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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To improve staff appreciation for psychiatric services and to improve their understanding of the reasons behind initiation of certain interventions, the psychiatrist conducted inservice sessions and began to "think aloud" during his evaluations. This helped the staff gain a more thorough understanding as to how they could impact the resident's environment and thereby his/her behavior.

An obstacle at the outset of this project was the lack of an assessment tool. The psychiatrist, clinical nurse specialist, Director of Social Services, and charge nurse developed an assessment tool for the staff to utilize to gather data prior to the first psychiatrist visit and, thereafter, during one-on-one visits.

V. Indicators of Success

Describe how the intervention contributed to the optimum well-being, function or autonomy of residents. The key is demonstrable success - evidence that the intervention achieved the objectives.

Our physical restraint reduction has made major strides since its inception. In the span of twelve months, we have progressed from having 51 residents in physical restraints to 8. There has been an increase in falls, as expected, but no correlating increase in injuries. All residents who fall with a subsequent Incident and Accident Report sent to Administration are referred to Rehabilitation Services for review and follow-up. We have seen a decline in falling incidents and believe that it may be attributable to this intervention.

Staff now questions as a matter of course any order for restraint that accompanies a resident's admission. Evaluation is begun immediately to initiate restraint reduction.

Staff now ambulates the resident who is becoming restless and agitated. If the resident is unable to ambulate, staff will encourage him or her to participate in recreational programs, or will just take time to sit and talk with the resident for a few minutes. Referrals are also encouraged, when appropriate, to our Restorative Nursing Program.

Some anecdotal evidence of success: Our facility partners with local colleges and universities to provide a site for students to complete their nursing clinicals. At one recent classroom session, a speaker from Citizens for Better Care, our state's ombudsman program, was commenting on the use of restraints in nursing homes and OBRA regulations against this practice. One of the students spoke up, sharing that her clinical experience at our facility indicated no restraints were used for newly admitted residents. The speaker didn't believe her until several other students confirmed her account. The ombudsman was speechless.

One particular success story involved the committee working with a very confused gentleman who, staff believed, would be prone to falls due to his confusion and agitation. The committee spent a great deal of time with this resident, his family members, and our own staff. We discovered that when the family came to visit, they always brought the resident his watch, which he had received when he retired. They knew how much he loved the watch and that he was always asking for it. The family had never informed the staff that they were bringing the watch during their visits and then taking it home, and the staff would find the resident mysteriously agitated after their departure. The committee suggested that the family find an inexpensive watch that closely resembled the resident's cherished watch and that they could leave with the resident. (The same situation was occurring with the resident's wallet!) We believed that the resident became agitated when the family left because he was frustrated looking for these treasured items which had "disappeared." Being able to "keep them" calmed him considerably.