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Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

Exercising Restraint

Jules Bell, MS, RN, CDE

Shands Vista

Health care organizations around the world continue to make strides in the reduction of the use of restraints. In the United States, both the Centers for Medicaid Services (CMS) and the Joint Commission recently revised and tightened the standards for restraint use and seclusion in health care. A physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body. A chemical restraint is a medication used to control behavior or to restrict the patient’s freedom of movement that is not a standard treatment for the patient’s medical or psychiatric condition. Seclusion is an involuntary confinement of a patient in a room or area alone where the patient is physically prevented from leaving. This is typically limited to inpatient psychiatric units. There are two primary considerations when determining whether or not a patient should be restrained or placed in seclusion: 1.) Performance of an accurate patient assessment, 2.) Determination of what is the least restrictive measure that would meet the patient’s needs and plan of care. Education and training is an important component of the revised standards and staff need to be adept at identifying behavioral indications, application of restraints (whether chemical or physical), and the risks associated with restraint use for patients who exhibit violent/self-destructive as well as nonviolent behaviors. Training should address underlying causes of escalating behavior by patients which may include medical reasons such as pain, low blood glucose, increased intracranial pressure, drug toxicity; psychiatric reasons such as hallucinations, dementia, psychosis; emotional reasons such as fear, anger, frustration; psychosocial reasons such concerns about finances, relationships or housing and other issues such as communication deficits or poor impulse control. These precipitating factors for patients in combination with visitors, discouraging news from health care providers, environmental factors such as noise or lighting, a staff member’s response to the patient’s behavior provide the milieu in which behavior develops. Some early signs of escalating behavior may include anxiety such as pacing, tapping fingers, or any noticeable change from, or increase in, a patient’s normal behavior. One appropriate response at this stage would be to be supportive, and listen to the concerns of the patient. When behavior continues to escalate, e.g. the patient is asking a lot of questions, refusing to cooperate, raising his or her voice or ventilating about perceptions or feelings, verbal de-escalation techniques should be employed. Staff should be skilled in these techniques which include answering questions rationally, setting limits, and allowing patients to verbally vent, as long as it is in a place/ situation where the patient, staff, and others are safe. Additional effective de-escalation techniques include distraction, encouraging patients to breathe deeply or to participate in activities which calm them, involving family members, or a 30 minute or less time-out in an unlocked room. If verbal behavior escalates into threats, name calling or foul language, staff should seek assistance and not deal with the threatening behavior alone. If the patient’s behavior becomes physically threatening, utilizing the chain of command including contacting security would be appropriate. When patients exhibit violent behavior and nonrestrictive interventions have been attempted and are unsuccessful, staff should follow their internal restraint and seclusion policy. (See Shands Healthcare Core Policy 2.21.) Facility restraint policies and procedures should address obtaining orders for restraints, physician evaluation of patients, initiation and application of restraints, restraint monitoring time frames, release of restraints and requirements for clinical record documentation. Patients and families should also be educated on the facility’s philosophy relative to restraints which should be reflected in the Patient’s Rights and Responsibilities. It is also recommended, as early as possible in the restraint or seclusion process, that patients be informed of the behavior that caused their restraint and the behavior and conditions necessary for restraint release.