Version: / 1
Author: / Prepared by Eithne Ni Dhomhnaill, Nursing Matters.
Ratified by: / Education and Steering Committee, Nursing Homes Nursing Projects.
Issue Date: / December 2008
Review date: / December 2010
Authorised by:
1.0Policy Statement.
Restraint will be used only as a time-limited emergency intervention using the least restrictive alternative where a resident’s unanticipated behaviour places him/herself or others in danger; or for a brief period to allow for provision of essential care. Restraint should be considered a last resort to be used only in accordance with the requirements outlined in this policy and with the intention of providing a positive outcome for the resident.
2.0Purpose:
The purpose of this policy is to ensure that decisions regarding the use of restraint place the needs, rights, known wishes and preferences of the resident at the centre of all decision –making and promote the best possible outcome for the resident.
3.0Objectives:
3.1To outline the requirements for use of restraint, including specific procedures to be followed where the use of restraint is deemed appropriate.
3.2To promote an environment that minimizes the need for restraint use.
3.3To promote alternative approaches to the use of restraint.
4.0Scope:
This policy applies to all staff in the facility.
5.0Definitions:
For the purpose of this policy, restraint is defined as:
“Any physical, chemical or environmental intervention used specifically to restrict the freedom of movement - or behaviour perceived by others to be antisocial – of a resident designated as receiving high or low care in an aged care facility. It does not refer to equipment requested by the individual for their safety, mobility or comfort. Neither does it refer to drugs used – with informed consent- to treat specific, appropriately diagnosed conditions where drug use is clinically indicated to be the most appropriate treatment. Thus restraint by definition may be seen to be a human rights rather than a medical issue”
(Nay, Koch and Trigar, 1999 cited in Nay and Koch, 2006)
5.1Classification of restraint:
a.Physical restraint: The intentional restriction of a resident’s movement, mobility or behaviour by the use of device or removal of mobility aids or the use of physical force (The Australian Government, Department of Health and Ageing 2004),
b.Chemical Restraint / Use of Psychotropic Medication: The intentional use of medication to control a resident’s behaviour when no medically identified condition is being treated; where the treatment is not required to treat the underlying condition or amounts to over treatment of the condition.(Adapted from the Australian Government, Department of Health and Ageing 2004),
c.Aversive treatment practices / punishments: Any intervention or practice that uses unpleasant, physical, sensory or verbal stimuli in an attempt to curb undesired behaviour. This includes voice tone, threats, seclusion, isolation, withholding of basic human rights or needs for the purpose of behaviour management (The Australian Government, Department of Health and Ageing 2004),
5.2Enabler: During the course of care planning a decision may be made to use a device or item for the specific purpose of enabling functional ability. Such an item / device would be referred to as an ‘enabler’ or enabling device, only if it does not restrict the residents’ independent movement and is used only for the period where enablement is required. An example of such a device would be the use of a lap tray to promote independence with eating and / or drinking.
However, if the ‘enabling’ device also restricts movement, this device / item would be considered both an ‘enabler’ and a restraint and its use would be subject to the same conditions and requirements (laid out in this policy) as for any other form of restraint use. The effect of the device determines whether it is an enabler/restraint or both.
(Health Services Executive, 2008; Draft Policy on the Use of Physical Restraints in Residential Care Settings).
5.3Conditions and Requirements for Restraint Use:
These are outlined in more detail throughout the policy and include:
Documented full team assessment of need (except in emergency situations outlined).
Documented risk assessment.
Evidence of alternatives to restraint used.
Explanation of rationale for use to resident.
Consent of resident as far as he/she is able.
Involvement of all team members and residents’ representative to inform decision-making.
Documented rationale for use of restraint.
Documented care plan addressing hoe the residents’ needs will be met during any period of restraint.
Monitoring / observation schedule.
Schedule for release of restraint.
Documented evaluations for continuing use of restraint.
6.0Restraint or Enabler Decision Making Tools.
The following tools can be used when making a decision about whether or not an intervention is an ‘enabler’; restraint or both.
Enabler / Restraint.- Enhances movement
- Promotes improved function
- Resident can remove easily
- Restricts movement
- Restricts access to body
- Resident cannot remove easily
7.0Decision-Making Flowchart for use of Physical Restraint.
, Department of
8.0Responsibilities.
Actions. / Responsible Person (s)Nurses and healthcare staff will be provided with an explanation of the policy for management of restraint use as part of an induction programme. / Director of Nursing or other named staff member in the facility.
All nursing and care staff will attend training on management of restraint use on induction and every two years.. / Director of Nursing or other named staff member in the facility.
Nurses will maintain their competence in management of restraint use and communicate any knowledge deficits / education needs to the Director of Nursing. / All registered nurses.
Each resident should have an initial screening for the presence of risks such as challenging behaviours / falls as part of their admission assessment process and as part of their three monthly reassessment or more frequently if there is a significant change to their condition. / Admitting / named nurse.
Where a resident has an identifiable risk on admission, immediate care needs will be documented in the resident’s care plan and communicated to all relevant care staff. / Admitting / named nurse.
A detailed assessment of identified risks and behaviours that challenge as per policy will be carried out as part of the resident’s comprehensive assessment.
Assessments will include risk assessment where the potential for violence or aggression is identified. / Named nurse or other delegated nurse in collaboration with the resident’s GP and other healthcare professionals involved in the residents care
Except in the case of emergency, an assessment of the presenting problem / behaviour leading to consideration of restraint use will be carried out and documented prior to the use of any intervention being used as restraint. This assessment will involve the consideration of alternatives and an assessment of risk related to the use of any device that would be considered a restraint. The restraint use assessment form must be completed. / Senior nurse on duty in collaboration with the resident’s GP and other healthcare professionals involved in the residents care
Where restraint use is deemed as providing the best outcome, a plan of care to include monitoring for side effects; meeting care needs and measures to minimise or eliminate the use of restraint will be documented. / Senior nurse and duty in collaboration with other nurses on duty as well as other healthcare professionals involved in the resident’s care.
Where restraint is used in an emergency situation, an assessment of the presenting problem/behaviour as per this policy will be carried out at the earliest opportunity and include completion of the restraint use assessment form. / All nursing staff on duty.
Actions / Responsible Person(s).
Where the resident’s presenting problem results in an incident, an incident form will be completed and managed as per the risk management strategy of the facility.. / Senior nurse on duty at the time of the incident.
The resident will monitored for adverse or side effects of treatment and / or interventions used to manage challenging behaviours. / Registered nurses and care staff on duty.
A restraints register will be maintained in the facility. Every episode / incident involving the use of restraint in the nursing home will be documented in this register. Documentation will include precipitating factors/behaviours and the actions taken to address these. / Director of Nursing and Senior nurses on duty at the time of any episode of restraint use.
Any episode involving the use of restraint will be discussed at the next scheduled risk management meeting, or within 24 hours if the episode involved an incident that resulted in injury or harm to any body in the facility. / Director of Nursing or other delegated nurse manager in his/her absence.
Decisions regarding the use of bed rails will adhere to the requirements of this policy with particular reference to the risk assessment outlined. / Senior nurse on duty or a delegated nurse with responsibility for the care of the resident at the time bed rails are used.
An audit of the management of restraint use in the facility will be conducted on an annual basis and a record kept of each audit. This should include an inspection of all bedrails being used in the nursing home. / Director of Nursing.
9.0Assessment and Care Planning Protocol for Physical Restraint Use in the Nursing Home.
9.1Admission Assessment:
9.1.1Every resident should have an assessment of risks and immediate care needs on admission using the facility assessment form.
9.1.2For the purpose of assessment and care planning on admission, the admitting nurse should ask about any risks / challenging behaviours and how they have been managed prior to admission to the facility and follow the Management of Challenging Behaviors Policy, including:
How long the risk or behaviour is present.
Are there any limiting or aggravating factors?
How does the resident/family cope with the behaviour and /or risk at home?
What has been tried?
What has worked?
What has not worked?
What preferences or wishes does the resident have with regard to care and outcomes related to the risk / behaviour?
9.1.3Where the admission assessment identifies any risks / behaviours that are immediate and have a potential to cause serious harm to the resident or others, an immediate care plan should be documented and put in place to address these risks.
9.1.4Where further assessment of the risk / behaviour is required, (such as a behaviour monitoring log), this should be documented in the resident’s care plan and commenced as soon as is practicable.
9.1.5Where a resident has a known challenging behaviour on admission, the admitting nurse should establish whether or not the behaviour / problem is likely to be a risk to the resident or others in the residential care facility. If yes, he/she should discuss all available options with the resident as far as he/she is able and / or representative and other healthcare professionals involved in the residents care.
9.1.6Where any serious risk such as violence or aggression have been identified as a potential problem, the specific risks to the resident and others should be identified, documented and a plan of care developed to promote the safety and welfare of all those at risk.
9.1.7The least restrictive type of intervention should be first choice for residents presenting with risks including challenging behavior.
9.1.8All other alternatives to the use of restraint should be explored – what alternatives are available and what are the likely outcomes of using the alternatives for the resident and for others?
9.1.9All decisions regarding the use of restraint should be aimed at achieving positive outcomes for the resident.
9.1.10The capacity of the resident to consent to treatment and interventions should be established from assessment and in collaboration with the resident’s general practitioner.
9.1.11Where the resident is deemed incapable of informed consent, the named nurse must collaborate with the resident’s representative and other healthcare professionals involved in the residents care in developing a care plan to meet the resident’s needs.
9.2Procedure for Initiating Restraint Use:
9.3Assessment prior to using restraint during the course of a resident’s care in the facility.
9.3.1In emergency situations or where immediate action is required to safeguard the resident or others, or for brief provision of essential care, restraint may be used without prior assessment. However, assessment should be performed as soon as possible after the event.
9.3.2Apart from an emergency situation, a full and thorough assessment of the resident’s needs must be taken prior to the use of any form of restraint. The assessment should include:
- The specific medical symptom / behaviour /risk to be treated by the use of physicalrestraint.
- Any known wishes / preferences of the resident regarding the management of the symptom, behaviour, risk.
- The steps that have been taken to identify the underlying physical and/or psychologicalcauses of the medical symptom
- The alternative measures that have been taken, for how long, how
recently, and with what results
- The evidence that a physical restraint will benefit the symptom / provide a positive outcome for the resident.
- The risks involved in using the physical restraint, physical, psychological and social.
- The specific circumstances under which physical restraint is being
considered
- The type of physical restraint; period of physical restraint; and location of physical restraint.
9.3.3Assessment should involve the resident, his/her representative, nursing staff and all team members involved in the resident’s care.
9.3.4A full explanation of the intervention should be given to the resident prior to use. This should include benefits and any potential negative outcomes. Informed consent should be obtained from the resident as far as he/she is able. Consent should be obtained by the healthcare professional who will be applying the restraint.
9.3.5Except in the case of emergency, where the resident is deemed to lack the capacity to give informed consent, the decision must be a collaborative decision involving resident’s representative, the nursing and clinical team involved in the resident’s care.
9.3.6The least restrictive form of restraint should be used for the shortest time
9.3.7Outside of normal working hours where other healthcare workers and family may not be available as in night duty, the nurse may make the decision to apply restraint, following assessment and identification of need. The nurse should however, ensure that a collaborative assessment and plan of care is completed at the earliest opportunity.
9.3.8No physical restraint should be used that causes discomfort or distress to the resident as evidenced by agitation, pleas for release or attempts to release him/herself.
9.3.9Assessment and the specific need for restraint ie immediate danger/risk to the patient or others must be documented and should include the rationale for type of restraint used.
Family
9.4 Care Planning :
9.4.1Family members should be encouraged to be involved in the resident’s care particularly where restraint is being used.
9.4.2The nurse must initiate a plan of care for the patient from the moment restraint is applied. This plan should include:
- The time restraint was applied.
- The specific symptom being treated by the use of restraint.
- Objective for using restraint.
- Steps taken to identify the underlying cause.
- Alternative measures that have been tried, for how long and with what results.
- Type and location of restraint being used.
- Risks involved in using the restraint and how these will be managed.
- How usual care needs such as toileting, pressure area care, nutrition, warmth and comfort will be met during the period of restraint.
- What means the patient has for calling for assistance.
- Observation of the resident and specific monitoring for adverse effects of restraint using the restraint observation form.
- Two hourly time schedule for removing restraint / position change and providing not less than ten minutes for limb exercise where the resident is awake.
- The need for staff to be in direct visual and verbal contact with the resident during any period of restraint.
- Interventions to address the specific symptom, behaviour or risk including interventions to eliminate the need for restraint.
9.4.3Care plans should focus on providing a person centred approach to care.
9.4.4Full review by all healthcare professionals and family should take place following an episode of restraint use. This review should take place no later than 24 hours.
9.4.5Reviewsand their outcomes should be documented.
9.4.6A record of all episodes of restraint use must be kept by the nursing homeThis record should include the reason for restraint use and actions taken for each episode.
10.0Appropriate Use of Restraint.
10.1Restraint use is not permitted for the following circumstances:
- For wandering behaviour, unless the behaviour poses an immediate and serious risk to the resident or others.
- To prevent falls, unless the risk of harm is immediate and serious.
- To impose discipline.
- As a substitute for correct staffing levels and competence and / or environmental deficiencies.
- Where the resident expresses a clear and consistent wish not be restrained either verbally or through non-verbal behaviours.
- Routine or ‘as needed’ or indefinite orders for physical restraint must not be used.
10.2The use of restraint is only permitted in the following circumstances:
- The physical restraint of the resident as an emergency measure when his/her unanticipated behaviour places him/ her in imminent danger of serious physical harm. In such circumstances the use of the physical restraint does not exceed beyond an immediate episode.
- For brief provision of time limited essential or emergency care, where there is an immediate or serious threat to the health of the resident if the care is not provided...
- When a resident requires emergency medical care such as the presence of a life-sustaining medical device (e.g., endotracheal tube, healing percutaneous feeding tube tract) that if disrupted would create immediate jeopardy to the resident’s health - specifically in a resident who is at high risk for unintentionally disrupting that device (e.g., a delirious resident).
10.3The following methods of restraint must not be used: