Pulling together for restraint reduction: submitted by Botsford Continuing Care Corporation - The 1996 Optima Awards: Resident-Focused Care - Cover Story

Nursing Homes,  Sept, 1996  by Linda S. Mlynarek,  Linda C. Mondoux

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How were the results used to formulate interventions?

The team involved in the physical restraint reduction pilot program had to be very cautious in their next steps, as failure could bring the loss of staff support. They placed the waist-restrained resident in a self-releasing waist restraint and taught him how to release the restraint at his own choosing. Staff directly involved with the resident carefully monitored him during the initial phase for attempts to ambulate alone, thus creating a risk for fall and/or injury.

They met with the resident after one week to review his progress, both from the staff's and the resident's perspective. The staff felt his behavior had been appropriate and decided to take "the big step" and remove the restraint entirely.

To their surprise the resident, who had always sat in the hallway waiting for staff to take him to activities or meals, became mobile. When it was time for meals, he would propel his wheelchair to the dining room. If there was a program in which he wished to participate, he propelled his wheelchair there. We discovered in follow-up discussions with the resident that he had believed that, when he wore the restraint, he couldn't move the wheelchair!

For our residents who were chemically restrained, the psychiatrist recommended changes in any aspect of the residents' environment that might impact a negative behavior pattern. These included, in part, changes in medication type or dose, room changes, and provision of one-on-one therapy. Staff and family were informed of the psychiatrist's intentions with regard to resident care throughout the individualized care plan process.

The charge nurse also monitored the lab results and behavior changes as documented on the behavior report, notifying the psychiatrist as needed for medical intervention. This nurse served as a liaison between the psychiatrist and nursing staff.

As the psychiatrist's caseload increased, he hired a clinical nurse specialist to provide one-on-one and group therapy during the week, thus allowing the psychiatrist the time for evaluations. This also permitted time for the psychiatrist to conduct 14-day evaluations for newly admitted residents.

Meanwhile, the psychiatrist inserviced the interdisciplinary team on psychiatric drug signs and symptoms and on treating the elderly depressed resident.

What findings or conclusions emerged?

The team working with the waist-restrained resident learned how important it was to talk with the resident and staff, and truly understand their fears and frustrations. Based on this experience, we decided to roll-out the program to the entire facility, utilizing the motto, "Retrain, Don't Restrain" (the title of an American Health Care Association program that our facility purchased for inservice use).

For our chemically restrained residents, the need for interaction with a psychiatrist was confirmed through his caseload increase; this reinforced our intent to conform with the OBRA mandate concerning reduction of psychotropic medications.