback and consent alternatives, the care provided, the the strategies and timeframe triggers,the of removal the of the restraint, the family review involvement,to client/family/SDMand the and team health-care the include should review automatic This seclusion. and restraint environmental including client, restrained every and each of review automatic an include must framework event prior to, during and post event assists in changing the the culture of of psychiatric analysis fromsettings. client’s Learning progress.Partthe of anytrack organization’sstaff help and quality staff for strategies learning as used be can cidents Restraining episodes can be associated with feelings of discomfort, fear and self-blame from the perspective of the client the of perspective the from self-blame and fear discomfort, of feelings with associated be can episodes Restraining health-care providers makewho the decision to apply restraints Studies demonstrate that restraints the has applicationnegative of psychological effects not only on the clients but also the respectto restraints.with and the requirements for monitoring when restraints are considered and any education provided to the client/family/SDM Chart audits should review evidence of the client’s assessment, exploration of alternatives to restraint use, (2006) suggested evidence that the use and observation of chart audits tools of are feasible waysconsent to assess restraint use in organizations. posted on each unitto promote restraints thereduction intheuseof and disseminated be should monitoring from produced data restraint Postevents. restraint challenging of episodes and use restraint of rates reviewing include should programs improvement Quality form. audit an of example an provides Y be ongoing data collection, monitoring and evaluation which are part of an overall quality improvement program. Appendix In order to ensure the safety clientsof and achieve and maintain restraint minimization within an organization, there must Evaluation andMonitoring (Chuang &Huang, 2005; Fonad, Burnard&Emami, 2008; Kontos &Nagilie, 2007; Mayers, Keet, Winkler, &Flisher, 2010) 2005) Chien, & (Wong episodes restraint future preventing in helpful been has staff and clients/families/SDMs with Debriefing Debriefing Promoting Alternative Safety: Approaches to theUse Restraints of eea suis ae eosrtd ht raiain ta fcsd n ult ipoeet e abtos agt for targets ambitious set improvement quality on restraint reduction and subsequently demonstrate a greater reduction in the restraints use of focused that organizations that demonstrated have studies Several changing the culture around restraint use restraint around culture the changing in assist to restraints of use the on targets setting and trends both identifying in assist provider, on health-carealso and but client effects psychological the with dealing in assist can episodes event restraint post debriefing that outline Studies Patry, Harris, &Gravenstein, 2009; Donat, 2003) The organization’s model of care should promote an interprofessional team approach in collaboration RECOMMENDATION 11 use ofrestraints. the prevents and approaches alternative of use the supports that family/SDM and client the with REGISTERED NURSES’ASSOCIATION OFONTARIO while the health-care providers feel uncomfortable from the perspective of the client’s human rights rights humanclient’s the of perspective the from uncomfortable feel providers health-care the while . (Wynn, 2004) (Wynn, (McCue et al., 2004) al., et (McCue . Petti, Mohr, Somers, & Sims (2001) identified that debriefing in- debriefing that identified (2001) Sims & Mohr,Petti,Somers,. (Duxbury, 2002; Holmes et al., 2004; Sequeira & Halstead, 2002, 2004) to weekly to (Amato etal. 2006; Castle, 2003) (Amato et al., 2006; Donat, 2003) Donat,2006;al., et (Amato (Baier et al., 2008; Baier, Butterfield, Level ofEvidence=III . . (Gillies et al., 2005) al., et (Gillies . Edwards et al. et Edwards.
. . RECOMMENDATIONS 49
(Castle, (Castle,
(Huizing et . . (Demir, 2007a, 2007a, (Demir, www.rnao.org ; staffing levels levels staffing ; and the autonomy nurse’s ; nurse absenteeism and workload workload and absenteeism nurse ; (Affonso et al., 2003; RNAO, 2007b) RNAO, 2003; (Affonso et al., (Huizing et al., 2007) al., et (Huizing on Doran, & the use Jeffs, of Affonso, restraints. (Capezuti et al., 2007; de Veer, Franche, Buijse, & Friele, 2009; 2009; Friele, & Buijse, Franche, Veer, de 2007; al., et (Capezuti BEST PRACTICE GUIDELINES • (Williams & Myers, 2001) Myers, & (Williams . Involving the client/family/SDM to guide the interprofessional interprofessional the guide to client/family/SDM the Involving . Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting , staff mix staff , (Yamamoto et al., 2006) al., et (Yamamoto (CNO, rev. 2009c; Downes et al., 2009; Fonad et al., 2008; Gallinagh et al. 2001; Werner, 2002) Werner, 2001; et al. Gallinagh 2008; et al., Fonad 2009; Downes et al., 2009c; rev. (CNO,
. . Friedman et al. (2009) identified thatco-management by geriatricians andorthopaedic surgeons using 2007b; Donat, 2002; Whitman, Davidson, Rudy, & Sereika, 2001) Sereika, & Rudy, Davidson, Whitman, 2002; Donat, 2007b; Literature is mixed on the influence of the type of job and ward characteristics ward of and typeof the job influence the on mixed is Literature mediators and part of the team in the decision-making process regarding the use or removal of physical restraints. Bourbonniere a standardized approach to leads care, to processes improved and outcomes restraints. including a reduction in the use physical of restraints of removal or use the of the role that as organizations should consider socialregarding (2002) recommended workers Werner in withclients hip fractures. process decision-making the in team the of part and mediators et al. (2003) found that use of part-time, inadequately of use in increased restraints. orientated resulted and weekends on hospital care influenced members staff and lack of supporting interprofessional team O’Hagan et al. (2008) identifies that reduction of seclusion and restraint tends to be more achievable when staff is involved involved staff is when achievable more be to tends restraint and of seclusion reduction reduction that identifies (2008) that al. et O’Hagan suggests al. et O’Hagan recruitment. and appraisal performance supervision, education, on focus a is there and is achievable when there is a high ratio of staff to clients, staffing is stable, mature andwell trained.Job descriptions, & Yin, Grunawalt (2008) Tzeng, outlined the need for further research on the optimum combination of staffing patterns restraint reduce and team, interprofessional the for environments safer support that settings hospital for infrastructure and use the to alternatives sustain that levels staffing ofappropriate provision the supports 2009c) (rev. CNO Furthermore, use. of of The restraints. Academy believes Nurses Canadian the Executive issue of nursing workload needs to be addressed to workloads qualitysustain regulatory that identify reasonable bodies and literature leadership, Nursing safety. client ensure settings restraint should carry use in all health-care to and this concept care over Ferguson-Paré (2003) identifiedFerguson-Paré workload as a significant issuefor nurses in delivering theprocesses of care in waya that et (2007) Huizing al. reviewsupports ofclient safety. organizational determinants leading to use of restraints physical did not confirmworkload as influencing restraint,but rather client characteristics (e.g.age, impaired cognitive mobility)especially as statistically impaired significantof in the use status,restraints. and restraintpractices. and seclusion reducing priority the to orientation appraisals should reflect and performance given 2000a, 2000b, 2002; 2000a, Castle 2000b, & Banaszak-holl, 2003; Ibe et al., 2008; Unruh, Joseph, & Strickland, 2007) client’s the meeting in important very and outcomes better of predictor known a is care of plan the of development the in team with clients of management the in valuable is approach team interprofessional an supports that model A needs. self-defined at riskbehaviours restraint use for Discussion of Evidence Discussion encourages and practice of standards evidence-based of use the facilitates that care of model a support should Organizations the when action of course appropriate most the identify to client/family/SDM the with collaboration team interprofessional of use the risk at is for restraintsclient Ludwick et 2008) al., providers health-care among education and mentorship feedback, consultation, collaboration, facilitate should care of Models ofrestraints use the strategiesto alternative and prevention to relation in al., 2007; Lepping et al., 2009; Pekkarinen, Elovainio, Sinervo, Finne-Soveri, & Noro, 2006) & Finne-Soveri, Noro, Sinervo, Elovainio, Lepping 2007; Pekkarinen, et al., 2009; al., RECOMMENDATIONS 50
theToolkit. of description a for D Appendix to refer Please change. practice implementing for model structured a provides Toolkit(2002) RNAO The organization. the within practice on impact that procedures and policies into recommendations evidence-based the transform toareable fromwho nursesprocessleadershipstructured,strong systematicplanning a and of requiresuse the has administrators) Promoting Safety: Alternative and Approaches to the Use researchers of Restraints. Successful implementation nurses, of the best practice guidelines of perspectives and panel consensus. The Toolkit a is recommended (through for guiding the Ontario implementation developed of the the of Toolkit:RNAO best Implementation practice Association of guideline Clinical Practice Nurses’ Guidelines (RNAO, Registered 2002), based The on available evidence, theoretical Discussion ofEvidence Promoting Alternative Safety: Approaches to theUse Restraints of • • • • • circumstances. An assessmentoforganizationalreadinessandbarrierstoeducation,takingintoaccountlocal Organizations maywishtodevelopaplanforimplementationthatincludes: planning, resources,organizationalandadministrativesupport,aswellappropriatefacilitation. Nursing bestpracticeguidelinescanbesuccessfullyimplementedonlywherethereareadequate RECOMMENDATION 12 REGISTERED NURSES’ASSOCIATION OFONTARIO guidelines. Opportunities forreflectiononpersonalandorganizationalexperienceinimplementing practices. Ongoing opportunitiesfordiscussionandeducationtoreinforcetheimportanceofbest implementation process. Dedication ofaqualifiedindividualtoprovidethesupportneededforeducationand practices. Ongoing opportunitiesfordiscussionandeducationtoreinforcetheimportanceofbest contribute totheimplementationprocess. Involvement ofallmembers(whetherinadirectorindirectsupportivefunction)whowill Level ofEvidence=IV RECOMMENDATIONS 51
life; restraints; evidence-based staffing patterns); www.rnao.org workload, to how should focus on research use of the to approaches alternative restraints; applied; restraints once restraints; BEST PRACTICE GUIDELINES • restraint use; the use of on settings in health-care that and culture) philosophy Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting processes, structures, and language, culture including (e.g. factors care, being used in specialty restraints which are to settings as intensive such the extent strategies of or weaning tools assist in the safe to achieve organizations and to providers assist health-care to and technologies best tools sectors/ risk at restraint riskin all use in clients that identify for health-care valid tools factors use restraints (e.g. to in the decision nurses influence known to factors safety while client balancing and quality care of in nursing the ethical involved dilemmas environments. health policy health-care in ensuring restraint-free of and reduction prevention on this guideline restraint risk on and prevention; reduction development professional nursing ongoing diversity, the use of reducing or preventing to in relation client the on the therapeutic relationship
the best of support implementation for promotes that care The impact of The impact of create a safe environment within staff organizations for report possible inappropriate on to environment a safe and clients/family/SDM create restraint use; paediatric and home health-care settings, and to explore and identify the most effective alternative approaches/ alternative the most effective and identify explore and to paediatric settings, health-care and home strategies these settings client populations; for to the specific of The development environments; restraint-free use of the inappropriate on review disputes to The optimal approach of strategies the uptake translation practice for clinical knowledge in nursing The for most effective practices for restraintpractices risk and prevention; for reduction of The identification use of to restraint restraint use practice and safe approach environments; an alternative to contribute of The identification The model of of The development specialties; restraints; identifying focus on that the trials interventions nursing-specific identify to control randomized multi-site Large the use of to restraints; approaches alternative most effective
The above list is an attempt to identify and prioritize some of the research gaps, although it in no way exhausts the exhausts although it in no way and prioritize identify gaps, of some to list is an attempt the research The above of in this area opportunities study. further for research • • of • The development • The and safety best monitoring practices during the restraining process; • • of • Identification • The impact of • • •
• The impact of • Research Gaps and Future Implications Future and Gaps Research literature research the in gaps several identified has guideline, this for evidence the reviewing in panel, development expert The panel the gaps, these considering In ofuse the use. restraint and to restraints approaches alternative safety, client to related followingpriority the areas: has identified research • • The impact of • • Exploration of RECOMMENDATIONS 52
Approaches Alternative theguideline: PromotingSafety: to theUse of and evaluation Restraints. of RNAOthe in outlined framework a on table,based following evaluated. The and monitored be will impact, its implementation,and to considerare recommendationsguideline advised the implementing practice how nursing Organizations best this the in Evaluation/Monitoring ofGuideline Promoting Alternative Safety: Approaches to theUse Restraints of System Level ofIndicator REGISTERED NURSES’ASSOCIATION OFONTARIO , illustrates some specific indicator for monitoringToolkit: indicator for specific Guidelines(2002),some Practice Clinical illustrates of Implementation clinical settings. use thatare effective inthe agement andleastrestraint man- de-escalation andcrisis tion, alternative approaches, relatedpractices to preven- theoretical andbest of and healthcare organizations nursing byreview schools of that allows for thejoint A mechanism isestablished into curricula. for practices client safety agement andleastrestraint man- de-escalation/crisis tive approaches, prevention, regardingpractices alterna - andbest theory embedding inplacestructure to facilitate nursing have programs a Academic with settings settings. across healthcare all system are inplace for adoption andmechanisms restraint of velop auniversal definition iscreatedA structure to de - to restraints. using alternative approaches thatfacilitatetion nurses available- intheorganiza To evaluate thesupports Structure effective inclinical settings. to known practices best be and current theory review health-care to organizations nursing and schools of facilitates between dialogue A process isinplace that forpractices client safety. agement andleastrestraint man- de-escalation/crisis tive approaches, prevention, regardingpractices alterna - andbest current theory isupdated with curricula to ensure nursing core processA review isinplace restraint. the universal definition of and procedures to include the organization’s policy to of facilitate thereview processA review isinplace alternative practices. prevention anduseof towards thatlead practice To evaluate changes in Process clinical settings. are to known effective be in healthcare that organizations tice recommendations from - prac andbest current theory Nursing Programs integrate learnings. program fromsafety their nursing for practices restraint client management andleast crisis prevention, de-escalation/ alternative approaches, regarding practices best and theory evidence-based awareness current anduseof Nursing students demonstrate system settings. acrossrestraint healthcare all Universal definition of restraints.prevents theuseof toward anenvironment that andmovementclient safety recommendations to ensure To evaluate theimpactof Outcome
RECOMMENDATIONS 53
-
alter restraints used; www.rnao.org client/ to Education regarding family/SDM do policy/practices to with restraints; Individualized plan ofIndividualized with preferred care client approach alternative strategies incorporated; Use of alternative strategies of alternative Use prior to restraint use; prior to precipitating factors; precipitating Assessment ofAssessment predisposing/
■ ■ ■ ■ of Type of in the rate A decrease restraint use; in the duration A decrease of restraint episodes; in use of increase An strategies used priornative least restraint use; to practices showing an in: increase documentation Improved
Outcome are and procedures Policy withthe best consistent - practice recommen guideline use ofdations for alternative de- prevention, approaches, escalation/crisis management and least restraint practices. evalua - Quality improvement to in place are tion processes of policy outcomes monitor - and practice implementa tion that support prevention, de- approaches, alternative escalation/crisis management and least restraint practices as evidenced by: • • • •
• - BEST PRACTICE GUIDELINES • Process that is in place A process the review ofallows or ganization policies and they ensure to procedures align with the best practice recommendations guideline current based on that are - regard theory and research approaches, ing alternative de-escalation/ prevention, crisis and least management restraint practices. (e.g. process A standardized and data evaluation tools is procedures) collection withinin place the orga- the facilitate nization to data ofcollection outcome - the implementa regarding tion of a policy based on - the best practice recom regarding mendations alternative prevention, de-escalation/ approaches, crisis and least management restraint practices. Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Structure a Organizations have to structure in place review best practice recommendations. guideline that A structure is in place quality for reviewallows of to related outcomes client ofthe implementation the organization policy based on - the best practice recommen - preven dations regarding approaches, alternative tion, de-escalation/crisis- man and least restraint agement practices.
Level of Indicator Organization RECOMMENDATIONS 54
Promoting Alternative Safety: Approaches to theUse Restraints of Client Nurse Level ofIndicator REGISTERED NURSES’ASSOCIATION OFONTARIO the organization’s policy ensure client education on Mechanisms are inplace to least restraint. management and tion/crisis native approaches, de-escala- regarding prevention, alter on policy theorganization to ensure nurse education A mechanism isinplace and practices surroundingand practices restraint practices. restraint management andleast crisis approaches, de-escalation/ prevention, alternative Structure
- • • by: asevidenced practices agement andleastrestraint man- de-escalation/crisis alternative approaches, regarding prevention, at educational sessions facilitate nurses attendance A process isinplace to Process education sessions; nurses attend who ber of An increase inthenum- restraint practices. restraint native approaches and alterregards to useof in reflectsbest practices Nursing documentation
- • • • by: use asalastresort, evidenced restraint with restraints use of alternative approaches to the toability execute prevention, Nurses display anincreased • • • • • Outcome ■ ■ from use. leastrestraint A decrease incomplications oragement strategies; man- escalation andcrisis alternative approaches, de- An increase inuseof restraint/seclusion use; of A decrease intheprevalence episodes. leastrestraint following A decrease incomplications family/SDM satisfaction;or An increase intheclient/ family/SDM andstaff; with client/ debriefing review follow updemonstrating An increase incident inpost monitoring protocols; and Use observation of Consent for use: restraint physician orders; client/family/SDM,
RECOMMENDATIONS 55
alternative precipitating articulate to www.rnao.org of Knowledge factors; and predisposing and and knowledge Awareness of policy and practice prevention, surrounding restraint use risks, alternative alternative restraint use risks, restraint and safe strategies, practices; strategies known to prevent strategies prevent known to escalating limit or responsive behaviours. Ability • Outcome Client/family/SDM an increased: demonstrate • • Reports indicate an increase an increase indicate Reports satisfac- in client/family/SDM the use oftion surrounding strategies least or alternative restraint. in place budget Annual costs the financial cover to supportingfor policy and practice. known BEST PRACTICE GUIDELINES • of Identification alternative successful be- incorpo to approaches planning care rated into the use of prevent to restraints; and preferred Consent method of least restraint as a last resort; use only and and ongoing Initial organiza- on education tion policy and practices of use prevention, for approaches, alternative least restraint use and monitoring/observation routines. and Assessment of identification risks; Process in place are Processes within the organization the setting that facilitates in the: involvement client’s • • • • A process is in place to to place is in A process - require financial determine support to annually ments best a policy that promotes use prevent, practices to approaches, alternative de-escalation/crisis man- and least restraint agement practices. Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Structure The model of facilitates care as the clients/family/SDM participantsactive in the and development assessment of the plan of ensure to care specific alternative the client strategies in are approach the use of prevent to place restraints. A structure is in place withinA structure is in place revieworganizations to financial impactof a policy best practices that promotes use alternative prevention, to de-escalation/ approaches, crisis and least management restraint practices.
Level of Indicator Financial Costs RECOMMENDATIONS 56
• • • • Appendix D. the document version isalsoavailable inPDFformat A full attheRNAO of website, www.rnao.org/bestpractices. website.Toolkitthe A on availableare resourcesthat RNAOdevelopedabove, the has mentioned strategies the to addition In • • • • follows: guideline. thesestrategies of A summary this implementing in interestedare that disciplines health-care or organizations health-care assist to strategies mentation The Registered Nurses’ Association of Ontario (RNAO) and the guideline development panel have compiled a list of imple- Implementation Strategies Promoting Alternative Safety: Approaches to theUse Restraints of • • • for implementing guidelines can be helpful if used appropriately. A brief description about this toolkit can be found in found be can toolkit this about description brief appropriately.A used if helpful be can guidelines implementing for • • guideline. reinforcement thatwill, over strategies time, build theknowledge andconfidence nurses inimplementing this of Beyond nurses, skilled implementing thisguideline should adoptofOrganizations arange (alternative approach and restraints materials). Orientation of the staff to the use of specific products specific (alternative and technologies to theuse of approach thestaff materials). andrestraints of Orientation must provided be andregular refresher planned. training documentation tools philosophypolicies and through procedures.best practices thatreflectsvalue the of Develop new assessment and by concerns distracted notbe aboutwork will andhaving anorganizational soparticipants replacementhiring staff Provide such inplace ashaving support thestructures organizational to facilitate the implementation. Program shouldinclude: design Create andsustaining tothevision. directfor help avision thechangeanddevelop achieving effort strategies work activities, planto track responsibilities andtimelines. member representation committed to thechange lead initiative. Identify andlong-term goals. short-term Keep a issues of immediate concernissues of to andoffer new skills practice opportunities ongoing thetraining. remindersPlaneducation sessions thatare interactive, of include problem-solving, address presentations, facilitator’s guide, handouts, andcasestudies. Binders, posters andpocket cards may as used be educational sessions for andongoing implementation.Design support Have atleastone dedicated individual, priority. asanorganizational prevent restraints theuseof Executive Senior theestablishment Leadership of shouldview Establish committee asteering comprised of (e.g. incidents. focusgroups) and critical Initial assessment may needs include ananalysis approach, Restraints to identify currenteducational requirements. knowledge baseandfurther Conduct related needs-assessment anorganizational toAlternative PromotingApproaches Safety: to theUse of and project management skills. provide support, andleadership. clinical expertise shouldalsohave individual The interpersonal, good facilitation resources theorganization. inthecommunity or within team are beneficialinimplementing guidelines successfully. or to services be made asnecessary should Referral Teamwork, Celebrate milestones andachievements, acknowledgingwork welldone Identify champions practice best designated on each unitto andsupport promote implementation. andsupport REGISTERED NURSES’ASSOCIATION OFONTARIO ■ ■ ■ ■ ■ Evaluation activities. Required resources (human resources, facilities, equipment); and Outcome measures; andobjectives; Goals Target population;
collaborative theclient/family/SDM assessment andinterprofessional andtreatment planning with required theinfrastructure to implement thisguideline includes access to equipment specialized (Davies &Edwards, 2004) such asanadvanced nurse practice or aclinical resource nurse, . key stakeholders, andquestionnaire, survey aculture alternative thatsupports approaches to interprofessional client/family/SDM members with self-learning, education sessions The may consist of (Davies &Edwards, 2004) (Davies &Edwards, 2004) group learning, group approaches format . mentorship and . For example, will who
RECOMMENDATIONS 57
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Developing a detailed work plan with a detailed work and deliverables. target dates Developing Compiling feedback received, questions encountered during the dissemination phase, as well as other comments comments as well as other during phase, the dissemination encountered questions received, feedback Compiling experiences. their regarding ofand experiences representatives site implementation Inviting specialists in the field to participate in the Review Team. The Review Team comprisedofwill be members Review The Team. Reviewto participate specialists in the field in the Inviting specialists. the originalfrom recommended panel as other as well technical papers, meta-analysis reviews, systematic practice in the field, guidelines clinical new Compiling literature. relevant and other trial controlled research randomized reviews, a) b) c) d)
During the period between development and revision, RNAO program staff systematic new for will monitor regularly RNAO During and revision, the period development between in the field. trials literature relevant and other controlled randomized reviews, consultation Appropriate an earlier revision plan. program staff recommend may ofBased the results on monitor, the with of a team of composed members original specialists and other panel in the field members will help inform the review and revise to milestone. decision earlier than the targeted the guideline the program staff the planning of the review will by: prior months milestone, to Three the review commence process Each nursing best practice guideline will be reviewed by a team of specialists (Review Team) in the topic area, to be to area, in the topic best practice will guideline nursing ofEach a team be reviewed by specialists Team) (Review following years setof the last revisions. five every to three completed 5. The revised will guideline established structures based on dissemination and processes. 5. undergo 2. 2. 3. 4. 1. 1. Process For Update / Review Guideline / Review Update For Process this best of practice as follows: guideline Association update to Ontario proposes Nurses’ The Registered REFERENCES 58
from www.chsrf.ca/other_documents/evidence_e.php#definition. Canadian Health ServicesResearchFoundation (2006).Conceptualizing andcombiningevidence. Retrieved en/projects/ltc.cfm symptoms). Toronto, ON:CanadianCoalitionforSeniors’MentalHealth. Retrievedfromhttp://www.ccsmh.ca/ The assessmentandtreatment ofmentalhealthissuesinLongTerm Carehomes(focusonmoodandbehaviour Canadian CoalitionforSeniors MentalHealth(CCSMH).(2006).Nationalguidelinesforsenior’s mentalhealth: agree-ii/. Doi:10.1503/cmaj.090449 healthcare. CanadianMedicalAssociationJournal.Retrievedfrom http://www.agreetrust.org/resource-centre/ AGREE NextStepsConsortium(2010).II:Advancingguidelinedevelopment,reportingand evaluationin Brouwers, M.,Kho,M.E.,Browman,G.P., Burgers,J.S.,Cluzeau,F., Feder. G.,…Zitzelsberger, L.,forthe use forhospitalizednursinghomeresidents.JournaloftheAmericanGeriatricsSociety, 51 (8), 1079-1084. Bourbonniere, M.,Strumpf,N.E.,Evans,L.K.,&Maislin, G.(2003).Organizationalcharacteristicsandrestraint Health Nursing,9(4),465-473. experience ofphysicalrestraintformentalhealth inpatients andstaff inthe UK.JournalofPsychiatric&Mental Bonner, G.,Lowe,T., Rawcliffe, D.,&Wellman, N.(2002).Trauma forall:Apilotstudyofthesubjective Research &Policy, 4(4),236-248. development methods:Reviewofbestpracticeincreatingclinicalguidelines.JournalHealthServices Black, N.,Murphy, M.,Lamping,D.,McKee,Sanderson,C.,Askham,J.,&Marteau,T. (1999).Consensus restraint. InternationalJournalofMentalHealthNursing,17(3),215-222. Bigwood, S.&Crowe,M.(2008).‘It’s partofthejob,butitspoilsjob’:Aphenomenologicalstudyphysical Bennet, J.(2008).Confrontingtheriskofelopement.NursingHomes,57(1),54. care residentsatriskforaccidentalfalls.Aging-Clinical&ExperimentalResearch,17(3),186-192. Becker, C.,Loy, S.,Sander, S.,Nikolaus,T., Rissmann,U.,&Kron,M.(2005).Analgorithmtoscreenlong-term restraint useatastatepsychiatrichospital.PsychiatricServices,59(9),1027-1032. Beck, N.C.,Durrett,Stinson,J.,Coleman,Stuve,P., &Menditto,A.(2008).Trajectories ofseclusionand program. JournalofHeadTrauma Rehabilitation,23(5),304-311. management onanacutebraininjuryunit:Evaluatingtheeffectiveness ofaninterdisciplinarytraining Beaulieu, C.,Wertheimer, J.C.,Pickett,L.,Spierre,Schnorbus,T., Healy, W.,… Jones,A.(2008).Behavior Applying stakeholderanalysistomergerlifecycle.JournalofNursingAdministration,29(3),11-20. Baker, C.,Ogden,S.,Prapaipanich,W., Keith,C.K.,Beattie,L.C.,&Nickleson,(1999).Hospitalconsolidation: Geriatrics Society, 57(8),1498-1503. relationship betweenambitioustargetsandnursinghomequalityimprovement.JournaloftheAmerican Baier, R.R.,Butterfield,K.,Patry, G.,Harris, Y., &Gravenstein,S.(2009).Identifyingstarperformers:The Association, 9(8),594-598. between settingtargetsandimprovednursinghomequalityofcare.JournaltheAmericanMedicalDirectors Baier, R.R.,Butterfield,K.,Harris, Y., &Gravenstein,S.(2008).Aimingforstarperformance:Therelationship alzheimer.ca/english/care/ethics-restraints.htm Alzheimer Society. (2011)TheAlzheimerCare:EthicalGuidelines,Restraints.(2011).Retrievedfromhttp://www. quality improvementstudy. RehabilitationNursing,31(6),235-241. Amato, S.,Salter, J.P., &Mion,L.C.(2006).Physicalrestraintreductionintheacuterehabilitationsetting:A Health ScienceJournal,1(4),7-13. Akansel, N.(2007).PhysicalrestraintpracticesamongICUnursesinoneuniversityhospitalwesternTurkey. issues. CanadianJournalofNursingLeadership16(4),69-81. Affonso, D.D.,Jeffs, L.,Doran,D.&Ferguson-Paré,M.(2003).Patientsafetytoframeandreconcilenursing Reference List Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO REFERENCES 59
Medical Care, www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
40(10), 868-878. information to nursing homes: Can it improve quality of care? Castle, N. G. (2003). Providing outcomes Gerontologist, 43(4), 483-492. of administrative resources on care in nursing homes. Journal The effect Castle, N. G. & Banaszak-Holl, J. (2003). 22(3), 405-424. of Applied Gerontology, control from staff treatment: Transferring G. (2008). From traditional inpatient to trauma-informed Chandler, Nurses Association, 14(5), 363-371. to patient. Journal of the American Psychiatric use of physical R. (2007). Review of the A., & Cooper, R. A., Collins, D. M., Karmarkar, Chaves, E. S., Cooper, 19(2), 94-107. users. Assistive Technology, restraints and lap belts with wheelchair Home Hebrew the of Institute Research (CMAI). Cohen-Mansfield, J. (1989). Cohen Mansfield Agitation Inventory f Retrieved from http://www.dementia-assessment.com.au/symptoms/CMAI_Scale.pd of Greater Washington. restraint use in a Korean ICU. Journal of Clinical Nursing, 12(5), 651-659. Choi, E. & Song, M. (2003). Physical physical restraints on (2005). Nurses’ feelings and thoughts about using H. & Huang, H. T. Chuang, Y. (3), 486-494. hospitalized older patients. Journal of Clinical Nursing, 16 College of Nurses. Retrieved Documentation Standard. Toronto: 2008). (rev. College of Nurses of Ontario (CNO). f from http://www.cno.org/Global/docs/prac/41001_documentation.pd College of Nurses. Retrieved from 2009a). Consent Standard. Toronto: College of Nurses of Ontario (CNO). (rev. f http://www.cno.org/Global/docs/policy/41020_consent.pd College of Nurses. Retrieved from 2009b). Ethics Standard. Toronto: College of Nurses of Ontario (CNO). (rev. f http://www.cno.org/Global/docs/prac/41034_Ethics.pd College of Nurses. 2009c). Restraints Standard, Revised. Toronto: College of Nurses of Ontario (CNO). (rev. f. Retrieved from http://www.cno.org/Global/docs/prac/41043_Restraints.pd . Revised 2006. Toronto: College of Nurses of Ontario (CNO). (2009d). Therapeutic nurse-client relationship f. College of Nurses. Retrieved from http://www.cno.org/Global/docs/prac/41033_Therapeutic.pd L., Boonen, S.,... Milisen, K. (2009). Den Noortgate, N., De, P. E., Lambert, M., Van Coussement, J., Dejaeger, survey in Belgian hospitals. fall incidence data into fall-preventive measures in geriatric wards–A Translating 55(4), 398-404. Gerontology, (2003). General anaesthesia D.,…Monagle, P. S., Ashley, Crock, C., Olsson, C., Phillips, R., Chalkiadis, G., Sawyer, perspective. Archives of Disease family’s or conscious sedation for painful procedures in childhood cancer: The in Childhood, 88, 253-257. of best practice guidelines. Registered Nurse Journal, Davies, B. & Edwards, N. (2004). RNs measure effectiveness 16(1), 21-23. Canadian Patient Safety Institute (CPSI). (2003). Canadian Patient Safety Dictionary. Retrieved from Retrieved Safety Dictionary. Canadian Patient (CPSI). (2003). Patient Safety Institute Canadian f http://rcpsc.medical.org/publications/PatientSafetyDictionary_e.pd outcomes among bed-related fall Side rail use and L. K. (2002). N., & Evans, E., Maislin, G., Strumpf, Capezuti, 50(1), 90-96. Geriatrics Society, Journal of the American nursing home residents. of an K. A. (2007). Consequences M., Renz, S., & Talerico, L. M., Brush, B. L., Boltz, Capezuti, E., Wagner, Geriatrics Society, homes. Journal of the American restrictive side rail use in nursing intervention to reduce 55(3), 334-341. restraints. and decreasing use of physical in nursing homes with increasing Differences Castle, N. G. (2000a). , 1154-1163. Medical Care, 38(2) Journals of Gerontology restraint use in nursing homes. Deficiency citations for physical Castle, N. G. (2000b). (1), S33-S40. Sciences & Social Sciences, 55 Series B-Psychological restraint use. deficiency citations for physical Nursing homes with persistent Castle, N. G. (2002). REFERENCES 60
Flannery, J.,Rachlin, S.,&Walker, A.P. (2002).Characteristics ofassaultive patientswithschizophrenia versus Institute ofMedicine, NationalAcademyPress. Field, M.J.&Lohr, K.N.(1990). Guidelinesforclinicalpractice: Directionsforanewprogram.Washington, D.C.: Psychiatry, 24(10),1110-1118. and antipsychoticmedications innursinghomes:Across-nationalstudy. InternationalJournalofGeriatric Feng, Z.,Hirdes,J.P., Smith,T. F., Finne-Soveri,H.,Chi,I.,Du,P. J.N.,…Mor, V. (2009).Useofphysicalrestraints residential caresettings.JournalofAdvancedNursing,40 (6), 616-625. Evans, D.,Wood, J.,&Lambert,L.(2002).Areviewofphysicalrestraintminimizationinthe acuteand research. ContemporaryNurse,13(1),126-135. Evans, D.&Fitzgerald,M.(2002).Theexperienceof physicalrestraint:Asystematicreviewofqualitative subsequent residenthealth.Gerontologist,48(4),442-452. Engberg, J.,Nicholas,G.,Castle,N.&McCaffrey, D.(2008).Physicalrestraintinitiationinnursinghomes and testing oftoolstoassessphysicalrestraintuse.Worldviews onEvidence-BasedNursing,3 (2), 73-85. Edwards, N.,Danseco,E.,Heslin,K.,Ploeg,J.,Santos, J.,Stansfield,M.,&Davies,B.(2006).Developmentand Nursing, 9(3),325-337. aggression andviolenceononementalhealthunit:Apluralisticdesign.JournalofPsychiatric&MentalHealth Duxbury, J.(2002).Anevaluationofstaff andpatientviewsofstrategiesemployedtomanageinpatient of GerontologicalNursing,27(10),40-48. Dunn, K.S. (2001). The effect of physical restraints on fall rates in older adults who are institutionalized. reduce restraintuse.AnnalsofLong-Term Care,8(24),47-54. Dunbar, J.&Neufeld,R.(2000).Partnershipbeyondrestraints:Astatewideeducationalinterventionto Psychiatric andMentalHealthNursing.18DOI: 10.1111/j.1365-2850.2010.01679.x seclusion withorwithoutrestraintinaCanadianpsychiatrichospital:A2-yearretrospectiveaudit. Dumais, A.,Larue,C.,Drapeau,Menard,G.,&GiguereAllard,M.(2010).Prevalenceandcorrelates of agitated patientintheemergencydepartment.EmergencyMedicineAustralasia,21(3),196-202. Downes, M.A.,Healy, P., Page,C.B.,Bryant,J.L.,&Isbister, G.K.(2009).Structuredteamapproachtothe psychiatric hospital.PsychiatricServices,54(8),1119-1123. Donat, D.C.(2003).Ananalysisofsuccessfulefforts toreducetheuseofseclusionandrestraintatapublic Psychiatric RehabilitationJournal,25(4),413-416. Donat, D.C.(2002).Impactofimprovedstaffingonseclusion/restraintrelianceinapublicpsychiatric hospital. psychiatric patients.JournalofForensicandLegalMedicine,16(5),284-286. Dickson, B.C.&Pollanen,M.S.(2009).Casereport:Fatalthromboembolicdisease:Ariskinphysicallyrestrained Netherlands. JournaloftheAmericanGeriatricsSociety, 57,1881-1886. de Veer, A.J.,Francke,L.,Buijse,R.,&Friele,R.D.(2009).Theuseofphysical restraintsinhomecarethe Turkey. InternationalNursingReview, 54(4),367-374. Demir, A.(2007b).Theuseofphysicalrestraintsonchildren: Practicesandattitudesofpaediatricnursesin 39(1), 38-45. Demir, A.(2007a).Nurses’useofphysicalrestraintsinfour Turkish hospitals.JournalofNursingScholarship, residents withdementia.InternationalJournalofGeriatricPsychiatry, 20(7),651-657. de Jonghe-Rouleau,A.P., Pot,A.M.,&deJonghe,J.F. (2005).Self-injuriousbehaviourinnursinghome inpatient psychiatricunitsforyouths.PsychiatricServices,56(2),186-192. Delaney, K.R.&Fogg,L.(2005).Patientcharacteristicsandsettingvariablesrelatedtouseofrestraintonfour Psychiatry, 46(6),711-720. in achildandadolescentpsychiatricinpatientunit.JournaloftheAmericanAcademyChildAdolescent Dean, A.J.,Duke,S.G.,George,M.,&Scott,J.(2007).Behavioralmanagementleadstoreductioninaggression Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO Journal of Journal REFERENCES 61
Journal of www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
American Geriatrics Society, 57(7), 1139-1148. American Geriatrics Society, Journal of Forensic Journal of Program (ASAP). Action Assaulted Staff analysis of the disorder: Six year personality 47(3), 558-561. Sciences, fall risk and views on staffs’ or caging? Healthcare A. (2008). Shielding & Emami, Burnard, P., Fonad, E., 3, 46-54. People Nursing, (1) Journal of Older International in Stockholm. protection of Physical restraint management N., & Bell-Bowe, J. (2000). J., Walsh, D. A., McCabe-Bender, Forrester, Development-JNSD, 16(6), 267-276. in Staff Journal for Nurses and follow-up study. hospitalized adults Encyclopedia of M. Blouin, (eds). International of Daily Living. In: J.H. Stone, Fricke, J. (2011). Activities / from http://cirrie.buffalo.edu/encyclopedia/en/article/37 Rehabilitation. Retrieved Geriatric (2009). Impact of a co-managed & Kates, S. L. Mendelson, D. A., Bingham, K. W., Friedman, S. M., Medicine, 169(18), 1712-1717. Archives of Internal short-term hip fracture outcomes. Fracture Center on . Iowa City (IA): guideline. Wandering Evidence-based practice K. D., & Remington, R. (2008). Futrell, M., Melillo, Dissemination Research Translation Research Center, Gerontological Nursing Interventions University of Iowa Core. L., & Campbell, L. (2001). Perceptions of older people who have experienced Gallinagh, R., Nevin, R., McAleese, (13), 852-859. physical restraint. British Journal of Nursing, 10 restraint use at A. (2005). An innovative model for Fox, C., & Cooney, Pesnell, P., H., Short, T., Gillies, J., Moriarty, (1), 45-56. 29 Nursing Administration Quarterly, Medical Center. Affairs the Philadelphia Veterans with cognitively impaired nursing home (2004). Use of physical restraints Gulpers, M. J., & Strik, W. Hamers, J. P., (3), 246-251. residents. Journal of Advanced Nursing, 45 R. (2009). Attitudes of Dutch, G., Kopke, S., Lindenmann, R., Groven, R., & Huizing, A. Meyer, Hamers, J. P., restraint use in nursing home residents, a cross-sectional study. towards physical German and Swiss nursing staff 46(2), 248-255. International Journal of Nursing Studies, [Review]. approach to prevent treatment interference in critical care. Happ, M. B. (2000). Using a best practice 15(2), 58-62. Progress in Cardiovascular Nursing, http:// Project: Final report. [Online]. Retrieved from Health Canada (2006). Advance care planning: The Glossary p. www.hc-sc.gc.ca/hcs-sss/pubs/palliat/2006-proj-glos/index-eng.ph E. (2007). Decreasing the use of restraint and seclusion among Hellerstein, D. J., Staub, A. B., & Lequesne, (5), 308-317. psychiatric inpatients. Journal of Psychiatric Practice, 13 Reviews of Interventions Version & Green, S. (Eds.). (2008). Cochrane Handbook for Systematic T. Higgins, J. P. g 5.0.1. Retrieved from www.cochrane-handbook.or A critical examination of S. L., & Perron, A. (2004). The mentally ill and social exclusion: Holmes, D., Kennedy, perspective. Issues in Mental Health Nursing, 25(6), 559-578. the use of seclusion from the patient’s and implementation of Hospital Bed Safety Group. (2003). Clinical guidance for the assessment US Department of Health and bedrails in hospitals, long- term care facilities, and home care settings. Human Services. Retrieved from http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ generalhospitaldevicesandsupplies/hospitalbeds/default.htm (2007). Organizational determinants of the M. P. deJonge, J., Candel, M., & Berger, Huizing, A. R., Hamers, J. P., (5), 924-933. use of physical restraints: A multilevel approach. Social Science & Medicine, 65 (2008). Preventing the use of physical restraints M.P.F. H., Gulpers, M. J. M., & Berger, Huizing, A. R., Hamers, J. P. trial. BioMed A cluster-randomized on residents newly admitted to psycho-geriatric nursing home wards: http://www.biomedcentral. Central Geriatrics, 6(17), 459-469. Doi:10.1186/1471-2318-6-17. Retrieved from com/1471-2318/6/17 M. (2009). A cluster randomized trial of educational Huizing, A., Hammers, J., Gulpers, M., & Berger, nursing home residents. interventions to decrease the use of physical restraints with psycho-geriatric REFERENCES 62
Aging-Clinical &ExperimentalResearch, 20(5),447-453. Kong andthe roleofrestraints:Across-sectional surveyusingthe ResidentAssessmentInstrument (RAI)2.0. Lee, J.S.,Hui,E.,Chan,F., Chi,I.,&Woo, J.(2008).Associatedfactorsoffallsinnursing homeresidentsinHong or elimination.PsychiatricServices,56 (9), 1109-1114. Lebel, J.&Goldstein,R.(2005). Theeconomiccostofusingrestraintandthe valueaddedbyrestraintreduction 23-31. older peopleandahospital-based communitygeriatricassessmentservice. Hong KongNursingJournal,(1), 42 retrospective studyontheoutcomesofacollaborative restraintreductionprojectbyaresidentialhomefor Lai, C.K.Y., Chan,M. H., Szeto,S.L.,Law, A.K.Y., Cheng,Y., Chan,T. M.F., &Leung,V. W. M.(2006).A interviews. BioMedCentralNursing,6(5),1-7. Lai, C.K.Y. (2007).Nurses usingphysicalrestraints:Aretheaccusedalsovictims?Astudyfocusgroup Quality, 23(4),331-337. Kratz, A.(2008).Useoftheacuteconfusionprotocol: Aresearchutilizationproject.JournalofNursingCare in residentialcare:Impactonhealthoutcomes.InternationalPsychogeriatrics,17 (3), 475-485. Kotynia-English, R.,McGowan,H.,&Almeida,O.P. (2005).Arandomizedtrialofearlypsychiatricintervention 198-207 and physicians’educationalneedsinseclusionrestraintpractices.PerspectivesPsychiatricCare,45 (3), Kontio, R.,Valimaki, M.,Putkonen,H.,Cocoman,A.,Turpeinen, S.,Kuosmanen,L.,&Joffe, G.(2009).Nurses’ dementia care.DementiaNovember, 6(4),549-569.Doi:10.1177/1471301207084394 Kontos, P. C.&Naglie,G.(2007).Bridgingtheoryandpractice:Imagination,thebody, andperson-centred Washington, DC:NationalAcademyPress,2000. Kohn, L.T., Corrigan,J.M.,&Donaldson,M.S.(2000).To errishuman:Buildingasaferhealthcaresystem. International JournalofOlderPeopleNursing,1(3),151-158. Koch, S.,Nay, R.,&Wilson,J.(2006).Restraintremoval:Tension betweenprotectivecustodyandhumanrights. Kitwood, T. (1997).Dementiareconsidered:Thepersoncomesfirst.OpenUniversityPress,Buckingham. of Nursing,13(15),902-905. Kirkevold, O.&Engedal,K.(2004).AstudyintotheuseofrestraintinnursinghomesNorway. BritishJournal geriatric caresettings.JournaloftheAmericanGeriatricsSociety, 49(12),1722-1728. Karlsson, S.,Bucht,G.,Eriksson,&Sandman,P. O.(2001).Factorsrelatingtotheuseofphysicalrestraintsin psychiatric inpatientcare.InternationalJournalofLawandPsychiatry, 26(2),139-149. Kaltiala-Heino, R.,Tuohimaki, C.,Korkeila,J.,&Lehtinen,V. (2003).Reasonsforusingseclusionandrestraintin case studyofchangemanagementinagedcare.Worldviews onEvidence-Based Nursing,6(4),210-218. Johnson, S.,Ostaszkiewics,J.,&O’Connell,B.(2009).Movingbeyondresistancetorestraintminimization:A calmer personalspace.IssuesinMentalHealthNursing,22(7),651-668. Johnson, M.E.&Hauser, P. M.(2001).Thepracticesofexpertpsychiatricnurses:Accompanyingthepatienttoa issue. RehabilitationNursing,27(6),221-226. Janelli, L.M.,Kanski,G.W., &Wu, Y. B.(2002).Individualizedmusic–Adifferent approachtotherestraint Retrieved fromhttp://www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprint%20final.pdf Interprofessional CareSteeringCommittee.(2007).Care:AblueprintforactioninOntario. Bloomington (MN):InstituteforClinicalSystemsImprovement. Institute forClinicalSystemsImprovement(ICSI)(2008).Preventionoffalls(acutecare).Healthcareprotocol. physical restraintprevalenceinJapaneseacutecareunits.JapanJournalofNursingScience,5(2),91-98. Ibe, T., Ishizaki,T., Oku,H.,Ota,K.,Takabatake, Y., Iseda,A.,…Ueda,A.(2008).Predictorsofpressureulcerand prevention. JournalofPsychosocialNursingandMentalHealthServices,42(9),.22-33. Huckshorn, K.A.(2004).Reducingseclusionandrestraintinmentalhealthsettings:Corestrategiesfor Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO REFERENCES 63
Annals of www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
the Academy of Medicine, Singapore, 34(2), 158-162. the Academy of Medicine, Singapore, and experiences A. J. (2010). Mental health service users’ perceptions G., & Flisher, Keet, N., Winkler, Mayers, P., 56 (1), 60-73. Psychiatry, The International Journal of Social of sedation, seclusion and restraint. use in a public & Chambers, M. J. (2004). Reducing restraint T., Tobias, McCue, R. E., Urcuyo, L., Lilu, Y., & Research, 31(2), 217-224. psychiatric inpatient service. Journal of Behavioral Health Services of agitated behaviours Non-pharmacological management M. L., & Schutte, D. L. (2004). McGongal-Kenney, and other chronic dementing conditions. University of Iowa Gerontological in persons with Alzheimer Disease and Dissemination Core. Research Translation Nursing Interventions Research Center recovery and well-being. A framework for a mental (2009). Toward Mental Health Commission of Canada. x from http://www.mentalhealthcommission.ca/English/Pages/Reports.asp health strategy for Canada. Retrieved Health Care Consent Act. Retrieved from http://www.e-laws.gov. Care. (1996) Ministry of Health and Long-Term m on.ca/html/statutes/english/elaws_statutes_96h02_e.ht from http://www.e-laws. Care. (1990). Ontario Mental Health Act. Retrieved Ministry of Health and Long Term m gov.on.ca/html/statutes/english/elaws_statutes_90m07_e.ht Act. Retrieved from http:// Care. (2001) Patient Restraints Minimization Ministry of Health and Long Term m www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_01p16_e.ht from http://www. Care Home Act. (2007). Retrieved Care. (2007). Long Term Ministry of Health and Long-Term l health.gov.on.ca/english/public/legislation/ltc_homes/ltc_homes.htm Johnson, M. E., Catrambone, C., & Leipzig, R. (2007). Prevalence and variation of Mion, L. C., Minnick, A. F., (1), 30-37. physical restraint use in acute care settings in the US. Journal of Nursing Scholarship, 39 Köpke S., & Meyer G. (2011). Interventions for preventing and reducing the use of physical Möhler R., Richter T., 2011, 2. Art. No.: restraints in long-term geriatric care (Review). Cochrane Database of Systematic Reviews, CD007546. DOI: 10.1002/14651858.CD007546.pub2 2nd edition. (2008). Retrieved from http://medical-dictionary.thefreedictionary.com/ Dictionary, Dental Mosby’s predisposition m 8th edition. (2009). Retrieved from http://medical-dictionary.thefreedictionary.co Dictionary, Medical Mosby’s with serious mental illness. Cochrane Muralidharan S., & Fenton, M. (2008). Containment strategies for people Database of Systematic Reviews 2006, Issue 3, Art. No.: CD002084. DOI: 10.1002/14651858.CD002084.pub2 Lee, S., Wright, S., Sayer, J., Parr, A. M., Gray, R., & Gournay, K. (2001). Physical restraint training for nurses in for nurses restraint training K. (2001). Physical R., & Gournay, M., Gray, A. J., Parr, S., Sayer, Lee, S., Wright, 10(2), 151-162. Mental Health, secure units. Journal of care and regional intensive psychiatric Welsh English and safety perceived (2009). Ward Schmid, P. E., & C., Flammer, I., Abderhalden, Needham, T., Steinert, P., Lepping, to deal with that improve ability factors Switzerland: Identifying Germany and managers in Britain, by ward (7), 629-635. & Mental Health Nursing, 16 violence. Journal of Psychiatric review of the effectiveness (2010). A narrative & Nicholls, T. P., S., Brink, J., Lussier, Livingston, J., Verdun-Jones, Nursing 6(1), 15- Journal of Forensic psychiatric hospital staff. training programs for of aggression management 28. maintaining, and terminating R. (2008). Safety work: Initiating, O’Toole, R., & A., Zeller, Ludwick, R., Meehan, 22(2), 81-87. restraints. Clinical Nurse Specialist, of Iowa: The University . Iowa City, older adults: Evidence-based protocol S. S. (2004). Fall prevention for Lyons, Core. and Dissemination Center Research Translation Nursing Interventions Research Iowa Gerontological (2003). T. E., McLean, B. A., Kuszaj, J. M.,…Peruzzi, W. Brown, B. R., Mazuski, J. Maccioli, G. A., Dorman, T., Use of maintenance of patient physical safety in the intensive care unit: Clinical practice guidelines for the Force 2001-2002. Critical Care Medicine, of Critical Care Medicine Task restraining therapies–American College 31(11), 2665-2676. physical restraints in nursing homes: Current practice in Singapore. Mamun, K. & Lim, J. (2005). Use of REFERENCES 64
34(1), 96-105. acute psychiatric caresettingsusingrapid responseteams.JournalofBehavioral HealthServices & Research, Prescott, D.L.,Madden,L. M.,Dennis,Tisher, P., &Wingate,C.(2007). Reducingmechanicalrestraintsin Quarterly, 78(1),73-81. reduction intheuseofseclusion andrestraintproceduresonanacutepsychiatric inpatientunit. Pollard, R.,Yanasak, E.V., Rogers,S.A.,&Tapp, A.(2006).Organizationalandunitfactorscontributing to staff inanintermediate-termcarefacility. JournalofChild&AdolescentPsychiatricNursing,(3),115-127. 14 Petti, T. A.,Mohr, W. K.,Somers,J.W., &Sims, L.(2001).Perceptionsofseclusionandrestraintbypatients 62-69. knowledge, attitudes,andpractice:Aclusterrandomized trial.JournaloftheAmericanGeriatricsSociety, 58(1), Pellfolk, T. J.,Gustafson,Y., Bucht,G.,&Karlsson,S.(2010).Effects ofarestraintminimizationprogram onstaff relation torestraintpracticesinlong-termcareunits. MedicalCare,44(12),1114-1120. Pekkarinen, L.,Elovainio,M.,Sinervo,T., Finne-Soveri,H.,&Noro,A.(2006).Nursingworkingconditionsin and DisseminationCore. Iowa City(IA):UniversityofGerontologicalNursing InterventionsResearchCenter, ResearchTranslation Park M.,Hsiao-ChenTang, J.,&Ledford,L.(2005).Changingthepracticeofphysicalrestraintuseinacutecare. Research, InformationandWorkforce Development. restraint; Seclusion:Time forchange.Auckland:Te PouTe WhakaaroNui:TheNationalCentreofMentalHealth O’Hagan, M.,Divis,&Long,J.(2008).Bestpracticeinthereductionandeliminationofseclusion Retrieved fromhttp://www.sse.gov.on.ca/mohltc/PPAO/en/Documents/sys-inq-jam.pdf Office oftheChiefCoroner, ProvinceofOntario,Canada(2008).Verdict oftheCoroner’s Jury:Jeffery James. clinical outcomes?AlzheimerDisease&AssociatedDisorders,22(4),352-361. care unitscomparedwithtraditionalnursinghomefordementiacare:Aretheredifferences atadmissionandin Nobili, A.,Piana,I.,Balossi,L.,Pasina,Matucci,M.,Tarantola, M.,…Tettamanti, M.(2008).Alzheimerspecial Nursing Journal,35(4),10-17. Ng, K.P., McMaster, F. R.,&Heng,B.H.(2008).Theeffectiveness ofbedrailsinpreventingfalls.Singapore Evidence-Based Nursing,3(1),8-18. management ofviolenceinadultpsychiatricinpatientsettingsandemergencydepartments.Worldviews on systematic reviewofthesafetyandeffectiveness ofrestraintandseclusionasinterventionsfortheshort-term Nelstrop, L.,Chandler-Oatts, J.,Bingley, W., Bleetman,T., Corr, F., Cronin-Davis,J.,…Tsuchiya, A.(2006).A Journal ofGerontologicalNursing,32(1),33-38. Nay, R.,&Koch,S.(2006).Overcomingrestraintuse:ExaminingbarriersinAustralianagedcarefacilities. London, UK:Gaskell&BritishPsychologicalSociety. management andsecondarypreventionofself-harminprimarycare.Clinicalguideline16. National InstituteforClinicalExcellence(NICE).(2004).Self-harm:Theshort-termphysicalandpsychological attachments/cp65.pdf and reviewofthescientificliteratureRetrievedfromhttp://www.nhmrc.gov.au/_files_nhmrc/publications/ National HealthandMedicalResearchCentre.(1998).Howtoreviewtheevidence:Systematicidentification health.vic.gov.au/chiefpsychiatrist/creatingsafety/ntac/module6.pdf National Technical AssistanceCenterforStateMentalHealthPlanning(NTAC). Retrievedfromhttp://www. curriculum manual.Alexandria,VA: NationalAssociationofStateMentalHealthProgramDirectors(NASMHPD), National ExecutiveTraining Institute.(2005).Training curriculumforreductionofseclusionandrestraint.Draft www.thenationalcouncil.org/cs/public_policy/restraints_seclusion_rules_chart National CouncilforCommunityBehaviouralHealthcare.(2007)DefinitionofSeclusion.Retrievedfrom London (UK):NationalInstituteforClinicalExcellence(NICE). management ofdisturbed/violentbehaviourinpsychiatricin-patientsettingsandemergencydepartments National CollaboratingCentreforNursingandSupportiveCare(NCCNSC).(2005).Violence: Theshort-term Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO Psychiatric http:// . REFERENCES 65
Worldviews Worldviews www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
on Evidence-Based Nursing, 3(1), 31-39. on Evidence-Based G. (2007). Implementation J.,…Ouslander, Green, D., Brown, H., Hawley, J. A., A., Taylor, P. Rask, K., Parmelee, 55(3), Geriatrics Society, program. Journal of the American a nursing home fall management and evaluation of 342-349. clinical practice guidelines. Implementation of Association of Ontario (2002). Toolkit: Registered Nurses’ Nurses’ Association of Ontario. Canada: Registered Toronto, (ON): Registered Client Centred Care. Toronto 2006a). (rev. Association of Ontario (RNAO). Registered Nurses’ of Ontario. Nurses’ Association (ON): Registered 2006b). Crisis Intervention. Toronto Ontario (RNAO). (rev. Registered Nurses’ Association of Nurses’ Association of Ontario. 2006c). Establishing therapeutic relationships. Toronto Ontario (RNAO). (rev. Registered Nurses’ Association of of Ontario. (ON): Registered Nurses’ Association 2007a). Assessment & Management of Pain. Toronto Ontario (RNAO). (rev. Registered Nurses’ Association of of Ontario. (ON): Registered Nurses’ Association Workload and Staffing Ontario (2007b). Developing and Sustaining Effective Registered Nurses’ Association of Ontario. Registered Nurses’ Association of Practice. Toronto. with 2010a). Caregiving Strategies for Older Adults Ontario (RNAO). (rev. Registered Nurses’ Association of of Ontario. (ON): Registered Nurses’ Association . Toronto Delirium, Dementia and Depression and 2010b). Screening for Delirium, Dementia Ontario (RNAO). (rev. Registered Nurses’ Association of of Ontario. (ON): Registered Nurses’ Association Depression in Older Adults. Toronto in the older 2011). Prevention of falls and fall injuries Ontario (RNAO). (rev. Registered Nurses’ Association of of Ontario. (ON): Registered Nurses’ Association adult. Toronto analysis of nurses’ post-incident manual restraint reports. Journal of Ryan, C. J. & Bowers, L. (2006). An 13(5), 527–532. Doi: 10.1111/j.1365-2850.2006.00975.x Psychiatric and Mental Health Nursing, in institutional care of older people in Saarnio, R., Isola, A., & Laukkala, H. (2008). The use of physical restraint Journal of Clinical Nursing, 18(1), 132- Finland: Nurses’ individual, communal and alternative modes of action. 140. Retrieved from Safer Healthcare Now! (SHN). (2010). Reducing falls and injury from falls. Getting started kit. x. http://www.saferhealthcarenow.ca/EN/Interventions/Falls/Pages/default.asp (2010). Likelihood of ordering Sandhu, S., Mion, L., Khan, R., Ludwick, R., Claridge, J., Pile, J.,… Dietrich,M. (7), 1272- 58 physical restraints: Influence of physician characteristics. Journal of the American Geriatrics Society, 1278. Doi: 10.1111/j.1532-5415.2010.02950.x , 31, 321-325. Psychiatric Bulletin September Schrank, B., & Slade, M. (2007). Recovery in psychiatry. Service user perspectives. British Journal of Sequeira, H. & Halstead, S. (2002). Control and restraint in the UK: Forensic Practice, 4(1), 9-18. physical restraint of administering on nursing staff Sequeira, H. & Halstead, S. (2004). The psychological effects then that I think about it’. British Journal of Forensic in a secure psychiatric hospital: ‘When I go home, it’s Practice, 6(1), 3-15. of aggressive subjects in Shah, A., Chiu, E., Ames, D., Harrigan, S., & McKenzie, D. (2000). Characteristics (2), 145-161. Australian (Melbourne) nursing homes. International Psychogeriatrics, 12 Putman, L. & Wang, J. T. (2007). The Closing Group: Therapeutic recreation for nursing home residents with home residents for nursing Therapeutic recreation Closing Group: (2007). The J. T. L. & Wang, Putman, & Other Disease Journal of Alzheimer’s American anxiety. agitation and/or and accompanying dementia 22(3), 167-175. Dementias, Patient Scrim, C. (2006). J., & S., Sohmer, A., Pisterman, Benjamin, K., Leclerc, F., S. Knoefel, Ralphs-Thibodeau, restraint. to decrease bedrail use as physical factor on policy-related research choice: An influencing REFERENCES 66
Werner, P. (2002). Perceptions regarding the use of physical restraints with elderly persons: Comparison of Israeli Health, 30(2),131-140. practice nursingconsultative modeltoreducerestrictivesiderailuseinnursing homes.ResearchinNursing& Wagner, L.M.,Capezuti,E.,Brush,B.,Boltz,Renz,S., &Talerico, K.A.(2007).Description ofanadvanced Gerontology, 24(3),179-195. Determinants ofneuroleptic druguseinlong-termfacilitiesforelderlypersons. JournalofApplied Voyer, P., Verreault, R.,Mengue, P. N.,Laurin,D.,Rochette,L.,Martin,L.S.,&Baillargeon,(2005). American GeriatricsSociety, 57(11),2029-2036. daily clinicalpracticereducestheincidenceofdelirium duringhospitalizationinelderlypatients.Journalofthe Vidan, M.T., Sanchez,E.,Alonso, M.,Montero,B.,Ortiz,J.,&Serra,J.A.(2009).Aninterventionintegratedinto the intensivecareunit:Apilotstudy. AACNClinicalIssues,14(1),82-91. Vance, D.L.(2003).Effect ofatreatmentinterferenceprotocolonclinicaldecisionmakingforrestraintuse in incident reportsandmortality. JournalofAdvancedNursing,60(6),673-681. Unruh, L.,Joseph,&Strickland,M.(2007).Nurse absenteeismandworkload:Negativeeffect onrestraintuse, settings. JournalofAdvancedNursing,64(2),176-183. Tzeng, H.M.,Yin, C.Y., &Grunawalt,J.(2008).Effective assessmentofusesittersbynursesininpatientcare Specialist, 23(2),68-72. Turgay, A.S.,Sari,D.,&Genc,R.E.(2009).PhysicalrestraintuseinTurkish intensivecareunits.ClinicalNurse 1286. and exposureofpsychiatricinpatientstounnecessarypsychotropicmedications.PsychiatricServices,54 (9), 1282- Thapa, P. B.,Palmer, S.L.,Owen, R.R.,Huntley, A.L.,Clardy, J.A.,&Miller, L.H.(2003).P.R.N. (as-needed)orders Clinical Psychiatry, 71(1),80-86. restraint innursinghomeresidentswithdementia:Asingle-blind,randomizedcontrolledtrial.Journalof Testad, I.,Ballard,C.,Bronnick,K.,&Aarsland,D.(2010).Theeffect ofstaff trainingonagitationanduseof A single-blindrandomizedcontrolledtrial.InternationalJournalofGeriatricPsychiatry, 20(6),587-590. Testad, I.,Aasland,A.M.,&Aarsland,D.(2005).Theeffect ofstaff trainingontheuseofrestraintindementia: Psychiatric Nursing,23(4),283-288. the Staff ObservationAggressionScale-Revisedandtwootherindicatorsforaggressiveincidents.Archivesof Tenneij, N.H.,Goedhard,L.E.,Stolker, J.J.,Nijman,H.,&Koot,H.M.(2009).Thecorrespondencebetween Administration, 30(6),325-329. Swauger, K.C.&Tomlin, C.(2000).Movingtowardrestraint-freepatientcare.JournalofNursing Therapies inMedicine,14(2),113-119. intervention onagitatedbehavioursofinstitutionalizedelderswithdementiainTaiwan. Complementary Sung, H.C.,Chang,S.M.,Lee,W. L.,&Lee, M.S.(2006).Theeffects ofgroupmusicwithmovement nursing homeresidents:Predictorsandoutcomes.ClinicalGerontologist,24(1-2),85-101. Sullivan-Marx, E.M.,Kurlowicz,L.H.,Maislin,G.,&Carson,J.(2001).Physicalrestraintamonghospitalized 0349.2010.00694.x the qualitativeliterature.InternationalJournalofMentalHealthNursing19,416-427.Doi: 10.1111/j.1447- Strout, T. (2010).Perspectivesontheexperienceofbeing physicallyrestrained:Anintegrativereviewof Nursing, 30(1),31-40. Snyder, B.S.(2004).Preventingtreatmentinterference:Nurses’ andparents’interventionstrategies.Pediatric physical restraintsintheacutecaresetting.JournalofContinuingEducationNursing,34(1),26-33. Smith, N.H.,Timms, J.,Parker, V. G.,Reimels,E.M.,&Hamlin,A.(2003).Theimpactofeducationontheuse Translation andDisseminationCore. Iowa City, Iowa:TheUniversityofIowaGerontologicalNursingInterventionsResearchCenter Skemp Kelley, L.,PringleSpecht,J.K.,Maas,M.L.(2001).FamilyinvolvementincareforpersonswithDementia. Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO REFERENCES 67
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
(1), 59-68. Care, 16 Interprofessional workers. Journal of nurses and social health care with older use physical restraints intentions to members’ Nursing staff G., (2001). & Mendelsson, P., Werner, 35(5), 784-791. Advanced Nursing action. Journal of theory of reasoned the people: Testing mechanical Practice patterns related to E. B., & Sereika, S. M. (2001). L. J., Rudy, Whitman, G. R., Davidson, for Nursing Practice, 5(3), system. Outcomes Management a multi-institutional health care restraint use across 102-111. seclusion/restraints usage, less restrictive interventions with R. E. (2001). Relationship of Williams, J. E. & Myers, Psychiatric Nurses Association, mix. Journal of the American psychiatric experience, and staff average years of 7(5), 139-144. An exploratory study. experience of physical restraint: medical patients’ Young (2005). T. I. S. & Chien, W. Wong, Nursing, 14(1), 120-121. Journal of Clinical framework for the international (2009). More than words. Conceptual Health Organization (WHO). World Report, January 2009. Retrieved from http://www. Technical Version 1.1. Final classification for patient safety. who.int/patientsafety/en/ Psychology, experiences with restraint. Journal of Forensic Psychiatry and Wynn, R. (2004). Psychiatric inpatients’ 15(1), 124-144. facing Japanese nurses regarding the physical restraint of M., Izumi, K., & Usui, K. (2006). Dilemmas Yamamoto, 3(1), 43-50. elderly patients. Japan Journal of Nursing Science, REFERENCES 68
review ofthe literature.MentalHealth &LearningDisabilities Care, 3,370-372. Bell, F., Szmukler, G.,&Carson,J.(2000).Violence anditsmanagementinin-patient mentalhealthsettings:A of staff trainingcourses.JournalofAdultProtection, 3(2),8-17. Beech, B.(2001).Managing aggressionandviolenceincaresettings:Areview ofthelegalandethicalcontent unit. JournalofPsychosocialNursing &MentalHealthServices,47(1),34-40. Barton, S.A.,Johnson,M.R.,&Price,L.V. (2009).Achievingrestraint-freeonaninpatientbehavioralhealth Surgery, 117(5),1571-1575. the plasticsurgeonforrepairoffaciallacerations in childrentheemergencyroom.Plastic&Reconstructive Bar-Meir, E., Zaslansky, R., Regev, E., Keidan, I., Orenstein, A., & Winkler, E. (2006). Nitrous oxide administered by acute-brain-injury unit.RehabilitationNursing,34 (1), 11-16. Bailey, M.,Amato,S.,&Mouhlas,C.(2009).Acreativealternativeforprovidingconstant observationonan 378. and analyzingastate-widenursingqualitymeasurement database.JournalofNursingScholarship,36(4),371- Aydin, C.E.,Bolton,L.B.,Donaldson,N.,Brown,D. S.,Buffum, M.,Elashoff, J.D.,&Sandhu,M.(2004). Creating 77-90. environment forthemanagementofdepressionandagitationinlong-termcare.ClinicalGerontologist,32 (1), Ayalon, L.,Bornfeld,H.,Gum,A.M.,&Areán,P.A. (2009).Theuseofproblem-solvingtherapyandrestraint-free perspective. EthicalHumanPsychology&Psychiatry, 6(1),69-78. Austin, W., Bergum,V., &Nuttgens,S.(2004).Addressingoppressioninpsychiatriccare:Arelationalethics modeling: Thecaseofnursinghomecompare.HealthServicesResearch,42(3p1),1177-1199. Arling, G.,Lewis,T., Kane,R.L.,Mueller, C.,&Flood,S.(2007).Improvingqualityassessmentthroughmultilevel for nursinghomeresidents.Gerontologist,47(5),672-682. Arling, G.,Kane,R.L.,Mueller, C.,Bershadsky, J.,&Degenholtz,H.B.(2007).Nursingeffort andqualityofcare structural equationmodel.MedicalCare,41(7),802-812. Arling, G.&Williams,A.R.(2003).Cognitiveimpairmentandresourceuseofnursinghomeresidents: A Quality, 23(3),227-232. Antonelli, M.T. (2008).Restraintmanagement:Movingfromoutcometoprocess.JournalofNursingCare oxygen mixtureforpainfulprocedures:AFrenchsurvey. Pediatrics,105(4),e47. Annequin, D.,Carbajal,R.,Chauvin,P., Gall,O.,Tourniaire, B.,&Murat,I.(2000).Fixed50%nitrousoxide Nurse, 15(3),322-332. inpatient treatmentofmentallyillpatientsinThailand:Implicationsforpractice.[Review].Contemporary Anders, R.L.,Thapinta,D.,Wiwatkunupakan,S.,Kitsumban,V., &Vadtanapong, S.(2003). Assessmentof nursing homeresidentswithdementiaattheendoflife.Gerontologist,45(5),661-666. Allen, R.S.,Burgio,L.D.,Fisher, S.E.,Michael,H.J.,&Shuster, J.L.,Jr. (2005).Behavioralcharacteristicsofagitated Postgraduate Medicine,1-90. Behavioral Emergencies.(2001).TheExpertConsensusGuidelineSeries.Treatment ofbehavioralemergencies. Allen, M.H.,Currier, G.W., Hughes,D.H.,Reyes-Harde,M.,Docherty, J.P., &ExpertConsensusPanelfor 38. behavioral emergencies:Asummaryoftheexpertconsensusguidelines.JournalPsychiatricPractice,9(1),16- Allen, M.H.,Currier, G.W., Hughes,D.H.,Docherty, J.P., Carpenter, D.,&Ross,R.(2003).Treatment of 260-264. interdisciplinary collaborationandinnovation.JournaloftheAmericanPsychiatricNursesAssociation,15(4), Allen, D.E.,deNesnera,A.,&Souther, J.W. (2009).Executive-levelreviewsofseclusionandrestraintpromote Bibliography Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO REFERENCES 69
515-522. www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Boustani, M., Munger, S., Beck, R., Campbell, N., & Weiner, M. (2007). A gero-informatics tool to enhance the A gero-informatics tool to enhance M. (2007). N., & Weiner, S., Beck, R., Campbell, Boustani, M., Munger, In Aging, 2(2), 247-253. Clinical Interventions older adults with cognitive impairment. care of hospitalized about the use of physical M. E. (2000). A synthesis of what we know L., McCullough, C. S., & Timmons, F. Bower, in psychiatric and acute care settings. Online Journal of Knowledge restraints and seclusion with patients Synthesis for Nursing, 7(2), 22-44. about the use of physical M. E. (2003). A synthesis of what we know L., McCullough, C. S., & Timmons, F. Bower, in psychiatric and acute care settings: 2003 update. [Review]. Online restraints and seclusion with patients Nursing, 10(1). Journal of Knowledge Synthesis for (2004). Cultures of psychiatry and the P. J., Simpson, A., Ryan, C., & Carr-Walker, Bowers, L., Alexander, The case of containment methods for disturbed patients. Nurse Education professional socialization process: 24(6), 435-442. Today, (2007). Student psychiatric nurses’ approval P. J., Simpson, A., Ryan, C., & Carr-Walker, Bowers, L., Alexander, to perception of aggression and attitudes to personality disorder. of containment measures: Relationship 44(3), 349-356. International Journal of Nursing Studies, (2006). Preliminary outcomes of a trial to reduce Lipang, M., & Oladapo, P. Bowers, L., Brennan, G., Flood, C., psychiatric wards: City Nurses. Journal of Psychiatric & Mental Health conflict and containment on acute Nursing, 13(2), 165-172. management of L. (2006). Prevention and J., & Turner, Simpson, A., Warren, Bowers, L., Nijman, H., Allan, T., on U.K. Acute psychiatric wards. Psychiatric Services, 57(7), 1022-1026. aggression training and violent incidents need for education over legislation in reducing restraint use in health care facilities. (2002). The Bowers, T. [Review]. Perspectives, 26(4), 4-6. (2005). Factors relating to the use of physical & Nikolaus, T. P., B., Koczy, C., Eichner, D., Becker, Bredthauer, restraints in psychogeriatric care: A paradigm for elder abuse. Zeitschrift fur Gerontologie und Geriatrie, 38(1), 10-18. restraint. Learning Disability Practice, Brend, M. & Jackson, D. (2006). Finding positive alternatives to physical 9(4), 32-38. Child restraint in the acute setting of pediatric nursing: An extraordinarily stressful event. M. (2007). Brenner, Issues in Comprehensive Pediatric Nursing, 30 (1-2), 29-37. H.U. (2007). Mandated M., Fridman, M., Aronow, N., Brown, D. S., Sandhu, C. E., Donaldson, Burnes, B. L., Aydin, nursing-sensitive outcomes pre- and post nurse staffing ratios in California: A comparison of staffing and Politics, & Nursing Practice, 8(4), 238-250. regulation. Policy, interventions among Camp, C. J., Cohen-Mansfield, J., & Capezuti, E. A. (2002). Use of nonpharmacologic (11), 1397-1401. nursing home residents with dementia. [Review]. Psychiatric Services, 53 patients at risk for falling. Nursing Capezuti, E. (2004). Minimizing the use of restrictive devices in dementia Clinics of North America, 39(3), 625-647. Boudreaux, E. D., Allen, M. H., Claassen, C., Currier, G. W., Bertman, L., Glick, R.,…Camargo, C.A. (2009). The Bertman, L., Glick, R.,…Camargo, G. W., Allen, M. H., Claassen, C., Currier, Boudreaux, E. D., 31(6), Psychiatry, and results. General Hospital Research Collaboration-01: Methods Psychiatric Emergency Bernick, L. & Bretholz, I. (2001). Safe Mobility Program: A comprehensive falls prevention program for a multi- prevention program falls Program: A comprehensive Safe Mobility L. & Bretholz, I. (2001). Bernick, (3), 12-19. 25 Nursing Association, of the Gerontological The Journal setting. Perspectives: level geriatric of physical towards the use and approaches opinions Nurses and physicians’ H. (2005). & Tel, F. Beyaztas, 12 Brain Research, (2), 85-90. Psychiatry and Neurology restraints. of strength requirements R. (2006). Bedside safety rails: Assessment & McIlroy, A. K., Boocock, M. G., Weyman, (7), 631-650. of current designs. Ergonomics, 49 and the appropriateness Care Journal of Nursing and nursing home care quality. Relationship of nursing personnel Bostick, J. E. (2004). 19(2), 130-136. Quality, REFERENCES 70
Directors Association, 4(4),207-215. Dimant, J.(2003). Avoiding physicalrestraints inlong-termcare facilities.Journalofthe AmericanMedical Nursing &MentalHealth Services,38(10),14-18. Dewey, K.&Brill,C.(2000).Decreaseinrestraintusea study ofageropsychiatricunit.JournalPsychosocial among nurses.Turkiye KlinikleriJournalofMedicalSciences,29 (6), 1573-1581. Demir, Z.A.(2009).Attitudes,informed consentobtainingratesandfeelingsabout physicalrestraintuse adolescent psychiatricinpatienttreatment.Worldviews onEvidence-BasedNursing,3 (1), 19-30. Delaney, K.R.(2006).Evidencebaseforpractice:Reductionofrestraintandseclusion useduringchildand people: Aparticipatoryactionresearchstudy. InternationalJournalofNursingStudies,46 (10), 13-22. Day, J.,Higgins,I.,&Koch,T. (2009).The processofpracticeredesignindeliriumcareforhospitalizedolder International JournalofMentalHealthNursing,15 (2), 93-99. Daffern, M.,Mayer, M.,&Martin, T. (2006).Staff genderratioandaggressioninaforensicpsychiatrichospital. Anesthesia, 12(5),397-401. to halothaneinpediatricpatientsundergoingbilateral pressureequalizationtubeinsertion.JournalofClinical Cravero, J.P., Beach,M.,Dodge,C.P., &Whalen, K.(2000).Emergencecharacteristicsofsevofluranecompared aggressive behaviourinpatientswithtraumaticbraininjury. AustralasianJournalofNeuroscience,15(3),5-12. Cook, R.,Mayne,C.,Gardner, G.,&Lawrence,T. (2002).Policydevelopmentthroughactionresearch:Managing Medical Journal,339(7717),381-384. Quality ofcareinfor-profit andnot-for-profit nursinghomes:Systematicreviewandmeta-analysis.British Comondore, V. R.,Devereaux,P. J.,Zhou,Q.,Stone,S.B.,Busse,J.W., Ravindran,N.C.,…Guyatt,G.H.(2009). delirium. ConsultantPharmacist,21(4),293-297. Collins, R.J.(2006).Medicationsleuth:Animportantroleforpharmacistsindeterminingtheetiology of Paediatric Anaesthesia,15(5),421-425. Christiansen, E.&Chambers,N.(2005).Inductionofanesthesiainacombativechild:Managementand issues. Medicine, 29(6),351–364. education andpolicy:1.Definitions,objectives,evidenceofeffectiveness. ClinicalandInvestigative Choi, B.&Pak,A.(2006).Multidisciplinary, interdisciplinary, andtransdisciplinaryinhealthresearch,services, negative aspectsofphysicalrestraint.PatientEducationandCounseling,59(1),80-86. Chien, W. T., Chan,C.W. H.,Lam,L. W., &Kam,C.W. (2005).Psychiatricinpatients’perceptionsofpositiveand S234-S244. Are theyrelatedtooutcomes?JournalsofGerontologySeriesB-PsychologicalSciences&SocialSciences,55(4), Chappell, N.L.&Reid,R.C.(2000).Dimensionsofcarefordementiasufferers inlong-termcareinstitutions: 22-28. state hospital-universitycollaborativeendeavor. JournalofPsychosocialNursing&MentalHealthServices,41 (1), Chabora, N.,Judge-Gorny, M.,&Grogan,K.(2003).TheFourSModelinactionforde-escalation.Aninnovative facilities. JournalsofGerontologySeriesA-BiologicalSciences&MedicalSciences,60(9),1173-1179. Castle, N.G.,Degenholtz,H.,&Engberg,J.(2005).Statevariabilityinindicatorsofqualitycarenursing Castle, N.G.&Engberg,J.(2005).Staff turnoverandqualityofcareinnursinghomes.MedicalCare,43(6), Healthcare Quality, 22(4),10-19. residents’ rightsinlong-termcaresettings:Avalues-basedapproachtorestraintreduction. Carroll-Solomon, P. A.,Christian,V., Denny, D.S.,Nordan,V. N.,Therriault,M.F., &Van, W. R.(2000).Preserving 2(4), 1689-1699. Capezuti, E.A.,&Wagner, L.M.(2006).Restraintsandimmobility. PrinciplesandPracticeofGeriatricMedicine, Promoting Alternative Safety: Approaches to theUse Restraints of risperidone onseclusionandrestraintatastatepsychiatrichospital.CanadianJournalofPsychiatry, 45(9), Chengappa, K.N.R.,Levine,J.,Ulrich,Parepally, H.,Brar, J.S.,Atzert,R.,…Gopalani,A.(2000).Impactof REGISTERED NURSES’ASSOCIATION OFONTARIO Journal for 827-832 616-626. . REFERENCES 71
295-303. www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Gallinagh, R., Nevin, R., McIlroy, D., Mitchell, F., Campbell, L., Ludwick, R., & McKenna, H. (2002). The use of D., Mitchell, F., Gallinagh, R., Nevin, R., McIlroy, four rehabilitation wards: Findings from an physical restraints as a safety measure in the care of older people in International Journal of Nursing Studies, 39(2), 147-156. exploratory study. the use of seclusion in psychiatric Gaskin, C. J., Elsom, S. J., & Happell, B. (2007). Interventions for reducing 298-303. 191, facilities: Review of the literature. [Review]. British Journal of Psychiatry, Attitudes, opinions, N., & Bleich, A. (2009). Werbloff, Melamed, Y., Z., Behrbalk, P., Gelkopf, M., Roffe, toward patient restraint. [Review]. Issues in Mental Health behaviors, and emotions of the nursing staff Nursing, 30(12), 758-763. as a nursing-sensitive adverse outcome in Gerolamo, A. M. (2006). The conceptualization of physical restraint (4), 175-185. acute care psychiatric treatment settings. Archives of Psychiatric Nursing, 20 psychiatry: The reliability of nurse recall. Gerolamo, A. M. (2008). Measuring adverse outcomes in inpatient Archives of Psychiatric Nursing, 22(2), 95-103. against healthcare workers in a K. (2010). Violence M., & Howard, P. Gillespie, G. L., Gates, D. M., Miller, (1), 68-82. pediatric emergency department. Advanced Emergency Nursing Journal, 32 prescribing practices and subsequent seclusion M. J. (2010). Weekend Goldbloom, D. L., Mojtabai, R., & Serby, (2), 193-195. and restraint in a psychiatric inpatient setting. Psychiatric Services, 61 Downey, L. V. A., Zun, L. S., & Gonzales, S. J. (2007). Frequency of alternative to restraints and seclusion and uses and seclusion and to restraints of alternative S. J. (2007). Frequency L. S., & Gonzales, A., Zun, L. V. Downey, 29(6), 470-474. Hospital Psychiatry, General department. in the emergency reduction techniques of agitation hospital and staff frontline forensic between act. Collaboration (2003). The balancing M. & Pullan, S. Encinares, (12), 36-45. Health Services, 41 & Mental Psychosocial Nursing Journal of administration. and Understanding, prevention, restraints in patients with dementia: (1950). Avoiding T. V. Evans, L. K. & Cotter, of Nursing, 108(3), 40-49. the keys. American Journal management are amongst the elderly in prevalence and risk factors of delirium (2008). The L.F. D., & Yin, Faezah, S.K., Zhang, Journal, 35, 11-14. acute hospital. Singapore Nursing management A comparison of content of 28 aggression K. (2005). Nurses under threat: Farrell, G. & Cubit, of Mental Health Nursing, 14(1), 44-53. International Journal programs. [Review]. inhalation for outpatient & DeRowe, A. (2005). Nitrous oxide-oxygen E., Marouani, N., Fishman, G., Botzer, of International Journal on the uncooperative child. and minor procedures performed otologic examination 69(4), 501-504. Pediatric Otorhinolaryngology, J. E. (2003). A model for managing A., & Morley, S. H., Raghavan, S., Bakshi, S., Moinuddin, J. H., Tariq, Flaherty, (7), 1031-1035. 51 Society, delirious older inpatients. Journal of the American Geriatrics of severe perceptions of successful management (2003). Staff D., & Gold, D. T. K. L., Sudha, S., Sloane, P. Foley, special care units. Dementia, 2(1), 105-124. behavioral problems in dementia H. (2009). Falls in somatic and dementia wards at B., Winblad, B., & Sandmark, T. Fonad, E., Emami, A., Wahlin, 23(1), 2-10. Community Care Units. Scandinavian Journal of Caring Sciences, behavior on acute psychiatric wards: Prevalence, severity C., Bowers, L., & Nijman, H. (2007). Aggressive Foster, (2), 140-149. and management. Journal of Advanced Nursing, 58 for crisis management by adolescents in a used as an integrative tool N. A. (2006). Aromatherapy, Fowler, Nursing, 19(2), 69-76. Journal of Child & Adolescent Psychiatric residential treatment center. 31(3), 219-225. project. Nursing Administration Quarterly, Fralick, S. L. (2007). A restraint utilization and risk management initiative (2000). A quality improvement P. C. Frezza, E. E., Carleton, G. L., & Valenziano, of physical restraints and sedation on the incidence of self- of the effects for surgical ICU patients: A study (5), 221-225. 15 extubation. American Journal of Medical Quality, residentialUnlicensed (2006). C.K. M.,…Young, Epstein, A., Chirolla, N., Bush, L., Behar, A., Pinto, M., R. Friedman, 76(3), youth. American Journal of Orthopsychiatry, programs: The next challenge in protecting REFERENCES 72
Hoelzel, S.L. (2003).Reducinguseofrestraints onarehabilitation unit.Rehabilitation Nursing,28(3),72-73. Hine, K.(2007).Theuseof physicalrestraintincriticalcare.[Review].NursingCriticalCare,12 (1), 6-11. psychiatric inpatients:Apilot study. MedscapeJournalofMedicine, 10(12),271. Hellerstein, D.J.,Seirmarco, G.,Almeida,&Batchelder, S.(2008).Assessingbehavioral copingpreferencesof 15(6), 777-788. Helene, H.M.,Heggen,K.,&Ruyter, K.W. (2008). Creatingtrustinanacutepsychiatricward.NursingEthics, Journal ofClinicalNursing,16(3),495-501. Heinze, C.,Halfens,R.J.,&Dassen,T. (2007).FallsinGermanin-patientsandresidentsover65yearsofage. [ISRCTN34974819]. BMCGeriatrics,9(42). based guidanceonthereductionofphysicalrestraints innursinghomes:Acluster-randomised controlledtrial Haut, A.,Kopke,S.,Gerlach,Muhlhauser, I.,Haastert,B.,&Meyer, G.(2009).Evaluationofanevidence- rehabilitation phaseafterseveretraumaticbraininjury: Anhistoriccohortstudy. BrainInjury, 18(8),787-796. Harmsen, M.,Geurts,A.C.,Fasotti,L.,&Bevaart,B. J.(2004).Positivebehaviouraldisturbancesinthe Health Nursing,30(8),491-494. Harmon, R.B.(2009).Hydrotherapyinstatementalhospitalsthemid-twentiethcentury. IssuesinMental Pulmonary Medicine,9(2),81-86. Happ, M.B.(2002).Treatment interferenceincriticallyillpatients:Anupdateonunplannedextubation.Clinical Heart &Lung,29(1),60-69. Happ, M.B.(2000).Preventingtreatmentinterference:Thenurse’s roleinmaintainingtechnologicdevices. making onrestraintuse:Aqualitativeandinterpretativestudy. JournalofClinicalNursing,10(2),246-256. Hantikainen, V. (2001).Nursingstaff perceptionsofthebehaviouroldernursinghomeresidentsanddecision staff perceptionsanddecision-making.JournalofAdvancedNursing,32(5),1196-1205. Hantikainen, V. &Kappeli,S.(2000).Usingrestraintwithnursinghomeresidents:Aqualitativestudyof acute care:Aninterdisciplinaryapproach.JournalofNursingAdministration,31(2),74-77. Hancock, C.K.,Buster, P. A., Oliver, M.S.,Fox,S.W., Morrison,E.,&Burger, S.L.(2001).Restraintreductionin Gerontologie undGeriatrie,38(1),19-25. Hamers, J.P. &Huizing,A.R.(2005).Whydoweusephysicalrestraintsintheelderly?Zeitschriftfur Patient ethnicityanduseofmedication,restraintseclusion.BritishJournalPsychiatry, 184(3),258-262. Gudjonsson, G.H.,Rabe-Hesketh,S.,&Szmukler, G.(2004).Managementofpsychiatricin-patientviolence: old question.JournaloftheAmericanGeriatricsSociety, 56(2),199-205. Gruneir, A.,Lapane,K.L.,Miller, S.C.,&Mor, V. (2008).Isdementiaspecialcarereallyspecial?Anewlookatan improve nursinghomequality?JournalofAging&Health,20(7),837-854. Gruneir, A.,Lapane,K.L.,Miller, S.C.,&Mor, V. (2008).Doesthepresenceofadementiaspecialcareunit Nursing, 15(4),224-225. Grigg, M.(2006).EliminatingseclusionandrestraintinAustralia.InternationalJournalofMentalHealth Health Practice,9(4),40-44. Green, B.&Robinson,L.(2005).Reducingviolenceinaforensicmentalhealthunit:Aseven-yearstudy. Mental Health Practice,6(4),10-15. Graham, A.(2002).Theuseofphysicalinterventionsinmanagingviolencementalhealthsettings.Mental measures. HealthAffairs, 23 (5), 243-252. Grabowski, D.C.,Angelelli,J.J.,&Mor, V. (2004).Medicaidpaymentandrisk-adjustednursinghomequality approach. Gerontologist,48(3),338-348. Goodson, J.,Jang,W., &Rantz,M.(2008). Nursinghomecarequality:InsightsfromaBayesiannetwork Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO REFERENCES 73
www.rnao.org Journal of the American BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Geriatrics Society, 48(8), 931-937. Geriatrics Society, 33-38. in nursing older people. [Review]. Nursing Older People, 20(3), Hughes, R. (2008). Chemical restraint of an educational (2006). Short-term effects M. P. Gulpers, M. J., & Berger, Huizing, A. R., Hamers, J. P., use: A cluster randomized trial. BMC Geriatrics, 6, 17. intervention on physical restraint project to develop and M. (2009). A clinical improvement Fenton, K., & Kilshaw, Hyde, S., Fulbrook, P., for the use of seclusion. International Journal of Mental Health implement a decision-making framework Nursing, 18(6), 398-408. on research on the use of O. (2006). A report Nakao, K., Fukui, S., Fukui, N.,…Yuji, H., Hisashi, T., Inoue, K., Tanii, setting. International Medical Journal, 13(3), 191-194. risperidone oral solution in a clinical of conduct: Are restraints inevitable? Journal of Advanced Nursing, Irving, K. (2002). Governing the conduct 40(4), 405-412. hospitals. Australian Journal of Irving, K. (2004). Inappropriate restraint practices in Australian teaching Advanced Nursing, 21(4), 23-27. K., & Brilli, R. J. (2001). Postoperative management of children Lyons, Jacobs, B. R., Salman, B. A., Cotton, R. T., (1), 164-168. after single-stage laryngotracheal reconstruction. Critical Care Medicine, 29 bind. Perspectives, 24(2), 2-7. Janelli, L. & Kanski, G. (2000). The use of music to release the ties that of individualized music on patients in physical (2004). The influence W. Y. & Wu, Janelli, L. M., Kanski, G. W., State Nurses Association, 35(2), 22-27. Journal of the New York restraints: A pilot study. psychiatric inpatient care: Literature review. Jarrett, M., Bowers, L., & Simpson, A. (2008). Coerced medication in Journal of Advanced Nursing, 64(6), 538-548. (2003). International H., Rook, M., & Grando, V. I., Gudmundsdottir, M., Hjaltadottir, A. B., Rantz, Jensdottir, nursing facilities. International comparison of quality indicators in United States, Icelandic and Canadian 50(2), 79-84. Nursing Review, Respiratory assessment in child and adolescent residential treatment settings: Reducing D. (2007). Johnson, T. (3), 176-183. restraint-associated risks. Journal of Child & Adolescent Psychiatric Nursing, 20 Hofso, K., & Coyer, F. M. (2007). Part 1. Chemical and physical restraints in the management of the mechanically of the mechanically in the management physical restraints 1. Chemical and M. (2007). Part F. & Coyer, Hofso, K., Nursing, 23(5), 249-255. and Critical Care factors. Intensive ICU: Contributing patients in the ventilated of mechanically in the management physical restraints 2. Chemical and M. (2007). Part F. & Coyer, Hofso, K. 23(6), 316-322. & Critical Care Nursing, Intensive [Review]. ICU: A patient perspective. patients in the ventilated Journal of for greater accountability. intervention trainers: The case & Paterson, B. (2009). Physical Hollins, L. P. Health Nursing, 16(4), 376-381. Psychiatric & Mental [Review]. Nursing Times, legal aspects of patient restraint. The ethical implications and Horsburgh, D. (2003). 99(6), 26-27. attitudes, and practices: Nurses’ physical restraint knowledge, (2009). & Chiang, K. F. H., Chuang, Y. Huang, H. T., Research, 17(4), 241-248. education program. Journal of Nursing of an in-service The effectiveness of schizophrenia: Implications (2005). Treatment H., Iwai, K., & Cording, C. B., Spiessl, Hubner-Liebermann, of Social between Germany and Japan. International Journal intercultural hospital comparison derived from an 51(1), 83-96. Psychiatry, in the treatment of difficult N. A. (2003). The use of DBT skills R. M., & Lundy, A., Harley, J. C., Stern, T. Huffman, (5), 421-429. patients in the General Hospital. Psychosomatics, 44 of Administrative initiatives for reducing inappropriate prescribing Hughes, C. M. & Lapane, K. L. (2005). How successful have they been? Drugs & Aging, 22(4), 339-351. psychotropic drugs in nursing homes: Ljunggren, G., Sgadari, A. (2000). The impact V., Ikegami, N., Jonsson, P. V., Hughes, C. M., Lapane, K. L., Mor, use in nursing homes: A cross-national perspective. of legislation on psychotropic drug REFERENCES 74
an acutecare hospital:Anexploratory study. JournalofAdvanced Nursing,55(2),135-141. Kwasny, P., Hagen, B.,&Armstrong-Esther, C. (2006). Useofmajorandminor tranquilizerswith older patientsin Germany. InternationalPsychogeriatrics,(2),295-308. 21 Training indementiacare:Acluster-randomized controlledtrialofatrainingprogram fornursinghomestaff in Kuske, B.,Luck,T., Hanns,S.,Matschinger, H.,Angermeyer, M.C.,Behrens,J.,&Riedel-Heller, S.G.(2009). 600-608. for DepressioninDementia inafrail,nursinghomepopulation.AmericanJournalofGeriatric Psychiatry, 10(5), Kurlowicz, L.H.,Evans,K.,Strumpf,N.E.,&Maislin, G.(2002).ApsychometricevaluationoftheCornellScale 4(2), 125-136. in dementia:Aqualitativestudytopromoteunderstanding andimprovetreatment.Alzheimer’s CareQuarterly, Kunik, M.E.,Lees,Snow, A.L.,Cody, M.,Rapp,C.G.,Molinari,V. A.,&Beck, C.K.(2003).Disruptivebehavior Kraft, N.L.(2003).Apictorialandvideoguidetocircumcision withoutpain.AdvancesinNeonatalCare,3,50-62. facilities. [Review].JournalofPsychosocialNursing&MentalHealthServices, 39(3),32-38. Kozub, M.L.&Skidmore,R.(2001).Leasttomostrestrictive interventions.Acontinuumformentalhealthcare inpatient psychiatricwardsinGreece.IssuesMentalHealthNursing,30 (5), 327-336. Koukia, E.,Madianos,M.G.,&Katostaras,T. (2009).“Onthespot”interventionsbymentalhealthnursesin of NursingPractice,7(3),156-161. Koch, S.,Lyon, C.,&Lyon, K.S.(2001).Casestudyapproachtoremovingphysicalrestraint.InternationalJournal elderly. InternationalJournalofGeriatricPsychiatry, 18(6),491-497. Kirkevold, O.,Laake,K.,&Engedal,K.(2003).UseofconstraintsandsurveillanceinNorwegianwards forthe correlates. ScandinavianJournalofCaringSciences,22(4),560-567. Kirkevold, O.&Engedal,K.(2008).QualityofcareinNorwegiannursinghomes–deficienciesandtheir homes. InternationalJournalofGeriatricPsychiatry, 19(10),980-988. Kirkevold, O.,Sandvik,L.,&Engedal,K.(2004).UseofconstraintsandtheircorrelatesinNorwegian nursing children. OrthopaedicNursing,19(6),31-34. Kier-York, J.E.(2000).Developingaspecialneedsrestraintloanerprogramfortransportingmedicallyfragile the intensivecareunit?Dynamics,16(1),16-19. Kielb, C.,Hurlock-Chorostecki,&Sipprell,D.(2005).Canminimalpatientrestraintbesafelyimplemented in 11(11), 503.InternationalJournalofTherapy&Rehabilitation,12(2),88. Khadivi, A.&Levine,J.M.(2005).Lettertoeditorre:Patient-focusedcareandseclusion…Sullivanet al.(2004), Kelly, A.&Dowling,M.(2004).Reducingthelikelihoodoffallsinolderpeople.NursingStandard,18(49),33-40. continuous flownitrousoxide.JournalofUrology, 174(4pt.2),1598-1600. during voidingcystourethrography:Comparisonoftheefficacyandsafetyusingoralmidazolam Keidan, I.,Zaslansky, R.,Weinberg, M.,Ben-Shlush,A.,Jacobson,J.Augarten, A.&Mor, Y. (2005).Sedation among registerednurses.JournalofClinicalNursing,9(6),842-850. Karlsson, S.,Bucht,G.,Rasmussen,B.H.,&Sandman,P. O.(2000).Restraint useineldercare:Decisionmaking finding. ForensicScienceInternational,178(2-3),178-184. Karger, B.,Fracasso,T., &Pfeiffer, H.(2008).Fatalitiesrelatedtomedicalrestraintdevices-asphyxiaisacommon Journal ofAging&SocialPolicy, 20(3),279-285. Kapp, M.B.(2008).Resistancetonursinghomerestraintsreductionrevisited:Introductionasymposium. three physicalrestraintprocedures.JournalofIntellectualDisabilities,12(3),229-237. Jones, P. &Stenfert,K.B.(2008).Serviceusersandstaff fromsecureintellectualdisabilitysettings:Views on Care Medicine,33(6),978-985. traumatic stressdisorderfollowingintensivecare:Ahypothesisgeneratingstudyofdiversityincare. Jones, C.,Backman,Capuzzo,M.,Flaatten,H.,Rylander, C.,&Griffiths,R.D.(2007).Precipitantsofpost- Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO Intensive REFERENCES 75
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Kwok, T., Mok, F., Chien, W. T., & Tam, E. (2006). Does access to bed-chair pressure sensors reduce physical sensors reduce to bed-chair pressure Does access E. (2006). Tam, & T., Chien, W. F., Mok, Kwok, T., 15(5), 581-587. Clinical Nursing, Journal of care setting? use in the rehabilitative restraint during immunizations: on fear The impact of positioning (2008). M. V. M., & Thygeson, C. M., Finkelstein, Lacey, , 195-200. 23(3) Pediatric Nursing, sitting up. Journal of Supine versus reduction program in a (2003). A restraint Lee, J. C. S., & Lok, C. K. W. S. K. Y., Chow, Kong, S. K. F., Lai, C. K. Y., Nursing Studies, 6(2), 1-10. Asian Journal of local old age home. individuals with behavioural Special care units for dementia & Chi, I. (2009). V., J. H., Mok, Lai, C. K., Yeung, of Systematic Reviews, (4), CD006470. problems. Cochrane Database The association between M., Noro, A., & Hakkinen, U. (2005). U. H., Bjorkgren, M., Linna, Laine, J., Finne-Soveri, for Quality in Health Care, 17(3), care. International Journal technical efficiency in long-term quality of care and 259-267. residents: A restraint use among nursing home J. (2004). Physical P. R., & Durand, Verreault, P., Laurin, D., Voyer, methods. BMC Nursing, 3(5). comparison of two data collection dental patient: A review of nonpharmacologic behavior C. S. & Blain, S. (2003). Approaching the pediatric Law, 31(9), 703-713. management strategies. Journal of the California Dental Association, M.,…Sudders, M. (2004). Child and R., Weeks, J., Goldstein, K., Kerzner, Lebel, J., Stromberg, N., Duckworth, A state initiative to promote strength-based care. Journal of the adolescent inpatient restraint reduction: 43(1), 37-45. Psychiatry, American Academy of Child and Adolescent on the use of of nursing staff J. (2003). Views A. M., & Sayer, S., Parr, K., Wright, R., Gournay, Lee, S., Gray, Nursing, 10(4), 425-430. physical restraint. Journal of Psychiatric & Mental Health incidents involving male and female patients: attributions for violent J. (2003). Care staff Leggett, J. & Silvester, , 393-406. 42(4) British Journal of Clinical Psychology, A field study. C., & Plati, C. (2002). Nurses’ perceptions toward A., Kalafati, M., Tafas, Lemonidou, C., Priami, M., Merkouris, 16(2), 81-90. psychiatric patients in Greece. European Journal of Psychiatry, seclusion and use of restraints for A program to reduce the use of seclusion K., & Parks, J. (2009). Crisis prevention management: Lewis, M., Taylor, health setting. Issues in Mental Health Nursing, 30(3), 159-164. and restraint in an inpatient mental M., & Ek, A. C. (2004). Immobility – A major risk factor for development Lindgren, M., Unosson, M., Fredrikson, Scandinavian Journal of Caring patients: A prospective study. of pressure ulcers among adult hospitalized Sciences, 18(1), 57-64. decision to restrain. Journal of Psychosocial Nursing & Mental Health L. (2009). Psychiatric nurses’ P. Lindsey, Services, 47(9), 41-49. S. H. (2009). Single ability among activities of R., & Tang, L., Watson, S. C., Kao, C. C., Tzeng, Y. Lin, L. C., Wu, (1), 117-123. daily living as a predictor of agitation. Journal of Clinical Nursing, 18 says ‘no’: Experiences of nurses working Lloyd, M., Urquhart, G., Heard, A., & Kroese, B. (2008). When a child , 29-34. with children having invasive procedures. Paediatric Nursing, 20(4) self- S., & Rinalducci, E. (2001). Products for Alzheimer’s Lucero, M., Pearson, R., Hutchinson, S., Leger-Krall, Disease & Other Dementias, 16(1), 43-50. stimulatory wanderers. American Journal of Alzheimer’s R. A. (2001). The factorial survey: An experimental method to replicate real world Ludwick, R. & Zeller, problems. Nursing Research, 50(2), 129-133. of therapeutic dance/movement therapy to augment the effectiveness P. (2005). Using H. & McGuffin, Lundy, (3), 135-145. holding with children. Journal of Child & Adolescent Psychiatric Nursing, 18 K. (2008). Nursing home staffing and training J., & Bechen, K. C., Gittler, Buckwalter, Maas, M. L., Specht, J. P., Part 1. Deficits in the quality of care due recommendations for promoting older adults’ quality of care and life: (2), 123-133. to understaffing and undertraining. Research in Gerontological Nursing, 1 REFERENCES 76
Journal ofAdvanced Nursing,58(6),532-540. Moore, K.& Haralambous, B.(2007).Barriers toreducingtheuse ofrestraintsinresidential eldercarefacilities. of Psychiatry–RevueCanadienne dePsychiatrie,48(5),330-337. Mohr, W.K., Petti,T.A., &Mohr, B.D. (2003).Adverseeffects associatedwithphysicalrestraint.CanadianJournal No.:CD007546. DOI:10.1002/14651858.CD007546.pub2 physical restraintsinlong-term geriatriccare.CochraneDatabaseofSystematic Reviews2011,Issue2,Art. Möhler, R.,Richter, T., Köpke,S.,&Meyer, G.(2011).Interventionsforpreventing andreducingtheuseof removal inintensivecareunits:Anationalprevalence study. CriticalCareMedicine,35 (12), 2714-2720. Mion, L.C.,Minnick,A.F., Leipzig,R.M.,Catrambone,C.D.,&Johnson,M.E.(2007).Patient-initiateddevice Quality Improvement,27(11),605-618. following physicalrestraintreductionprogramsin twoacutecarehospitals.JointCommissionJournalon Mion, L.C.,Fogel,J.,Sandhu,S.,Palmer, R.M.,Minnick,A.F., Cranston,T.,…Leipsig, R.(2001).Outcomes in intensivecareunits.AmericanJournalofCriticalCare,10 (3), 168-171. Minnick, A.F., Leipzig, R.M.,&Johnson,M.E.(2001).Elderlypatients’reportsofphysicalrestraintexperiences influence theuseofphysicalrestraints.NursingManagement,32 (3), 37-39. Minnick, A.F. &Leipzig,R.M.(2001).Therestraintmatch-up.Threelessonsshowhownurseleaderscan physical restraintuse.JournalofNursingScholarship,39(4),363-370. Minnick, A.F., Fogg,L.,Mion,L.C.,Catrambone,&Johnson,M.E.(2007).Resourceclustersandvariationin nursing homequalityindicators.SocialScience&Medicine,63(12),3046-3059. Miller, S.C.,Papandonatos,G.,Fennell,M.,&Mor, V. (2006).Facilityand countyeffects onracial differences in Care, 16(3),305. conventional versusalternativemeasurestorestraints:Anexploratorypilotstudy. AmericanJournalofCritical Mijares, A.,Reyes,C.,Robinson,Isip,H.,&Coleman,B.(2007).Perceptionsofintensivecarenurses on judgement alone:Acluster-randomised controlledtrial.Age&Ageing,38(4),417-423. Meyer, G.,Kopke,S.,Haastert,B.,&Muhlhauser, I.(2009).Comparisonofafallriskassessmenttoolwithnurses’ sectional studyandprospectivecohortstudy. JournalofClinicalNursing.18(7),981-990. Meyer, G.,Kopke,B.,Haastert,B.&Muhlhauser, I.(2008).Restraintuseamongnursinghomeresidents:Cross- haematology: Theethical,legalandpracticeimplications.JournalofLaw&Medicine,10(1),84-96. McGrath, P., Forrester, K.,Fox-Young, S.,&Huff, N.(2002).“Holdingthechilddown”fortreatmentinpaediatric in Nursing,5(5),346-363. McDougall, T. (2000).Violent incidentsinaforensicadolescentunit:Afunctionalanalysis.JournalofResearch psychiatric nurses.JournalforNursesinStaff Development,21(5),236-242. McCain, M.&Kornegay, K.(2005).Behavioralhealthrestraint:Theexperienceandbeliefsofseasoned Journal ofCriticalCare,14(4),133-142. Martin, B.&Mathisen,L.(2005).Useofphysicalrestraintsinadultcriticalcare:Abiculturalstudy. American [Review]. JournalofClinicalPsychiatry, 67,(Suppl10),13-21. Marder, S.R.(2006).Areviewofagitationinmentalillness: Treatment guidelinesandcurrent therapies. unplanned extubationinthepediatricintensivecareunit.PediatricCriticalCareMedicine,6(3),254-257. Marcin, J.P., Rutan,E.,Rapetti,P. M.,Brown,J.P., Rahnamayi,R.,&Pretzlaff, R.K.(2005).Nursestaffingand dilemma. JournalofAdvancedNursing,31(2),362-369. Marangos-Frost, S.&Wells, D.(2000).Psychiatric nurses’thoughtsandfeelingsaboutrestraintuse:Adecision staff. JournaloftheAmericanGeriatricsSociety, 58(1),161-167. (ACE) trackerande-Geriatrician:MethodstodisseminateACEconceptshospitalswithnogeriatricianson Malone, M.L.,Vollbrecht, M.,Stephenson,J.,Burke,L.,Pagel,P., &Goodwin,J.S.(2010).AcuteCarefor Elders Mac Dermaid,L.&Byrne,C.(2006).Restraintreductioneducation.CanadianNursingHome,17(3),10-14. Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO REFERENCES 77
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Moore, T., Hollett, J., Pilkington, F. B., & Jonas-Simpson, C. (2003). A pilot study of the lived experience for lived experience pilot study of the C. (2003). A B., & Jonas-Simpson, F. Hollett, J., Pilkington, Moore, T., 27(2), 5-14. unit. Perspectives, on a locked dementia residing persons with and M. (2009). Restraint Valimaki, & Staniuliene, V., A., Matthews, A., Scott, P. Cocoman, A., Moran, A., 16(7), 599-605. Health Nursing, Psychiatric & Mental Journal of option? A distressing treatment seclusion: program to K. (2000). A nurse-led, unit-based J., & Gitter, S., Goodloe, L., Blosser, Fox, S., Burger, Morrison, E. F., 14(3), 72-80. Care Quality, in acute care. Journal of Nursing reduce restraint use injuries and L. (2002). Reducing staff C., Abraham, I., & Lathan, Taylor, G., G., Bonner, Morrison, E., Morman, Nursing, 16(3), 108-117. psychiatric setting. Archives of Psychiatric violence in a forensic nursing and other students (2009). Comparison in attitudes between D. L., & Jeffery, E., Bowers, Muir-Cochrane, 29(1), 83-90. Today, psychiatric patients. Nurse Education measures for disturbed in relation to containment risk J. S., & Mosqueda, L. (2008). Does D., Zinn, W. D. L., Spector, Weimer, L. G., Li, Y., Mukamel, D. B., Glance, (5), 532-541. homes matter? Medical Care, 46 CMS quality measures for nursing adjustment of the Management, 50(8), 64-69 Bedrails: Restraints or enablers? Ostomy Wound Mullette, B. & Zulkowski, K. (2004). America, 18(2), 243-252. B. A. (2000). Delirium. Emergency Medicine Clinics of North Murphy, use and Nurses’ use of restraints and their attitudes toward restraint Myers, H., Nikoletti, S., & Hill, A. (2001). Nursing & Health Sciences, 3(1), 29-34. the elderly in an acute care setting. B. (2007). A Slade, M. D., Calvocoressi, L., Wild, D. M., & Tessier-Sherman, Nawaz, H., Abbas, A., Sarfraz, A., the use of safety net enclosures with standard restraints in agitated randomized clinical trial to compare (6), 385-393. hospitalized patients. Journal of Hospital Medicine 2 Coercive procedures and facilities in J. E. (2002). & Fischer, Haug, H. J., T., Needham, I., Abderhalden, C., Dassen, 132(19-20), 253-258. Swiss Medical Weekly, Swiss psychiatry. “Acute care nursing: A naturalistic investigation of alternatives to A. (2005). Norris III, J. S., Rogers, C., & Omery, Congress Renew Nursing Through _16th International Nursing Research restraint use in an acute care setting”. Scholarship_, Hawaii Big Island. incidents from violent and suicidal acts in J. (2010). Seasonal variation of seclusion & Tiihonen, Paavola, P. 33(1), 27-34. Psychiatry, forensic psychiatric patients. International Journal of Law and quality minimum staffing standards on nursing home staffing and of state Park, J. & Stearns, S. C. (2009). Effects (1), 56-78. of care. Health Services Research, 44 D., & Hawes, C. (2000). Use of physical restraints and psychotropic K. M., Sloane, P. Phillips, C. D., Spry, (1), 92-96. medications in Alzheimer special care units in nursing homes. American Journal of Public Health, 90 function as predictor of falls (2005). Lower limb F. R., & Loew, S., Trento, M., Bernasconi, Tettamanti, Quadri, P., among elderly inpatients. Aging – Clinical and loss of mobility with social repercussions one year after discharge and Experimental Research, 17(2), 82-89. M., & Peterson, M. (2008). An analysis of falls occurring in patients with stroke on an Rabadi, M. H., Rabadi, F. acute rehabilitation unit. Rehabilitation Nursing, 33(3), 104-109. R. S., & Pitkala, K. H. (2007). Neither atypical nor E., Tilvis, Strandberg, T. Raivio, M. M., Laurila, J. V., among elderly patients with dementia: A conventional antipsychotics increase mortality or hospital admissions 15(5), 416-424. American Journal of Geriatric Psychiatry, two-year prospective study. persons undergoing hip repair surgery. Rateau, M. R. (2000). Confusion and aggression in restrained elderly Applied Nursing Research, 13(1), 50-54. (2010). Decreasing the costs of constant observation. Journal of Nursing Rausch, D. L. & Bjorklund, P. Administration, 40(2), 75-81. Ethics and human rights issues experienced by nurses in leadership roles. (2003). S. T. Redman, B. A. & Fry, Nursing Leadership Forum, 7(4), 150-156. REFERENCES 78
children: Arandomized controlledtrial. JournalofPediatric Nursing,22(6),440-447. Sparks, L.A., Setlik,J.,&Luhman,J.(2007). Parentalholdingand positioningtodecrease IVdistressinyoung Nursing Standard,16(27), 33-36. Southcott, J.,Howard,A., &Collins,E.(2002).Controlandrestrainttraining inacutementalhealthcare. psychiatric intensivecare unit. NursingStandard,21(6),35-41. Southcott, J.&Howard,A. (2007).Effectiveness and safetyofrestraintandbreakawaytechniquesin a hospital: Prevalence,disruptiveness,andstaff burden.InternationalPsychogeriatrics,13 (2), 183-197. Sourial, R.,McCusker, J.,Cole,M.,&Abrahamowicz,M.(2001).Agitationindementedpatientsanacute care required tomanagedisruptions.JournalofGerontologicalNursing,29 (8), 31-36. Souder, E.&O’Sullivan,P. (2003).Disruptivebehaviorsofolderadultsinaninstitutional setting.Staff time emergency department:Controversiesandrecommendations. CurrentOpinioninPediatrics,16(2),201-205. Sorrentino, A.(2004).Chemicalrestraintsfortheagitated, violent,orpsychoticpediatricpatientinthe 11(6), 543-552. Slettebo, A.&Bunch,E.H.(2004).Solvingethically difficultcaresituationsinnursinghomes.NursingEthics, of theNursingHomeReformAct.ResearchonAging,24(5),513-527. Sirin, S.R.,Castle,N.G.,&Smyer, M.(2002).Riskfactorsforphysicalrestraintuseinnursinghomes:Theimpact 526-529. restraint orders,andtheriskoffallsinhospitalizedpatients.JournalAmericanGeriatricsSociety, 50(3), Shorr, R.I.,Guillen,M.K.,Rosenblatt,L.C.,Walker, K.,Caudle,C.E.,&Kritchevsky, S.B.(2002).Restraintuse, nursing homes.AgingandMentalHealth,4(1),43-47. Shah, A.,Chiu,E.,&Ames,D.(2000).AggressivebehaviourandenvironmentalcharacteristicsinAustralian developmental disabilities.Violence AgainstWomen, 7(4),462-476. Sequeira, H.&Halstead,S.(2001).“Isitmeanttohurt,isit?”Managementofviolenceinwomenwith usage intheacutepsychiatricsetting.ArchivesofPsychiatricNursing,23(4),277-282. Sees, D.L.(2009).ImpactoftheHealthCareFinancingAdministrationregulationsonrestraintandseclusion Evidence-Based MentalHealth,4(1),31. Schofield, N.(2001).Psychiatricnursesexpressedconflictingfeelingsinthedecisiontousephysicalrestraints. 44(2), 245-255. minimum datasetprevalenceofrestraintqualityindicator:Doesitreflectdifferences incare?Gerontologist, Schnelle, J.F., Bates-Jensen,B.M.,Levy-Storms,L.,Grbic,V., Yoshii, J.,Cadogan,M.,&Simmons, S.F. (2004).The 13(3), 194-202. in institutionalcareforelderlypersons:Exploringanarrativefromoneinvolvedprovider. NursingInquiry, Sandvide, A.,Fahlgren,S.,Norberg,&Saveman,B.I.(2006).Fromperpetratortovictiminaviolentsituation intellectual disabilityinFinland.JournalofIntellectualandDevelopmentalDisability, 27(1),21-30. Saloviita, T. (2002).Challengingbehaviour, andstaff responsestoit,inresidentialenvironmentsforpeoplewith patients andtheirfamilymembers.ResearchinGerontologicalNursing,2(4),276-286. Saarnio, R.&Isola,A.(2009).UseofphysicalrestraintininstitutionalelderlycareFinland:Perspectives post-seclusion debriefing.InternationalJournalofMentalHealthNursing,18(2),100-107. Ryan, R.&Happell,B.(2009).Learningfromexperience:Usingactionresearchtodiscoverconsumerneedsin Mental HealthNursing,12(6),695-702. Ryan, C.J.&Bowers,L.(2005).Coercivemanoeuvresinapsychiatricintensivecareunit.JournalofPsychiatric mental healthfacility. JournalofPsychosocialNursing&MentalHealthServices,47(10),25-31. Roberts, D.,Crompton,Milligan,E.,&Groves,A.(1950).Reflectionontheuseofseclusion:Inanacute psychiatric inpatientservice.NursingTimes, 102(3),42-45. Riley, D.,Meehan,C.,Whittington,R.,Lancaster, G.A.,&Lane,S.(2006).Patientrestraint positionsina Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO REFERENCES 79
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Journal of the American Geriatrics Society, 57(9), 1678-1684. Geriatrics Society, Journal of the American statement of work. th Stubbs, B. (2008). Injuries to staff from implementation of physical interventions: Could poor manual handling physical interventions: Could poor from implementation of Injuries to staff Stubbs, B. (2008). (4), 12-14. Forensic Practice, 10 be at fault? British Journal of Learning lessons from our as a manual handling procedure: Considering physical intervention Stubbs, B. (2009). Forensic Practice, 11(2), 32-37. British Journal of general nursing colleagues. of the aggressive patient: A review of the risk of injury to nurses. Stubbs, B. (2009). The manual handling Nursing, 16(4), 395-400. Journal of Psychiatric & Mental Health on its Physical interventions to manage patients with brain injury: An audit Stubbs, B. & Alderman, N. (2008). 22(9), 691-696. techniques. Brain Injury, and patient injuries from the use and staff (2009). Physical intervention: A review G., Knight, C., & Davis, S. D., Paterson, B., Yorston, Stubbs, B., Leadbetter, views, and the impact of training. Journal of Psychiatric & Mental and patient of the literature on its use, staff Health Nursing, 16(1), 99-105. (2006). Use of physical I.Y.C. S. K., Kong, S. K., Ho, J. Y.,…Wong, K., Chow, T. Suen, L. K., Lai, C. K., Wong, attitudes and predictors. Journal of Advanced Nursing, knowledge, Staff restraints in rehabilitation settings: 55(1), 20-28. patient-focused care on seclusion in a psychiatric intensive of Effects M., & Lloyd, C. (2004). Sullivan, D., Wallis, , 11(11), 503-508. care unit. International Journal of Therapy Rehabilitation facts about side rails. American Journal of Nursing. 101(7), 43-8. K. A. & Capezuti, E. (2001). Myths and Talerico to safety issues in frontotemporal dementias. [Review]. K. A. & Evans, L. K. (2001). Responding Talerico, 56(Suppl 4), S52-S55. Neurology, Mental health correlates of aggression in nursing home K. A., Evans, L. K., & Strumpf, N. E. (2002). Talerico, (2), 169-177. residents with dementia. Gerontologist, 42 compared with ketamine for invasive A. (2004). Midazolam & Kamps, W. J., Armbrust, W., R. Y. Tamminga, 21(1), 93-94. procedures. Pediatric Hematology and Oncology, and seclusion in a psychiatric J. C. (2002). Ethics and praxis: Alternative strategies to physical restraint Taxis, setting. Issues in Mental Health Nursing, 23(2), 157-170. & Archea, C. (2007). Gender differences S. W., D. C., Hagan, H. C., Miller, J., Strasser, Whittington, F. L. F., Taylor, drug prescribing. Journal of Aging and in chemical restraint use in a nursing home: Patterns of psychotropic 13(2), 67-81. Pharmacotherapy, & Archea, C. (2003). Psychotropic Drug C. H., Hennessy, S. W., D. C., Miller, Strasser, Whittington, F., L. F., Taylor, (4), 474-489. 22 Use in a Nursing Home: A 6-year retrospective. Journal of Applied Gerontology, living of group I. A., De, Lange, J., Pot, A. M., & Eefsting, J. A. (2009). The effects te Boekhorst, S., Depla, M. F. nursing home care. International Journal homes on older people with dementia: A comparison with traditional 24(9), 970-978. of Geriatric Psychiatry, & attitudes toward seclusion M. (2001). Nursing staff’s L., Pettee, E. J., & Hunter, T. L., Terpstra, T. Terpstra, (5), 20-28. restraint. Journal of Psychosocial Nursing & Mental Health Services, 39 Steinert, T., Eisele, F., Goeser, U., Tschoeke, S., Uhlmann, C., & Schmid, P. (2008). Successful interventions on an interventions (2008). Successful P. C., & Schmid, S., Uhlmann, U., Tschoeke, Goeser, Eisele, F., T., Steinert, disorders and with adjustment in in-patients coercive interventions violence and level to reduce organizational from http://www. (27). Retrieved Health, 4 in Mental and Epidemiology disorders. Clinical Practice personality d ncbi.nlm.nih.gov/pmc/articles/PMC2596103/?tool=pubme survey of nurses in a tertiary for restraint discontinuation: A qualitative & Newton, L. (2001). Reasons St. John, P. 4(2), 125-129. the Canadian Geriatrics Society, Journal of Geriatrics Today: care teaching hospital. the Quality Improvement Organization nursing homes under (2009). Targeting V. & Mor, Stevenson, D. G. 9 program’s REFERENCES 80
comparison offorensicand non-forensicsettings.InternationalJournalofMental HealthNursing,15(4), Whitehead, E. & Mason, T. (2006). Assessment of risk and special observations in mental health practice: A Public Health,119(1),3-10. Weze, C.,Leathard, H.L.,Grange,J.,Tiplady, P., &Stevens,G.(2005).Evaluationofhealing bygentletouch. being inanursinghome.Aging&MentalHealth,12 (6), 786-794. Werner, P. (2008).Discriminatory behaviortowardsapersonwithAlzheimer’s disease:Examiningtheeffects of people: Testing thetheoryofreasonedaction.JournalAdvancedNursing,35(5) , 784-791. Werner, P. &Mendelsson, G.(2001).Nursingstaff members’intentionstousephysicalrestraintswitholder prevalence ofphysicalrestraintuseinintensivecare. Dynamics,19,43-44. Wen, V., Mauceri,J.,Smith,O.,&Wilson,G.(2008). Leastrestraintornot:Anobservationalstudyonthe Journal ofGeriatricPsychiatryandNeurology, 15(2),91-94. unit: ImpactoftheHealthCareFinancingAdministration’s newrestraintandseclusionstandards forhospitals. Weintraub, D.&Spurlock,M.(2002).Changeintherateofrestraintuseandfallsonapsychogeriatric inpatient nursing staff inIsrael.JONA’s HealthcareLaw, Ethics, &Regulation,5(4),87-93. Weiner, C.,Tabak, N.,&Bergman, R.(2003).Useofrestraintsondementiapatients:Anethicaldilemmaa Nursing Ethics,10(5),512-525. Weiner, C.,Tabak, N.,&Bergman, R.(2003).Theuseofphysicalrestraintsforpatientssuffering fromdementia. [Review]. AustralianJournalofAdvancedNursing,22(4),46-52. Wang, W. W. &Moyle,W. (2005).Physicalrestraint useonpeoplewithdementia:Areviewoftheliterature. Western JournalofNursingResearch,28(8),974-993. Wan, T. T., Zhang,N.J.,&Unruh,L.(2006). Predictorsofresidentoutcomeimprovementinnursinghomes. being mechanicallyrestrainedinapopulationofpsychiatricpatients.Memory, 16(5),548-555. Wallsten, T., Kjellin,L.,&Sjoberg,R.L.(2008).Thediagnosticaccuracyofquestionsaboutpastexperiences Psychiatric Nursing,16(2),80-85. Vittengl, J.R.(2002).Temporal regularitiesinphysicalcontrolatastatepsychiatrichospital.Archivesof perspectives oflimit-settinginmentalhealthnursing.JournalPsychiatric&MentalHealthNursing,14 (1), Vatne, S.&Fagermoen,M.(2007).To correctandtoacknowledge:Two simultaneousandconflicting prevention offallsinhospital.Gerontology, 51(1),66-70. Vassallo, M.,Wilkinson,C.,Stockdale,R.,Malik,N.,Baker, R.,&Allen,S.(2005).Attitudestorestraintforthe Doi: 10.1186/cc7892 (2009). Riskfactorsfordeliriuminintensivecarepatients:Aprospectivecohortstudy. CriticalCare,13(3),R77. Van Rompaey, B.,Elseviers,M.M.,Schuurmans,J.,Shortridge-Baggett,L.Truijen, S.,&Bossaert,L. The caseofseclusionintheNetherlands.PsychiatricQuarterly, 79(2),97-109. van Doeselaar, M.,Sleegers,P., &Hutschemaekers,G.(2008).Professionals’attitudestowardreducingrestraint: directives. PsychiatricServices,58(11),1467-1471. Van Citters,A.D.,Naidoo,U.,&Foti,M.E.(2007).Usingahypotheticalscenariotoinformpsychiatricadvance Journal ofClinicalNursing,17(11),1503-1509. Tzeng, H.M.&Yin, C.Y. (2008).Heightsofoccupiedpatientbeds:Apossibleriskfactor forinpatientfalls. elderly population.Thegeriatricresourcenursemodel.JournalofGerontologicalNursing,27(3),8-18. Turner, J.T., Lee,V., Fletcher, K.,Hudson,&Barton, D.(2001).Measuringqualityofcarewithaninpatient The InternetJournalofAdvancedNursingPractice,3(1). physical restraint:Mythsandtruthsaboutrestraints.Includinganursingsurveyonrestraintpractices. The UniversityofTexas MDAndersonCancerCenterRestraintsImprovementGroup.(1999)Alternativesfor Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO
235-241. 41-48. REFERENCES 81
Journal of www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Forensic Psychiatry and Psychology, 16(2), 380-398. Forensic Psychiatry and Psychology, seclusion S., Castle, D., Zeeman, Z., Headford, C.,…Finn, M. (2001). The use of Wynaden, D., Orb, A., McGowan, of Nursing, Australia, 8(3), 19-25. Collegian: Journal of the Royal College in the year 2000: What has changed? in or seclude? Strategies for dealing with violent and threatening behaviour Wynn, R. (2002). Medicate, restrain 16 hospital. Scandinavian Journal of Caring Sciences,(3), 287-291. a Norwegian university psychiatric and seclusion in a Norwegian university psychiatric attitudes to the use of restraint Wynn, R. (2003). Staff’s 57(6), 453-459. hospital. Nordic Journal of Psychiatry, of the use of restraint and force on C. (2009). The prevalence and correlates Lee, D., & Tang, E., Kwok, T., Yan, (2), 147-155. hospitalized older people. Journal of Nursing & Healthcare of Chronic Illnesses, 1 Methods developed to elucidate nursing related adverse (2003). Y. M., Kanda, K., & Takemura, Yamagishi, events in Japan. Journal of Nursing Management, 11(3), 168-176. physical restraints on older people with dementia. Nursing Ethics, 16(2), (2009). Placing M. & Aso, Y. Yamamoto, 192-202. S. K. (2003). A longitudinal evaluation of nursing home care quality in Taiwan. & Lo, S. H., Lin, L. W., Yeh, 18(3), 209-216. Journal of Nursing Care Quality, L. (2004). The effects & Shu-Yuanm, Hsu, C. Y., H., Chiang, M. C., Lin, L. W., Ho, T. S. H., Hsiao, C. Y., Yeh, care units. Journal of Nursing of continuing education in restraint reduction on novice nurses in intensive Research, 12(3), 246-256. (2004). Implications of nursing care in the occurrence Chiang, M. C., & Lin, L. W. H., S. H., Lee, L. N., Ho, T. Yeh, units. International Journal of Nursing and consequences of unplanned extubation in adult intensive care Studies, 41(3), 255-262. factors of the patient with endotracheal tube unplanned extubation in the ICU”. M. (2005). “The related Yung, Scholarship_, Hawaii Big Island. ”. _16th International Nursing Research Congress Renew Nursing Through Whitman, G. R., Davidson, L. J., Sereika, S. M., & Rudy, E. B. (2001). Staffing and pattern of mechanical restraint of mechanical and pattern E. B. (2001). Staffing M., & Rudy, L. J., Sereika, S. G. R., Davidson, Whitman, (6), 356-362. Research, 50 system. Nursing a multiple hospital use across staffing on patient The impact of S. L. (2002). G. A., & Wang, L. J., Wolf, Davidson, G. R., Kim, Y., Whitman, 32(12), 633-639. Nursing Administration, units. Journal of across specialty outcomes patient L. (2007). Measuring nurse-sensitive S. Wang, G. A., & Davidson, L. J., Wolf, Y., Whitman, G. R., Kim, 6(4), 152-158. specialty units. Outcomes Management, outcomes across ratings of inpatient coercive A., & Neil, L. (2009). Approval Simpson, Bowers, L., Nolan, P., Whittington, R., 60(6), in England. Psychiatric Services, service users and staff national sample of mental health interventions in a 792-798. of patients in acute D. (2006). Physical restraint C., Lane, S., & Riley, G., Meehan, Lancaster, Whittington, R., of a horizontal factors associated with the use and environmental settings: Patient, staff, mental health care 17(2), 253-265. Psychiatry and Psychology, Journal of Forensic restraint position. droperidol pre-medication D., Scheiman, J. M., & Elta, G. H. (2000). Routine W. Barnett, J. L., Chey, Wille, R. T., 52(3), 362-366. Gastrointestinal Endoscopy, improves sedation for ERCP. sensitive decision-making in acute hospital care: Using hand-control Williams, J. (2008). Exploring ethically 4(4), 1-4. mittens in adult patients. Developing Practice Improving Care, usage, Relationship of less restrictive interventions with seclusion/restraints Williams, J. E. & Myers, R. E. (2001). Nurses Association, mix. Journal of the American Psychiatric and staff average years of psychiatric experience 7(5), 139-144. restraint K. (2005). Breakaway and physical R., Southern, D., & Gournay, A. M., Gray, J., Parr, S., Sayer, Wright, Results from a national survey of training and practice. techniques in acute psychiatric nursing: REFERENCES 82
365-371. Zun, L.S.&Downey, L.(2005).Theuseofseclusioninemergencymedicine.GeneralHospitalPsychiatry, 27(5), department. JournalofEmergencyMedicine,24(2),119-124. Zun, L.S.(2003).Aprospectivestudyofthecomplicationrateusepatientrestraintinemergency cognitively impairednursinghomepatients.JournalofGeriatricPsychiatry&Neurology, 20(1),41-49. Zuidema, S.,Koopmans,R.,&Verhey, F. (2007).Prevalenceandpredictorsofneuropsychiatricsymptomsin nursing homecomparewebsitediffer bynursinghomecharacteristics?Gerontologist,45(6),720-730. Zinn, J.,Spector, W., Hsieh,L.,&Mukamel,D.B.(2005).Dotrendsinthereportingofqualitymeasureson Gerontologist, 44(1),13-23. Zhang, X.&Grabowski,D.C.(2004).Nursinghomestaffingandqualityunderthenursingreformact. Economics, 24(2),78-85. Zhang, N.J.,Unruh,L.,Liu,R.,&Wan, T. T. (1993).Minimumnursestaffingratiosfornursinghomes.Nursing Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO APPENDICIES 83
.
identify . (Canadian
states, (CNO, rev. 2009d; rev. (CNO, . (Fricke, 2011) (Fricke, www.rnao.org (Field & Lohr, 1990) (Field & Lohr, emotional (WHO, 2009, pg. 22) pg. 2009, (WHO, internal . recognize to . BEST PRACTICE GUIDELINES • and . (RNAO, rev. 2006) rev. (RNAO, clients Systematically developed statements to assist practitioner assist to statements developed Systematically . (WHO, 2009) (WHO, assist to programs; management anger Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting (Dean et al., 2007) (Dean et al., training - manage patient individualized incorporate programs management Behaviour . Actions taken to reduce, manage or control any future harm, or probability of harm, ofharm, probability or harm, future any control or manage reduce, to taken Actions . Activities of Daily Living (ADL) is used in rehabilitation as an umbrella term relating to self to relating term umbrella an as rehabilitation in used is (ADL) Living Daily of Activities problem-solving Risk: (World Health Organization [WHO], 2009) Organization [WHO], Health (World An approach in which clients are viewed as whole; it is not merely about delivering services and - devel originor the part in a played have to thought is that influence or action circumstance, A Reduce
Care: A situation or factor that may influence an event, agent or person(s) or person(s) agent an event, influence may that factor or A situation to A disease or injury that arises subsequent to another disease and/or health care intervention modeling
as, such techniques cognitive-behavioural of Taken A client may be an family/SDM, group individual or (patient, consumer, resident, community use precipitating factors and develop self-control strategies that can increase their repertoire of strategies options. repertoire their response that can increase self-control and develop factors precipitating Definition/Source
- sub be can activities The life. everyday their in routinely undertake people that tasks or activities those comprising care, divided personal ADL into or care Basic(BADL) and domestic and activitiescommunity ADL – (IADL). Instrumental BADL is typically restricted housekeeping, to activitiescooking, involving functional shopping, mobility as (ambulation, wheelchair tasks mobility, bed - mobil adaptive such of terms ity and transfers) in and personal care (feeding, environment toileting, hygiene, bathing and dressing). IADL her/his functions are concerned with cope to ability person’s a with laundry, use of transportation, managing money, managing medication and the use of the telephone use of transportation, managing money, laundry, Complication: Contributing Factor: Contributing Clinical Practice Guidelines or Best Practice Guidelines: Practice Best or Guidelines Practice Clinical Client-Centred Circumstance: Client: Behaviour Management Programs: Management Behaviour Actions Living: Daily of Activities Term: Patient Safety Institute [CPSI], 2003) Safety Institute [CPSI], Patient associated withassociated an incident and client decisions about appropriate health care for specific clinical (practice) circumstances specificclinical (practice) for circumstances health care about appropriate decisions and client Mental Health Commission of Canada, 2009) Mental Health Commission of Canada, where the client is located. Client centred care involves advocacy, empowerment, and respecting the client’s autonomy, autonomy, and respecting empowerment, the client’s advocacy, where the client is Client care centred involves located. and participation in decision-making self-determination, voice, ment ment plans, early detection and staffprevention, training, reinforcement of appropriate behaviours, and intervention using the behaviours least restrictive option challenging and are used manage in patients with or challenging Individualized behaviours. patient - manage prevent to and admission an for goals treatment the on focus to created are behaviours plans ment challenging potential for consequences predictable and logical provide can Programs triggers. known on based and include: • use of conflict; or • skills problems identify training help the client to • opment of an incident or to increase the risk of of increase opment to or an incident an incident
dangerous potentially and disruptive extinguish and behaviours appropriate reinforce to is programs such of principle The use to options restrictive least from ofinterventions hierarchy a using managed are behaviours Challenging behaviours. of restraints as last resort and engaginginclude the patient about behaviour such as choices using time-out quiet time, seclusion or closed), or (open in a designated room Appendix A: Glossary of Terms of Glossary A: Appendix APPENDICIES 84
Promoting Alternative Safety: Approaches to theUse Restraints of treatment is specified as a possibility for informed possibility asa consenttreatment isspecified insome legislation cannot be obtained, and full informed consent is the standard required for any health care treatment. no The option of substitutedecision-makeror mayplace.give theirconsent in consent Unless informed emergencysuchthat an thereis proxyconsent,a giving of incapable is person a treatment.If proposed the of consequences and nature the appreciate with expedience while privileging theformer over expedience privileging thelatter while with or stand-insfor research. combined evidence to for evidence-base adecision The balance isthemultiple of forms rigor often incomplete and sometimes contradictory or unavailable, other kinds of information are necessary supplements to, findings high-quality, of methodologically appropriate research provide the mostaccurate evidence. Because research is influences thinking, actions decisions and who workwho collaboratively to deliver andacross care settings quality within pants development makes available the best use information,of be that scientific data- or the the partici wisdomcollective of pation insociety, pastor present associated with harm Disability implies any of type impairment of body structure or function, activity limitation and/or restriction - of partici unpleasant. subjectively anything dysfunction.psychologicalor psychological. or social physical, be may and death, and disability suffering,injury, disease, Harm: Evidence: Elopement: Recommendations: Education De-escalation: Culture: Management: Crisis Consensus: Interprofessional Care: Consent: Informed Heath Harmful Incident: under circumstances thatplace theresident’s health, safety, or welfare atrisk” of healthcare, of diseaseor injury thananunderlying rather the introduction, implementation and sustainability of the best practice guideline. the introduction, practice thebest of implementation andsustainability to recognize to danger prevent signs negative outcomes deterioration, to achieve at functioning,least a pre-crisis levelto of promote growth and effective problem solving, and toprevent crisis the environmentalfurther and social resolutionintervention areresources. rapid of crisis of goals The both verbalboth andnon-verbal communication skills (Black etal.,1999) REGISTERED NURSES’ASSOCIATION OFONTARIO The impairment structure of or function the of body and/or any deleterious effect arising there from, including Care-Associated Culture refers to the shared and learned values, beliefs, norms and ways of life of an individual or a group.a or individual an It Culture of lifevalues, referslearned ways sharedand beliefs,toand the of norms Evidence is information that comes closest to the facts of a matter. The form it takes depends on context. The Elopement is “a departure and or dependentknowledge resident observation of without leaving a facility A process for making policy decisions, not a scientific method for creating new knowledge. Consensus knowledge. new creating for method scientific a not decisions, policy making for process A A complex range of skills designed to abort the assault cycle during the escalation phase, including phase, escalation the during cycle assault the abort to designed skills of range complex A . Previously asadverse known event: anincident thatresulted to inharm apatient Agreement to a health care treatment given by a capable person who is able to understand and understand to able is who person capable a by given treatment care health a to Agreement A process that focuses on resolution of the immediate problem through the use of personal, of use the through problem immediate the of resolution on focuses that process A Refers to the provision of comprehensive health services to patients by multiple health caregivers Harm: is damage to tissues caused by an agent or event and suffering is the experience of of experience the is suffering eventand or agent byan caused tissues todamage is Injury includes pain, malaise, nausea, depression, agitation, alarm, fear and grief. and fear alarm, agitation,depression, nausea,malaise, pain, includes Suffering Harm arising from, or associated with, plans or actions taken during the provision the during taken actions or plans with, associatedfrom, or arising Harm Statements of educational requirements and educational approaches/strategies for approaches/strategies educational and requirements educational of Statements (CNO, rev. 2009d) (NCCNSC, 2005) (WHO, 2009) (RNAO, rev. 2006b) . (WHO, 2009) (Canadian HealthServicesResearchFoundation, 2006) . . . . (Interprofessional CareSteeringCommittee, 2007) (Bennet, 2008) (Health Canada, 2006) . is a physiological a is Disease . (WHO, 2009) . . . APPENDICIES 85
. . . (Mosby’s (Mosby’s Medical www.rnao.org (WHO, 2009) (WHO, . (Ministry of Health and Long Term Care, 2007) Care, Term (Ministry of Health and Long (WHO, 2009) (WHO, (Mosby’s Dental Dictionary, 2nd edition, 2008) 2nd edition, Dental Dictionary, (Mosby’s . BEST PRACTICE GUIDELINES • (Kitwood, 1997) (Kitwood, Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Statements of conditions required for a practice setting that enables enables that setting practice a for required ofconditions Statements A device used to assist a person with a routine activity of living, used living, ofactivity routine a with person a assist to used device A An event or circumstance that could have or resulted, did result, in unnecessary Statements of best practice directed at the practice of health-care professionals that are are that professionals ofhealth-care practice the at directed practice ofbest Statements An element that causes or contributes to the occurrence of a disorder Factors that an increase vulnerability a particular that an increase to or genetic disease based factors Factors on Recommendations: . The reduction of risk of unnecessary harm associated with health care to an acceptable minimum acceptable an to care health with associated harm unnecessaryof risk of reduction The . Factor): Policy
(WHO, 2009) (WHO, and (Risk A standing or status that is bestowed upon one human being by others, in the context of the relationship relationship ofthe context the in others, by being human one upon bestowed is that status or standing A Accepted by the community as avoidable in the particular set of as avoidable the community circumstances by Accepted . The degrees to which health-care services for individuals and populations increase the likelihood of desired a physician, a registered nurse, a registered a registered practical nurse, a registered ofa member of the College Therapists of Occupational Ontario, a member ofa member or of the College of Physiotherapists Ontario, in the regulations. for provided person other any
i. v. ii. iv. vi. iii. The use of the PASD is reasonable, The in and use and lightis physical of mental reasonable, and condition of personal history, the PASD the resident’s assist withto that the be would resident effective the activityroutine is the least ofrestrictive PASDs reasonable such of living. The use of the PASD has been consented to by the resident or, if the resident is incapable, a substitute decision-maker decision-maker substitute a incapable, is resident ifthe or, resident the by to consented been has PASD ofthe use The of with that consent. authority the resident give to Alternatives to Alternatives the use of and been have triedconsidered, a but PASD where would appropriate, not be, or not have with activity the routine assist the resident to of effective living. been, the existence of certain underlying conditions not yet active or revealed revealed or of active yet not certainthe existence underlying conditions ideally evidence-based. evidence-based. ideally Quality: Preventable: Factor): (Risk Predisposing Precipitating Practice Recommendations: Practice Personhood: Personal assistance service(PASDs): devices assistance Personal (WHO, 2009) (WHO, Patient (Client) Safety Incident: Patient (Client) Safety: (Client) Patient Organization and social being. It implies recognition, respect and trust implies recognition, It and social being. Dictionary, 8th edition, 2009) 8th edition, Dictionary, the successful implementation of the best practice guideline. The conditions for success are largely the responsibility of responsibility the largely are success for conditions The of implementation bestpracticethe guideline. successful the societal or level. government policy at a broader for implications although have they may the organization, harm to a patient harm to 2. 2. by, has been approved The use of the PASD 3. Inclusion in plan ofInclusion care The use to ofassist a withresident a PASD a routine activity of living plan may be of included in a care only resident’s if all of satisfied: the following are 1. only if the use of the PASD is included in resident’s plan of care. plan of care. in resident’s is included ifonly the use of the PASD health outcomes and are consistent with current professional knowledge knowledge with professional current consistent and are health outcomes
4. everything the legislation The for plan of under provides care required 5. APPENDICIES 86
Promoting Alternative Safety: Approaches to theUse Restraints of and processes plan) (safety that minimize the interceptinglikelihood of them when they occur which thepatientisphysically prevented from leaving a or room area from in alone a patient of involuntaryenvironmental the an as confinementdefined restraint, been has
or unhealthy event, such as immunosuppression, which increases the incidence and severity of infection, or cigarette or infection, of severity and incidence the increases whichimmunosuppression, as such event,unhealthy or Risk: Restraints: Responsive Behaviours: Rapid Response Team: Randomized Factors: Mitigating Seclusion: Safety Plans: orcardiovascular developing respiratory a disease smoking,of increaseswhich risk the Risk this client? with occur will episodes restraining additional that likelihood the decrease to done be question:can What the address to client with working nurse Master’slevel and nurse, charge unit/areaphysician, client’sattending the with restraint mechanical anyforincidence of meet will and episode restraining of hours 24 within activated is responseteam Rapid •Nurse Manager of •Clinical Supervisor, •Medical Director or 2000) harming apatient harming restrictive form of restraint to restraint the client’s meet restrictive of form used shouldbe needs alternative possible Leastall means restraint interventions are exhausted before decidingto least the and restraint a use form of psychoactive medication used not to treat illness, but to anyintentionally are restraints inhibitroom. Chemical a time-out a a control or garden,seclusion particular restraints or Environmental unit behaviour secure client. client’sa mobility.or include the Examples movement. by opened restraints be Physical cannot movement. that client’srail bed a a or limit chair a restraints to fixed Physical table body.a include his/her of portion a or person a of activity 2009) istered are by selected arandomprocess. concurrent enrolment and follow-upthe test- of and control-treated groups, and in which the treatments to be - admin . .
Factor: (b) (a) An inaperson, need unmet cognitive, whether physical, emotional, social, environmental or other, or The probability that an incident will occur probability The thatanincident will REGISTERED NURSES’ASSOCIATION OFONTARIO confusing to aperson responseA to circumstancesor physical social the within environment or maythat frightening frustrating, be (Prescott etal., 2007) The restriction of a person’sa of restriction The physicallythrough mobility defined confining a area. patient to the Seclusion, Restraints are physical, chemical or environmental measures used to control the physical or behavioural behavioural or physical the control to used measures environmental or physical,chemical are Restraints A factor that causes a person or a group of people to be particularly susceptible to an unwanted, unpleasant, Freedom from accidental injury ensuring patient safety involves the establishment of operational systems Controlled (WHO, 2009) An action or circumstance that prevents or moderates the progression of an incident towards incident an of progression the moderates or prevents that circumstance or action An area where of service restraining Team members from psychiatric care areas thatusephysical consisting restraints of: and Assistant Medical Director, Responsive behaviours meansbehaviours thatoften indicate: , Trials: . (Ministry ofHealthandLong Term Care, 2007) Clinical trials that involve at least one test treatment and one control treatment, control one and treatment test one least at involve that trials Clinical (WHO, 2009) (National CouncilforCommunityBehavioural Healthcare, 2007) client occurred. . , (CNO, rev. 2009c) . (Mosby’sDictionary,Medical edition,8th (Kohn, Corrigan & Donaldson, .
APPENDICIES 87 to new or
a
to . National Health National assistance, patient a www.rnao.org .
nursing for relocating a bed; (Higgins & Green, 2008) (Higgins & Green, and ask (CNO, 2009c) (CNO, when to
or . surgery perimeters, BEST PRACTICE GUIDELINES • bed . Stakeholders include all individuals or groups who groups or individuals all include Stakeholders . . the
following of patients patient Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting bed controls; to access facilitate or (Baker et al., 1999) al., et (Baker (RNAO, rev. 2006c) rev. (RNAO, the (Hospital Bed Safety Workgroup, 2003) Workgroup, (Hospital Bed Safety . remind transporting A person identifiedby theMinistry of Health andCare: Long-Term Health to . while barrier (SDM): beds and security, comfort The therapeutic relationship is grounded in an interpersonal process that occurs between between occurs that process interpersonal an in grounded is relationship therapeutic The . . Systematic reviews establish where the effects of health care are consistent and research or Treatment interference refers to the self-removal or disruption of technological devices Mental health treatment that is directed by a thorough understanding by leaders and staff ofstaff and leaders by understanding thorough a by directed is that treatment health Mental (Happ, 2000) (Happ, physical Maker a An application of a rigorous scientific approach to the preparation of a review article ( article review of a preparation the to approach scientific rigorous ofa application An A significant other may include, but is not limited to, the person who a client identifies as the most most the as identifies client a who person the to, limited not is but include, may other significant A as
stretchers on used An individual, group, or organization with a vested interest in the decisions and actions oforganizations actions and decisions the in interest vested a with organization or group, individual, An . Other: Decision be Siderails/Bed rails are adjustable metal or rigid plastic bars that attach to the bed and are available in a variety a in available are and bed the to attach that bars plastic rigid or metal adjustable are rails Siderails/Bed used (National Executive Training Institute, 2005) Institute, Training (National Executive are restrict voluntary movement out of out restrict bed voluntary movement may room or unit; unit; or room the nurse and the client(s). Therapeutic relationship is a purposeful, goal-directed relationship that is directed at ad- of client the and outcome vancing the best interest human individual the ofeffects on social violence and traumaand psychological biological, neurological, profound the being, and an appreciation for the high prevalence of traumatic experiences services in persons who receive mental health that may attempt to influence decisions and actions and decisions influence to attempt may that of shapes and sizes from full to half, one-quarter, and one-eighth in lengths. In the spectrum of care – including hospital, hospital, including – care ofspectrum the In lengths. in one-eighth and one-quarter, half, to full from sizes and shapes of long term care and home care settings – bed rails serve a variety of purposes, some of which are in the best interest of Bed rails: and safety. health the patient’s • Treatment Treatment Interference: Trauma Informed Care: Informed Trauma Therapeutic Relationship: Therapeutic (CNO, rev. 2009a) rev. (CNO, Review: Systematic Substitute Stakeholder: Significant Siderails: will be directly or indirectly affected by the change or solution to the problem. to solution or the change will by affected indirectly or be directly Care Consent Act, 1996 (HCCA) who may make a 1996 (HCCA) treatment decision for someone whomake who may is incapable ofAct, making his/her Consent Care SDM The decision-maker. substitute a be to eligible is who determine to hierarchy a provides HCCA The decision. own is usually a partnerspouse, A power of or relative. attorney for personal care is not necessarily required to act as SDM and Medical Research Centre, 1998) used for diagnosis, treatment, physiologic monitoring of acute and critically ill patients. can Interference apply to the disruption ofor self-removal including urinary device, pulse feeding any intravascular oximetrytubes, lines, catheters, masks and oxygen probes results results can be applied across populations, settings, and differences in treatment (e.g. dose); and where effects may vary effects, chance reduces methodsreviews The and systematic in useof errors) limitsbias (systematic explicit, significantly. decisions and make conclusions draw to upon which results reliable more providing thus important in his/her life. It could be a spouse, partner, parent, child, sibling or friend or sibling child, parent, partner, be a spouse, could It important life. in his/her a feeling of provide • may • within turning and repositioning • can facilitate the bed transferring or of out in or APPENDICIES 88
by thedevelopment discussion panel andconsensus resulted to document to inrevisions prior thedraft publication. to opportunity give overall feedback and general impressions. The feedback from stakeholders was compiled and reviewed the as well as comment, for questions specific with provided werestakeholders External associations.professional as well clients/families/SDMs,as groups,advocacy and professionalhealth-care representedvarious Stakeholdersdocument. this set externalof stakeholders for review and feedback – an acknowledgement these of reviewers is provided on page 11-16 of a to submitted was draft subsequent a settings, practice in disciplines across collaboration of importance the Recognizing refined was further to clinical practice. readily support document The recommendations. of set final the on consensus to came and evidence the reviewed gaps, discussed tions, education and organization and policy recommendations. The panel members as a whole reviewed the draft recommendapractice,- of development the in resulted process This approval. and consensus for panel whole the to back brought then wererecommendations guideline The themes.recommendation major developed questions, clinical seven the answering on based subgroups, panel process consensus Through recommendations. the of development the for basis the formed guideline. The subgroups linked the evidence from(ranging randomized controlled totrials grey literature) to themes that the for recommendations drafting of purpose the for analysis thematic for questions clinical the accordingto summaries The panel was divided into expert subgroups by area of clinical and academic expertise and interest to consider the evidence theSystematicAppendix Cfor andoutcomes. detailsof Review andsearch strategy restraints. topiconthe See of research the more abstracts 1308 than literature of of resulted searchretrieval the in strategy opment process for the Nursing Best Practice Guidelines Program, a systematic review the of literature was conducted. The was conducted. Nineteen existing best practice guidelines on the topic were found. the rigorous guideline Asof devel - part Subsequently, a search of the literature for best practice guidelines, systematic reviews, relevant research studies and websites to guideline recommendations: thedevelopmentwas acritical of tandem guiding ( principles with Figure 1, pg. 20-21) alongthe development with the following seven of clinical questions the scope this of best practice guideline. It was the consensus the of guideline development panel that the use a of model in work,consensusRNAO.toontheir the came convened and was of of auspices the underpurpose the discussed panel The restraints of use possible the in resulting self/others to harm of behaviours of risk at clients with research and education In April 2010,of a panel nursesof and health-care professionals from a range practice of settings with expertise in practice, influence from Government. theOntario or bias any of independentconducted was work guideline. This RNAOthis convenedprofessionalsthe developedcare by of areas the of health- other and nurses of panel One restraints.A of use the uptake.and safety client to related interventions nursing on is of emphasis support and dissemination evaluation, implementation, pilot development, guideline The RNAO, with funding from the Government of Ontario, has embarked on a multi-year program of nursing best practice Appendix B:GuidelineDevelopmentProcess Promoting Alternative Safety: Approaches to theUse Restraints of 7. What are studies available to conducive restraint-free onenvironments practices ? 6. 5. 4. 3. 2. andtools are availableWhat strategies nurses to to prevention support care for for clients use? restraint atrisk 1. What approaches andtools assessment are available to assistnurses to identifyfor clients use? restraint atrisk practice environment?practice nursesto across move support settings practice all What characteristics towards organizational arestraint-free for for clients use? restraint caring when atrisk restraints or theuseof What alternative andtraining isrequiredintheimplementation education of approaches nurses toand/ support ? intervention does thenurse to need consider restraints strategies What are andmonitoring when considered asalast safety for use? restraint techniques management areWhat available andcrisis nurses to de-escalation to support care for clients atrisk REGISTERED NURSES’ASSOCIATION OFONTARIO
APPENDICIES 89
www.rnao.org http://www.inmo.ie/ http://www.who.int/chp/en/ http://www.med.umich.edu/ http://www.guidelines.gov/ http://cadth.ca/ Person: the Older http://www.cma.ca/index.php/ci_id/54316/ BEST PRACTICE GUIDELINES • Medicine: Critical Care Organization: Health World http://www.chspr.ubc.ca/ http://www.crd.york.ac.uk/crdweb/ http://www.bcguidelines.ca/gpac/ (CCOHTA): Assessment http://www.hc-sc.gc.ca/index-eng.php of in Care Restraint http://www.brentlscb.org.uk/ Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Assessment: the Society of http://rodp.ridne.net/node-54615.html http://www.cdc.gov/ http://www.icsi.org/guidelines_and_more/ http://secure.cihi.ca/cihiweb/splash.html http://cebmh.com/ http://www.cno.org/en/learn-about-standards-guidelines/publications- www.ices.on.ca http://wearcam.org/decon/full_body_restraint.htm Guidelines: Practice Clinical http://www.hcanj.org/docs/hcanjbp_fallmgmt6.pdf (DARE): Effectiveness http://www.gacguidelines.ca/index.cfm?pagepath=Resource_Centre/GAC_ http://www.srsb.ie/ in Canada: Care Health Standards: http://www.topalbertadoctors.org/ http://aappolicy.aappublications.org/cgi/reprint/pediatrics;119/5/1018.pdf http://www.phac-aspc.gc.ca/chn-rcs/index-eng.php Jersey: New Technology Health http://www.campbellcollaboration.org/ http://www.eboncall.org/ of the Use on Guidelines of Reviews of Medicine Critical Care Ontario: Infobase: Association http://www.medicine.ox.ac.uk/bandolier/ http://clinicalevidence.bmj.com/ceweb/conditions/index.jsp Association: Advisory Board:
Association: of Association Abstracts of
Advisory Committee: of Nurses Acts DesktopModules/articles/Documents/Guidelinesonrestraint.pdf Irish Nurses Sciences: Evaluative Clinical for Institute Improvement: Systems Clinical for Institute la_id/1.htm of College list/standards-and-guidelines/ Medical Canadian Publications&id=18876 Care Health Resource: Geriatric Nursing Guidelines AnesCriticalCare/Documents/Guidelines/SCCM/restraint.pdf American of College AlbertaMedical Clearinghouse): Guideline and Quality (National Research Healthcare for Agency Conditions Observatory Chronic for Care European Health on
• • Database of • • and Prevention: Disease Control for • Centers Health: Mental Evidence-Based for • Centers Pharmacotherapy: Evidence-Based for • Centre • Children Evidence: • Clinical Journal: • Bandolier • of the Future on • Commission (LSCB): Board Children Safeguarding Local • Brent of Office • British Columbia • Campbell Collaboration: Technology Health for Office Coordinating • Canadian Network: Health • Canadian Information: Health for Institute • Canadian • Services Guidelines: Medical • Emergency On-Call: • Evidence-based • • Guidelines: Practice Clinical on Council • British Columbia • • • •
Step 1: Guideline Search Step 1: Guideline ofsites list This 2009. January in area topic the to related content for ofwebsites list established an searched individual One was compiled based on existing knowledge of evidence-based practice websites, known guideline developers and - recom searched. date as well as searched site each for of noted was absence guidelines or Presence literature. the from mendations Guidelines retrieval. guideline for source or website another to directed but guidelines, house not did times at websites The phone/email. by ordered were or available downloaded if either were were full versions • Appendix C: Process for Systematic Review for Systematic Process C: Appendix search website structured a areas: key two on focused of guideline this development the strategyduring utilized search The review literature a and 2005; January, than earlier no ofrestraints topic the on published guidelines practice best identify to 2010. April January 2000 to from reviews published in this area primaryand systematic identify meta-analyses to studies, APPENDICIES 90
• evidence. 10includeddiscussions The of guidelines were: guideline to be developed and would be used to inform the panel when developing the recommendations supporting with • • • II clinical guidelines related to the use of restraints, using the Appraisal of Guidelines for Research and Evaluation Instrument existing retrieved 19 the of appraisal critical conducteda review, developmentpanel guideline evidence the the of part As criteria: The search abovedescribed strategies resulted 19 in guidelines the of on retrieval the topic restraints that met of the following notalready had they identified inthesearch been theinclusion andmet guidelines if criteria. intoand integrated thelistof searchstrategies. Identified guidelines where members panel by checked from list established the against guideline websites above the through found previously not guidelines identify archivesto personal review to asked also were members Panel Step 3:HandSearch/PanelContributions websites for content related to thetopic. websites the search, the of guideline result of list established the into integrated then searchwas the the results.of result The of summary a noting and reviewed,date search this conducted individual One terms. search key “Google”, using search the engine conducted was via restraints topicInof the addition,on guidelineswebsite search a practice existing for Step 2:SearchEngineWeb Search • • Promoting Alternative Safety: Approaches to theUse Restraints of • • • • • • • • • • • • (Brouwers, et al., 2010) al., et (Brouwers, 5. Available andaccessible for retrieval. 4. Evidence-based (contains references, evidence, evidence); source and of description of 3. on thetopic areas Strictly listed below; 2. Developed thanJanuary, noearlier 2005; 1. Published inEnglish, nationalandinternational inscope; Virginia Henderson International Nursing Library: Futrell, University Iowa of Gerontological Nursing Interventions Research Center, Research Translation DisseminationCore. College of Gerontological Nursing Interventions Research Center Research Translation andDissemination Core. Lyons, Bloomington (MN): Institute for Clinical Systems Improvement. Institute for Clinical Systems Improvement (ICSI). National Institute for Clinical Evidence (NICE): NBK16710/ InstituteJoanna Briggs for Evidence Nursing Based (Australia): &Midwifery National Institute of National R&DHealth Health Technology Service National Centre Health for Reviews andDissemination: Service Monash University Centre for Clinical Effectiveness: New Zealand Guidelines Group: Scottish Intercollegiate Guidelines Network: Royal College of cfm?doc_id=5243 RoyalThe Children’s Hospital Melbourne Clinical Practice Guideline: Registered Nurses’ PhysiotherapyThe Evidence Database: Psychiatry Online: REGISTERED NURSES’ASSOCIATION OFONTARIO S. M., S. Nurses of Melillo, (2004). . This process resulted in the decision that 10 of these guidelines were relevant to the scope of the of scope the to relevant were guidelines these of 10 that decision the in resulted process This . Nursing:
http://www.psychiatryonline.com/resourceTOC.aspx?resourceID=5 Fall prevention for older adults: Evidence-based protocol. Fall for older adults: Iowa Evidence-based prevention City, Iowa: University The Iowa of Association of K. (CNO). Ontario Health (US)Consensus Development Program: D. &Remington, http://www.rcn.org.uk/ http://www.nzgg.org.nz/ Ontario, (rev. http://www.pedro.org.au/ R. (2008). 2009c). Nursing Practice Best Guidelines: www.sign.ac.uk http://www.nice.org.uk/guidance/index.jsp Evidence-based practice guideline. Evidence-based Wandering. Iowa (IA): City Restraints standard. Toronto Nurses Ontario. (ON): College of of (2008). Assessment Programme: http://www.nursinglibrary.org/vhl/ http://www.med.monash.edu.au/centres-institutes.html Prevention of falls (acute falls care). of Health Prevention care protocol. http://www.york.ac.uk/inst/crd/ http://consensus.nih.gov/ http://www.rch.org.au/clinicalguide/cpg. http://www.ncbi.nlm.nih.gov/books/ www.rnao.org/bestpractices http://www.joannabriggs.edu.au/
APPENDICIES 91
www.rnao.org Violence: The short-term Violence: (2005). BEST PRACTICE GUIDELINES • Prevention of fallsand fall injuries in the older adult. Family involvement in care for persons for in care with involvement Dementia. Family 2011). (2001). (rev. Changing use care. in acute restraint of the practice physical L. Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Non-pharmacological management ofagitated behaviours in Self-harm:The short-term and psychological physical management M. (2005). (2004). (2004). L. L. & Maas, D. K. Ontario (RNAO). J. & Ledford, J. & Schutte, L. M. of Association
Pringle Specht,
L., Tang, Hsiao-Chen M., Assessment tools, tools, Assessment Risk factors (clinical features) for the use of restraints (behaviours, cognitive impairments, treatment interference, triggers), interference, treatment impairments, cognitive the use of for features) (clinical restraints (behaviours, factors Risk Client-centered care, care, Client-centered Education/training programs, Ethics, safety, Client legislation/standards, Restraint use, Restraint Alternative approaches to the use of restraints, the use of to restraints, approaches Alternative Prevention strategies, strategies, Prevention McGongal-Kenney, University of Iowa Gerontological Nursing persons Nursing Gerontological with Disease ofAlzheimer dementing other and chronic Iowa conditions. University Core. and Dissemination Translation Research Center Research Interventions (NCCNSC). Care and Supportive Nursing for CollaboratingCentre National management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. London (NICE). Excellence Clinical for Institute National (UK): Excellence. Clinical for Institute National and secondary prevention & Gaskell of self-harm UK: in primary London, and secondary 16. guideline Clinical care. Society. British Psychological Park, Toronto (ON): Registered Nurses’ Association ofAssociation Ontario. Nurses’ Registered (ON): Toronto Kelley, Skemp Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Translation Translation Research Center, Research Interventions Nursing Gerontological of Iowa University City (IA): Iowa Core. and Dissemination Nurses’ Registered Iowa City, Iowa: The University of Iowa Gerontological Nursing Interventions Research Center Research Translation Translation Research Center Research Interventions Nursing Gerontological of Iowa The University Iowa: City, Iowa and Dissemination Core.
j. i. f. c. e. a. g. b. d. h.
Inclusion Criteria: Inclusion of more or one focus on Studies the following topics: 1.
A university health sciences librarian conducted a database search for existing evidence related to restraint An use. initial search of the databases CINAHL Embase, MEDLINE, for primary studies and systematic reviews published from January 2000 to April 2010 was conducted in April 2010 - “Pharmaco using the “Chemical and following “ Restrain”, “Physical search Physical and terms: and Immobilization”, and “Restraint”, Isolation “Manual “Patient and Restrain”, Restrain”, “Mechanical and Restrain”, Restrain”, and “Patient Restrain”, and “Seclusion Restrain”, and “Environmental Restrain”, and logical “Restrict Restraint, “Restrain and Physical”, and Restrain Device”, “Restraining and Free”, and Minimization”, Restrain”, “Nurse or “Nurses”, “Restrain Nurses “Nursing”, “Nursing “Nursing and or Assistants”, Practice”, Reduction”, Nursing”, Step 4: Literature Review The search was structured to meet the following inclusion/exclusion criteria and to answer the clinical questions identified by identified questions clinical the answer to and criteria inclusion/exclusion following the meet to structured was search The development the inform to reviewed quality was ofrestraints topic the on identified The . panel development guideline the of Restraints: the Use to Approaches Safety:Alternative Promoting of the guideline, “Patient Care”, “Patient and Care”, “Immobilization and Stress”, Physical and Immobilization”, “Treatments and Procedures Procedures and “Treatments Immobilization”, and Physical Stress”, and “Immobilization Care”, and “Patient Care”, “Patient panel development guideline ofthe members The SelfRestraint”. and “Suicide Coordination”, Care “Nursing Restrain”, and captured was evidence all ensure to topic the on literature sentinel key identify to archives personal review to asked also were needed. where conducted were searches literature supplemental panel, the consensus by directed As search. in the literature •
• • • • • APPENDICIES 92
• • • from thefindings toin themanuscript systematic support theinitial review: but did support the further content already identified in the initial systematic review.The following four articles were used applicable based on the established inclusion and exclusion criteria. Panel consensus agreed that however, identified; findings. they were were three new articles only offeredin Twenty-five resultedRestraints of no Use the tonew Approaches findings guideline and topic the to relating research published recently no ensure to conducted was A hand search of articles published since the database search that resulted in the systematic review (April 2010 to April 2011) Step 5:HandSearch included inthesystematic review. identify to order in assistants research two byto be articles 290 totalof exclusiona inclusionforpanel, byand assess the established and as duplications yielding criteria screened then were abstracts These Restraints. of Use the to Approaches topicthe on of abstracts 1312 above of described resulted retrieval the in search The strategy Search Results: 7. What are studies available to conducive restraint-free onenvironments practices ? 6. 5. 4. 3. 2. andtools are availableWhat strategies nurses to to prevention support care for for clients use? restraint atrisk 1. What approaches andtools assessment are available to assistnurses to identifyfor clients use? restraint atrisk Clinical Questions: 5. Dissertations, commentaries (Note: andnarrative reviews thesemay included be asbackground information). 4. Study inEnglish. publications that are notwritten 3. Assessment nursing or interventions practice. thescope thatare of notwithin 2. to useinclusion restraint thatdoes notpertain criteria. Article 1. Study focusdoes notrelate to physical/mechanical, chemical or environmental use. restraint Exclusion criteria: 5. Systematic reviews, meta-analysis, qualitative andquantitative research studies. 4. Study publications that were publishedinEnglish. 3. 2. outcomes The intervention studies must related be of for to for clients use. restraints caring atrisk Promoting Alternative Safety: Approaches to theUse Restraints of does thenurse to need consider restraints strategies What are andmonitoring when considered asalastintervention? safety practice environment?practice nursesto across move support settings practice all What characteristics towards organizational arestraint-free for for clients use? restraint caring when atrisk restraints use of What alternative andtraining isrequiredintheimplementation education of approaches nurses toand/or support the for use? restraint techniques management areWhat available andcrisis nurses to de-escalation to support care for clients atrisk January 2000were alsoincluded for review). Study publication dates from range January2000to April 2010(Note: seminal papersthatwere publishedbefore k. l.
tative literature. Journal International Mental of Health Nursing 19, 416-427. doi: 10.1111/j.1447-0349.2010.00694.x Strout, 1278. doi: 10.1111/j.1532-5415.2010.02950.x physical restraints: 58(7), Influencephysician 1272- Society of characteristics. Journal the of American Geriatrics Sandhu, No.: CD007546. DOI:10.1002/14651858.CD007546.pub2 physical, care (Review). inlong-term restraints 2011, geriatric Reviews Cochrane Systematic of 2. Database Art. Möhler, Organizational responsibilities.Organizational Type (physical/mechanical, restraints of chemical-pharmacological, environmental/seclusion), and REGISTERED NURSES’ASSOCIATION OFONTARIO T. R., S., (2010). Mion, Richter, Perspectives on theexperience of L., T., Khan, Köpke, R., S. Ludwick, &Meyer, R., G. Claridge, (2011). physically being restrained: Interventions for preventing and reducing theuseof J., Pile, J.,… Dietrich,M. (2010).
An integrativeof review Likelihood of Promoting Safety: Alternative Safety: Promoting Promoting Safety: Alternative PromotingSafety: ordering thequali-
APPENDICIES 93
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting is recommended for guiding the implementation of any clinical practice clinical any of implementation the guiding for recommended is Toolkit Toolkit: Implementation Toolkit: of Clinical Practice Guidelines based on available evidence,
2. Identification, assessment and engagement of engagement and assessment stakeholders. Identification, 2. implementation. guideline for readiness ofAssessment environmental 3. and planning evidence-based strategies. implementation Identifying 4. evaluation. Planning and implementing 5. implementation. for resources and securing Identifying required 6. 1. Identifying a well-developed, evidence-based practice guideline. clinical a well-developed, Identifying 1.
provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating in coordinating, planning, directions to individuals and step-by-step provides groups involved Toolkit
Implementing guidelines in practice that result in successful practice changes and positive clinical impact is is one for key managingresource The this toolkit undertaking. can The process. a beToolkit downloaded at www.rnao.org/ complex bestpractices.
Appendix D: Description of the Toolkit of the Description D: Appendix Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support as well as appropriate facilitation. through In a this panellight, RNAO, of nurses, researchers and administrators has developed the a guideline: in implementing steps the following key addresses the Toolkit Specifically, implementation. the guideline The theoretical perspectives and consensus. The consensus. and perspectives theoretical organization. in a health-care guideline APPENDICIES 94
audiotaped and transcribed for content andtranscribed analysis.audiotaped No andreliabilitystudies have validity done been on thisinstrument. was used to guide the interview, but an open-ended, free-flowing discussion was soughtwith the subject; the interviews were thisinstrument. for useof The authors give permission Subjective ExperienceOfBeingRestrained(SEBR) study The Restrained (SEBR)InterviewTool Appendix E:Example:ExperienceofBeing Promoting Alternative Safety: Approaches to theUse Restraints of
______(Record patient’s words) own 1. ______3. you Do applied? recall having the(device) situation, including in bed/chair, whether stretcher, w/c). (NOTE: Use patient’s word own for the “devices” -you may time, coach with place, persons involved, patient’s behavior, ______2. No,If go to #14 in any way? (Use patient’s words own or coach with down,” tied “being “posey vest,” “bedrails,” “safety belt”). While hospital/nursing home here), in(nameof have you ever experienced having your movement limited or restricted identified in#1above)? IF YES, your could you recollection to of thecircumstances thebest the(namedevice describe surrounding theuseof is a structured interview guide used with patients, first in a hospital hospital a in first patients, with used guide interview structured a is (SEBR) Restrained Being of Experience Subjective (Strumpf & Evans, 1988) REGISTERED NURSES’ASSOCIATION OFONTARIO No Yes and then in a subsequent nursing home study 2 1
(Evans & Strumpf, 1987; Evans et. al., 1991) Subject No. Interviewer
Interview Guide Date_ Yes No ______
______(TYPE) belt/tie belt/tie bedrail bedrail ankle other wrist wrist mitt vest
. This instrument 1 2 3 4 6 5 7 8 APPENDICIES 95 ”)?
www.rnao.org BEST PRACTICE GUIDELINES • ) removed? Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting ) applied? ) is (was) applied? ) left on? ) left ) prevent you from doing that you want(ed) or need(ed) to do? need(ed) want(ed) or to that you doing from you ) prevent 1 2 1 2
)? No No Yes Yes Yes Yes No No se patient’s own words, or “tied down”, “restrained”, “restricted in your movement in your “restricted “restrained”, down”, “tied or own words, with deal being (use patient’s you did (do) How What ideas do you have about other ways you might be (have been) helped with (Response given in #4) ratherthan the been) helped given with might (Response be (have you ways about other have you do ideas What use of the (device ______10. 10. the (device having about you to is (was) explained What 12. ______
8. What did (does) the (device (does) did What 8. is (was) the (device long How 9. the (device) having removed? ever recall Do you 11. ______7. What do (did) you do when the (device do (did) you do What 7. ______6. What do (did) you feel when the (device having (did) you do What 6. ______5. 5. ______4. Did someone tell you why the (device) was being applied? why you tell Did someone 4. what did they you? tell Yes, If APPENDICIES 96
Web link:www.nursing.upenn.edu/cisa/Pages/Research.aspx Source: Evans, L. and Strumpf, N. (1986). Subjective Experience of Being Restrained. Penn Nursing Science: University of Pennsylvania School of Nursing. © 1986UniversityofPennsylvania School ofNursing Lois Evans andNevilleStrumpf Thank ______15. Have you any had immediate from effects (e.g., this(device)? “discomfort”). yes, If describe. ______If Yes, describe. 14. you Do have ever hospital/nursing confused being home here)? while any of in(nameof memory ______13. (IFSTILLRESTRAINED) How long do you this(device expect Promoting Alternative Safety: Approaches to theUse Restraints of You for REGISTERED NURSES’ASSOCIATION OFONTARIO Your Participation!
) to used? be APPENDICIES 97 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ High
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Mod Middle ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Low ❑ ❑ ❑ ______5_ Yes Yes Yes Yes Yes www.rnao.org yy/mm/dd ❑ ❑ ❑ T.H.R.E.A.T No No No Current Management Plan: Current SIGNATURE RISK SIGNS SIGNATURE SPECIFIC RISK ESTIMATES First ______CURRENT MANAGEMENT MEASURES CURRENT MANAGEMENT OTHER Risks ______Violence Self-Harm Suicide Unauthorized Leave Abuse Substance Self-Neglect Victimized Being ______Risk: Specific Case ❑ Specify: Specify: date: ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ Hx* ______4_ D.O.B cal ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ Item Criti- BEST PRACTICE GUIDELINES • Last
❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ______: ______: ______Female CORRECTIONS REVIEW _ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ______❑ Status Specify: ❑ _ ❑ Vulnerabilities ecord #: 2 Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Name: R Male
______
3_
† ‡ ) ❑ ______ADMISSION COMMUNITY Plans Insight Coping Conduct Self-Care Attitudes Treatability ❑ ❑ Status
Social Skills Recreational Mental State Occupational Substance Use Rule Adherence Rule Emotional State Impulse Control External Triggers External START Items START Material Resources Relationships (TA: Y/N)* Relationships (TA: Social Support (PPS: Y/N) Social Support (PPS: Med. Adherence (N/A Med. ❑ ______Case Specifis Item: ______Case Specifis Item: ______Case Specifis Item: days/weeks/months
______
1. 6. 7. 2. 3. 4. 5. 8. 15. 15. 16. 17. 18. 19. 20. 21. 22. 9. 10. 11. 12. 13. 14. 2 _ ICD-10
0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
TR ______what factors/predict-explain/which person/will carry out/what act/when? _ HOSPITAL REFERAL 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Status: ❑ ❑
______Strengths 2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
______❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍ Key Key Item
completed by: _ completed by: 1.1 © 2009 Version Applicable Hx - Historical Support †N/A – Not Peer - Positive Alliance ‡PPS Therapeutic - *TA _ Tests: Health Concerns/Medical ______Risk Formulation: START Time Frame: ______Time Frame: START PURPOSE: Diagnosis: DSM-IV Diagnosis:
of Risk and Treatability Tool (START) (START) Tool Treatability and Risk of Appendix F: Example: Short-Term Assessment Assessment Short-Term Example: F: Appendix 1 _ STATUS:
APPENDICIES 98
Reprinted withpermissionfromBritishColumbiaMentalHealth&AddictionServices. leave, by substance others low, isassessed abuse, andvictimization self-neglect moderate or high. ascribed meanings.with Key termsand items critical are highlighted. Seven including risks violence toof others, self-harm, set suicide, unauthorized a using 2) 1, (0, vulnerabilities & 2) 1, (0, strength for rated are vulnerabilities and Strengths the START athttp://www.bcmhas.ca/Research/Research_START.htm andrelevant evidence . The START was designed for psychiatric and forensic inpatients and outpatients. A guide is available that details the use of identified.be key and also risk formulation can strengthsidentified. vulnerabilities be can and Critical signs risk Signature assessed. also is risks 2.0,1,or of seven ratings presenceusing or absence of the degree the on evaluated are Twenty forvulnerabilities and strengths patient History high. or moderate low, as treatability) and absences unauthorized neglect, self- abuse, substance victimized, being self-harm, suicide, others, to (violence risks dynamic seven STARTassesses The Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO APPENDICIES 99
Night Night Night Night Evening Evening www.rnao.org Day Day Patient/ Client data Client Patient/
BEST PRACTICE GUIDELINES • Confused Irritable Boisterous threats Verbal threats Physical objects Attacking SUM Confused Irritable Boisterous threats Verbal threats Physical objects Attacking SUM Thursday / / Thursday Tuesday / / Tuesday Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Night Night Night Evening Evening Day Day
The Broset Violence Checklist (BVC)- quick instructions: Score the patient at the patient instructions: Score quick (BVC)- Checklist Violence The Broset Presence of of 0. score a behaviour gives Absence agreed every time on shift. If is behaviour is 6. (SUM) score Maximum ofof 1. a score behaviour gives if e.g. 1, scores in behaviour an increase only a well known client, normal for time) a long this willbeen (has so for normally is confused client a well know of 1. a score is observed If this gives of in confusion an increase 0. a score give Physical threats threats Physical objects Attacking SUM threats Physical objects Attacking SUM Confused Irritable Boisterous threats Verbal Confused Irritable Boisterous threats Verbal Wednesday / / Wednesday Monday / /
Checklist Tool Checklist Violence Broset Example: G: Appendix APPENDICIES 100
Nursing,10 Reprinted with permission from John Wiley andSons. Reprinted withpermissionfromJohnWiley Source: Almvik, R. & Woods, P. (April1, 2003). Short-termriskprediction: The Broset Violence Checklist. Promoting Alternative Safety: Approaches to theUse Restraints of
Sunday / Friday / SUM Attacking objects Physical threats Verbal threats Boisterous Irritable Confused SUM Attacking objects Physical threats Verbal threats Boisterous Irritable Confused REGISTERED NURSES’ASSOCIATION OFONTARIO (2), 236-238.
Day Day Evening Evening Night Night Saturday / SUM Attacking objects Physical threats Verbal threats Boisterous Irritable Confused
Journal ofPsychiatricandMentalHealth Day Evening Night APPENDICIES 101
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Previous Violence Previous Incident Violence at First Age Young Instability Relationship Problems Employment Problems Use Substance Illness Mental Major Psychopathy Early Maladjustment Disorder Personality SupervisionPrior Failure ofLack insight Attitudes Negative Illness of Mental Symptoms Major Active Impulsivity Treatment to Unresponsive Feasibility Plans Lack De-stabilizers to Exposure Support ofLack Personal Attempts with Remediation Noncompliance Stress R1 R2 R3 R4 R5 C1 C2 C3 C4 C5 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10
Reprinted with permission from: Ronald Roesch, Professor, Director of Mental Health Law and Policy Institute, Simon Fraser University. Reprinted with permission from: Ronald Roesch, Professor, Historical Scale Historical Scale Clinical Scale Management Risk clinical- historical- 20 the of absence or presence The settings. justice criminal and forensic health, mental in future used for is risk The HCR-20 Present. The Definitely or Present; Possible Absent; levels: 3 to according identified Institute are Policy factors and management Law risk Health, Mental the by published is HCR-20 items. risk 20 the of evaluation the by assessed is violence at Simon Fraser University. The HCR-20 Violence Risk Management Companion Guide is available. For information: http://kdouglas.wordpress.com/hcr-20/ Management: 20 (HCR-20) 20 Management: 20 (HCR-20) Management: Historical-Clinical-Risk Appendix H: Example: Historical-Clinical-Risk Historical-Clinical-Risk Example: H: Appendix APPENDICIES 102
in your treatment. you. with Togethercopingagreement and plan changesyour treatment make any review necessary again oncewill we will control,have staff gained yousafe.Once others or youkeep help to protective method a as used be only will intervention youintervenethat so by alternativearean youusing yourself will safe,control helped gain intervention. of staff physicalA If at any time, your emotional state puts you or others in an unsafe situation, and the information you have given us has not
. If 3.
usassistyou.help abouthow informed you Pleasekeep are thestaff times. atall feeling to questions few emotions.youra We answer towith you dealing asking are help need you and upset becomeyou case in Hospitalization can be a stressful time. Therefore, the nurse wouldinterviewer like to find out thebest ways to care for you New (Copyright NYStatePsychiatricInstitute-fromHellersteinetal., 2007) Coping AgreementQuestionnaire(CAQ) Questionnaire (CAQ) Appendix I:Example:CopingAgreement Promoting Alternative Safety: Approaches to theUse Restraints of
4. 2. 1. York State Psychiatric Institute
Family recommendations: ______❑ Have medeep breathe ❑ Allow meto sitquietly by inaroom myself ❑ Talk me with ______❑ Other: ❑ Hurt myself Slam doors❑ Slam ❑ Withdraw ❑ Cry What have you done you when were or upset lostcontrol? ❑ Not able being to go home Being touched❑ Being ❑ Having visitors Hungry ❑ Being Being Tired❑ Being What you upsets and/or causesyou to losecontrol? REGISTERED NURSES’ASSOCIATION OFONTARIO to Iamabout losecontrol, TREATMENT PLAN Coping Agreement
to mecalmdown. things help thefollowing try please
Unit/Ward No. Sex ______Patient’s Name (Last, First, M.I.) ______❑ Other:______❑ Give memedicine ❑ Help involved meget inanother activity Yell ❑ ❑ Strike out ❑ Hit people ❑ Throw things Other: ______❑ Other: ❑ Feeling rejected ❑ Not having visitors ❑ Feeling lonely ❑ Too much noise _ Birth Date of ______“C NO.” APPENDICIES 103
www.rnao.org ______BEST PRACTICE GUIDELINES • Date: Date: Date: Not clinically indicated ❑ Not Staff_ Signature Staff_ Signature Staff_ Signature Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting family/significant notified? other your wish have you to do No Preference ❑ No clinically indicated: ______❑ No ❑ Restraint restraint is used, ______Revision ( )_ Revision Revision ( )_ Revision Revision ( )_ Revision prefer? in a crisis situationyou which treatment would (If revision necessary Sheet) history a UCR Continuation continue on
______of seclusion either a last resort,As
If Yes Seclusion ______Date: Date: Date: Patient’s Signature: Patient’s Reprinted with Permission from David J. Hellerstein, MD. Reprinted with Permission from David J. Hellerstein, B. Revision History:Revision notes. (X) if debriefing document also meeting Place progress in the seclusion/restraint; the revision is after 5. The following questions will if be asked ❑ Nurse’s Signature: Nurse’s A. ❑ Treating Physician’s Signature: Physician’s Treating APPENDICIES 104
Professional Practice. All requeststouseoradapttheAlternativeApproachesRestraint UsemustbedirectedtotheOttawaHospital,DepartmentofNursing Appendix J:Example:AlternativeApproachesList Promoting Alternative Safety: Approaches to theUse Restraints of
1. Falls Presenting Behaviours REGISTERED NURSES’ASSOCIATION OFONTARIO Table behaviours andpatient alternatives examples/suggested with • • Helmet • Night light • Non-slip on floor strips • Mattress on floor/lower bed • Clutter free rooms • • Scheduling daily naps • Diversional activities: • Involve family inplanningcare demonstration • Callbell • Redirect simplecommands with • Increase interactions social • Glasses, • • Normal schedule/individual routine • Pain relief/comfort measures • Increasedin participation • Routine (Q2H) positioning exercise:• Quad • Toileting regularly • Medication review Examples ofSuggested Alternatives Acceptance of bed/chair/ door devices- Alarm Assess for hunger, aids, hearing Least Restraint LastResort Policy risk ambulation mobility/ The OttawaThe Hospital pain, ADM VIII 540_ walkingaidseasily available pets, heat, music, ADL cold puzzles, crafts, cards, snacks APPENDICIES 105
www.rnao.org snacks cards, crafts, BEST PRACTICE GUIDELINES • puzzles, cold cold music, heat, heat, door bathroom door bathroom pets, Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting available walking aids easily available walking aids easily pain, pain, hearing aids, hearing aids, hunger, for Assess strategies past coping Assessing strategies past coping Assessing Alarm devices- bed/chair/door Alarm devices- bed/chair/door Orders underlying for see cause- Pre-Printed Work-Up hunger, for Assess i.e. • Label environment Examples of Suggested Alternatives of Suggested Examples regularly • Toileting routine schedule/individual • Normal • social interactions • Increase with simple commands • Redirect touch • Gentle • in planning care family • Involve activities: • Diversional social interactions • Increase/decrease with simple commands • Redirect touch • Gentle • in planning care family • Involve naps daily • Scheduling • rooms free • Clutter light• Night i.e. • Label environment • Reminiscence naps daily • Scheduling permitted • Pacing • rooms free • Clutter light• Night • Glasses, review • Medication • measures relief/comfort • Pain • Glasses, regularly-start q2h • Toileting routine schedule/individual • Normal •
Cognitive Impairment- Cognitive Impairment- dementia e.g. Acute Confusion- delirium 2. 2. Presenting Behaviours Presenting 3. 3. APPENDICIES 106
Promoting Alternative Safety: Approaches to theUse Restraints of
6. Sliding 5. Wandering 4. Agitation Presenting Behaviours REGISTERED NURSES’ASSOCIATION OFONTARIO • Non slipcushion (consult OT) • demonstration • Callbell • Pain relief/comfort measures • Routine (Q2H) positioning • Consults to OT/PT • Glasses, • Room close to nursing station • Night light • Clutter free rooms • • Tape (stop) lineon floor • Diversional activities: • Involve family inplanningcare • • Redirect simplecommands with • Increase interactions social environment• Label i.e. • Buddy system among staff/consistency • • Pacing permitted • Scheduling daily naps • Diversional activities: • Involve family inplanningcare • • Gentle touch • Relaxation techniques (tapes, • Redirect simplecommands with • Increase interactions social • • Normal schedule/individual routine • Toileting regularly • Pain relief/comfort measures • Medication review • Routine (Q2H) positioning • Mobility/ambulation/exercise routine Examples ofSuggested Alternatives Wedge cushions/tilt wheelchairs(consult OT/ PT) bed/chair/door devices- Alarm Assessing pastcoping strategies Assess for hunger, Assessing pastcoping strategies Assess for hunger, aids, hearing pain, pain, walkingaidseasily available pets, pets, bathroom door heat, heat, music, music, cold cold environment) dark puzzles, puzzles, crafts, crafts, cards, cards, snacks snacks APPENDICIES 107
www.rnao.org BEST PRACTICE GUIDELINES • quiet/dark room) cold heat, Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting available walking aids easily pain, injuries hearing aids, of Acceptance strategies past coping Assessing hunger, for Assess PEG over binder Abdominal bending) elbow Arm splint (prevent • Mobility/ambulation/exercise review • Medication social interactions • Increase • Call bell demonstration naps daily • Scheduling rooms free • Clutter bed floor/lower on • Mattress strips floor on • Non-slip light• Night • • Glasses, review • Medication measures relief/comfort • Pain • routine schedule/individual • Normal • social interactions • Increase/decrease (tapes, techniques • Relaxation measures relief/comfort • Pain social interactions • Increase with simple commands • Redirect • Call bell demonstration • Stimulation/meaningful distraction procedures/treatments • Explain touch • Gentle care in planning family • Involve IV on tubing • Camouflage • asap intermittent IV to • Change • Examples of Suggested Alternatives of Suggested Examples in planning care family • Involve permitted • Pacing • Soothing music
Pulling out invasives/ tubes 9. Unsteadiness 9. 7. Aggression 7. 8. Presenting Behaviours Presenting All requests to reproduce must be directed to The Ottawa Hospital Alternative to Restraints Decision Tree” must be directed to the Ottawa Hospital, must be directed to the Decision Tree” All requests to reproduce must be directed to The Ottawa Hospital Alternative to Restraints Department of Nursing Professional Practice for permission”. APPENDICIES 108
and a coefficient alpha of .94 and acoefficient alpha of personnel, this version had a coefficient .96. alpha of 87In a sample of American nursing home staff, 3.65 it had a mean of interference; this 17 item 5-point Likert scale is the one we currently employ in our research. Among 184 European nursing nurses. NursingResearch,37,132-137. Strumpf, N.E.,&Evans,L.K. (1988).Physicalrestraintofthehospitalizedelderly: Perceptionsofpatientsand American NursesAssociation CouncilofNurseResearchersMeeting,410.KansasCity:ANA. Strumpf, N.E.,&Evans,L.K. (1987).Patternsofrestraintuseinanursinghome (Abstract).Proceedingsofthe Journal oftheAmericanGeriatrics Society,37,65-74. Evans, L.K.,&Strumpf,N.E.(1989).Tying downtheelderly:Areviewofliterature onphysicalrestraint. Aging andmusculoskeletaldisorders,pp.324-333.NewYork: Springer. Evans, L.K.,&Strumpf,N.E.(1993).Frailtyandphysical restraint.InH.M.Perry, J.E. Morley, &R.M.Coe(Eds.), 272A-273A. Evans, L.K.,&Strumpf,N.E.(1987).Patternsofrestraint: Across-culturalview. Gerontologist,27 (Supplement), References: made forbe useinnursing homes or other settings. This version of the PRUQ is for use in acute care settings; minor modification in the demographic items (e.g., #16, #19) may OAP: other, appropriate intervention (e.g., increase instaff). other,OIN:siderails; SR: restraint; chemical CR: facility); inappropriate(e.g.,seclusion,interventionanother to discharge Key: PH: physiological; PS: psychosocial; PA: ENV: physical activity; environmental; PR: physical restraint; and modederived for each. mean, a median and tallied are identified.interventions type of each for subtotal and interventions types of number Total environmental. The Matrix of Behavioral Interventions (attached, and Strumpf, et. al., 1998, activity,psychosocial,pp.physiologic,and types: 137-139) four is into categorizedused tobe may codeinterventions named the score. These (sum) total a forrespondent the by suggested interventionsdiscrete alternatives” the Forof of number “knowledge the section,count averaged 3.8(+/-0.86, n=55), 4.02(+/-0.68, n=29)and3.64(+/-0.83, n=55)atbaseline. [JAGS trial 1997] clinical our in homes nursingthree the in scale]. Likert example,the an Asstaff on positions of number To score the PRUQ, calculate a mean total scale score by summing the scores for each the of 17 items and dividing by 5 [the for thePRUQ Instructions Scoring 1987] Strumpf, & [Evans staff home nursing 20 of sample a with .74 of and nurses hospital face and content five by gerontologic aof validity panel nurse experts. with 18 of .80 professionalIt a had coefficient alpha now 5-point) from a review of the literature that included reasons for and attitudes about restraint use. It was judged to have toascribe reasons for using physical the restraints with elderly. The tool was developed as a Likert 3-point,scale (originally caregivers importance relative the determine to developed was (PRUQ) Questionnaire Use Restraint of Perceptions The Background andInstructionsforUse Perceptions ofRestraintUseQuestionnaire(PRUQ) of RestraintUseQuestionnaire(PRUQ) Appendix K:Example:CaregiversPerceptions Promoting Alternative Safety: Approaches to theUse Restraints of
items, it had a coefficient alpha of .86 with 51 nurses who worked with the elderly in geriatric and geropsychiatric and settings geriatric in elderly the with who worked nurses 51 with .86 items,coefficient of alpha a had it REGISTERED NURSES’ASSOCIATION OFONTARIO e ae ic mdfe te ntuet o nld mr ies eadn fl rs andtreatment risk fall regarding items more to include instrument the modified since have We. [Evans &Strumpf, 1993] . [Strumpf & Evans,& [Strumpf 1987, 1988] . Following its expansion to 11 to.expansion its Following APPENDICIES 109 - 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 tant most impor
4 4 4 4 5 4 4 4 4 4 4 4 5 4 4 4 4 4 DATE___/___/___ - www.rnao.org 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 tant what Some- impor 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 not at all im- portant BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting The authors give permission for use of permission for give The authors instrument. this Perceptions of Restraint Use Questionnaire (PRUQ) Questionnaire of Use Restraint Perceptions
e. Removing a dressing? Removing e. d. Breaking open sutures? open Breaking d. c. Pulling out an IV? out Pulling c. b. Pulling out a feeding tube? out Pulling b. a. Pulling out a catheter? out Pulling a. c. Unsafe ambulation? Unsafe c. b. Falling out of out Falling chair? b. a. Falling out of out Falling bed? a. Managing agitation?Managing - abusiveness/combat staff physical patients from other Protecting or iveness? Substituting for staff for Substituting observation? Providing for safety for when judgment is impaired? Providing Providing quiet time or rest for an overactive older person? older an overactive for time rest quiet or Providing Preventing an older person from taking things from others? taking things from from person an older Preventing Preventing an older person from wandering? from person an older Preventing Keeping a confused older person from bothering others? from person older a confused Keeping Preventing an older person from getting into dangerous places or supplies? or places dangerous getting into from person an older Preventing 11. 11. 10. 10. 9. 9. 8. 8. 7. 7.
3. 3.
2. 2. 6. Preventing an older person from: person an older Preventing 6.
5. 5.
4. 4. 1. Protecting an older person from: person an older Protecting 1. Following Following are reasons sometimes given for restraining older people. In general, how important do you believe the use of choice) your that represents the number (please circle listed? reason each for restraints are physical In caring for the older adult, physical restraints are sometimes used. Such restraints include vests, belts or sheet ties, crotch crotch sheetties, belts or vests, include restraints Such sometimesused. are restraints physical adult, older the caring for In geriatric tables. tray with locked or chairs fixed wrists hand mitts, ankle or ties, diaper restraints, or The Study Has Been Explained Me To My To Satisfaction. By Completing This Questionnaire, I Am Giving My Consent To Participate. Evans, L. and Strumpf, N. (1986). Subjective Experience of Being Restrained. Penn Nursing Science: University of Pennsylvania School of Nursing. Nursing. of School Pennsylvania of University Science: Nursing Penn Restrained. Being of Experience Subjective (1986). N. Strumpf, and L. Evans, Source: www.nursing.upenn.edu/cisa/Pages/Research.aspx link: Web Developed by Lois Evans and Neville Strumpf and Neville Strumpf Lois Evans Developed by 2010. revised 1990 &, School of Nursing; University of Pennsylvania © 1986. Restraint-free care: Individualized approaches approaches care: Individualized Restraint-free & Evans, L.K. (1998). J.S., Wagner, J.P., N.E., Robinson, Strumpf, Springer. . New York: for frail elders APPENDICIES 110
Last updatedMay12, 2010 University ofPennsylvania SchoolofNursing ©1986, 1990Evans &Strumpf Coding: Total_____ PH_____ PS_____PA_____ ENV_____PR_____CR_____SR_____OIN_____OAP_____ 19. Position: Nurse ❑Staff ❑Nurse Manager ❑ Advanced Practice Nurse ❑Certified Nursing Assistant 18. Any ❑yes❑ no education ingeriatrics? specialized 17. Total ______years ______months employment inthisfacility: length of 16. Type Unit: of ❑Medical Care ❑ SurgicalCritical ❑ Other 15. Sex: ❑FM 14. Age: ____ 13. Education: ❑MSNBSNDiploma ADN ______12. Promoting Alternative Safety: Approaches to theUse Restraints of Use the back of this sheet if necessary.Use if thissheet theback of above.listed situations or behaviors the physicalfor restraints of instead used couldbe measureswhich identify Please REGISTERED NURSES’ASSOCIATION OFONTARIO APPENDICIES 111
- appro
safety control resident trust and sense underlying of sense PRN www.rnao.org Other Behaviors Comfort of Correction dehydration e.g., problem, of Provision and security/validation of concerns of Promotion of purpose/mastery orientation (if Reality priate) of Facilitation activities ofover living daily visitsFamily and information sharing that are Communications and cues, to sensitive calm, use simple statements/ instructions with Attention/assistance eliminations listening Active agenda resident’s to Attention feelings and to Attention concerns “Timeout”
relief • Pain • • Positioning • • Sensory aids therapy • Massage/aroma • • Companionship • Therapeutic touch • approach • Calm • • consistency • Caregiver • Supervision • • • • Remotivation • • counselling • Pastoral/spiritual • •
device appropriate BEST PRACTICE GUIDELINES • restraint” “no
communication
short-term for change need for of Treatment Interference Treatment Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting and Companionship supervision Comfort of Evaluation IV/ remove (e.g., in treatment wean catheters; NG tubes, ventilator) from advance directive advance with elimination Assistance of Encouragement Maintenance with family/resident of Authorization from resident/family from “Contracting” treatment use (if invasive device)
• Reassurance • • relief • Pain • • • • • as indicated consult • Ethics of exploration • Guided •
Building integrativeBuilding science and complex common addressing associatedproblems withaging Center for Integrative Science in Aging Science for Integrative Center restraint” “no
for reasons needs Fall Risk Fall
of Identification and prescription Evaluation etc. PT/OT, for falling and comprehensive falling comprehensive and assessment of Anticipation review/elimination Medication of drugs troublesome of Authorization from resident/family from • Supervision • • Fall/risk program • • • • Rest • Elimination schedule • tions Types of Types Interven- Psycho- social Physiologic Matrix of Behaviors and Interventions* Matrix of Behaviors
APPENDICIES 112
Reprinted withpermissionfromPenn NursingScience. Source: ModifiedfromStrumpf, et. al., (1998), pp. 137-139. *List providesexamples, notintendedtobeexhaustive. Promoting Alternative Safety: Approaches to theUse Restraints of mental Environ- Activities Interven- Types of tions REGISTERED NURSES’ASSOCIATION OFONTARIO lighting • Optimal • • • • • • Meaningful activity • Restorative program • Transfer assistance • Fall-prevention program • Gaittraining • Varied locations sitting elevated toiletelevated seat system,signal assistive devices, environment,fall-safe alarm awarenessSafety training, shoes Mobility aidsandsupportive chairtable placed infront of on floor,bedside commode, accessible light, call mattress side rails,or single pads, Low beds, seating pillow or other customized wedge cushions, abductor Chairs thatslantor fitbody, bearing ambulation/weight Daily physical therapy/ down rails bed Fall Risk
• • • • to• Something hold • Television, • Distraction Accessible light call Protective sleeves, treatment site Camouflaged or padded station Placement nearnursing etc. Treatment Interference radio, music garments,
• Room change asappropriate environment• Structured • Personal space • clothing • Special • • locks • Special • • andoutlets activities • Spiritual routines• Structured • Pet therapy • Redirection toward unit PRN • Night-time activities • activity • Social • PT/OT/ADL training • Exercise • • Distraction • • • Rocking chair • • • Decreased useof Varied andfurnishings seating signs Velcro systemsAlarm and interesting Contained areas thatare safe hallway endto of signal or planters (grids) Floor tape elevators especially structured activity structured especially Outlets for anxiousbehavior, interest/abilities)with recreationPlanned (consistent Camouflaged doors, environment/familiar objects Personalized area/homelike background music roomQuiet or soothing appropriate Decreased/increased as light Other Behaviors “doors”/gates/stop intercom exits,
APPENDICIES 113
ONSEQUENCE RESPONSE?) , February, 52, pg.193. pg.193. 52, February, , www.rnao.org C (WHAT WAS THE WAS (WHAT Canadian Family Physician EHAVIOUR BEST PRACTICE GUIDELINES • B (DESCRIPTION) Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting NTECEDENT A (IS THERE A TRIGGER?) A THERE (IS
DATE AND TIME OF DAY AND DATE
Reprinted with permission from the Canadian Family Physician. Omelan, C. (2006). CME: Approach to managing behavioural disturbances in dementia. disturbances in dementia. behavioural Approach to managing CME: (2006). C. Omelan, Source: Adapted from Proulx.10
Behaviour-Consequence) Charting Template Charting Behaviour-Consequence) template charting 1. Antecedent-Behaviour-Consequence Figure (Antecedent- ABC Example: L: Appendix APPENDICIES 114
5. 3. Record thelog: behavior the in designated relevant columnsfor each of episode of observations specific 2. Record theclient’s nameandroom number inthespaces provided. 1. Directions for use: To behaviors facilitatesothatpatterns determined. andmeaningcanbe consistent anddocumentation of observation Purpose: Background andInstructionsforUse Behavior MonitoringLog Appendix M: Example: Behaviour Monitoring Log Promoting Alternative Safety: Approaches to theUse Restraints of 4.
patterns. As interventions thatalter thebehaviour are identified,be incorporated thesecan into theindividualized care plan. thebehaviourandaroundprobably toMaintenance detect theclock for the log necessary will several be episodes of of bed, leaves unit, hitsothers, atdressing). pulls In thespace next to theitem labeled “Specific behavior,” Target record (e.g.,behavior the under from falls observation behaviour corresponds with a lifetime habit of afternoon walks, habitbehaviour corresponds alifetime of etc.). with persons (e.g., day; inthe environmentcertain behaviourseems totimes occura of appear atspecific trigger response;to (a)pattern(s) behaviours designated until inoccurrence anddocumentation detectedContinue canbe of observation g. c. h. f. e. d. b. a.
No one available to take client to bathroom; client’s reach chair; behind floor out of recently walkingframe polished). In Column 7, record could what happening externally be (outside theclient) to precipitate thebehavior (Example: In Column 3, record behavior(Example: exactly wasobserved what attempting when fell from to arise chair unassisted). In Column 1, behavior. record of theobservation thedate of walking frame next towalking frame chair non-skid soles). seated; when with new shoes obtained (Example: Taken to hour9:30 thebathroom every AM to 12:30PM, two bedtime; hours thenkept until every In Column 8, interventions (or could what helped describe have theclient to helped) resolve thebehavior (Example: Client stated to shehad go to thebathroom adiuretic had urgently; at9:00 AM). In Column 6, could what happening internally be inside theclient) ( describe to precipitate thebehavior C.N.A. (Certified Nursing Assistant) F. Foxwith client talking T. Jones). In Column 5, note were persons who present were they andwhat doing (Example: Clients T. Jones &P. Smith; In Column 4, record where location theepisode occurred (Example: red chair in day room). In Column 2, record thebehavior(Example: when wasobserved theexacttime 10:30 AM). REGISTERED NURSES’ASSOCIATION OFONTARIO Center forIntegrativeScienceinAging problems associated with aging with problems associated addressing common andcomplex science Building integrative
APPENDICIES 115
client? New York: York: New help (could help) What interventions What ______www.rnao.org Room #_ Room What could be What (outside client) to happening externally happening externally precipitate behavior? precipitate BEST PRACTICE GUIDELINES • Restraint-free care: Individual approaches for frail elders. Restraint-free care: Individual approaches for What could be What (inside client) to happening internally happening internally precipitate behavior? precipitate Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Who else Who was present? Building integrativeBuilding science and complex common addressing associatedproblems withaging Center for Integrative Science in Aging Science for Integrative Center Where? ______What _ happened?
______Exact time Date Reprinted with permission from Penn Nursing Science. Adapted from: Strumpf, N., Robinson, E.J.P., Wagner, J.S., & Evans L.K. (1998). (1998). L.K. & Evans J.S., Wagner, E.J.P., Robinson, N., Strumpf, Adapted from: The authors give permission for use of this instrument. give permission for use The authors Target Behavior: Specific Name: Client’s Behavior Monitoring Log Behavior Monitoring
Springer Publishing, pp. 44-46. 44-46. pp. Springer Publishing, APPENDICIES 116
Professional Practice. All requeststouse oradapttheAlternativetoRestraints DecisionTree mustbedirectedtotheOttawaHospital,Department ofNursing Restraints DecisionTree Appendix N:Example:Alternativeto Promoting Alternative Safety: Approaches to theUse Restraints of REGISTERED NURSES’ASSOCIATION OFONTARIO • Document&monitor • Continue/Initiatealternatives(seelist) • Assess needse.g. Pain, nutrition, etc. • Discusspreferredcopingstrategies • Collaborate withteam/SDM** • Document&monitor • Re-orderrestraint asperpolicy • Re-evaluate leastrestraint • Trial newalternatives • ConsultSDM** • Codewhiteasrequired Yes Yes Implement carestrategies/ alternatives Explore etiologyofbehaviour Describe Behaviour Reassess needfor least restraint Strategies Effective? • Document&monitorasperpolicy • Educate: offerhandoutforteaching • Initiaterestraint. • ImplementPre-PrintedOrder(MD/RN). • • • Continue/implementalternatives • ‘Code White’ asrequired (Emergent) • Attempt de-escalatingstrategies *** MentalHealth Act ** SDM=SubstituteDecision Make * Patient Restraints Minimization Act 2001 within 12hours. MHA***excludesformedpatients Obtain consentfrompatient/SDM**immediatelyor least Consider chemical, environmentaland/orphysical • Document&monitor • ConsultSDM** • D/Crestraint restraints. Collaborate withteamwhenpossible. •Enhancefreedomorqualityoflife •Preventseriousbodilyharmtoselforothers Review CriteriaforLeastRestraint* No No APPENDICIES 117
www.rnao.org
patient’s Connect ______*Initial & date each new entry new each & date *Initial (DD/MM/YY) BEST PRACTICE GUIDELINES • history and patient story and behaviours. _ Initiated: Date and behaviours maladaptive and/or strengths, feelings,
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting signing or occurring rarely should be as reported incidents
self-injurious, escalating, sensory or and tools techniques behaviours self-injurious maladaptive and/or as early signs verbalization of increase and agitated movement tools, communication relationship, and therapeutic intervention and interprofessional appropriate aggressive, verbal,
physical) or
social withdrawal, Recognize when incidents; documenting precision Ensure triggers the aggressive, leading to any Isolate communication style and episodes of aggressive/maladaptive behaviour. behaviour. style of and episodes communication aggressive/maladaptive “highly infrequent” measures. preventative recognize aggression. increased thoughts, the patient’s between connection any Identify of knowledge Maintain relationship strategies.relationship interpreter, need for Assess making and power-sharing flexibility in decision Allow
How does the patient best communicate? • How does the patient best learn? How does the patient learning style and adapt teaching the patient’s • Identify • • imminent, • Early Warning Signs Warning Early early signs of • Identify Patient’s aggressive, self-injurious, and/or maladaptive Behaviours and/or maladaptive Behaviours self-injurious, aggressive, Patient’s these behaviours details about • Precise whether• Determine is sporadic the behavior reoccurring or • Triggers Antecedents and • triggers environmental potential any • Consider re-traumatization (be trauma-sensitive) prevent we do • How Techniques and De-escalation Preferences preferences de-escalation the patient’s to strategies according • Personalize the use of • Identify • (subtle, the escalation continuum to • Refer Describe the Therapeutic Interventions Therapeutic Describe the • known previous trauma? any • Does the patient have re-traumatization (be trauma-sensitive) prevent we do • How values, the patient’s to according interventions • Personalize ______Name: Patient (MAP) Behaviour Profile Behaviour (MAP) Profile MAP Behavioural Appendix O: Example: Mutual Action Plan Plan Action Mutual Example: O: Appendix APPENDICIES 118
Sciences. All right reserved. ReproductioninwholeorpartbyanymeanswithoutexpresswrittenconsentofOntarioShoresisprohibitedlaw.Sciences. Allrightreserved. MAP BehaviouralProfile–DRAFT2009/11/18AdaptedfromSafeManagementGroupInc.2008.Copyright2009,OntarioShoresCentre for MentalHealth Update thepatient’s MAPwithpertinent informationfromtheBehavioural Profile Promoting Alternative Safety: Approaches to theUse Restraints of • • Staff monitoringresponsibilities • Identify theSMGintervention specifically • Which behaviours require PhysicalIntervention? of aware• Be thatthistype • Which behaviours canbeMonitored from aSafeDistance? training, Recognize staff’s individual status to determine to when discontinue thephysical intervention or seclusion. Continually monitor, strikes andkicks. Behaviors which require immediate physical to cancauseharm others asthey or self action environmental damage. Recognize behaviors thatnotall require physical intervention; and availability. REGISTERED NURSES’ASSOCIATION OFONTARIO assess, behaviourmay escalate support, physical andclinical intervention skills, thepatient’s andcheck inwith behaviour, such asthrowing soft objects, physical restriction physical andmental such as andcertain APPENDICIES 119
Staff Initials Non www.rnao.org Effective Effective Date Tried BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Therapeutic Interventions Therapeutic
Increased walking/exercise programs walking/exercise Increased 1:1 activities implemented Contributing factors assessed for and treated e.g. infection e.g. and treated assessed for Contributing factors Identified pain related issues are addressed are issues related pain Identified Activities reassessed and adjusted reassessed Activities Food & fluid intake reviewed re hunger/thirst issues hunger/thirst reviewedre & fluid intake Food Correct footwear in use footwear Correct Acceptable & useable call bell in place/ available call & useable bell available in place/ Acceptable Sleep & rest periods have been reviewed & adjusted periodsSleep & rest have Moved closer to Nurses station Nurses to closer Moved Hip protectors – tried? protectors Hip Can clearly find bathroom? – pictures used – pictures find bathroom? clearly Can Toileting routine has been individualized & reviewed has been individualized routine Toileting Chair alarmChair Bed alarm Low bed Low Chair seating has beenChair reassessed Powered lift chair (if chair lift available) Powered Room temperature adjusted temperature Room Improved lighting/night lights Improved Visual monitoring increased monitoring Visual Orientated to surroundings Orientated to
Safety Plan Interventions behaviors, inappropriate falls, frequent signs disorientation, exhibiting of who are those residents aggression, for Purpose: be tried ______to issues: identified and evaluated are interventions the following suggested Appendix P: Example: Safety Plan Interventions Plan Safety Example: P: Appendix APPENDICIES 120
Reprinted withpermissionfromCaressantCare. Promoting Alternative Safety: Approaches to theUse Restraints of
Foam mattress perimeter seatbelt Alarmed Bed Wedges chairAnti-glide pad. Music Therapytried External referrals made (OT/PT etc) Behaviour mapping completed Elbow/knee tried/implemented pads #&type) rail(specify Bed wall against Bed Floor mat Trapeze available poles /bed commodesBedside inplace Assistive are devices accessible Sturdy chairs for in sitting Diversion therapy implemented Medication Review –dose/schedule adjusted REGISTERED NURSES’ASSOCIATION OFONTARIO Therapeutic Interventions Date completed Tried Date Effective Effective Non Initials Staff APPENDICIES 121 Yes Yes Yes Yes No
up in bed? as needed Does resident need assistance in sitting Refer to team for Refer to team for bed SRs or transfer bar SRs or transfer , Issue 7, pp. 43-48. pp. Issue 7, , that allows resident to self-adjust head of bed adjustable-height bed, adjustable-height bed, Refer to team for ½ or ¼ www.rnao.org No Would an adjustment in bed Would height facilitate transferring? Can resident get in and out of Can resident get in and bed without human assistance? No No (device) to promote safe transferring? Does resident need mechanical assistance bed mobility or transferring?) Yes removal of SRs removal Is resident immobile (no self-initiated Is resident immobile (no Refer to team for mat(s) at side of bed hip pads Refer to team for • • BEST PRACTICE GUIDELINES • Yes American Journal of Nursing, Volume 101 American Journal of Nursing, Volume Yes Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting or ¼ SRs or transfer bar or ¼ SRs or transfer therapist and consider trial of ½ therapist Refer to physical or occupational to improve transferring skills? to improve transferring Does resident have the potential Does resident have the Yes severe osteoporosis or history of fracture? Is the resident at high risk for injury due to No SR or foot of bed? risk of falling from bed Proceed to assessment of Proceed to assessment Does resident attempt to get out of bed unsafely (climbs over or around low (14”-20” above floor) or very low-height (7”-13”above floor) above floor) or low (14”-20” mat(s) at side of bed body-length or other pillows motion-sensor light bed alarm • • • • • Refer to team for one or more interventions: Yes No No Yes Yes
½, ¾, of full-length SRs with narrowly spaced inner bars, of full-length SRs with narrowly spaced inner bars, ¾, ½, fitted flush to mattress with SR pad or pillows boundary reminders (body-length pillows, rolled blankets, rolled blankets, boundary reminders (body-length pillows, under mattress edges “swimming noodles” or No mattress with raised edges mattress with raised Refer to team for one or more interventions: • • • No Yes Yes No out of bed
SR, or both? SR, of SRs use a transfer bar? use a transfer Refer to Is resident willing to removal of SRs removal
full or ¾, or four ½ SRs? full or ¾, side of bed, side of side of bed, Does resident prefer two Does resident prefer two team Refer Has the resident rolled for removal make decisions? make Refer to team for change to ½ or ¼ SRs or Does resident lean to Is resident able to Reprinted with permission from Wolters Kluwer Health Reprinted with permission from Wolters *SR=side rail. “Team” refers to a decision-making person/group as specified by the institution: a multi-disciplinary restraint-reduction team, a multi-disciplinary restraint-reduction refers to a decision-making person/group as specified by the institution: “Team” *SR=side rail. Talerico, K. & Capezuti, E. Myths and facts about side rails: Despite ongoing debates about safety and efficacy, side rails are still a standard rails are still a standard side ongoing debates about safety and efficacy, Despite Myths and facts about side rails: E. & Capezuti, K. Talerico, Source: AJN: use? So how do you determine their safe component of care in many hospital. geriatric-consultation team, rehabilitation department, nurse manager or supervisor, or a gerontologic APN. or a gerontologic nurse manager or supervisor, rehabilitation department, geriatric-consultation team, at PubMed. available Abstract 101:43-48. Am J Nurs, Myths and facts about side rails. (2001). E. & Capezuti, K.A. Talerico, Adapted from:
Equipment Intervention Decision Tree Decision Intervention Equipment Appendix Q: Example: Siderail and Alternative Alternative and Siderail Example: Q: Appendix APPENDICIES 122
❑ Crying ❑ Squatting legs ❑ Bouncing ❑ Wringing hands ❑ Clenching teeth ❑ Sweating to losecontrol? WARNING your signs, SIGNS:Pleasedescribe warning for Exampleother may people what notice you when begin ❑ Other: year: ❑ Particular of time day/❑ Particular night: of time teased❑ Being or picked on ❑ Darkness ❑ Feeling lonely privacy ❑ Lack of ❑ Not listened being to make (triggers) things you unsafe feel TRIGGERS: or upset? of What type ❑ Other: ❑ Injuring yourself ❑ Feeling unsafe ❑ Losing control PROBLEM BEHAVIORS: behaviours are problems of forWhat you? type Date:_ Patient Name:_ Personal De-escalationPlan Appendix R:Example:PersonalDe-escalationPlan Promoting Alternative Safety: Approaches to theUse Restraints of
Getting ahug❑ Getting breathing❑ Deep exercises ❑ Using cold face cloth ❑ Lying down ❑ Blanket wraps ❑ Taking a hotshower ❑ Hugging astuffed animal ❑ Coloring ❑ Pacing ❑ Reading abook ❑ Time out inyour room INTERVENTIONS: What are to thathelp some things calmyou down or keep you safe? ❑ Other: more❑ Eating inappropriately❑ Singing ❑ Not self takingcare of ______REGISTERED NURSES’ASSOCIATION OFONTARIO ______
______❑ Hurting myself ❑ Suicide attempts ❑ ❑ Cant sitstill ❑ Rocking ❑ Loud voice ❑ Clenching fists ❑ Breathing hard family______❑ Contact with isolated❑ Being ❑ Arguments ❑ People yelling ❑ Feeling pressured ❑ Running away ❑ Assaultive behaviour ❑ Going for awalk ❑ Having your handheld ❑ Using ice ❑ Ripping paper Running❑ cold water on hands ❑ Taking a cold shower ❑ Writing inajournal ❑ Exercising ❑ Talking peers with staff ❑ Sitting with ❑ Time outroom intheQuiet rude ❑ Being less ❑ Sleeping Isolating/ avoiding people
Drug or alcohol❑ Drug abuse ❑ Swearing ❑ Pacing alot ❑ Sleeping ❑ Red faced heart ❑ Racing stared❑ Being at ❑ Not having control ❑ Loud noises touched❑ Being ❑ Feeling suicidal ❑ Restraints/Seclusion ❑ Hurting others or things Hyper ❑ Speaking with therapist with ❑ Speaking ❑ Crying ❑ Punching apillow ❑ Screaming into pillow ❑ Humor ❑ Molding clay ❑ Callingfamily (who?) (who?) ❑ Callingafriend ❑ Talking staff with ❑ Watching TV ❑ Listening to music giddy loudly/ ❑ Laughing less ❑ Eating APPENDICIES 123
www.rnao.org Being read a story❑ Being read people other ❑ Being around staff❑ Female support special jobs ❑ Doing chores/ ❑ Humor ❑ Being ignored ____ Date:______Date:______BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting 85 E. Newton St. 85 E. Boston, Ma. 02118 Ma. Boston, Boston Medical Center Intensive Residential Treatment Program Treatment Intensive Residential ❑ Bouncing ball in QR staff❑ Male support the gym ❑ Using of tone ❑ Loud voice me people around many ❑ Having teasing ❑ Peers Snapping bubble wrap bubble ❑ Snapping Reprinted with Permission from The Massachusetts Department of Mental Health.
______Are you able to communicate to staff when you are having a hard time? If not, what can staff time? If help?? staff a hard having to to at these moments not, are do whenyou communicate to able you Are List any special plans that help you (things you have used in the past or would like to try). to like would used in the past or have (things you special plans that help you List any SPECIAL PLANS: ______help you calm down or stay safe? stay or down calm things not help you some that do are What ❑ Being alone when of feeling out strengths your control? are What STRENGTHS: ______good at? you what are have/ skills you do What SKILLS: ______OTHER: you? for work kinds ofWhat incentives ______Signature:______Patient a collage ❑ Making cards ❑ Playing games Video ❑ ❑ Other: to being listened ❑ Not ❑ Being disrespected ❑ Other: ______Staff Signature:______INTERVENTIONS (continue): INTERVENTIONS ❑ Drawing APPENDICIES 124
Reprinted withpermissionfromthe CenterofAddictionandMentalHealth Chart Tab: Assessments/ Plans F0458-20110419 Page 137 of146–SafetyPlan Women’s Program a controlleddocument. Any documentsappearing inpaperformarenotcontrolledandshouldalways bechecked againsttheelectronicversionpriortouse. organization notassociatedwithCAMH. NopartofthisdocumentmaybereproducedinanyformforpublicationwithoutthepermissionCAMH. This is DISCLAIMER: This materialhasbeenpreparedsolelyforinternaluseatCAMH. CAMHacceptsnoresponsibilityforuseofthismaterialbyanypersonor © Centrefor Addiction andMentalHealth(2008) ______Unit/Clinic/Service: (lastname, first name) Client/Patient Name:______Health Record #:______WOMEN’S PROGRAM SAFETY PLAN Program Appendix S:Example:SafetyPlanWomen’s Promoting Alternative Safety: Approaches to theUse Restraints of
Moderate Distress Severe Distress experience… Mild Distress When I REGISTERED NURSES’ASSOCIATION OFONTARIO sensations, thoughts, I havethesebody and/or feelings…
…So Idothistostay safe andfeelbetter Client/Patient Id Label Resources APPENDICIES 125
male staff female staff ❑ ❑ If at all possible Gender Concerns: I am aware that gender of staff is out of my control, but in an emergency I would prefer to speak with www.rnao.org (name of person) Being hungry Being tired Staff telling me to come back later made fun of Being called names, Being forced to do something Physical force Being isolated Being threatened Being anxious Being lonely space violated Personal Contact with person who upsets me Someone else lying about me Other ______Being touched Security in uniform Yelling Loud noises Being restrained ______My Triggers or Irritants: Triggers My ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Some things that make me angry, very me angry, Some things that make upset or cause me to go into crisis? ❑ ❑ ❑ ❑ ❑ ______yes no or other provider
Comments______I find it helpful to be touched appropriately when I am upset: ❑ ❑ I am aware that staff may prefer not to touch me. Physical Contact: BEST PRACTICE GUIDELINES •
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting (name of nurse) Going for a walk Drinking a beverage Eating certain food(s) artwork on a craft, Working Medication Reading religious/spiritual material Writing a letter Hugging a stuffed animal time in quiet/comfort room Voluntary Other ______Listening to music Reading a book myself in cozy blanket Wrapping Writing in a journal TV Watching with staff Talking with peers on the unit Talking Calling a friend or family member a shower or bath Take Exercise in the halls Pacing ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ These 5 activities that have helped me feel These 5 activities that have better when having a hard time. Comfort & Calming Measures: Comfort & Calming If I need or want medications to help calm me, these would be my preference: ______Medications: We Practice Trauma Informed Care Practice Trauma We ______
______
Other ______Exercise room Medications by mouth Emergency injection Comfort or quiet room Over eating / binging Being rude Other ______Clenching fist Swearing Not eating Clenching teeth Not taking care of myself Running Throwing objects Throwing Pacing Injuring self by Breathing hard Yelling Hurting others Sweating Crying
I developed this plan with my nurse I developed this plan with Seclusion & Restraints: I have experienced seclusion and/or ___yes ___no in the past. restraint ❑ ❑ ❑ ❑ ❑ In extreme emergencies seclusion and/ or restraint may be used as a last resort. I would find the In emergencies, following helpful in trying to prevent these from being used? ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ My Distress Signs & Signals: Signs My Distress things that My warning signals, or others might see when I am upset or losing control are: I like to be called: I like (Please do not label individuals personal copy) (Please do not label individuals TAG ID Reprinted with permission from St. Joseph’s Health Care Hamilton, Ontario Reprinted with permission from St. Joseph’s ❑ Health And Addiction Program Addiction And Health PLAN COMFORT Appendix T: Example: Comfort Plan Mental Plan Mental Comfort Example: T: Appendix APPENDICIES 126
20. 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. De-Escalation Tips Milwaukee, WI Provided bytheMilwaukee CountyMentalHealthDivision Interventions toAssistPatientCope Appendix U:Example:De-escalationTips and Promoting Alternative Safety: Approaches to theUse Restraints of
Ask thepatient’s to conversations permission share important other caretakers with for on-going discussion. Ask thepatienthow we else canhelp. Acknowledge thesituation for thepatient. thesignificance of Make andtalkover itokay to situation evenitmay theupsetting painful or try difficult. though very be Empower patients. step towards every Encourage them with calmingthemselves take. they shame, thepatientmay andembarrassment experiencing). be Respect to needs communicate indifferent ways (recognize differences language/ possible cultural aswellthefear, to talkto she/hewould couldyou willing, be try Ask (repeat the patientif requests, persistently, kindly). Allow for quiet time patents to respond –silent pausesare important. to them). help Reassure patientsandmaintainprofessional (tell patientsyou boundaries wantthem to safe, be thatyou are here avoidmight incident). arestraint Use approach. team or third-party down patientiswearing one staff, If have another take over talking (10minutes of apatientscreams andswears,If replyacalmnod, with okay, don’t react. Interventions Survey. Help patientsremember andusecoping identified mechanismson the they Patient Therapeutic reported appropriate.Offer if medication Let thepatent know you are there to. listen thepatientandhave with member rapport/relationship thathasagood himor her talkto thepatient. Find astaff Remember why thepatientisinhospital. were they before what happened or having somegotupset. difficulty Ask they patientsif are (assessfor problems). medical they hurt Ask patientsif Ask patientshow are they doing, or what’s going on. Talk andthinkcalm. Always identify yourself. REGISTERED NURSES’ASSOCIATION OFONTARIO
APPENDICIES 127
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Milwaukee, WI Milwaukee, Provided by the Milwaukee County Mental Health Division County Mental Health the Milwaukee Provided by
Listen to the patient’s concern even if you don’t understand. if even don’t you concern the patient’s to Listen sincerely. LISTEN sincerely. and is, what the problem you tell the patient to Ask Recognize and acknowledge the patient’s right to his/her feelings. right feelings. his/her to patient’s the and acknowledge Recognize Sit down if possible (maintain safety) and invite the patient to do likewise. if down likewise. Sit do the patient to possible (maintain safety) and invite Invite the patient to talk in a quiet room or area where there is less of an audience and less stimulation. of is less and less stimulation. there where an audience area or room in a quiet talk the patient to Invite Apologize if you did something that inadvertently upset the patent. Acknowledge feelings (not reasons) and state and state feelings (not reasons) Acknowledge upset the patent. ifApologize did something that inadvertently you that it was unintentional. Let the patient suggest alternatives and choices. and choices. alternatives the patient suggest Let To maintain patent and staff safety, have adequate personnel available for crisis situations. crisis for situations. available personnel adequate have and staff maintain patent safety, To Speak in a calm, even, non-threatening voice. Speak in simple, clear and concise language. language. and concise clear Speak in simple, voice. non-threatening even, Speak in a calm, Use non-threatening non-verbal gestures and stance. and stance. gestures non-verbal non-threatening Use Be aware of language, hearing, and cultural difference. and cultural hearing, difference. of language, Be aware Assure the patient that she/he is in a safe place and we are here to help. help. to here are and we place the patient that she/he is in a safe Assure Recognize your personal feelings about violence and punishment and how it affects you when a patient is violent. when a patient is violent. it affects you feelings personal and how about violence and punishment your Recognize Be aware of staff other interact with how Be aware angry positively and model interventions. their patents
j. l. i. f. c. e. a. g. b. k. d. h. n. m. Adapted from Dr. Gudeman’s interaction with patient on interventions interaction with patient with de-escalating patient 10/99 Gudeman’s Adapted from Dr. County Mental Health Division. Reprinted with permission from the Milwaukee Interventions to Assist Patient to Cope Patient to Assist Interventions
APPENDICIES 128
Appendix V: ResourceListofWebsites Promoting Alternative Safety: Approaches to theUse Restraints of
Assessment & Approaches Prevention, Alternative REGISTERED NURSES’ASSOCIATION OFONTARIO
• • • BC Mental Health and Addictions Services • •Protocols andtopics Consult -Physical GeriRN.org Restraints •Ideas for Implementation &Instructions With Mental Illness Seclusion inFacilities Individuals thatServe to Reduce theUse Restraint and of Comfort Rooms - A Preventative Tool Used • Measurement Injury: inBrain CentreCOMBI -The for Outcome Putting theP.I.E.C.E.S •Restraint/Seclusion Reduction Initiative (Adult/Child/Adolescent) Health (DMH) MentalMassachusetts of Department •Responsive Behaviours •Falls Prevention &Management Program (Examples) for: Policy &Procedures Training Packages for Seniors(OANHSS):and Services NonOntario Association of Profit Homes •Report Gentle Persuasive Approach Curriculum Personal (PASD) Devices Assistance Services Minimizing Restraining andtheUse of &training, ABS forms education Framework for assessment, Treatability (START) Short-Term Older Adults Dementia with thisissues: try ■
adult interview tools adult interview Age appropriate child, adolescent and Assessment of
Avoiding Restraints in Site TM Together testing. Risk and tools &
fort_rooms.pdf sources/publications/comfort_room/com- http://www.omh.state.ny.us/omhweb/re- http://tbims.org/combi/abs/index.html START.htm http://www.bcmhas.ca/Research/Research_ http://www.piecescanada.com/ ments/dmh/ http://www.mass.gov/eohhs/gov/depart- cfm?Section=Home http://www.oanhss.org/AM/Template. GPAProjectFinalReportJuly2005.pdf.pdf http://www.marep.uwaterloo.ca/research/ sultgerirn/ http://www.hartfordign.org/practice/con- Website Link APPENDICIES 129
www.rnao.org Website Website http://www.hc-sc.gc.ca http://www.sse.gov.on.ca/mohltc/ppao/en/ default.aspx http://www.mentalhealthrecovery.com/ aboutwrap.php - http://www.health.vic.gov.au/chiefpsychia trist/creatingsafety/index.htm - https://www.crisisprevention.com/Special ties http://www.fda.gov/default.htm http://store.samhsa.gov/product/SMA06- 4055 http://www.samhsa.gov/nctic/trauma.asp - http://www.mhrds.govt.nz/page/398-seclu sion-reduction-and-sensory-modulation http://www.tidal-model.com/ http://www.tmf.org/
BEST PRACTICE GUIDELINES •
of Waist
Seclusion Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting staff direct-care Beds: Hospital Adult Chemical, Site Site (WRAP®) Plan® Action information framework Physical, Prevention and elimination of seclusion Prevention and restraint Approach focused on consumer well-being consumer focused on Approach
■ ■ adult clients with clients adult serious illness mental strategies disturbances in emotional for training organizationInternational behaviour best safe on practices for prevention that focuses on management violentand non crisis intervention. On sensorymodulation information and help use of limit the to tools prevention and restraint. seclusion training for of Toolkit of Safety the Use on Information seclusion/ for On line training resources leadership trauma informed care, restraint, & organizational change. Restraints Patient and Torso Document Guidance Patient Entrapment Hazards, Side Rail Side Entrapment Hazards, Patient Hazards. and Other Reliability, Latching Services & Trauma Care Trauma-Informed
Psychiatric Patient Advocacy Office (PPAO) Office Advocacy Patient Psychiatric • Restraint, CPI: Crisis, Prevention, Intervention: Prevention, Crisis, CPI: • Canada: Health • Te Pou- The National Centre of Mental of Centre Mental The National Pou- Te Workforce: & Information Research, Health • Model Tidal • Philosophy, TMF Health Foundation: Medical Texas Care) Term (Long Quality Institute Recovery Wellness – Mary Ellen Copeland
• Substance Abuse and Mental Health Services Health and Mental Abuse Substance toolkit: (SAMHSA) Administration • FDA Food and Drug Administration and Drug Food FDA Bed Safety to • Guide definitions Restraint • Physical • Chief Psychiatrist, Victoria, Australia Victoria, Chief Psychiatrist, •
Restraints Management De-Escalation & Crisis & De-Escalation APPENDICIES 130
Promoting Alternative Safety: Approaches to theUse Restraints of
Legislation REGISTERED NURSES’ASSOCIATION OFONTARIO Other • Nursing Homes Advancing Excellence in Americas of •Ministry Canadian Mental Health Association
•Resident Restraint Free Care Flyer UniversityThe Iowa: of
• Patient’s Restraint Minimization Act (2001) Health andLong-Term of Ministry Care • Long-Term Care Homes Act, 2010 Health and Long-Term of Ministry Care •Standard on Restraints Nurses Ontario College of of • Hogg Foundation for Mental Health • Program Directors (NASMHD) National State MentalAssociation of Health Texas, USA Advances mental health wellnessfor Tracking theUse Restraints of ImprovementQuality Resources –Tools and the District of Columbia providing: of and theDistrict zation representing 50states, 4territories, Ontario, Canada) and Long Term Care [MOH-LTC] – Health of (Ministry hospital andfacilities regardingLegislation use in restraint Sections: 30-36 term care (MOH-LTC- Ontario, Canada) regardingLegislation inlong- restraints United States of ■ ■ ■ ■ ■ ■ A Risk Management Guide White Papers: Restraint andSeclusion: planning tool seclusion andrestraint the useof References andTraining presentations and Seclusion andRestraint Tools, Resource includes Debriefing Library Tools: Six Core Strategies Health agencies. Policy, publications andlinksto Mental Health Care Consent Act (1996) MentalOntario Health Act (1990) Health andLong Term Care:
- (USA)organi America Site Site © to reduce
english/elaws_statutes_07l08_e.htm#BK38 http://www.e-laws.gov.on.ca/html/statutes/ http://www.cno.org/ http://www.ontario.cmha.ca/legislation.asp care.pdf lications/info-connect/assets/restraint_free_ http://www.healthcare.uiowa.edu/igec/pub- http://www.hogg.utexas.edu/index.php cfm http://www.nasmhpd.org/publicationsOTA. http://www.nhqualitycampaign.org/ htm statutes/english/2001/elaws_src_s01016_e. http://www.e-laws.gov.on.ca/html/source/ Website Website APPENDICIES
131
If emergency chemical restraint (CR) is administered to a patient while in mechanical restraints or seclusion, record this in both Section I and Section II. Section and I Section both in this record seclusion, or restraints mechanical in while patient a to administered is (CR) restraint chemical emergency If 4)
3) The clock symbol indicates the nurse must provide mandatory care and initial. and care mandatory provide must nurse the indicates symbol clock The 3)
b) On the seclusion form each block represents a 15 minute timeframe. minute 15 a represents block each form seclusion the On b)
a) On the mechanical restraint form each block represents a 30 minute timeframe. minute 30 a represents block each form restraint mechanical the On a)
2) Time frames for entry on each form: form: each on entry for frames Time 2) 1) Use either of these forms for ongoing monitoring and care provided during mechanical restraint or seclusion. or restraint mechanical during provided care and monitoring ongoing for forms these of either Use 1)
www.rnao.org
Restraints’ Record-Mechanical ‘Assessment a) either Choose II: Section Seclusion’ Record- ‘Assessment b) or
5) Any additions to the Communication section should be initialed with date and time of entry. entry. of time and date with initialed be should section Communication the to additions Any 5)
If any communication (as specified) is done within a 12 hour time frame after Section 1 is completed, it must be added to the Communication section. Communication the to added be must it completed, is 1 Section after frame time hour 12 a within done is specified) (as communication any If 4)
3) The nurse also initials and dates any documentation done in the Communication section (on the lower right). lower the (on section Communication the in done documentation any dates and initials also nurse The 3)
2) The nurse completes this section and signs the form at the bottom of the page. the of bottom the at form the signs and section this completes nurse The 2)
1) Complete when initiating or re-ordering chemical restraint, seclusion, and/or mechanical restraint. mechanical and/or seclusion, restraint, chemical re-ordering or initiating when Complete 1)
Assessment Re-Order or Assessment Initiation I: Section
BEST PRACTICE GUIDELINES •
The nurse must complete Sections I and II of the 12-Hour Emergency Use of Chemical Restraint, Seclusion & Mechanical Restraint Record. Restraint Mechanical & Seclusion Restraint, Chemical of Use Emergency 12-Hour the of II and I Sections complete must nurse The 6)
The restrained client/patient must be asked if s/he would like a PPAO advocate contacted. Once consent is obtained call PPAO @ 416-535-8501, x 3099. x 416-535-8501, @ PPAO call obtained is consent Once contacted. advocate PPAO a like would s/he if asked be must client/patient restrained The 5)
If needed, mechanical restraint or seclusion must be reordered every 12 hours following face-to-face assessment by a physician. a by assessment face-to-face following hours 12 every reordered be must seclusion or restraint mechanical needed, If 4) 3) An order for mechanical restraint or seclusion must not exceed 12 hours. 12 exceed not must seclusion or restraint mechanical for order An 3)
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting b) A physician must assess the client/patient within 2 hours after the use of restraint and co-sign the order. the co-sign and restraint of use the after hours 2 within client/patient the assess must physician A b)
a) An RN obtains a telephone order immediately following the use of emergency mechanical restraint or seclusion. or restraint mechanical emergency of use the following immediately order telephone a obtains RN An a)
2) If a physician is not available in an emergency: an in available not is physician a If 2)
1) A physician’s order is needed for emergency restraint. emergency for needed is order physician’s A 1)
Requirements for Emergency Seclusion and Restraint Usage Restraint and Seclusion Emergency for Requirements
Emergency Use of Chemical Restraint, Seclusion and Mechanical Restraint Policy Restraint Mechanical and Seclusion Restraint, Chemical of Use Emergency policy: CAMH following the consult Please
restraints, chemical emergency when Complete used are restraints mechanical and/or seclusion,
SECLUSION & MECHANICAL RESTRAINT RECORD RESTRAINT MECHANICAL & SECLUSION
RESTRAINT, CHEMICAL OF USE EMERGENCY -HOUR 12
Seclusion & Mechanical Restraint Record Restraint Mechanical & Seclusion
Restraint, Chemical of Use Emergency 12-Hour Record:
Documentation and Observation Example: W: Appendix APPENDICIES 132
Promoting Alternative Safety: Approaches to theUse Restraints of 5) All status changes and/or significant findings require a corresponding progress note. Place an asterisk (*) beside any item for which you have written a progress note.
REGISTERED NURSES’ASSOCIATION OFONTARIO 6) The ‘assigned nurse’ is the nurse assigned to care for the patient or the covering nurse (e.g. covering breaks). The assigned nurse is accountable for reviewing and ensuring that standards of care are met. This includes assessments, monitoring, the use of alternatives and other policy requirements. S/ He continues to have this accountability even if some aspects of care are assigned to other team members (who initial in boxes to indicate care and/or observations). The assigned nurse initials a minimum of once every 3 hours in the box to indicate accountability. 7) Notes: a) Typically, after two hours, a release trial (RT) should be considered successful and seclusion/mechanical restraint should be discontinued. b) Enter initials for face to face continuous observation to indicate ongoing monitoring. You must initial a minimum of once every hour.
Electronic Tools to be used in addition to Progress Notes for Emergency Use of Restraints: All chemical restraint, seclusion, and mechanical restraint episodes must be entered in the Restraint Events Tool on TREAT on initiation and when discontinued.
Forms to Be Used: (Effective June 2009/ Updated January 2010) Physicians’ Orders Form; Medication Administration Record; 12-Hour Emergency Use of Chemical Restraint, Seclusion & Mechanical Restraint Record; Physical Monitoring Vital Signs & Intake/Output.
© Centre for Addiction and Mental Health (2009) Adapted from The Ottawa Hospital (2003) and Trillium Health Centre (2006) Instruction page - Restraint Record DISCLAIMER: This material has been prepared solely for internal use at CAMH. CAMH accepts no responsibility for use of this F0475-20111110 material by any person or organization not associated with CAMH. No part of this document may be reproduced in any form This page not to be filed in client/ for publication without the permission of CAMH. This is a controlled document. Any documents appearing in paper form are patient health record. not controlled and should always be checked against the electronic version prior to use. APPENDICIES 133
(dd/mm/yyyy – 24 hr) 24 – (dd/mm/yyyy
Date/Time Given Date/Time
Restraint Events Tool Events Restraint
______
TREAT on Entry ❑ www.rnao.org
(last name, first name) name) first name, (last
difficulties required) (dd/mm/yyyy – 24 hr) 24 – (dd/mm/yyyy
Physician Name Physician
visual and hearing PRN Medication (consent (consent Medication PRN ______
______
______cognitive communication, cognitive Date/Time Initiated Date/Time
CR Episode # 3 (TREAT) 3 # Episode CR ❑
______Assess for linguistic and and linguistic for Assess ______# of points of # ❑
Other______Spiritual Care Spiritual Describe: ______Describe: (MR) Restraint (dd/mm/yyyy – 24 hr) 24 – (dd/mm/yyyy ❑ ❑
Date/Time Given Date/Time Separate from situation from Separate Peer Support Worker Support Peer Toward Other(s)* Toward Mechanical ❑ ❑ ❑ ❑
______Support/reassurance Support/reassurance involvement ______Seclusion (SR) Seclusion ❑ ❑
BEST PRACTICE GUIDELINES • Pain management Pain OT/PT/SW/RT/BT ______
Chemical – stat medication stat – Chemical (last name, first name) name) first name, (last ❑ ❑ ❑
Physician Name Physician Music Family/friends ______(last name, first name) first name, (last ❑ ❑
______angry, lonely, tired) lonely, angry, Exercise Describe: ______Describe: ______❑
CR Episode # 2 (TREAT) 2 # Episode CR (hungry, HALT Ask 1:1 Engagement 1:1 Toward Self * * Self Toward Physician Name Physician ❑ ❑ ❑ ❑
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting SERIOUS BODILY HARM BODILY SERIOUS
ORDER
ALTERNATIVES & INTERVENTIONS ATTEMPTED INTERVENTIONS & ALTERNATIVES SUBSEQUENT OF RISK IMMINENT AND
PHYSICIAN’S
BEHAVIOUR(S) OBSERVED BEHAVIOUR(S)
Check all boxes that apply. Place an asterisk (*) for items that have a corresponding progress note. progress corresponding a have that items for (*) asterisk an Place apply. that boxes all Check
SECTION I: INITIATION ASSESSMENT OR RE-ORDER ASSESSMENT ASSESSMENT RE-ORDER OR ASSESSMENT INITIATION I: SECTION
(last name, first name) first name, (last
______Unit/Clinic/Service: ______#: Record Health ______Name: Client/Patient
12 -HOUR EMERGENCY USE OF CHEMICAL RESTRAINT, SECLUSION & MECHANICAL RESTRAINT RECORD RESTRAINT MECHANICAL & SECLUSION RESTRAINT, CHEMICAL OF USE EMERGENCY -HOUR 12
Id Label Id
Client/Patient
APPENDICIES 134
Promoting Alternative Safety: Approaches to theUse Restraints of
HEALTH STATUS AT INITIATION / COMMUNICATION *document APPLICATION / RE-ORDER communication details in Progress Notes REGISTERED NURSES’ASSOCIATION OFONTARIO Significant medical problems, physical disabilities, pain ❑ Family/SDM/Other notified with client’s consent* ______(Date/Time/Initial)______Difficulty breathing (Y*/N) ____ ❑ PPAO notified with client’s consent* Breathing complaint (Y*/N) ____ (Date/Time/Initial) ______Observable skin color change (Y*/N) ____ ❑ Client declined PPAO notification Skin condition (e.g., warm, dry, clammy) ____ (Date/Time/Initial) ______Injury due to CR/SR/MR (Y*/N) ____ ❑ eIPCC updated Bleeding (Y*/N) ____ Cuts (Y*/N) ____ (Date/Time /Initial) ______Scratches (Y*/N) ____ Bruises (Y*/N) ____ Comments (include date/time initial): Other (Y*/N) ______Describe emotional state:______
Trauma Considerations:
Nurse Completeing Section I at initiation (others to intiate/date data entered after initiation and print name at end of Section II)
______Date: ______Signature Print Name and Credentials (dd/mm/yy)
Page 1 of 3 Restraint Record F0475-20111110 Chart Tab: Assessments/Plans © 2009 CAMH, *see disclaimer on instruction page APPENDICIES 135
Assigned Nurse Initial Nurse Assigned Observing Staff Initial Staff Observing
www.rnao.org
Food/fluids offered /mouth care q2hrs care /mouth offered Food/fluids
Toileting q2hr /PRN q2hr Toileting
Circulation/skin q30min q30min Circulation/skin
Vital signs q1hr signs Vital
Ambulation q8hr Ambulation
Limbs release/ reposition/ROM q1hr reposition/ROM release/ Limbs
BEST PRACTICE GUIDELINES • F-F monitoring in progress in monitoring F-F
Alternatives/ interventions Alternatives/ B.
Behaviours Observed Behaviours A. 30 min. intervals min. 30
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
TIME
= face-to-face continuous observation. continuous face-to-face = F-F initials; for need and care mandatory of reminder =
(dd/mm/yy) Use an asterisk (*) to flag all status changes/significant findings and to indicate corresponding narrative in progress notes. progress in narrative corresponding indicate to and findings changes/significant status all flag to (*) asterisk an Use
______Date: Initial in appropriate boxes to indicate “in progress” or “completed”. Each box represents approximately 30 minutes. 30 approximately represents box Each “completed”. or progress” “in indicate to boxes appropriate in Initial
SECTION II: Assessment Record - Mechanics restraints Mechanics - Record Assessment II: SECTION
(last name, first name) first name, (last
______#: Record Health ______Name: Client/Patient
12 -HOUR EMERGENCY USE OF CHEMICAL RESTRAINT, SECLUSION & MECHANICAL RESTRAINT RECORD RESTRAINT MECHANICAL & SECLUSION RESTRAINT, CHEMICAL OF USE EMERGENCY -HOUR 12
Id Label Id
Client/Patient
APPENDICIES 136
Promoting Alternative Safety: Approaches to theUse Restraints of
A. Behaviours Observed B. Alternatives or Interventions Implemented (record 1 to 3 prominent behaviours above) (record 1 to 3 primary alternatives or interventions above) REGISTERED NURSES’ASSOCIATION OFONTARIO Restraint Interventions: 1. Agitation a. 1:1 Engagement 2. Combative b. Attempted to d/c restraint* 3. Disorientation/confusion c. Breathing exercises 4. Unable to follow instructions d. De-escalation techniques 5. Asleep e. Diversional activities 6. Quiet/cooperative f. Family/friends present 7. Other*______g. Medication review h. Orientation x 3 i. OT/PT/BT/SW j. Pain management k. PRN Rx (with consent) l. Sensory interventions m. Support/reassurance n. Other______o. Adjust MR straps* p. Decrease points* (min 3 points) q. Increase points* r. Chemical restraint* (pg 1) s. Release trial t. Discontinue restraint* (TREAT)
Print Name/Designation Initials Print Name/Designation Initials Print Name/Designation Initials
Page 2 of 3 Restraint Record F0475-20111110 Chart Tab: Assessments/Plans © 2009 CAMH, *see disclaimer on instruction page APPENDICIES
137
Assigned Staff Assigned Initials
Observation Staff Observation
Toileting q2h /PRN q2h Toileting
Foods / Fluids q2h Fluids / Foods
www.rnao.org Alternatives/ interventions Alternatives/ B.
Behaviours Observed Behaviours A.
TIME
Assigned Staff Assigned Initials
Observation Staff Observation
Toileting q2h /PRN q2h Toileting
BEST PRACTICE GUIDELINES •
Foods / Fluids q2h Fluids / Foods
Alternatives/ interventions Alternatives/ B.
Behaviours Observed Behaviours A.
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
(15 min. intervals) min. (15
TIME
(dd/mm/yy) = reminder of mandatory care and need for initials; for need and care mandatory of reminder = minutes 15 approximately represents box Each
______Date: Use an asterisk (*) to flag all status changes/significant findings and to indicate corresponding narrative in progress notes. progress in narrative corresponding indicate to and findings changes/significant status all flag to (*) asterisk an Use
Initial in appropriate boxes to indicate “in progress” or “completed”. “completed”. or progress” “in indicate to boxes appropriate in Initial
SECTION II: Assessment Record - Seclusion - Record Assessment II: SECTION
(last name, first name) first name, (last
______#: Record Health ______Name: Client/Patient
12 -HOUR EMERGENCY USE OF CHEMICAL RESTRAINT, SECLUSION & MECHANICAL RESTRAINT RECORD RESTRAINT MECHANICAL & SECLUSION RESTRAINT, CHEMICAL OF USE EMERGENCY -HOUR 12
Id Label Id
Client/Patient
APPENDICIES 138
Promoting Alternative Safety: Approaches to theUse Restraints of
A. Behaviours Observed B. Alternatives or Interventions Implemented (record 1 to 3 prominent behaviours above) (record 1 to 3 primary alternatives or interventions above) REGISTERED NURSES’ASSOCIATION OFONTARIO 1. Agitation Restraint Interventions: 2. Combative a. 1:1 Engagement 3. Disorientation/confusion b. Attempted to d/c restraint* 4. Unable to follow instructions c. Breathing exercises 5. Asleep d. De-escalation techniques 6. Quiet/cooperative e. Diversional activities 7. Other*______f. Family/friends present g. Medication review h. Orientation x 3 i. OT/PT/BT/SW j. Pain management k. PRN Rx (with consent) l. Sensory interventions m. Support/reassurance n. Other______o. Adjust MR straps* p. Decrease points* (min 3 points) q. Increase points* r. Chemical restraint* (pg 1) s. Release trial t. Discontinue restraint* (TREAT)
Print Name/Designation Initials Print Name/Designation Initials Print Name/Designation Initials
All reproductions contain the notice: “The copyright for this document/form belong to the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario
Page 3 of 3 Restraint Record F0475-20111110 Chart Tab: Assessments/Plans © 2009 CAMH, *see disclaimer on instruction page APPENDICIES 139
www.rnao.org BEST PRACTICE GUIDELINES • Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting one) (circle No Yes one) (circle No Yes one) (circle No Yes
Were you treated with treated respect? you Were privacy maintained? your Was the intervention? regarding was the most helpful What was the least helpful? What you? for peers) easier your group, the unit, to re-entry made return (your have we could How Is there anything staff could have done to assist you with regaining control prior to going into R/S? into going prior to with control regaining assist you to done staff anything have there could Is in need of were beginning or special feel assistance cues that you to others give to attempting you Were of control”? “out restraints? and/or staff be in seclusion needed to why that you determined know Do you one) (circle No Yes of was the length time estimation, spent R/S appropriate? in your In one) (circle No Yes the unit sooner? to returned have could think you Do you you? that time did pass for How ____ hours. for in restraint/ seclusion were You you? to that was provided the care feel regarding you do How needs met? your Were
Used with permission, Northwestern Memorial ® Hospital Used with permission, 7. 8. 1. 2. 3. 4. 5. 6. Following Restraint/ Seclusion Following Restraint/ be(to completed within seclusion restraint/ assigned (r/s) by 4-24 hours after release from RN) Patient Debriefing Tool Patient Debriefing Seclusion of Psychiatry Provided by Stone Institute Hospital Northwestern Memorial IL Chicago, Patient Debriefing Tool following Restraint/ following Tool Debriefing Patient Form: Debriefing Example: X: Appendix APPENDICIES 140
Data Collectors: Program Adherence for theLeastRestraintLastResort(LRLR) Program: Unit-basedDataCollectionForm Form: LeastRestraintLastResort(LRLR) Appendix Y: Example:OrganizationAudit Promoting Alternative Safety: Approaches to theUse Restraints of
Physical/Environmental Restraints - for theLRLRprogram thecriteria Complete meet who inpatients on all 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. INDICATORS: Unique tion form ortion form inter-professional notes) behaviour (LRLRNursing documenta- the causeof addressed theunderlying Are interventions documented that Q15min, q1h, q2h? ments clearly outlined inthechart? Are monitoring theinitial require- interventions attempted? Is therelease q2hnoted with noted? 12hours within of notification Is or therethepatient consent of necessary? q24hoursrestraint if Is there anorder for aphysical LRLR form) (Physician’sand duration? Order or Is theordertype specific to restraint (Physician’s Order form) Is there anorder documented? a restraint? todocumented implementing prior Are alternatives /interventions Form (or unit-specific)? on LRLRNursing Documentation Is thepatientbehaviourdocumented REGISTERED NURSES’ASSOCIATION OFONTARIO ______Unit: thefamily/SDM 1 SampleSize: 2 3 4 5 Total beds/unit: 6 7 8 9 Date: 10 + Totals - + & - +=% Page 1of5 Results APPENDICIES 141
Page 2 of 5 Page Patient 5 Patient www.rnao.org Patient 4 Patient Patient 3 Patient Patient 3 Patient BEST PRACTICE GUIDELINES • (if no, go to question 5) (if no, Patient 1 Patient Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting Physical/Environmental Restraint
of discussion documented? Is consent refused) or accepted F*) (either or N, (Y, *F= patients formed MHA under Restraint type ordered- Chemical (C), Physical (P), (P), Physical (C), type Chemical Restraint ordered- 3a) and go to “no” if N/A or answered Both you (B), “Section C” to restraint use, is there evidence of is there a new restraint use, continued For N/A) or N, (Y, hrs. q24 order restraint order? chemical &/or a physical there Is (Y N) or Has the patient been screened for falls (Fall Risk falls Risk (Fall for the patient been screened Has completed-ICU/HI)? protocol or unit specific Profile (Y N) or Are “Individualized Fall Interventions” documented? documented? Interventions” Fall “Individualized Are (Y N) or Alternatives/ Interventions attempted & documented & documented attempted Interventions Alternatives/ (select C#) Code 3. COMPLETE FOR ALL PATIENTS: Least Restraint Assessment Least Restraint ALL PATIENTS: FOR COMPLETE 3. a) b) with Review for Patients Chart 4. b) Are Universal Fall Interventions documented? (Y documented? N) or Interventions Fall Universal Are b) c) I. COMPLETE FOR ALL PATIENTS: Demographics ALL PATIENTS: COMPLETE FOR I. a) Is there an order Physician order form? (Y N) order or Physician an order there a) Is (Y N) or described the LRLR Record? on the order b) Is (Y N) a PRN order? or there Was c) d) (select B#) Code & behaviour documented Assessment e) f) restraintdevice?to specific g) Order or N) (Y (Y implemented? N) or the order h) Is restraint device of (select D #) Code physical i) Type (Y N) or as per protocol? monitored j) Patient k) a) Patient room number room a) Patient Age b) (F) Female (M) or Male indicate c) Gender: A #) d) Service Code (use key Assessment Risk Fall PATIENTS: ALL COMPLETE FOR 2. a) Section B Section A Section ______2. ______Data Collectors: ______Census: Unit ______Unit: ❑ TRC HI ❑; General ❑; ❑; Civic Y ❑ N ❑ Program/Portfolio:______Unit Locked APPENDICIES 142
Comments Promoting Alternative Safety: Approaches to theUse Restraints of
d) c) Isor N) there (Y therestraint? proper application of yes, (Code D#) b) If identify type a) Section C: Walk Through: Observationof All Patients asperCodeD&Universal Fall RiskInterventionsSheet Is theorder or N) implemented? (Y f) e) d) Assessment &behaviourdocumented Code B#) (select 5. ChartReviewforPatients with c) b) Was thechemical ordered restraint or N) PRN?(Y a) Type Code chemical E#) (select restraint of (select Code C#) (select Alternatives/ Interventions attempted &documented under MHA *F= patientsformed (either accepted or refused) consentIs documented? discussion of (Y, N, or F*) (Y or N)if (Y Physical/ environmental on observed patient restraint place? (Y or N) place? (Y Are 3or more Universal Fall Risk Interventions in REGISTERED NURSES’ASSOCIATION OFONTARIO no, end here. Chemical Restraint (ifno, gotoSection C) Page 3of5 APPENDICIES 143
Page 4 of 5 Page 1. 2. 3. 4. 5. 6. 7. 8. 9. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 10. 11. 12. 13. 14. 15. 16. Numeric Code Numeric www.rnao.org Service Code LCM: Ward A Ward LCM: B Ward NMS: C Ward NCS: ENT, OPH, EST, DEN, URO PLA, THO TRA VAS PAL ER RES ACM ACS, BMT CAR, CSG (HI only), (HI only), CSG CAR, care CCH is coronary DER FAM GSU GSC, GSB, GSA, GER GYN HEM ICU NRL NRS NLB, NLA, RAD ONC, G/O, ORT PER PSY REH ME, MEA, MEB, MEC, MEC, MEB, MEA, ME, GI NEP, MEO, BEST PRACTICE GUIDELINES •
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting grouped as Service New Streams: New
NCS: Neurocognitive stream previously grouped as Neurocognitive NCS: Brain Injury) & BRS (Aquired “ABI Service)(Behavioural Rehab NMS: Neuromuscular Stream previously grouped as Neuromuscular NMS: & STR (Stroke)” “NSP (Neurospinal) “MRS (Musculoskeletal) & RSP (Respiratory)” “MRS (Musculoskeletal) LCM: Locomotor Stream previously Locomotor LCM: • • • Plastic Anaesthesia, Dental, Otolaryngolgy, Surgery (Ophthalmology, Urology) Surgery, Thoracic Surgery Trauma Vascular Care Palliative only) (Queensway-Carleton beds- with awaiting service no admission in emergency yet codes Patients Respirology APU ALC/ Other -gyne Bone Marrow Transplant Bone Marrow Cardiac Care (Cardiology, Cardiac Surgery, and Coronary Care) and Coronary Surgery, Cardiac (Cardiology, Care Cardiac Dermatology & General Practice Medicine Family General Surgery Geriatrics/GAU Gynaecology/obstetrics Haematology – critical care Care Intensive Gastroenterology, Allergy, (Metabolism, General Medicine Neurosciences and Radiation Oncology) Oncology, Medical Oncology (Gyn.-Oncology, Orthopaedics (antepartum) Perinatology Psychiatry (Civic) Rehab Short Term TRC Rehab: Term Long
Rheumatology, Nephrology) Rheumatology, KEY CODES Code A: Service Code Code A: KEY CODES APPENDICIES 144
to theOttawaHospital,DepartmentofNursingProfessionalPractice forpermission” All requestsreceivedbyRNAOforpermissiontouseoradapttheAppendix: “TheOttawaHospitalOrganizationalAuditForm”mustbedirected KEY CODES Promoting Alternative Safety: Approaches to theUse Restraints of
(May choose more thanone) Code B: Reasonforrestraint use: (May chose more thanone) Code D: Type ofPhysicalRestraint: 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. 7. 6. 5. 4. 3. 2. 1. 9. 8. No reason given Family request incomments* specify Other: Pulling out tubes/drains Combative Memory deficit Movement disorder confusionDisorientation/ Unable to follow instructions Impaired mobility Agitation Other: specify incomments* specify Other: 4 or 5pointrestraint ankle) Limb holder (wrist/ Pelvic support Soft waist belts Wheel chair belts Mitts Geri chair with laptray chair with Geri intent to with restrain rails Bed (Include homemade, sheets, etc) REGISTERED NURSES’ASSOCIATION OFONTARIO Code E: list: see Type Chemical Restraint of (May choose more thanone) Code C: Alternatives &Interventionsattempted: 20. 19. 18. 17. 16. 15. 10. 14 13 12 11 2. 1. 1. 9. 8. 7. 6. 5. 4. 3. 2. Antipsychotic (Haldol, mellaril, respiradone, etc.) (ie Anxiolytic Ativan, valium, Lorazepam, etc) No alternatives documented device,safe wandering etc.) Alternatives (e.g. splint, arm Poseyfloor mat, alarm,bed or De-escalating incomments* specify Other: Family request Nourishment Positioning Increase / mobility ADLs Room change Medication review Pain management reassuranceOrientation/ Sitter atbedside Explain procedure/ treatment aids Sensory Diversional activities Family atbedside (e.g., q1hor q2h) Observation Regular toileting Occupational /Physio Therapist Page 5of APPENDICIES 145
www.rnao.org
BEST PRACTICE GUIDELINES •
Promoting Safety: Alternative Approaches to the Use of Restraints the Use to Approaches Safety: Alternative Promoting
Notes Notes Notes Clinical Best Practice Guidelines Promoting Safety: Alternative Approaches to the Use of Restraints FEBRUARY 2012 Clinical Best Practice Guidelines
FEBRUARY 2012
Promoting Safety: Alternative Approaches to the Use of Restraints
ISBN 978-1-926944-46-3