Health Policy on Restraint in Health Care Settings

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23/11/17 Nursing Reference this

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Health Planning and Policy Development: Leadership Issues

  • Jinyi Kim

Health Policy on Restrain

According to the World Health Organization (WHO, 2015), health policy can be defined as the decisions, plans, and actions towards achieving specific goals in health care within a society. They mention that a successful health policy can achieve several things: “it defines a vision for the future; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people” (WHO, 2015). Center for Disease Control and Prevention (CDC, 2015) state that public health policies affect national health strategies, plans, and resource allocations. Restrain have been using the reasons for protection patient from injury, maintaining treatment, and controlling disruptive behavior. It was thought that without the restraint, patients could be in danger of injuring themselves or others. However, it is a legal issue that when and how use the restraints. The overall purpose of this paper is to understand the significant policies of restraint intervention in health care setting and address my position as a future Advanced Practice Nurse (APN).

History of the Restrain Problem

The use of restraint is a widespread intervention in health care in many countries (Goethals, Dierckx de Casterlé, & Gastmans, 2012). According to Strunk (2014), the prevalence of restraint in United States ranges 4 to 85% in nursing homes and 8 to 68% in hospitals. Restraint has been used as a treat intervention for patients or prevent others from harm by patients especially mentally ill patients. Strunk (2014) argue that terms were used to describe mental illness such as “idiots, lunatics, insane, and epileptic” labeling and justifying individual who need restraint for keeping themselves and others from harm in the 18th and 19th centuries (p. 19). Gerace, Mosel, Oster, and Muir‐Cochrane (2013) state that restraint of elderly who aged over 65 have been utilized to control aggression and prevent falls. Many studies indicate that restraint has been applied for staff centered reasons including lack of staff and organization goals (Goethals et al., 2012; Gerace et al., 2013). Abuse has been widely documented in various articles and journals about the use of restraints (Strunk, 2014).

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The United States Food and Drug Administration (FDA) estimated in 1992 that at least 100 deaths occur annually in the U.S. from their improper use in nursing homes, hospitals and private homes. Adverse Effects of Physical Restraints throughout the last decade and there has been an increasing amount of evidence and literature supporting the idea of a restraint free environment due to their contradictory and dangerous effects. According to the College of Nurses of Ontario (2009), about 150 deaths caused by restraint each year and using restraint also cause “pressure ulcer, higher rates of falls, incontinence, bone demineralization, and increase patients’ aggression” (p. 2). These days, many people already recognized the negative effect of restraint; however, it is still using in health care settings for various reasons. There are no clear evidences that restraint to prevent injuries.

Major Policy Makers Involved

Restraint use is regulated by national and state agencies. The major stakeholders in the restraint policies in the U. S are the federal government, health care organizations, and health care providers. Also, each health care facility has its own restraint policy. According to Center for Medicare and Medicaid Services (CMS, 2011), a physician or a licensed independent practitioner who are permitted by state and hospital may order restrains and they have responsibility to assess and evaluate the patient who need for intervention within one hour after the restraint is initially ordered. In addition, the health care facilities should educate and train their staff with direct patient contact and must properly use restrain and alternatives (CMS, 2011). CMS (2011) state that hospital must report to CMS any death occurs while a patient is in restraint.

As noted, internationally many health care facilities have their own restraint policy. The hospital policy manual of New York Presbyterian Hospital (2006) mention that the use of restraints is a patients’ rights issue and the benefits are weighed against the patient’s inherent right to be free from restraint. Maintaining the patient’s rights, dignity and well-being are a primary consideration when restraints are used. The College of Nurses of Ontario (2009) state that restraint will only be used when a patient is in imminent danger of harm to self or others, and nonphysical or less restrictive measures have failed, or are not expected to be effective. NSW Ministry of Health (2012) argues that restraint should be a last option to manage the risk of serious imminent harm because it involves risk to the physical and psychological health of both staff and patient.

Nurses’ Involvement

ANPs and Registered nurses play a crucial role in the restraint reducing by proving the negative effects of restraint. The position statements of American Nurses Association (ANA, 2012) state that using restraint to patients is contrary to the fundamental goal and ethical tradition of the nursing profession. ANA (2012) believes that restraint should be utilized only when no other feasible option is available. In addition, when restraint is necessary, more than one witness should document and treat the patient with preserving human dignity (ANA, 2012). Likewise, the position statement of American Psychiatric Nurses Association (APNA, 2014) about using restraint state that restraint must never be used for staff convenience or to punish or coerce individuals. In addition, restraint reduction and elimination efforts must include a focus on necessary culture change because restraint use is influenced by the organizational culture that develops norms for how persons are treated (APNA, 2014).

Nurses are patient advocator who respect patients’ wishes and have responsibility for ensuring that the patient has received information and consenting to the proposed plan of care. According to College of Nurses of Ontario (2009), nurses have responsibility to understand the patient’s behavior to accurately determining the need of restraint and collaborate and discuss about using lease restrictive restraints if necessary. Consent is crucial to nursing interventions because patients have the right to make decisions regarding their care and treatment (CMS, 2011). In addition, College of Nurses of Ontario (2009) state that although the restraint is necessary, the nurses should regularly reviewing the continued use of restraints is needed or not and documenting the assessment of the patient.

Ethical Issues

Expanding health technologies and increasing demands for cost containment have emphasized the need for ethical decision making by all health care professionals. Health care providers may struggle to balance their responsibility to protect patients’ right of freedom and their obligation about patients’ safety. ANA (2012) state that the most essential ethical concept of nursing is avoiding harm and respect individual’s autonomy and right to make their own decision. In terms of making decisions about physical restraint, it is often difficult to avoid harm both restraining and not restraining could bring about harm. In order to make effective ethical decision about restraint, careful thought of balancing the options is necessary. Health care providers should consider their personal values, professional responsibilities, and patients’ best interest to make appropriate ethical decision (Goethals et al., 2012). As noted, health care providers should try first alternative methods to ensure patient’s safety due to restraints should be used only as last choice and should not cause harm or be used as punishment (CMS, 2011). Even though, the restrain used for good intervention, it is still violate the human rights because restraint may force to immobilize and isolate patient, and do not alleviate their suffering (APNA, 2014). If unavoidably applied restraint to patient, health care providers should check the restraint are not cutting off patients’ blood flow and reassess that the restraint can be discontinued as soon as situation is safe. It is though that health care provider should make decision about restraint following their facility policies and guidelines with multidisciplinary team.

Options for Resolving

There are philosophical debates and questions about the restraint issue in health care settings such as individual rights, ethics, and financing topics include minimize costs and maximize the efficiency of health care delivery (Gerace et al., 2013). One of the strategies to resolve this problem is the creation of awareness on the advantages of the alternatives instead of restraint. Politicians are an obvious stakeholder in this matter. Because the policy encompass decision made at state or national level including funding decision that affect whether and how services are delivered (Gerace et al., 2013). Therefore, policy makers should consequently try to call for allocation of state and federal financing for utilizing the best practices proved by researches.

ANA (2012) argue that educating nurses, other health care staff, and caregivers on the appropriate use of restraint and the alternatives is helpful to reduce restrictive intervention of restraint. In addition, if using restraint is only viable option, ensure sufficient nursing staff to monitor the patient (ANA, 2012). The legal basis consent is required before treatment and the consent to an agreed form of restraint after providing sufficient information include risks and implications (Strunk, 2014). It is thought that the information about alternatives should be provided when patient or family are need to decide write consent about restraint. NSW Ministry of Health (2012) suggests the alternatives to restraints to reduce restraint use through physical modification as below Table 1.1:

TABLE 1.1 Alternatives to Restraints

Alternative

Examples

Modify environment

  • Increase / decrease lighting
  • Establish wandering paths
  • Disguise exits
  • Room or bed change

Adapt wheelchairs

  • Wedge pillow
  • Lap buddy

Provide body props / postural enhancer

  • Bed or chair alarm

Install alarm / safety devices

  • Eliminate buzzers
  • Bells
  • Intercoms
  • Television
  • Shut doors

Reduce unnecessary visual or auditory stimuli

 

Personalize rooms

 

Use secured unit

  • Med / psych only

Note: Adapted from NSW Ministry of Health. (2012). Aggression, Seclusion & Restraint in Mental Health Facilities in NSW.

   

Health care facility leaders and administrators should focus on assistance to quickly identify and address legal and financial risks about the use of restraint. According to NSW Ministry of Health (2012), in order to reduce the use of restraint successfully, executive staffs in clinical settings should have clear leadership to give outlines about the role and responsibilities to all staff members. Strunk (2014) states that performance improvement plan involving collaboration with multidisciplinary team, a broad consultation process, and weekly team meeting to analyze restraint event are key component of this strategy. In addition, collect and use data by an organization is another strategy to identify the successful use restraint prevention practice can be shared (Strunk, 2014).

Health care providers need to intensively educate to make proper decision on this matter. Also, health care facilities and state should suggest accessible guideline and standard to health care providers. Especially, the national standards for use of restraint and accredited training for health care providers are needed to establish by government. Goethals et al. (2012) argue that stimulate and educate nurses are urgently needed for making appropriate decision about the use of restraints. According to ANA (2012), in order to make appropriate decision regarding restraint, clear and nationally accepted standards and guideline should be available to health care providers. In addition, ethical consultation should also available to health care providers in clinical setting to make proper decision to restrain (ANA, 2012).

As noted, providing educational initiatives related to restraint is also good strategy to reduce the use of restraint. It is believed that nationally accepted program for restraint is need such as certification program for restraint. Most of health care facilities require basic life support certification when they hire health care provider. Likewise, the nationally accepted certification program for restraint should be prepared and required to health care provider who directly contact with patients. Many health care facilities have their own strategies and guideline to reduce the use of restraint. For instance, New York Presbyterian Hospital (2006) suggests the manual to make restraint free environment as below Table 1.2:

TABLE 1.2 Steps for Restraint Free Environment

Step

Action

1

Obtain an order for restraint from the physician or other LIP prior to application of restraints or immediately after application of restraint.

Reminders:

  • The attending physician must be consulted as soon as possible if the attending physician did not order the restraint
  • Use of a PRN order of restraint use is not acceptable

2

Apply restraints under the direction of a RN, physician, or other licensed independent practitioner (LIP)

3

Obtain an order with each new episode of restraint and daily if patient restrained greater than 24 hours

4

Re-assess the patient every 2 hours or more frequently based on the individual needs of the patient.

Note:

  • Take into consideration
  • Patient’s condition
  • Cognitive status
  • Risks associated with the chosen intervention
  • Type of intervention used
  • Include in the assessment
  • Circulation and range of motion in restrained extremities
  • Nutrition
  • Hydration
  • Hygiene
  • Elimination
  • Comfort
  • Physical / psychological status
  • Readiness for discontinuation of restraints

5

Inform patient, patient’s family or authorized representative about reasons for restraint use

6

Provided an educational handout entitled ‘Understanding Restraints’ as appropriate

7

Update the patient’s problem list

8

Update restraint log

Note: Adapted from New York Presbyterian Hospital. (2006). Hospital Policy and Procedure Manual.

   

At first, there is no single remedy to remove restraint in health care settings. There are some options have been suggested to resolve this problem. It is thought that the most effective strategy to resolve this problem is to provide restraint supportive environment and education for health care providers. According to ANA (2012), a systematic approach of assessment, intervention, and evaluation it needed to resolve restraint issue in health care settings. In other word, open communication at the highest administrative levels, including health care providers and community representatives is crucial to implement change. In order to ensure restraint is not used abusively and to support health care providers making appropriate decision, health care organizations, as well as the government intent to promote a reduced restraint environment by sufficient nursing staff to monitor, intention to comply with policies, and environmental designs to facilitate restraint reduction (ANA, 2012). According to College of Nurses of Ontario (2009), health care providers should know the information about restraint in health care settings as below:

(1) Understand what restraint is; (2) Provided person-centered care that minimizes the need for restraint; (3) Understand the legal and ethical frameworks relevant to restraint; (4) Know what to do if they suspect inappropriate or abusive use of restraint; (5) Understand the circumstances in which restraint may be legally or ethically required; (6) Understand how to minimize the risks if restraint is used (p. 11).

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Many facilities have been tried to make restraint free environment in their clinical settings (Strunk, 2014; New York Presbyterian Hospital, 2006). Gerace et al. (2013) mention that the applying restraint free environment framework (Table 1.3) support health care providers to make decision about the use of restraint more appropriately. Also, this framework is helpful to assess and manage restraint patients in clinical settings.

TABLE 1.3 Restrain Utilization Decision Tree

Note: Adapted from Gerace, A., Mosel, K., Oster, C., & Muir‐Cochrane, E. (2013). Restraint use in acute and extended mental health services for older persons. International journal of mental health nursing, 22(6), 545-557.

In conclusion, the restraint is applied to patients for some reasons in health care settings. It is ongoing issue need to discuss and debate due to the use of restraint is frequently challenging and difficult decisions in health care system. Health care providers should consider that the restraint is really needed for their patients, is there any alternatives instead of restraint, and what the most appropriate way to utilize it is through education about clear and ethically accepted guideline and policy. Therefore, educational opportunities and clear guideline to support health care providers in developing the necessary assessment and intervention skills to reduce the use of restraint are critically needed to provide in health care system.

References

American Nurses Association. (2012). Reduction of Patient Restraint and Seclusion in Health Care Settings. Retrieved from http://www.nursingworld.org

American Psychiatric Nurses Association. (2014). The Use of Seclusion and Restraint. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageid=3728

Center for Disease Control and Prevention. (2015). Public Health Policy. Retrieved from http://www.cdc.gov/stltpublichealth/policy/

Center for Medicare and Medicaid Services. (2011). CMS Manual system. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R75SOMA.pdf

College of Nurses of Ontario. (2009). Restraints. Retrieved form www.cno.org

Food and Drug Administration. (1992). Potential Hazards with Restraint Devices. Retrieved from http://www.fda.gov/MedicalDevices/Safety/

Gerace, A., Mosel, K., Oster, C., & Muir‐Cochrane, E. (2013). Restraint use in acute and extended mental health services for older persons. International journal of mental health nursing, 22(6), 545-557. doi: 10.1111/j.1447-0349.2012.00872.x

Goethals, S., Dierckx de Casterlé, B., & Gastmans, C. (2012). Nurses’ decision‐making in cases of physical restraint: a synthesis of qualitative evidence. Journal of advanced nursing, 68(6), 1198-1210.

New York Presbyterian Hospital. (2006). Hospital Policy and Procedure Manual. Retrieved from http://www.hospitalist.cumc.columbia.edu

NSW Ministry of Health. (2012). Aggression, Seclusion & Restraint in Mental Health Facilities in NSW. Retrieved from http://www.health.nsw.gov.au/Pages/default.aspx

Strunk, L. L. (2014). Seclusion and Restraint Policy and Practice: Are We Doing the Right Thing? All Theses, Dissertations, and Other Capstone Projects, Paper 381.

World Health Organization. (2015). Health policy. Retrieved from http://www.who.int

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