The Use and The Risks of Restraints - Research Paper Example

Introduction In sensitive and long-term health care situations, restraints are used to slow down a patient’s physical movements which may cause harm or disrupt the treatment process. They are usually administered through physical means where devices which the patients are unable to remove are used or chemical means whereby medications are administered to the patient. It is highly recommended that these chemicals should have a label indicating their use (The Food and Drug Administration (FDA) 2009). Physical restraints include; roll belt for the waist, wrist restraints, Swedish belt for wheel chair, and leather bands amongst many others. The use of restraints is not a guarantee for prevention of injury. There are several other alternatives which can be used to prevent harm or injury in patients, and so restraints should be used when there is no other choice. The presence of family members is significant in the reduction of agitation in a patient. It is therefore important for family members to visit their sick as often as possible. This should be done when the patient is not in a stressful mood such as during mealtime (Mason, T., & Chandley, M. 1999 pp. 68-74). The Use of Restraints It is necessary for an extensive review to be carried out before administering physical restraints on patients, especially where there are no emergency cases. Considerations should be done in order to ensure that there is no other alternative apart from physical restraint. Health care workers have an obligation of encouraging collaboration amongst all the people involved in a particular case, beginning with the patient and the family members, social workers, physical therapist etc. It is important to engage a team from a variety of disciplines in order to ensure that all factors that can facilitate normal treatment without restraint are put in to reflection. In case restraints must be used, health care workers should use the least restraining method. It is important for them to review the decision from time to time as well as regular assessment to determine the effectiveness of the restraint. Through this, it is easier to determine the available alternatives that can work better (Kemshall, H and Pritchard, J. 1999 pp.36-47). Investigations in to the cause of the actions in the patient which necessitate intervention and trying to eliminate them before using restraint are important. This is because the problem may be the behavior of staff that triggers the actions of the patient. There is also the need to ensure that instructions are followed when administering physical restraints. Without such precautions, it may be injurious to the patient especially to the skin. The health care workers are supposed to understand that maintenance of the health of the patient is their duty. They should guarantee the safety of the patient through careful handling especially when restraint must be applied. The orders to administer restraint should be given by a licensed health practitioner who assesses and certifies the need for the use. It is necessary to ensure that limbs are not restrained for a long time without exercise. The patient should be allowed to interact with visiting family members and friends. He should not be denied comfort and access to information. The care givers should be trained regularly on the use of restraint as well as alternative strategies other than restraint (Davies, W., & Frude, W. 1999 pp.67-78). Legal Issues There are several regulations that prohibit the use of restraints in nursing homes. These were set by the Omnibus Budget Reconciliation Act 1987 (OBRA). They seek to ensure that there is discipline and expediency in the use of restraint. Under these regulations, nurses are required to conduct a wide ranging investigation in to the challenging behaviors of the patients. They are also required to document the agreements amongst themselves before instituting restraints, and whether it was the last resort as recommended by the regulations. All alternatives should be tried and restraint should be employed only when they have failed. More over, the rules recommend that information regarding the devise to be used in restraining the patient be offered to a legal representative or a family member, after which it should be used for a short period of time (Health & Education Services 2009). It is however recommended that the emergency restraint be applied in case of a situation where life is threatened. There are extra guidelines regarding the use of restraint. These have been set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which cover all the health care facilities which use isolation and restraint. The free standing psychiatric hospitals and treatment centers in residential places are included. The guidelines are applied in cases which involve behavioral health (Crowner, M.L. 2000 p.76). Alternatives to restraints With the absence of restraints, it is important to consider several other methods that can assist in the management of difficult behaviors amongst patients. Recreational sessions can be useful in prevention of situations that may necessitate the use of restraint. Several other methods such as improved physical therapy, pads and cushions can also be effective in avoiding problematic incidences. The presence of attentive staff is essential in solving problematic cases. Proper education to staff is necessary in order to equip them with the desired knowledge in regard to handling complex situations. Many health care facilities have achieved the use of alternative methods through educating their staff (Turnbull J., & Patterson B. 1999 pp. 78-83). Training should be a continuous process in order in order to ensure the effective performance of staff. This can effectively be achieved through constant studies in work place routines, whose performance is usually the obligation of informed and skilled people. They are people who care about the outcome of their activities. Their actions are usually governed by institutional or organizational regulations as well as personal perspective and profession. Administration of restraints requires a strong ethical background with a strong will to act positively. However, the procedures may at times be challenging to the health care personnel, necessitating guidance and thorough inspection. In order for the managers to be competitive in offering guidance to the work force, they should be well informed in regard to all the procedures. Due to their multiplicity, it is usually difficult for a manager to grasp all at once. It is therefore necessary to ensure that they study adequately in order to offer the appropriate guidance (Crowner, M.L. 2000 pp. 67-71). Studying of healthcare work place procedures involves continuous learning especially when the nature of the problem to be solved and the outcome of the restraints vary from one situation to the other. The health care profession is usually faced with the challenge of dealing with related cases which respond differently to procedures. A particular procedure can not be applied in all the situations and end up in similar results. Health care managers are therefore required to hold back from assuming that the everyday practice is common sense (Crowner, M.L. 2000 pp. 16-21). They should be keen to learn through experience in order for them to understand the variations in implementation of the procedures. This allows them to be informed advisors. On the other hand, flexibility in the manner through which restraints are organized in is essential in order to give the system a chance for improvements. This necessitates studies by health care mangers in order for them to be in a position to identify new ideas which can be incorporated in to the organization to boost performance, and remove the obsolete ones which are no longer necessary. The gradual learning process allows health care managers to learn from situations which arise in the system. It is usually difficult to learn everything at once (Braine.M. E. 2005). While putting the welfare of the patient in the fore, it is necessary to have healthcare staff who feel appreciated and empowered. This can help in motivating them while in their duty, dealing with many kinds of service users. When a healthcare staff is kicked by a violent patient, the morale is lost and he/she can not have the desired confidence while dealing with patients. The staff should be given the necessary attention as well as proper training in order for them to deal effectively with such cases. There should be an all-inclusive approach for developing a strong culture of managing and preventing the occurrence of violence against staff and other service users by discontented patients. This culture should be developed through an integrated approach of understanding the physical environment, assessment of the risks associated with clinical practices, data collection about the incidences of violence amongst patients as well as formulation of policies that can assist in prevention of violence (Chein W. T. 2003. pp. 425-430). At times, things might happen too fast and result in injuries if the necessary action is not taken in an equal swiftness. This is why it is usually important to capitalize on primary prevention which is easier and less risky. Communication with aggressive patients in order for them to cool down is necessary as a de-escalation technique without involving restraints. However there should be a framework of approaching such a situation (Krahe’,B. 1999 pp.56-57). The health care professionals should be trained and knowledgeable on how to assess the possibility of physical confrontation. This is because verbal de-escalation in a bid to avoid restraints may be misunderstood by the patient and can result in worsening of the situation. The nurses should be trained on practical approaches in order to deal effectively with such a situation. They should be able to understand the possible stimulus that can lead to violence and injury. Pros and Cons of Restraints The use of restraints is usually the initiative of nurses. The main reason for using them is to ensure that they are not exposed to harm by a problematic patient. The other reason is to prevent them from causing harm to the other patients as well as to protect them from injuries which may occur as they engage in risky actions such as moving out of the bed without support. Restraints can also assist healthcare workers to administer treatment to resisting patients. On the other hand the nursing staff may not be sufficient to attend to all the patients within a healthcare facility. It becomes necessary to restrain the patients in order to allow the health care workers to follow an organized way in administering the treatment. This is usually common in emergency cases such as accidents involving many people for example bomb victims. In incidents of this nature, patients flock in to hospitals with multiple injuries, which become overwhelming to the health care personnel. This necessitates restraint of some of the patients depending on the level of urgency (Minesota department of health. 1999). Restraints are usually necessary especially in cases where treatment is administered in the Intensive Care Unit. This is because such patients are usually under delicate conditions whereby violent movements can lead to death. The patient is restrained for his personal safety. Other forms of treatment which are administered through delicate parts of the body necessitate restraint since they can be harmful to the patient if disturbed or mishandled. These include the use of indwelling catheters and the delicate administration of medication through the veins. On the other hand, restraints are necessary for patients suffering from dementia and other ailments which reduce the recognition of the surrounding, making the patient to move out of bed without support thereby causing injuries (Turnbull J., & Patterson B. 1999 pp. 84-87). On the other hand, restraints are known to cause depression, uncertainty, confusion and decline in self esteem. Prolonged restraints can result in permanent depression especially when there are no people available to keep the patient company. Anger may also result, escalating the problem. They are also known to low blood circulation, and many irregularities in the circulatory system which are known to lower body metabolism. Restraints in old age are known to be detrimental to the person, causing functional impairment and many other infections. According to Blofeld, J. (2004 p. 78), “Cardiac and motor weakness, cognitive disabilities and restlessness are associated with stresses due to restraints”. The intensity of the injuries caused by restraints has almost the same detrimental effects as the unrestrained problematic patient. In case the restraints are administered without following instructions of using the devices, injuries may be acquired and they may end up prolonging the stay of patients in hospital. In the administration of restraints, problems may arise especially through pharmacological sedation. The situation may be made worse by patients failing to provide sufficient history regarding their health. This may lead to the use of unnecessary forms of sedation which may lead to escalating of the disease or loss of life. Gag reflex is one of the dangers posed by over sedation causing incapacity of the respiratory system. Patients who vomit while under restraint are exposed to the risk of choking. Sedation may also cause drug interactions which may produce undesirable reactions in the body. On the side of the staff, administration of restraints may be risky especially when it involves physical action. Violent patients can injure the health workers through actions such as; kicking and biting. Some patients may even use objects hidden under their garments to hit the health workers (College of Nursing 2004 pp. 89-93). Pathways to the Use of Restraints The use of restraints should be implemented only in cases where a legalized health worker is involved. In case the restraint is to be implemented in residential health care facilities, there should be adequate information obtained from physicians, and healthcare workers in regard to the risks associated with the methods of restraint administration. This is significant in enabling the residents in to make the right decisions. They should be allowed to ask questions where they need clarification. Before embarking on the use of restraints, health care workers should make several considerations. These include; Attempts of verbal de-escalation if the patient has become aggressive. In such a situation, the nurses are supposed to ensure that they keep a safe distance when trying to talk to the patient. This is because under certain circumstances, verbal de-escalation may end up aggravating the situation further, resulting in physical assault on the health care workers. Interpersonal skills should be used effectively in order to ensure that the patient cools down without intimidation or force. He should be made to understand that there is no force that can be exerted on him to change his/her behaviour. Before making a decision of physical restrain which may involve removal of a violent patient from a room where other patients are being attended, the health care workers should exercise patience and control in order to prepare themselves for the action. This presents them with a chance of strengthening the team in order to cope with any resistance from the patient; hence they can be able to avoid incidences whereby the patient engages them in physical assault unprepared. It is also important for the health care workers to ensure that they do not create a commotion by alerting the rest of the patients who may panic while others may crowd the area creating further tension in the agitated patient. In such cases, the other patients should be encouraged to remain where they are and speak in low tones if they have to. In order to ensure cooperation from the patient, the health care workers should ensure that the patient’s confidence is maintained through providing information in regard to the safety measures undertaken by the organization to ensure that all the patients are protected from external threats. This is because some patients act out of fear of being confined in a hospital where they feel insecure. It is necessary to ensure that all the underlying factors necessitating the use of restraints are analyzed and the most appropriate action taken depending on the analysis. The observations that were made in order for the recommendations to be made should be critically assessed to enhance identification their causes. This is because they might have been caused through failures by the care providers who may have used hostile restorative techniques. It is also important to consider the various ways through which these causes can be mitigated. This can be an important measure in the prevention of situations which may necessitate restraint (Kemshall, H and Pritchard, J. 1999 pp.66-68. In many circumstances, restraining the patient is usually not effective in the long run because the causes of the problematical behaviour remain. This means that if the patient has to stay longer in hospital, there is the challenge that he/she will be problematical since the causes have not been addressed. More over, the patient can not be restrained for more than the recommended period of time. Alternative approaches should be employed if the health care facility is the cause of the problem. The patient can be moved to another facility that he feels more accommodating. If restraints are the only option, the underlying risks should be assessed as well as the possible problems that may arise due to restraint. It is necessary for the health care workers to use the standard protocols for example the Physical Resident Assessment Protocol to assist in the evaluation of the suitability of the procedures (Blofeld, J. 2004 p. 56-59). Conclusion The health care profession is usually faced with many challenges due to the uniqueness of the patient cases that are encountered. Most of the practices require a health worker to be capable of doing the correct analysis of the situation and make the correct judgment according to the available alternatives. This forms the fundamentals of effective performance. However, health care managers have the mandate of offering guidance in all decisions regarding restraint since they have authority and the appropriate knowledge as well as experience in dealing with difficult circumstances in the health care facilities. The rules and regulations governing practices such as restraint act as a guidance for the effective performance of medical personnel while maintaining protection of the patient. Work place learning enables healthcare professionals to solve problems collectively and to solve cases such as those of problematic patients without engaging risky procedures such as restraint. Bibliography 1. Blofeld, J. 2004. Independent Inquiry into the death of David Bennet. Cambridgeshire 2. Braine.M. E. 2005. The Management of Challenging Behavior and Cognitive Impairment. British Journal of Neuroscience Nursing, vol. 1(2), 67-74. 3. Chein W. T. 2003. The use of Physical Restraints in Hospitalized Patients. Journal of Psychiatry mental health nursing, vol. 10, 425-430. 4. College of Nursing 2004. Restraint Revisited: Risks and Responsibilities, Guidance for Nursing Staff. RCN London. 5. Crowner, M.L. 2000. Understanding and Treating Violent Psychiatric Patients. Washington USA. American Psychiatric Press. 6. Davies, W., & Frude, W. 1999. Preventing Face to Face Violence; Dealing with Anger and Aggression at Work. Leicester. APT Press. 7. Health & Education Services 2009. OBRA (Omnibus Budget Reconciliation Act of 1987), Health & Education Services, Inc. viewed on 25th Mar. 2009 at, < http://www.hes-inc.org/smhsa_obra.htm.> 8. Kemshall, H and Pritchard, J ed(s) 1999. Good Practice in working with Violence, Jessica Kingsley, London 9. Krahe’,B. 2001. The Social Psychology of Aggression. Psychology Press Ltd. Esat Sussex. 10. Mason, T., & Chandley, M. 1999. Managing Violence and Aggression; A manual for nurses and health care workers. Churchill Livingstone. Edinburgh. 11. Minesota department of health. 1999. Everyone Wins, Quality Care Without Restraints, Independent Production. 12. The Food and Drug Administration (FDA) 2009. Patient Restraints: Improving Safety, Reducing Use, viewed on 25th Mar. at, < http://www.enotalone.com/article/8025.html> 13. Turnbull J., & Patterson B. 1999. Aggression and Violence; Approaches to Effective Management. MacMillan Press Ltd. London Read More