On the Use of Physical Restraints in Hospital Settings

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Table of Contents

Stakeholders
Implementation Strategy
Background
Implementation
References

Stakeholders

The present implementation plan is concerned with the main stakeholders of the proposed solution, who are the nursing staff from various departments, and administrative and managerial staff. The departments involved are psychiatric, geriatric, and shift charge nurses. The administrative departments involved are nursing shift supervisors, head nurses, and unit supervisors. During the implementation, the list of the stakeholders can be accordingly revised and updated.

Implementation Strategy

The main implantation strategy chosen for the proposed solution is education. Such strategy will be implemented according to the following outline:

Preparation
- Identifying training needs
- Setting scope and criteria measures
- Identifying responsibilities and setting deadlines
- Drawing project plan
Implementation
- Developing assessment tools
- Allocating resources
- Following learning schedules of the training programs
- Developing a unified document of the learning outcomes of training objectives
- Distribution of documents through printed brochures.
Evaluation
- Individual assessment of nurses through surveys and questionnaires
- Evaluation of established patient-related metrics
Monitoring
- Regular inspection of the use of physical restraints
- Comparison of results
- Revision of training needs, if necessary

Background

Approval

The approval of the proposed solution will be obtained by the top management of the hospital in which the intervention will be implemented, the head nurses of psychological and geriatrics units, medical wards, and ICUs. Accordingly, informed consent will be obtained from the participants of the study.

Problem Description

The main problem identified in the present document is related to the excessive use of physical restraints in hospital settings. The justification of such use can be explained through the use in cases of agitated patients and geriatric patients. The use of physical restraints is still used despite the debate that goes on the ethical and medical debates on such an approach.

In that regard, the use of physical restraints are justified by nurses when it is “the only possible course of action open to caregivers, and holding or tying a patient down is a better alternative than allowing patients to injure themselves or compromise others’ safety” (Mohr, 2010).

The problem is in the use of physical restraints by many nurses as the easiest path for action, without considering alternatives to such intervention. Other reasons for which nurses might apply physical restraints without considering other options results from pressure from family members of the patient (Hall & Marr, 1993).

The negative effects of implementing physical restraints can be seen through reported deleterious effects such as death skin abrasion, psychological distress, distress, decreased socialization, and death from strangulation. Higher morbidity and mortality rates were described in Cubbin (2000) as a characteristic of excessively restrained patients.

Proposed Solution

The solution proposed for the aforementioned problem is in developing a training program that will guide nurses in making decisions on the appropriateness of using physical restraints in each case. Training will be supported through additional education materials in the form of printed brochures.

The main aim of the training program will be to reduce the cases of physical restraints to the absolute minimum. Nurses will be educated on the existent alternatives for physical restraints, and accordingly, they will be trained to develop the skills needed for alternatives. The education will be concerned with the nursing staff who deals with cases in which physical restraints are applied, psychiatric and geriatrics departments.

Pre-program assessment will be conducted for nurses who will participate, and accordingly, an evaluation will be conducted after the program ends. Monitoring will be established through periodic assessments that will measure the changes in the use of the practice of physical restraints.

Rationale

The main rationale for selecting the proposed solution can be seen through the negative outcomes that result from the use of excessive physical restraints. From an ethical standpoint, the use of physical restraints can be seen as a violation of one’s respect for autonomy (Mohr, 2010).

The use of restraints is incompatible with such right, the violation of which puts pressure on patients. The reduction of such practice, in that regard, can be justified. The ethical impact of such practice can extend to caregivers as well (Liukkonen & Laitinen, 1994, p. 1082), where pressure might result from acknowledging the risks involved in patients’ behavior.

Additionally, it can be stated one of the reasons excessive physical restraints are applied is the misconceptions held by many nurses on the proper use of such practice (Huang, Chuang, & Chiang, 2009, p. 241). Being the key decision-maker on whether to implement a restraint or not, their education is an important aspect.

Support

The choice of education as a solution can be supported through the results of a study that was held on nurses’ practices for agitated patients, documented in Ozdemir and Karabult (2009). The result of the study found that the training program provided nurses “the knowledge and skills needed to evaluate and to manage the causes of agitation” (p. 119).

Additionally, a short-term in-service education program was conducted to improve nurses’ knowledge, attitudes, and self-reported practices on physical restraints use. An assessment of the results of the program indicated in Huang, Chuang, and Chiang (2009), showed significant improvements in knowledge, attitudes, and self-reported practices (Huang, et al., 2009, p. 241).

In that regard, it can be stated that the use of training and education program is supported to be useful for the specific case of increasing the knowledge and the awareness of practicing nurses on the use of physical restraints. The theoretical framework that can partially be used to support educating nurses is Dorothea Orem’s Self-Care Theory.

The theory simplifies the decision-making process for determining whether an intervention is required or not, stating that “… when individuals can care for themselves, they do…when they are not in a position to do this the nurse interacts to care for the individual” (Carey, 2000, p. 110).

Nevertheless, such a theory is only partially helpful in this case as it does not indicate which solution to choose. There are various alternatives to physical restraints, the knowledge about which, as indicated in the findings of previous research, will reduce the cases for using physical restraints by nurses (Huang, et al., 2009; Liukkonen & Laitinen, 1994; Özdemir & Karabulut, 2009).

Implementation

Logistics

The implementation of the training session will be assigned to an expert working group that will be formed with the help of the HR manager department in the hospital and invited restraint nursing experts (Huang, et al., 2009). The group led by the top management of the company will establish the main objectives of the training program, concerning best practices and literature.

Similarly, the number of training sessions will be determined along with the metrics to measure the success of the intervention. The HR department along with the staff managers from various departments will identify the participants of the program and work on a schedule for the training sessions so that the normal workflow of the organization is not interrupted. The group will appoint change agents that will guide the training sessions in the workplace.

An assessment will be conducted before the implementation of the program to measure the results. The length of the program will be determined through a review of literature, best practices, and the number of participants. Such length largely varies, between four and eight hours, and 23 formal classroom in-service programs.

The length of the program will be determined according to the load of the hospital, and according to previous research. After the training program, the brochure will be distributed with the main learning outcomes of the program, in which the main guidelines will print for nurses.

Evaluating the effectiveness of the program, such assessment tools can be used as questionnaires testing the knowledge of the participants, e.g. Nurse Practice Form, developed in Özdemir and Karabulut (2009). A period of 4 months will be established to repeat the assessment and review the outcomes of the program.

Resources

The main resources used in the hospital will include the costs for printing educational materials and equipment, as well as the costs associated with inviting expert nurses for leading the intervention group in the program. Other resources required for the program include printing brochures, and questionnaires, as well as the assessment that will be conducted for monitoring change. Statistical software will be used to analyze the results of the questionnaires.

References

Carey, L. (2000). Practice nursing. Philadelphia, PA: Elsevier Health Sciences.

Cubbin, J. K. (2000). Mechanical restraints: To use or not to use? Nursing Times, 66, 752.

Hall, M., & Marr, J. (1993). Patient restraint: a new philosophy. Leadership in Health Services, 2(4), 22-26.

Huang, H.-T., Chuang, Y.-H., & Chiang, K.-F. (2009). Nurses’ Physical Restraint Knowledge, Attitudes, and Practices: The Effectiveness of an In-Service Education Program. [Article]. Journal of Nursing Research (Taiwan Nurses Association), 17(4), 241-248.

Liukkonen, A., & Laitinen, P. (1994). Reasons for uses of physical restraint and alternatives to them in geriatric nursing: a questionnaire study among nursing staff. Journal of Advanced Nursing, 19(6), 1082-1087.

Mohr, W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24(1), 3-14. Web.

Özdemir, L., & Karabulut, E. (2009). Nurse education regarding agitated patients and its effects on clinical practice. [Article]. Contemporary Nurse: A Journal for the Australian Nursing Profession, 34(1), 119-128.

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