Introduction
The use of physical restraints in the care of psychiatry in-patients has been prevalent for centuries. However, in recent years there has been a call among nurse practitioners to reduce and altogether eliminate the process which is in contrast to the goals and ethical practices of the nursing professions which states that all human beings have the right to autonomy and the right to be treated with dignity. After examining the existing research on the use of restraints, it is proposed that a reduction in restraints is beneficial to patients and improves quality of care. This paper will present a method to devise a plan to implement this quality improvement initiative.
Background
The term restraint means to restrict, confine, limit, or deprive of personal freedom of action of a person through the use of physical means like reducing movements of upper and lower body by physically handling them. Restraining psychiatric patients has been a common practice in the event that the patient is likely to injure themselves or others. It was proposed as the method for promoting patient safety. However, it is also used as a treatment method although international standards clearly state that restraint must be used as an emergency measure only. Physical restraint is a specific form of coercion that restricts movement and limits patient freedom . For several years, following incidences of injuries and deaths through the use of restraints, the nursing profession has been involved in attempts to reduce use of restraints for psychiatric patients in order that they receive equitable and patient-centered care . Studies have shown that control interventions may have long term detrimental effects both for patients and caregivers which reduces effectiveness of treatments , . Psychiatric in-patients who had been exposed to physical restraints were more likely to have difficulty consenting to treatment, make themselves understood and had difficulty adhering to medication. Patients have also reported feelings of isolation and dissatisfaction with the treatment process in general . Apart from this, ethical questions have also been raised with respect to the problem of abuse which is unacceptable and with respect to identifying the circumstances in which the use of restraints is acceptable . Therefore it becomes clear that the use of restraints need to be reduced or altogether eliminated in order to improve the quality of care for psychiatric patients.
Any change comes with its own set of challenges. The biggest challenge is to overcome resistance from the people impacted by the change. Changing people’s behavior, that is, their approach to the use of physical restraint will be more difficult to overcome than strategy, systems and culture . Therefore a framework is provided within which the change in quality of care can be implemented. Kotter’s Change Management Theory is applied to this particular scenario since the biggest challenge here is changing established practice and personnel perception that restraint is a necessary tool in psychiatric treatment. Kotter’s theory has eight steps which can be roughly grouped into three phases . The first is to create the climate for change by establishing the urgency by helping people see firsthand the need for the change. This is done by first creating a group of people who have the power to lead the change, who will develop the vision and the strategy for the change. In this case it will be the nurse practitioners and doctors who work regularly with patients requiring restraints in the course of therapy. The next phase is to communicate this vision to the organization so that the organization and the people in it are engaged with the change process and can work towards enabling it. To enable acceptance of change the organization must device incentives for adopting the change because as time passes, the urgency will drop and the change will stall. In this case, the cases where use of restraints was limited or not at all it can contribute to positive points in the performance evaluation of the practitioner. By providing short-term wins, the initiative can be sustained over a longer period. This leads to the final phase of change management – implementing and sustaining the change. The small gains have to be consolidated to produce a process that becomes a habit and ensure that the new approach becomes entrenched in the organization’s culture. There has to be continuous focus on the changes and declaration of success must be deferred until tangible results are visible. This framework also allows for continuous engagement with the staff and allows them to take decisions in favor of the change by applying the change and enjoying the benefits firsthand. By allowing nurse practitioners to take the decision of managing symptoms without restraints, it creates an environment of empowerment. By empowering staff, the organization can ensure that the changes will be accepted faster and applied more diligently .
Improvement Tool
In order to understand the need for reduction in the use of restraints in psychiatry, the fundamental reasons for the current use of restraints and their effects have to be identified. For this purpose the cause and effect diagram or the Fish Bone Diagram can be used to show why restraints are used in psychiatric treatments for in-patients. Knowing the barriers can help to understand how each can be overcome so that the ultimate outcome of reducing restraint-use can be achieved. The Fishbone approach requires that a problem be clearly stated; in this case the problem is the use of physical restraints causing poor outcomes for psychiatric in-patients. The next step is to categorize the various inputs to the problem statement. In this case the categories would be stage of hospitalization, the reasons for using restraint, patient responses to restraints and treatment results. The third step is to identify the contributing factors to each category. In this case the contributing factors to barriers are historical use, lack of patient’s self-recognition of symptoms, limited successes of restraints recorded in many cases, the fact that some patients respond better to restraints than others and the mixed outcomes in studies about the extent of negative effects of restraints on patients. The next step is to assess why these factors contribute to the problem. And the final stage is to understand the deeper factors. Given the historical usage of restraints in psychiatric treatments, the barriers to change will be considerably large and this method will help assess the depth of the problem before implementing the changes to overcome these barriers.
Model
In keeping with the analytical nature of Kotter’s process and the Fishbone tool, the quality improvement solution can be implemented using the FADE model.
Focus (F): The goal of this quality improvement initiative is to reduce or negate the use of physical restraints in the care of psychiatric in-patients at hospitals. A study showed that physical restraints are harmful to patients and also increase the exposure to occupational hazard for nurse practitioners in mental health care (their risk of injury is 6.8%) . Of practitioners exposed to aggression over 40% experienced some level of psychological distress. However the use of restraints did not appear to reduce the risk, in fact there were indications that attempts at restraining could increase the risk of injury to both caregiver and patient. Extreme cases have resulted in deaths of patients . Another study showed that by not using restraints, there was no significant increase in the risk of injury through assault. In the light of evidence (or lack of it) regarding the efficacy of restraints as a therapeutic procedure, a restraint-free environment is beneficial for patient outcomes.
Analyze (A): In order to plan for reduction in restraints there is a need to examine the current perception of restraints among nurse practitioners. The extent of use of restraints and their effectiveness also needs to be evaluated. The first can be achieved through a survey and the second can be achieved through a study of the case files and making calculations based on the statistics thus gathered.
Develop (D): The reduction of restraint use should be planned in conjunction with nurse practitioners and doctors. Cases must be identified where restraint is not essential and a progressive decrease in use must be planned. Outcomes of the reduced use must be recorded. The plan must be delivered to also capture resource requirements and supervisory requirements.
Execute: Once the plan is devised and the subjects identified, the progressive reduction in restraints shall be implemented. The execution of the plan will be done under supervision of doctors and data shall be recorded as to how much restraint was reduced, how many resources were required and what the outcomes were when restraints were reduced.
Resources
At the outset, it would appear that the resources required for providing non-restraining treatments would be more since more staff would be required to manage a patient. However, therapy should be designed to reduce the number of incidents intervention is required. As the patient’s condition improves, staff intervention and therefore cost should also reduce. Facilities must also be modified to incorporate the lack of restraints which may add to cost one time; for example creating an area that is surrounded by Plexiglass where a patient can spend time alone when a violent episode is imminent while still being able to see and hear people, which reduces the sense of isolation. Providing counseling and education for patients to self-recognize the onset of violent episodes can help in reduction of application of restraints.
Evaluation methods
As with every system, the efficacy of reduction in use of restraints in relation to patient outcomes can only be measured through regular evaluation of the data that is collected and independent evaluations of the patients themselves. The first evaluation method requires data to be captured for each patient for whom restraint usage is reduced systematically. The data captured could be as follows:
This can be displayed in the form of a chart to display the changes from the baseline (see Appendix 1, Figure 1).
The second evaluation method is qualitative and captures the perceptions and feelings of patients when restraint has been used and when it hasn’t been used. The data could be presented in a column graph (see Appendix 1, Figure 2).
Conclusion
The use of restraints in therapy for inpatients of psychiatric care has been prevalent for several decades. In recent times there has been a call for improving quality of care through the reduction of restraint usage. This paper proposes a method for devising a quality improvement plan. The application of Kotter’s Change Management principles and utilizing the cause and effect diagram will help to identify key barriers and how to overcome them. The plan shall then be implemented using the FADE model and regular evaluations shall be done to verify the efficacy of the quality improvement plan.
Appendix 1
Figure 1: Chart to depict reducing trend in requirement of restraints following the implementation of the Quality Improvement (QI) plan.
Figure 2: Chart to depict the changes in patients’ feelings after implementing the Quality Improvement (QI) plan.
References
Abdollahzadeh, M. (2013). Empowerment and Organizational Change. International Research Journal of Applied and Basic Sciences, 4(1), 1-5.
APNA. (2014, April 8). APNA Position Statement on the Use of Seclusion and Restraint . Retrieved from APNA: http://www.apna.org/i4a/pages/index.cfm?pageid=3728
CIHI. (2011, August). Restraint Use and Other Control Interventions for Mental Health Inpatients in Ontario. Retrieved from Canadian Institute for Health Information.
Keski-Valkama, A. (2010, February). The Use of Seclusion and Mechanical Restraint in Psychiatry. Retrieved from University of Tampere.
Knox, D., & Holloman, G. H. (2012, February). Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. West Journal of Emergency Medicine, 13(1), 35-40. doi:10.5811/westjem.2011.9.6867
Kotter, J. (1996). Kotter’s 8-Step Process for Leading Change. Retrieved from Kotter International: http://www.kotterinternational.com/the-8-step-process-for-leading-change/
Minnesota Department of Health. (n.d.). Fishbone Diagram. Retrieved from Minnesota Department of Health: http://www.health.state.mn.us/divs/opi/qi/toolbox/fishbone.html
Mohr, W. K., & Petti, T. (2003). Adverse Effects Associated With Physical Restraint. Canadian Journal of Psychiatry, 48, 330-337.
Neumeier, M. (2013). Using Kotter’s Change Management Theory and Innovation Diffusion Theory In Implementing an Electronic Medical Record. Canadian Journal of Nursing Informatics, 8(1&2).
Petrini, C. (2013). Ethical considerations for evaluating the issue of physical restraint in psychiatry. Ann Ist Super Sanità, 49(3), 281-285. doi:10.4415/ANN_13_03_08
Sarayreh, B. H., Khudair, H., & alabed Barakat, E. (2013). Comparative Study: The Kurt Lewin of Change Management. International Journal of Computer and Information Technology, 2(4), 626-629.
Stewart, D., & Bowers, L. (2009, June). Manual restraint of adult psychiatric inpatients: a literature review . Retrieved from City University London: http://www.kcl.ac.uk/ioppn/depts/hspr/research/ciemh/mhn/projects/litreview/LitRevManRestr.pdf
