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Introduction
Physical and chemical restraints are widely used in critical care settings to prevent patients from inflicting harm on themselves and on those around them (Hamers, Gulpers, and Strik, 2004). However, many research studies have been carried out to examine the effectiveness of restraints. The majority of the studies show that physical and chemical restraints have adverse physical, emotional, and psychological effects on patients as well as their families (Cheney, Gossett, Fullerton-Gleason, Weiss, Ernst and Sklar, 2006; Mott, Poole and Kenrick, 2005). The negative effects of physical and chemical restraints can be attributed to a number of factors. The first factor is the ratio of nurses to patients. A small nurse-to-patient ratio makes it difficult for the nurses to monitor or provide adequate attention to patients. Hence, nurses resort to physical and chemical restraints as a means of managing aggressive patients (Demir, 2007). The complications that arise from physical and chemical restraints can be grave and life-threatening. In addition, some research studies indicate that patients who are physically or chemically restrained have worse outcomes than patients who are not restrained. Based on this evidence, this paper seeks to design an action plan that can be followed by critical care units in dealing with their patients. The plan aims at substituting the use of physical and chemical restraints with other alternatives.
Analysis of Literature Review
Scope of the problem in the health care realm
The problem that is to be addressed in this plan is the lack of effectiveness of physical and chemical restraints on patients safety. Physicians and nurses recommend and implement the usage of physical and chemical restraints in the hope that they will reduce the incidences of self-inflicted harm and injuries on patients. However, rather than reduce injuries, the restraints worsen the health condition of the patients. There is therefore the need for the critical care units to find other more effective alternatives.
Identification of the stakeholders
A number of stakeholders will be involved in this plan and include the director of the health facility, physicians, nurses, other physician assistants, lawyers, facility administrators, and risk management professionals. The director of the health facility will be the first to be contacted about the action plan. This is because, without permission and support from the director, the action plan cannot be successful. The physicians, physician assistants, and the facilitys administrators are included in the plan because they are directly affected by the use of physical and chemical restraints. The facilitys administrators permit the use of the restraints in the facility, the physicians give orders to their assistants to use the restraints, whereas the physician assistants apply the restraints on the patients. The lawyers and risk management professionals will educate the facilitys personnel on the legal issues that arise from the use of physical and chemical restraints and how such issues can best be addressed (Kielb, Hurlock-Chorostecki, and Sipprell, 2005).
General recommendations for reform
The reform will be in the form of a program consisting of four major goals: increase in the number of nurses in intensive care units, staff education, policy development, and restraint reduction. There is a need to increase the number of nurses working in intensive care units. As discussed above, a small nurse-to-patient ratio increases the use of physical and chemical restraints even in cases where such usage is not necessary. In addition, a small nurse-to-patient ratio increases nurses workload and fatigue which are in turn contribute to their job dissatisfaction. It is therefore important for intensive care units to increase their number of nurses so that the nurses would have more time to cater to the individual needs of the patients and to give them utmost attention. The hiring of additional nurses will be done using the best practice staffing technique. The education of the medical staff is essential due to the misperception surrounding the use of restraints. The majority of nurses and other medical staff believe that restrained patients are safer than non-restrained patients but this is not always the case (Kielb et al., 2005; Caprio, Katz and Karuza, 2008). They argue that restraints prevent patients from inflicting harm on themselves as well as on those around them. This is especially the case for aggressive patients. The dominant opinion held by medical staff is that restraints enable them to manage their patients and create a safe working environment (Demir, 2007). Policy development will deal with the change of a facilitys policy from restraint use to restraint reduction or elimination. The policy should provide the facility with guidelines as to how individualized assessments will be done and the development of care plans for each patient. The last goal of the program involves the reduction of restraints use and the use of alternatives. These decisions will be made based on individualized assessments of each patient.
Plan of implementation using evidence-based practice
Best practice staffing
Best practice staffing is defined by the Emergency Nurses Association as that which provides timely and efficient patient care and a safe environment for both patients and staff while promoting an atmosphere of professional nursing satisfaction, (cited in Robinson, Jagim, and Ray, 2004). Based on best practice, staffing will be done taking into consideration the following factors: patient census, patients acuity, length of stay of patients, nursing time for interventions and activities by patient acuity, and the mix of registered nurses vs. non-registered nurses skills. An automated tool (in this case an Excel workbook) will be used to calculate the number of full-time equivalents (Tess) that are needed to provide quality care to patients in the intensive care unit. The tool will then split the FTEs into a skills mix of registered nurses (86%) and non-registered nurses (14%). The ratio of RN to non-RN needed in intensive care units was determined by the Nursing Interventions Classification (NIC) system (Robinson et al., 2004). Once the tool determines the total number of FTEs needed for the ICU patients, they can be distributed throughout the day according to the trends of the patient volume. This staffing technique based on best practice will enable the unit to acquire the appropriate number of nurses as well as support staff needed to provide utmost care to the ICU patients. It is hoped that by having adequate nursing and support staff, the need to use physical and chemical restraints would be reduced drastically. As a result, the number and severity of injuries that often result from restraints use would also decline.
Staff education
The education of the medical staff concerning the use of physical restraints will be done using different media of communication. First and foremost, the program will begin by reviewing the current literature that addresses the effect of physical and chemical restraints on patients. The literature review will then be made available to the medical staff for evidence-based practice. The second channel of education will be a video presentation. The presentation will be prepared by medical experts in the field of physical and chemical restraints. It would be advisable for the video presentation to contain visual illustrations of the negative effects of using physical and chemical restraints on patients. Third, interactive face-to-face sessions will be held for the medical staff in conjunction with administrative, legal, and risk management professionals. In such sessions, the medical staff will be educated on the legal, ethical and social issues that pertain to physical and chemical restraints use and will be advised on the best precautions to take when faced with such situations. Staff education will also be conducted through posters. Large posters with graphical illustrations will be made and placed strategically within the facility so as to create awareness among the medical staff, patients, and patients families (Testad, Aasland, and Aarsland, 2005).
Policy development
A program cannot be successful without policies and guidelines that give directions to all the partners involved. In this case, the policy created will guide the medical staff in assessing patients and making decisions concerning either the use of physical and chemical restraints or other alternatives. Physical and chemical restraints would only be used as the last resort, that is when all other methods of managing the patient have failed. In cases where there is a need for the use of restraints, the least restrictive methods would be used. These methods include: raising the four side rails of the bed, applying untied mittens on the patient, and using vest/roll belts. It is the duty of the registered nurse to thoroughly assess the patients so as to recognize the need for the use of physical or chemical restraints.
The assessment should be done in accordance with the national protocol of the country in which the facility is located. An example of such protocols is the Restraints and Seclusion Protocol that is used in the majority of the hospitals that have intensive care units. Factors that need to be assessed before applying physical or chemical restraints include the age of the patient, marital status, mobility deficits, degree of cognitive impairment, weakening of joints and bones, body organ failures, communication abilities, availability of support systems, interests of the patient, and availability of a sitter. The assessment should be done in consultation with the patients physicians, other members of the medical team, and the patients significant others such as the family (Kielb, Hurlock-Chorostecki, and Sipprell, 2005). One important aspect of the action plan is the assertion that restraints or their alternatives should not be used as a substitute for observation. To enhance observation, the patients considered to be high-risk will be located in rooms that are closest to the nurses station. Safety rounds and patient checks will then be done after every one hour, with more frequent safety rounds at highly risky times (for instance during shift change). Documentation will be part and parcel of the assessment procedure. The documentation of the patients physical, emotional and psychological state will be done after every assessment. The records will be inserted in each patients folder and placed at the bedside for easy access by the nurse.
Restraint use reduction/use of alternatives
The major objective of the plan is to reduce the use of physical and chemical restraints. However, some situations require the use of restraints especially if other alternatives have been tried before and failed. Alternatives to physical and chemical restraints include: arranging for a family member or sitter to keep the patient company in his/her room and locating the patient in a room nearest to the nurses station. When these methods fail to calm patients and when there is a possibility that a patient will inflict harm either on himself or on those around him, the use of physical or chemical restraints may be considered (Delaney, 2006). If this happens, the patients records must show that an assessment was earlier conducted and the reason/behavior necessitating the physical/chemical restraint use was determined. In addition, the records should indicate the types of alternatives that had been tried on the patient and the patients reactions to them. Once this is done, the patient and his family must be informed of the need to use enforced restraints. An individualized care plan must then be prepared for the patient and the least restrictive method used to restrain him. The restraint must be accompanied by a physicians order. Most importantly, regular monitoring of the restrained patient should be done to minimize the possibilities of self-inflicted injuries (Moore and Haralambous, 2007).
Method to evaluate policy change
The effectiveness of the action plan can be evaluated through quality assurance indicators that include the attitudes of the medical staff towards physical/chemical restraints use, types and a number of patients injuries, and a number of patients who have been restrained (either physically or chemically) before and after the program. The attitudes of the medical staff towards restraint use will help to gauge the effectiveness of the education program offered within the program. The number of staff who favored the use of restraints before the program will be compared with the number of staff favoring restraint use after the program. The success of the policy development and restraint reduction objectives of the program will be gauged by the incidences and types of injuries sustained by the patients before and after the program as well as the number of patients restrained and the types of restraints used (Winston, Morelli, Bramble, Friday and Sanders, 1999).
Conclusion
The plan presented in this paper aims at reducing the use of physical and chemical restraints on patients admitted to critical care units. The literature presented shows that physical and chemical restraints are commonly abused by physicians and nurses. However, some situations necessitate the use of physical and chemical restraints and include aggressiveness on the part of the patient as well as the failure of the alternative methods to manage aggressive patients. In such situations, restraints can be used starting with the least restrictive means such as raising the four side rails of the bed, applying untied mittens on the patient, and using vest/roll belts. The action plan also emphasizes the need for educating the entire medical team on the need to reduce restraints use. Education can be done through face-to-face discussions, print, and electronic devices. The strength of the action plan lies in the fact that it helps to enhance patient safety through the use of non-restrictive methods, thereby upholding the dignity and civil rights of the patients.
Reference List
Caprio, T.V., Katz, P.R. & Karuza, J. (2008). Commentary: The physicians role in nursing home quality of care: Focus on restraints. Journal of Aging & Social Policy, 20(3), 295-304.
Cheney, P., Gossett, L., Fullerton-Gleason, L., Weiss, S.J., Ernst, A. & Sklar, D. (2006). Relationship of restraint use, patient injury, and assaults on EMS personnel. Pre-hospital Emergency Care, 10(2), 207-212.
Delaney, K.R. (2006). Evidence base for practice: reduction of restraint use and seclusion use during child and adolescent psychiatric inpatient treatment. Worldviews on Evidence-Based Nursing, 3(1), 19-30.
Demir, A. (2007). Nurses use of physical restraints in four Turkish hospitals. Journal of Nursing Scholarship, 39(1), 38-45.
Hamers, J.P.H., Gulpers, M.J.M. & Strik, W. (2004). Use of physical restraints with cognitively impaired nursing home residents. Journal of Advanced Nursing, 45(3), 246-251.
Kielb, C., Hurlock-Chorostecki, C. & Sipprell, D. (2005). Can minimal patient restraint be safely implemented in the intensive care unit? Canadian Association of Critical Care Nurses, 16(1), 16-19.
Moore, K. & Haralambous, B. (2007). Barriers to reducing the use of restraints in residential elder care facilities. Journal of Advanced Nursing, 58(6), 532-540.
Mott, S., Poole, J. & Kenrick, M. (2005). Physical and chemical restraints in acute care: Their potential impact on the rehabilitation of older people. International Journal of Nursing Practice, 11, 95-101.
Robinson, K., Jagim, M. & Ray, C. (2004). Nursing workforce issues and trends affecting emergency departments. Topics in Emergency Medicine, 26(4), 276-286.
Testad, I., Aasland, A.M. & Aarsland, D. (2005). The effect of staff training on the use of restraint in dementia: a single-blind randomized controlled trial. International Journal of Geriatrics Psychiatry, 20, 587-590.
Winston, P.A., Morelli, P., Bramble, J., Friday, A. & Sanders, J.B. (1999). Improving patient care through implementation of nurse-driven restraint protocols. Journal of Nursing Care Quality, 13(6), 32-46.
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