Restraint Free Patient Care Sustaining a Culture of Restraint Free - PDF document

APNA 29th Annual Conference Session 4015: October 31, 2015 Restraint Free Patient Care Sustaining a Culture of Restraint ‐ Free Patient Care: A Collaborative Effort to Educate Military Healthcare Professionals in the Restraint ‐ Free Management of Patients Joseph P. Tomsic, PMHNP ‐ BC, NEA ‐ BC Naomi L. Winterheld, ACCNS ‐ AG Disclaimer The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the United States Air Force, Department of Defense, nor the U.S. Government. Speakers have no conflicts of interest to disclose. Objectives • Objective 1: Identify warning signs and triggers in patients with agitation, use appropriate calming mechanisms, understand decision ‐ making capacity, and apply LEAP communication methodology prior to the escalation of behavior that might lead • Objective 2: Understand the concept of developing restraint free patient care training that is interactive and targeted at level of learning that results in nursing practice change. • Objective 3: Describe how to incorporate interactive learning when designing training to change clinical practice Tomsic 1

APNA 29th Annual Conference Session 4015: October 31, 2015 Enabling Objectives Background • Research • Key points • Design of education plan • – Developing Levels of learning – Small group facilitated discussions – Triggers, warning signs and calming mechanisms (TWC)/exercises – Review scales to measure agitation – Explain decision ‐ making capacity (DMC) – Applying Listen ‐ Empathize ‐ Agree ‐ Partner (LEAP) – Review pharmacologic management – Review restraints as a last resort Conclusions/closing remarks • Background • Royal Air Force Lakenheath Military Treatment Facility • “Restraint Free” added to policy in 2009 • Worked closely with the MTF Chief Nurse and multi ‐ purpose ward clinical specialist • Staff educated April 2014 • Restraint events: 2011 ‐ 3, 2012 ‐ 6, 2013 ‐ 3, 2014 ‐ 0, 2015 ‐ 0 (as of August) – Approximately 65% initiated by RNs Current Research • To sum it up, restraints are… – a low ‐ frequency, high ‐ risk patient care intervention – often avoidable • Places to look for information – Agency for Healthcare Research and Quality (2000+ articles • http://www.ahrq.gov/index.html – The Joint Commission (2700+ articles) • http://www.jointcommission.org/ – National Guideline Clearinghouse (often overlooked) • http://www.guideline.gov/ See Handout #4 for references Tomsic 2

APNA 29th Annual Conference Session 4015: October 31, 2015 Current Research (cont.) • Serious injuries and even death have been linked to the use of physical restraints. • Chemical restraint may lead to over ‐ sedation, the development of cardiorespiratory compromise, decreased gastrointestinal motility, DVT and other complications. See Handout #4 for references Key Points Everything stops until safety can be established. Safety What is the safest alternative? What is needed to provide the safest alternative? Suicidal ideation is a medical Suicidal emergency. and Homicidal ideation is a Homicidal medical emergency that carries a duty to warn for Ideations health care professionals. Work quickly to determine cause of agitation, many Patient diagnoses/substances can Assessment cause psychosis and/or agitation. Developed by J. Tomsic Levels of Learning: Cognitive Objectives Evaluation: validate learning in the clinical setting Clinical practice change happens at the higher levels of learning Synthesis: generate new interventions to calm patients Analysis: relate learning to current practice Application: demonstrate the use of new interventions Comprehension: generalize the need to prevent restraint use Knowledge: identify triggers, warning signs and calming mechanisms See Handout #1 for more on levels of learning Developed by J. Tomsic Tomsic 3

APNA 29th Annual Conference Session 4015: October 31, 2015 Levels of Learning: Affective Objectives Internalizing: Automatically considers calming mechanisms Clinical practice change happens at the higher levels of learning Organization: Values avoiding the use of restraints and organizes this into clinical priorities Valuing: Safe patent care is an important value Responding: Works with peers to discuss study questions and participates in role ‐ playing exercises Receiving: Is open to learning new interventions and skills to avoid using physical restraints See Handout #1 for more on levels of learning Developed by J. Tomsic Exercises • Small Group Discussion – What is your current attitude concerning the use of restraints? • Case Studies – When does a medication for agitation become a chemical restraint? See Handout #2 for example questions Triggers Common Triggers Receiving Feeling Not being in Isolation Loneliness Fear Darkness Noise Bad News Pressured Control Medical Professional Induced Triggers Talking Boundary Lack of Visiting Repeated Interruption Medical Touching Down to Invasion Privacy Hours Questions s Jargon patients Critical Triggers Not Being Being Yelled Being talked Being Not Being Being Being told to Being Teased Taken at down to Pressured Listened to Laughed at stay in room Seriously Taylor ‐ Trujilio, A., & Seams, B. (2011). A Violence Prevention Model for Acute Behavior Health Care. Paper presented at the APNA, Anaheim, CA. Tomsic 4

APNA 29th Annual Conference Session 4015: October 31, 2015 Warning Signs Early Warning Signs Clenching Wringing Threatening Refusing Poor Eye Restless Talking Fast Fidgeting teeth Hands to go AMA Care Contact In the Middle Warning Signs Demanding to Refusing PRN Walking away Not listening Not answering Clenching Fists No eye contact leave medications Late Warning Signs Making Bouncing Clinched Pacing Yelling Target Lock Shaking Rocking Threats Legs Fists Taylor ‐ Trujilio, A., & Seams, B. (2011). A Violence Prevention Model for Acute Behavior Health Care. Paper presented at the APNA, Anaheim, CA. Calming Mechanisms Interpersonal Calming Mechanisms Calling Gender Talking to Therapeutic Speaking to Getting a Having Hand Command family or Specific family Touch Staff Hug Held Support friends Support Individual Calming Mechanisms Listen to Deep Spiritual Exercise Journaling Molding Clay Meditation Reflection music breathing Practices Environmental Calming Mechanisms Change Going for a Comfort Take Hot or Lying down Quiet Room Time alone Step Outside lighting or walk Room Cold Shower Temp Taylor ‐ Trujilio, A., & Seams, B. (2011). A Violence Prevention Model for Acute Behavior Health Care. Paper presented at the APNA, Anaheim, CA. More About: Triggers, Warning Signs and Calming Mechanisms • Incorporate into initial and ongoing assessments • Helps to provide patient ‐ centered care • Should be reassessed frequently • Can be assessed during patient rounding • Powers Individual Agitation Prevention Plans • Practice, Practice, Practice Tomsic 5

APNA 29th Annual Conference Session 4015: October 31, 2015 Small Group Exercise Triggers and Calming Warning Signs Mechanisms Handout #3, TWC Learning Deck Warning Signs Calming Mechanisms Case One: A patient lets the nurse know on admission that they do not like being in the hospital. The patient states they do not feel in control, hospitals are noisy and they never understand what nurses are saying. You find the patient the next day very upset and agitated after a lab technician draws a blood sample. The patient is yelling that the tech did not ask before touching her, does not understand why there are so many lab tests and is threatening to go AMA. You go to speak to her and explain in layman’s terms why the tests are needed, get her in contact with her family and make sure the room is quiet and comfortable. After a few minutes the patient calms down. Triggers, warning signs and calming mechanisms worksheet developed by J. Tomsic v1.1 What additional calming mechanisms do you think would be appropriate? Handout #3, TWC Learning Deck Warning Signs Calming Mechanisms Being Touched Yelling Layman’s Terms Not being in Refusing Care Call Family Control Threatening to Calming Medical Jargon leave Enviroment Triggers, warning signs and calming mechanisms worksheet developed by J. Tomsic v1.1 Handout #3, TWC Learning Deck What additional calming mechanisms do you think would be appropriate? Tomsic 6