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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Our staff is noticeably more competent in caring for residents admitted with major psychiatric symptoms, and is able to keep them stabilized through alternate methods (although recently we have noticed a few admitted residents with histories of alcoholism, which has resulted in more difficulty in refining a treatment plan).

Lastly, our residents have benefited from in-house psychiatric care. We have been able to minimize the incidence of transfer of residents to the hospital for psychiatric care. Conversely, when hospitalization is required, it is facilitated by collaborative efforts spearheaded by our psychiatrist and his psychiatric team.

IV. Obstacles

Describe major, persistent or highly frustrating obstacles you experienced in implementation, and indicate how you coped with the difficulties.

With physical restraints, staff attendance at initial restraint reduction meetings was intermittent at best. Staff buy-in to the program was a slow, tedious process. Some staff refused to attend the initial restraint reduction meetings, even though they were notified of them. It was difficult to convene a multidisciplinary team on a regular basis, as well as on an as-needed basis. This was further hampered by staff failing to have residents ready for restraint reduction committee evaluation at their scheduled times. Some staff threatened to call residents' families, believing that we were endangering resident safety. This fed on families' fears, many having authorized restraints for their loved ones sight-unseen. Even some of the facility's upper management expressed doubts about resident safety in our moving to become a 0% restraint facility.

With our chemical restraint reduction efforts, once the psychiatrist was on staff, we found staff expected the psychiatrist to "cure" these residents. When they learned the residents' problems were not of a curable nature, they perceived the psychiatrist to be ineffective. It took time for the staff to learn to accept dementia as an incurable disease needing lifestyle and medical management.

When the intervention program was in place, it became a challenge for the staff to implement it consistently. Staff did not always follow the plan, creating delay in monitoring the success of various interventions. The staff also failed in some instances to notify the psychiatrist when major changes were noted in resident behavior.

There were also instances when the medical director, involved with every admission, would write an order for a psychiatric evaluation before the interdisciplinary team had evaluated the newly admitted resident, thus bypassing their data gathering. This was corrected through the intervention of the Administrator of Nursing Services to ensure that the interdisciplinary protocol was followed.

With staff better trained to identify potential behavior problems, and an increase in caseload, the psychiatrist increased the number and length of his weekly visits with our residents. The psychiatrist now attends the monthly quality assurance meeting to report on residents' progress.