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Evaluating the Application of Knowledge: The Use of Restraints
Journal of Pediatric Nursing (2011) 26, 259–261
CLINICAL PRACTICE COLUMN Column Editor: Mary D. Gordon, PhD, RN, CNS-BC
Mary D. Gordon, PhD, RN, CNS-BC
Evaluating the Application of Knowledge: The Use of Restraints Lorna Frank MSN, RN-BC ⁎, Anne Longo PhD(c), MBA, RN-BC, NEA-BC, Barbara Hensley MSN, CPNP, RN-BC Cincinnati Children's Hospital Medical Center
THE USE OF restraints has become a high-priority issue to assure appropriateness of treatment and protect patient rights (Centers for Medicare and Medicaid Services [CMS], 2006). The term restraint is defined in the literature as referring to the physical restriction of movement that may involve restraining all limbs (Jacobi, Fraser, and Coursin, 2002; Mohr, 2010). Restraints may be an intervention for children and adolescents to reduce the risk of treatment interference or to prevent abrupt discontinuation of medical devices used for diagnosis or monitoring. Restraints are also used to prevent patients from harming themselves or others (American Academy of Pediatrics, 1997). The Centers for Medicare and Medicaid's requires that all clinical staff with direct patient contact have ongoing education and training in the proper and safe use of restraints. Performance improvement processes through education of staff allow for ongoing opportunities to improve care and reduce risk associated with restraint use. Commitment to patient and staff safety is a top priority for health care organizations. To comply with regulatory initiatives in reducing the use of restraints, education and training for health care workers on safe application, reassessment, documentation guidelines, and alternatives to restraint use are necessary (Joint Commission of Accreditation of Healthcare Organizations, 1996). A review of the literature was conducted to uncover how other organizations have successfully implemented and evaluated restraint education and reduction programs. Key words used for the literature review included restraint, education, staff training and restraints, pediatric restraint, and education program evaluation. ⁎ Corresponding author: Lorna Frank, MSN, RN-BC. E-mail address: [email protected] (L. Frank). 0882-5963/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.03.001
Although publications regarding the use of restraints and de-escalation techniques in the hospital and psychiatric settings were evident in the literature, there are no articles within the last 5 years on how to evaluate the appliThe key for nurses cation of restraints in an inpatient to meet the educasetting. There are a limited numtional requirements ber of articles on the assessment of of regulatory instiknowledge gained related to restraint education programs, but none tutions such as The focused on evaluation of applicaCenter for Medition of restraints (Huang, Chuang, care/Medicaid is in & Chiang, 2009; Suen et al., 2006; identifying whether Yeh et al., 2004). a planned education One large Midwestern chilprogram has chandren's hospital chose to evaluate to what degree participants applied ged practice. to practice what they learned during education. The target audience for education included all staff across the spectrum of direct patient care. An inpatient rehabilitation unit whose staff infrequently used restraints was chosen as the pilot unit to determine baseline knowledge and skill on both behavioral and nonbehavioral restraints and de-escalation (restraint prevention). A group of subject matter experts from various disciplines developed an education plan that included a written pretest to assess learning needs and a demonstration of restraint application. The education plan was a blended learning approach using three online learning modules, a video of the phases of the stress model, and a skills checklist for both behavioral and nonbehavioral restraints. Safe use of restraints requires application of knowledge so a return demonstration was required to successfully complete the behavioral and nonbehavioral restraint education. Unit-
260 Tool 1
L. Frank et al. Restraint Observation Tool (2010)
Date:_______Unit:_________Bed:_______Patient Initials:_______Observer:______________ Check with charge nurse and wash hands before and after entering room Check Room Type of Restraint ____ Soft Velcro extremity in Use ____ Velcro locked (Twice as Tough) ____ Elbow immobilizers in use and documented as a restraint ____ Elbow immobilizers in use and NOT documented as a restraint ____ Other (describe) ____ Posey bed ____ Reverse seat belt Restraint Applied Appropriately Soft Velcro extremity ____ Tie is quick release ____ Tied to bed frame and not side rails ____ Two fingers rule used ____ Call light in reach Velcro locked ____ Attached to bed frame and not side rails ____ Two finger rule used Elbow Y or N Posey bed Y or N Leathers _____ Reason for Application Non-behavioral ____ Pulling on tubes, dressing, or IV ____ Protective intervention due developmental level ____ Other less restrictive alternatives ineffective ____ Not done Behavioral ____ Violent, aggressive, or an immediate or serious danger to safety of self or others Restraint Order Non-behavioral ____ In ICIS ____ On paper Y/N Order set ____ Progress note included Behavioral ____ Physician's Order & Assessment form complete and in chart ____ Order renewed Assessment/Documentation Non-behavioral ____ Assessed every 2 hours and documented every shift in electronic medical record ____ Not documented Behavioral ____ Assessed every 15 min and documented every 15 min on Behavioral Physical Restraint Record ____ Continual observer present ____ Behavioral Restraint and/or Seclusion Safety Measures Assessment form utilized Nurse/Observer Comments
based education specialists and experienced unit preceptors served as unit trainers for verifying the skills completion. Implementation of the education for direct care providers occurred over a 4-week period.
Evaluation Six months after the education, six units were chosen for evaluation based upon frequency of restraint usage. To evaluate whether the direct care providers applied what they had learned during restraint education, we developed the following tools: an online survey to assess retention of the online learning modules and practice application. A
behavioral observation tool was used to assess what types of restraints were in use and whether they had been applied correctly and according to hospital policy. Hospital policy included documentation, physician order, and hourly assessment. Additional observations included checking documentation for the reason for restraint application, physician order, and patient assessment as required (Tool 1).
Results • Of the 215 respondents out of a possible 498 direct care providers (RNs, patient care assistants, patient
Evaluating the Application of Knowledge attendance, paramedics, respiratory therapists, and health unit coordinators), 88.3% completed all three of the online modules related to restraints. • There were 96.7% of respondents who were either “consistently able to recognize” or “sometimes able to recognize” the steps of the Stress Model (trigger, escalation, violence, and recovery/learning). • Of the 215 respondents, 198 did use the Stress Model or related assessment/de-escalation techniques; 59.1% used the model for a patient who was agitated, aggressive, or violent; whereas 32.8% used it because a caregiver was agitated, aggressive, or violent. • Several of the interventions used to aid in de-escalation or protection of the patient are listed here in rank order: 1. 59.3% used de-escalation techniques 2. 36.2% used unit/hospital chain of command 3. 16.6% notified Protective Services. Twenty de-escalation techniques were listed for the respondents to choose from; the techniques chosen most often were listening, followed by distraction/diversion, such as music, play, reading, and games.
Lessons Learned Evaluating application to practice can be quite time consuming. Not only was restraint application observed, but documentation of the reason for restraint application, physician order, and patient assessment were monitored as well (see Tool 1). Setting the stage for nurse engagement requires concise communication of expectations and a positive approach to the ultimate goal of improving performance and application of learning at the bedside. Identifying the teachable
261 moments to strengthen retention or troubleshoot issues not previously identified in the education was invaluable.
Conclusion The key for nurses to meet the educational requirements of regulating institutions, such as The Center for Medicare/ Medicaid, is in identifying whether a planned education program has changed practice. Thus, evaluating the stated goals or outcomes allows the direct care provider to determine if they transferred the learning to behavior.
References Committee on Pediatric Emergency Medicine. (1997). The use of physical restraint interventions for children and adolescents in the acute care setting. Pediatrics, 99, 497−498. Department of Health and Human Services: Center for Medicare & Medicaid Services, Final Rule. (2006). (to be codified at 42 CFR, part 482). Rules and Regulations, 71, 71401−71403. Huang, H., Chuang, Y., & Chiang, K. (2009). Nurses' physical restraint knowledge, attitudes, and practices: The effectiveness of an in-service education program. Journal of Nursing Research, 17, 246−255. Jacobi, J., Fraser, G. L., & Coursin, D. B. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine, 30, 119−141. Joint Commission of Accreditation of Healthcare Organizations. (1996). “Standards, Intents, and Examples for Special Treatment Procedures,” Comprehensive Accreditation Manual for Hospitals: The Official Handbook. (Oakbrook Terrace, IL). Mohr, W. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24, 3−14. Suen, L., Lai, C., Wong, T., Show, S., Kong, S., Ho, J., et al. (2006). Use of physical restraints in rehabilitation settings: staff knowledge, attitudes and predictors. Journal of Advanced Nursing, 55, 20−28. Yeh, S., Hsiao, C., Ho, T., Chiang, M., Lin, L., Hsu, C., et al. (2004). The effects of continuing education in restraint reduction on novice nurses in intensive care units. Journal of Nursing Research, 12, 246−255.
CLINICAL PRACTICE COLUMN Column Editor: Mary D. Gordon, PhD, RN, CNS-BC
Mary D. Gordon, PhD, RN, CNS-BC
Evaluating the Application of Knowledge: The Use of Restraints Lorna Frank MSN, RN-BC ⁎, Anne Longo PhD(c), MBA, RN-BC, NEA-BC, Barbara Hensley MSN, CPNP, RN-BC Cincinnati Children's Hospital Medical Center
THE USE OF restraints has become a high-priority issue to assure appropriateness of treatment and protect patient rights (Centers for Medicare and Medicaid Services [CMS], 2006). The term restraint is defined in the literature as referring to the physical restriction of movement that may involve restraining all limbs (Jacobi, Fraser, and Coursin, 2002; Mohr, 2010). Restraints may be an intervention for children and adolescents to reduce the risk of treatment interference or to prevent abrupt discontinuation of medical devices used for diagnosis or monitoring. Restraints are also used to prevent patients from harming themselves or others (American Academy of Pediatrics, 1997). The Centers for Medicare and Medicaid's requires that all clinical staff with direct patient contact have ongoing education and training in the proper and safe use of restraints. Performance improvement processes through education of staff allow for ongoing opportunities to improve care and reduce risk associated with restraint use. Commitment to patient and staff safety is a top priority for health care organizations. To comply with regulatory initiatives in reducing the use of restraints, education and training for health care workers on safe application, reassessment, documentation guidelines, and alternatives to restraint use are necessary (Joint Commission of Accreditation of Healthcare Organizations, 1996). A review of the literature was conducted to uncover how other organizations have successfully implemented and evaluated restraint education and reduction programs. Key words used for the literature review included restraint, education, staff training and restraints, pediatric restraint, and education program evaluation. ⁎ Corresponding author: Lorna Frank, MSN, RN-BC. E-mail address: [email protected] (L. Frank). 0882-5963/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.03.001
Although publications regarding the use of restraints and de-escalation techniques in the hospital and psychiatric settings were evident in the literature, there are no articles within the last 5 years on how to evaluate the appliThe key for nurses cation of restraints in an inpatient to meet the educasetting. There are a limited numtional requirements ber of articles on the assessment of of regulatory instiknowledge gained related to restraint education programs, but none tutions such as The focused on evaluation of applicaCenter for Medition of restraints (Huang, Chuang, care/Medicaid is in & Chiang, 2009; Suen et al., 2006; identifying whether Yeh et al., 2004). a planned education One large Midwestern chilprogram has chandren's hospital chose to evaluate to what degree participants applied ged practice. to practice what they learned during education. The target audience for education included all staff across the spectrum of direct patient care. An inpatient rehabilitation unit whose staff infrequently used restraints was chosen as the pilot unit to determine baseline knowledge and skill on both behavioral and nonbehavioral restraints and de-escalation (restraint prevention). A group of subject matter experts from various disciplines developed an education plan that included a written pretest to assess learning needs and a demonstration of restraint application. The education plan was a blended learning approach using three online learning modules, a video of the phases of the stress model, and a skills checklist for both behavioral and nonbehavioral restraints. Safe use of restraints requires application of knowledge so a return demonstration was required to successfully complete the behavioral and nonbehavioral restraint education. Unit-
260 Tool 1
L. Frank et al. Restraint Observation Tool (2010)
Date:_______Unit:_________Bed:_______Patient Initials:_______Observer:______________ Check with charge nurse and wash hands before and after entering room Check Room Type of Restraint ____ Soft Velcro extremity in Use ____ Velcro locked (Twice as Tough) ____ Elbow immobilizers in use and documented as a restraint ____ Elbow immobilizers in use and NOT documented as a restraint ____ Other (describe) ____ Posey bed ____ Reverse seat belt Restraint Applied Appropriately Soft Velcro extremity ____ Tie is quick release ____ Tied to bed frame and not side rails ____ Two fingers rule used ____ Call light in reach Velcro locked ____ Attached to bed frame and not side rails ____ Two finger rule used Elbow Y or N Posey bed Y or N Leathers _____ Reason for Application Non-behavioral ____ Pulling on tubes, dressing, or IV ____ Protective intervention due developmental level ____ Other less restrictive alternatives ineffective ____ Not done Behavioral ____ Violent, aggressive, or an immediate or serious danger to safety of self or others Restraint Order Non-behavioral ____ In ICIS ____ On paper Y/N Order set ____ Progress note included Behavioral ____ Physician's Order & Assessment form complete and in chart ____ Order renewed Assessment/Documentation Non-behavioral ____ Assessed every 2 hours and documented every shift in electronic medical record ____ Not documented Behavioral ____ Assessed every 15 min and documented every 15 min on Behavioral Physical Restraint Record ____ Continual observer present ____ Behavioral Restraint and/or Seclusion Safety Measures Assessment form utilized Nurse/Observer Comments
based education specialists and experienced unit preceptors served as unit trainers for verifying the skills completion. Implementation of the education for direct care providers occurred over a 4-week period.
Evaluation Six months after the education, six units were chosen for evaluation based upon frequency of restraint usage. To evaluate whether the direct care providers applied what they had learned during restraint education, we developed the following tools: an online survey to assess retention of the online learning modules and practice application. A
behavioral observation tool was used to assess what types of restraints were in use and whether they had been applied correctly and according to hospital policy. Hospital policy included documentation, physician order, and hourly assessment. Additional observations included checking documentation for the reason for restraint application, physician order, and patient assessment as required (Tool 1).
Results • Of the 215 respondents out of a possible 498 direct care providers (RNs, patient care assistants, patient
Evaluating the Application of Knowledge attendance, paramedics, respiratory therapists, and health unit coordinators), 88.3% completed all three of the online modules related to restraints. • There were 96.7% of respondents who were either “consistently able to recognize” or “sometimes able to recognize” the steps of the Stress Model (trigger, escalation, violence, and recovery/learning). • Of the 215 respondents, 198 did use the Stress Model or related assessment/de-escalation techniques; 59.1% used the model for a patient who was agitated, aggressive, or violent; whereas 32.8% used it because a caregiver was agitated, aggressive, or violent. • Several of the interventions used to aid in de-escalation or protection of the patient are listed here in rank order: 1. 59.3% used de-escalation techniques 2. 36.2% used unit/hospital chain of command 3. 16.6% notified Protective Services. Twenty de-escalation techniques were listed for the respondents to choose from; the techniques chosen most often were listening, followed by distraction/diversion, such as music, play, reading, and games.
Lessons Learned Evaluating application to practice can be quite time consuming. Not only was restraint application observed, but documentation of the reason for restraint application, physician order, and patient assessment were monitored as well (see Tool 1). Setting the stage for nurse engagement requires concise communication of expectations and a positive approach to the ultimate goal of improving performance and application of learning at the bedside. Identifying the teachable
261 moments to strengthen retention or troubleshoot issues not previously identified in the education was invaluable.
Conclusion The key for nurses to meet the educational requirements of regulating institutions, such as The Center for Medicare/ Medicaid, is in identifying whether a planned education program has changed practice. Thus, evaluating the stated goals or outcomes allows the direct care provider to determine if they transferred the learning to behavior.
References Committee on Pediatric Emergency Medicine. (1997). The use of physical restraint interventions for children and adolescents in the acute care setting. Pediatrics, 99, 497−498. Department of Health and Human Services: Center for Medicare & Medicaid Services, Final Rule. (2006). (to be codified at 42 CFR, part 482). Rules and Regulations, 71, 71401−71403. Huang, H., Chuang, Y., & Chiang, K. (2009). Nurses' physical restraint knowledge, attitudes, and practices: The effectiveness of an in-service education program. Journal of Nursing Research, 17, 246−255. Jacobi, J., Fraser, G. L., & Coursin, D. B. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine, 30, 119−141. Joint Commission of Accreditation of Healthcare Organizations. (1996). “Standards, Intents, and Examples for Special Treatment Procedures,” Comprehensive Accreditation Manual for Hospitals: The Official Handbook. (Oakbrook Terrace, IL). Mohr, W. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24, 3−14. Suen, L., Lai, C., Wong, T., Show, S., Kong, S., Ho, J., et al. (2006). Use of physical restraints in rehabilitation settings: staff knowledge, attitudes and predictors. Journal of Advanced Nursing, 55, 20−28. Yeh, S., Hsiao, C., Ho, T., Chiang, M., Lin, L., Hsu, C., et al. (2004). The effects of continuing education in restraint reduction on novice nurses in intensive care units. Journal of Nursing Research, 12, 246−255.