The Restraint of Patient Policy at Hong Kong Adventist Hospital - Assignment Example

Policy Critique Policy Critique 0. Background of the Restraint of Patient policy at Hong Kong AdventistHospital The use of physical restraints when caring for older people has remained a common practice in many countries including Hong Kong (Ralph & Gabriele, 2013, p. 1). Originally, the use of physical restraint in nursing care was intended to promote good care that was determined by issue like practical considerations or necessity (Gastmans & Milisen, 2006, p. 148). In other words, the initial use of physical constraints was directed at controlling clinical situations perceived to be difficult by nurses like preventing patient or family from harm and falling from beds. As a result, most nurses and care givers ended up perceiving the use of physical restraint as therapeutically and morally correct (Zencirci, 2012, p. 519) especially in preventing injuries and accidents. The moralization of physical restraints use in Hong Kong, like most other countries, made it very common in caring for the elderly both in hospitals and nursing home settings. According to Lai (2007), the use of physical restraints by nurses was justified by the fact that there were few nurses and facilities such that the only way to provide safety in such nursing environments was through the use of physical restraints (Bryant & Fernald, 1997). As a result, nurses’ attitude contributed to inappropriate decision making concerning the use of restraints. In Hong Kong, the most common forms of physical restraints include trunk, limb holders, bedrails, lap tables, and mitts (Lai, 2007). However, for some nurses, the use of physical restraints was as a result of pressure from management or the patient’s family or both. According to Lai (2007), pressure from management prompt nurses to use physical restraints in order for them to have content to write in their incident report and patients who got hurt from lack of restraints would land the nurse in trouble with family members. Additionally, most nurses end up using physical restraints for lack of something to replace them since this would mean they have no responsibility when patients’ fall (Lai, 2007). Another reason why nurses resort to using physical restraints is the insufficient communication between numerous parties including management, patient families, patients, and front line staff. According to Lai (2007) the fact that some families’ attitudes and misunderstandings on the issue of physical restraints elevated the pressure facing nurses compounded to the need by nurses to use restraints. In some cases, the use of physical restraint is requested by the patient for fear that they may fall and no matter how much the nurse tries to convince them otherwise, the patient insists. In such a case, the patient compels the nurse to have physical restraints in place promising to use the call bell when they need them removed (Lai, 2007). Additionally, institution stakeholders’ viewpoint differences for lack of proper communication amongst various parties result to difficulties in apprehending the need to reduce physical restraints and apply what is best for the patient. As a result, Lai (2007) reveals that the institution resorts for usual practice of applying physical restraints to manage and control patients. 2.0. Brief Overview of Restraint of Patient Policy at Hong Kong Adventist Hospital At Hong Kong Adventist Hospital, Restraint of Patient policy is intended at creating a physical, cultural and social environment where restraints are only applied in justified and clinically appropriate situations. Additionally, the hospital management intends to have the policy so as to protect the health and safety while preserving the rights, dignity and well being of patient. To promote patients’ health and safety, the policy focuses on educating staff, patient family, and patients on preventative strategies, innovative substitutes, and improvements of the process. The Restraint of Patient policy at Hong Kong Adventist Hospital goes on to reveal that the institution recommends the use of restraints only when alternatives have been determined as contraindicative, insufficient, or ineffective in patient or other people’s protection from injury. Towards this cause, the only time to apply restraints in caring for the patient is during emergencies where the patient is subject to harming self, staff or others and there is reported inefficiency in other non-physical interventions. The defined alternatives to the use of physical restraints at Hong Kong Adventist Hospital are pain relief and comfort measures provision; regular provision f assistance to the bathroom; reduction of extraneous noise; increasing patient supervision by bringing him or her closer to the nurse station; diversion activities like reading, TV and music; repeated repositioning; patient education and orientation; and organizing regular supervision by private nurse, family or maid where appropriate. For a nurse to offer patient restraints at Hong Kong Adventist Hospital, they have to demonstrate competence through evaluation; must only use commercially produced physical restraints as specified by manufacturer, and that can easily be removed in case of emergency; and ensure that assessment, reassessment, monitoring and care of patients under restraints are recorded in the patient chart. During assessment and reassessment, the nurse is expected to identify injury during restraint; hydration or nutrition needs; hygiene/eradication; assessment of skin at restraint site; pain/comfort, environment/safety/dignity; patient mental status; and range of motion limits and circulation amongst others. The nurse should also identify and respond appropriately for life safety events, during death or injury of patient. The Hong Kong Adventist hospital also outlines the procedure for application or withdrawal of restraint from a patient in terms of what the nurse responsibilities are during the procedure. The alternative measures for restraints in the institution are avoidance of prolonged bed rest when no medical provision requires so; efforts to ensure that patient remains under customary pattern; focus on typical patient comfort measures; and ensuring continuity of care provision to patient; elimination of nonessential procedures and treatment amongst others. Other defined alternatives include psychological interventions environmental intervention, and diversionary intervention. In order for the institution to reduce restraints use amongst all involved staff, training requirements are provided for direct care staff, staff authorized to physically apply restraint, staff with the authority to perform the 15 minute assessment, and staff mandated to commence, retain, or perform evaluation or re-evaluations. 3.0. Consultation with consumer and colleagues to develop an updated policy In the context of introducing an updated Restraint to Patient policy at Hong Kong Adventist Hospital, substantial changes to the existing policy are expected and this will affect the patients and staff work culture and practices. In order to achieve sustained improvements a sense of ownership should be promoted through changes in attitudes of the consumers and staff concerning the quality of service currently provided and those expected as a result of updating the policy. The engagement component in the updating of the restraint policy is aimed at raising staff and stakeholders’ awareness of the concept of the updated policy and offered and understanding of the procedure to be implemented including issues of concern and benefits to stakeholders. The process involved several key aspects which are engagement in initial meetings with patients and institution stakeholders; presentation of the major policy components requiring improvement; conducting consecutive awareness meetings with the staff; and preparation, documentation and implementation of the updated policy. Consultation or stakeholders’ engagement in the development of the new policy involves steps outlined by The Australian Councils for Healthcare Standards or ACHS (2013, pp. 22-29). During the initial meeting, the objectives were to confirm the institution stakeholders’ direction in implementing the updated policy including any room for future changes and a framework for the institution wide program; obtain a consensus on the content of the updated policy; identify potential staff and patients to visit and engage in both within the authorized and direct care nurses population; and identification of any issues that could be presented from the visits, and by nurses or patients. Within a two week period, several staff and patients are monitored on their response to the updated restraint policy. During the second meeting after about two weeks, a presentation is done covering the institution’s commitment to continued quality improvement through restraint-free patient care; an outline on the updated Restraint of Patient Policy for Hong Kong Adventist Hospital; an overview of the observed benefits of the updated policy on patients care, nurses, and the institution; and necessary training needed for the stakeholders to adhere to the updated policy. This meeting will be more of a stakeholder’s communication and information to cover the information obtained during the updated policy trial period. With the updated policy well understood and improvements made depending on stakeholders’ needs, visits will be done during various shifts to monitor the level of nurse and patients’ engagement into the updated policy. In this case, any misconceptions about the policy/continued improvement of quality through restraint-free patient care will be clarified. Additionally, all available resources and quality improvement activities will be identified and nurses made aware of them; and ensure that the hospital continuously encourage activities that promote improvement of quality. 4.0. Review of evidence base to inform the context of the updated policy According to Gastmans & Milisen (2006), the use of physical restraints among older persons in nursing homes has to consider essential values and norms that reflect an ethical evaluation of physical restraint. Some of these ethical values and norms include respect for autonomy and older people’s well being; prioritizing the focus on the alternatives to physical restraint, interdisciplinary decision making; individualized care; and updated institutional policy. According to Qureshi (2009), although nurses in care homes for older people have different opinions on what restraints is and are not sure how to balance their responsibilities to take care of patients with the rights of patients to make their own decisions. In this regard, the updated policy recognises the range of related meanings concerning the term ‘restraint’ and offers the purpose in which each meaning applies. Ralph & Gabriele (2013, p.11) highlight that lack of static definitions of restraint resulted to nurses using the strategy of restraint re-definition based on the expected benefit of their patient instead of the positive intention in using it. This way, nurses managed to cope when employing physical restraints against their will. Additionally, Joanna Briggs Institute (2002), in order to apply physical restraints effectively, the hospital has to identify specific populations amongst the patients including cognitively impaired person; persons at higher risk of falling; violent or agitated patient; person who tampers with medical devices; persons with impaired mobility; and person who wanders. With the right definition of restraint and a specific population, patient management is easy especially in the identification of alternatives to restraints. For instance, a violent person could be provided with soothing music or offered diversion through radio or TV (Joanna Briggs Institute, 2002, p. 4). Further, Zencirci (2012, p. 2) adds that with the right information about a patient in terms of the specific population they are classified and the right restraints definition, barriers to restraint elimination like fear of patient injury, lack of information and education about alternative amongst other barriers will be eliminated. Ralph & Gabriele (2013, p. 14) reveal that by strictly changing the institution restraint policy towards a restraint-free environment, there are positive impacts on the nursing practice. In this case, the updated policy intends at ensuring that the nurses’ attitude change to prioritize alternatives to restraint over physical restraint interventions. Nurses Working for Nurses (2003, p. 8) highlights that the promotion of a restraint free hospital environment requires the use of individualized care informed by patient’s baseline history prior to admission. This way, the nurse manages to gain an understanding of the patient in terms of areas of mobility, mental status, disruptive behaviours, and patterns of sleep. Using this information, a multidisciplinary team will then design appropriate patient care needs and best alternatives to restraints for therapeutic intervention of patient’s condition depending on the specific population where the patient is classified (Joanna Briggs Institute, 2002, p. 2). However, in the cases where restraints are deemed appropriate, the updated policy offers ethical principles to guide the nurse towards appropriate practice. These ethical principles are Beneficence, non-malfeasance, justice, and autonomy. These principles should however be tailored to appropriate individualized care plan with detailed outcomes. 5.0. Review of evidence base focused on guidance to successful implementation policy in practice According to Schnelle, et al (1997, p. 527), care standards recommended for nursing homes that lack realistic assessment of whether or not there are intervention resources or protocols to meet them result to major barriers in the implementation of new or updated policies. For a successful restraint-free program implementation, an organizational commitment should be present prior to program implementation. According to Texas Department of Aging and Disability Services (2014), the resources needed for successful policy implementation are support of administrative staff; a multidisciplinary restraint team; modifications of environment and resources; and education for families and individual, and staff. According to Kwok, et al (2012, p. 648) the presence of a physical restraint program is essential. For successful implementation, the program implementation must be led by the nurse in charge of the department with the support of the hospital executive. In the updated policy, the implementation of the updated restraint policy will involve the leadership of the nurse in charge of the department and the hospital executive. Additionally, a multidisciplinary team will be in place to ensure that nurses can consult and collaborate with others while making decision on the best alternatives to restraint (Nurses Working for Nurses, 2003, p. 14). The hospital executive shall also provide continued monitoring and review of staffing levels to ensure appropriate levels of nursing care, for restricted use of restraint, and older person’s quality of life. Additionally, the Kwok, et al (2012), reveals that the management is obliged to provide additional resources to support the restraint-free program including shortened bed rails and electrical high low beds amongst others. In this policy the management is responsible for identifying required resources that support the policy. For the nurses, it is expected that they will be engaged in action planning and not just depend on the directives or top-down approach. For efficiency, front line nurses will be trained and provided with continued support by senior nurses or a multidisciplinary team. Additionally, nurses will be trained on proper nurse attitude towards restraints for reduced frequency of use, as well as training on development of strong relationships with patients and parents. In order to deal with fear and misconceptions, the hospital will offer an educational component that informs on the hazards of using restraints, alternate interventions, and restraint use myths and misconceptions (Texas Department of Aging and Disability Services, 2014). 6.0. Recommendations on how to measure successful implementation It is recommended that Hong Kong Adventist Hospital focus on a continued education program in the alternatives to restraint coupled with an executive assisted program to create a restraint-free environment. This way, nurses with follow the executive’s example and create an attitude and culture of restraint reduction. Additionally, ensuring that nurses have all resources needed to incorporate diversion activities into the care plan may help in restraint avoidance. Further, the updated policy should focus on using a consultative approach such that multidisciplinary teams collaborate with the nurse in the evaluation of patient’s baseline history information and design the right needs for the patient using alternatives to restraint. Additionally, it is recommended that all nurses are made aware of ethical and legal considerations on restraints use. For instance, the nurse should be made to understand that they are obliged to do no harm but be non-maleficence and promote good by being beneficence. Additionally nurses should be made to understand that they should treat patients autonomously and understand that the use of physical restraints results to violation of informed consent. Physical Restraint to Patient Policy at Hong Kong Adventist Hospital or HKAH 1.0. Policy statement HKAH is committed to protecting patients from physical restraint or damaging actions by nurses during administration of restraints to protect them from harming self or others, intentionally or unintentionally. Through the strict adherence to an environment that is restraint free, HKAH will address issues of unwarranted physical restraints proactively and using correct judgement and this will help set the organization apart from competitors. HKAH will not tolerate any impropriety or wrongdoing at any given time and appropriate measures will be used to act quickly in correcting the issue if any ethical or legal requirements are broken. Additionally, any infractions on this restraint of patient code will not be tolerated. 2.0. Aims HKAH’s purpose for this Restraint policy is to assist nurses and hospital executive in promoting a restraint free environment within the hospital setting. In particular, this updated policy outlines the following: a. Professional responsibility of the nurse concerning implementation of physical restraint; b. The responsibility of the hospital administration in spearheading the implementation of the new policy 3.0. Target audience This policy applies to nurses whether direct care nurses, nurse authorized to apply restraint, nurses authorized to perform patient assessment, or nurses authorized to initiate, retain or perform evaluations. The policy also involves all personnel affiliated with patients and restraint management. 4.0. Responsibilities 4.1. Top Executive commitment to ethics Management at HKAH must set a primer example by adhering and promoting physical restraint-free environment. Additionally, the executives must encourage and welcome suggestions and concerns from employees on physical restraint administration. An open door policy will enable nurses to feel comfortable discussing their issues with executives. Further, executives are expected to disclose conflict of interest concerning their position within HKAH. 4.2. Responsibility of the nurse Nurses are expected to continually assess and implement alternative measures prior to scheduling any restraint. However, whenever restraint is required, the nurse is expected to order for physical restraint. However, prior to requesting for physical restraint, nurses are expected to consult with multidisciplinary team and the hospital management such that the nurse manages to use personal knowledge and informed clinical judgement to make the best choice for resident. In their determination of the need to restrict movement or control patient behaviour, nurses are expected to a. Assess patient’s behaviour to identify factors attributed to the development of the difficult behaviour; b. Examine the options including alternative solutions c. Collaborate with team members in the development and implementation of the care plan and evaluating the restraints response and effectiveness through factors like seating, recreation etc d. Develop a care plan incorporating outcomes like increased safety or minimized agitation e. The nurse should use appropriate tools to assess the patient including assessment forms for progress notes f. Update written plan of care g. Document intervention evaluation, referrals, and restraint discontinuation 5.0. Definition 5.1. Physical restraint Physical restraint includes everything that prevents residents from reaching a part of their body, or from moving around thereby controlling them from harming self or others. Refers to any device adjacent or attached to a person’s body that cannot be easily controlled and whose removal is not easy so that the patient’s freedom of movement is deliberately restricted (Kwok, et al., 2012, p. 645) 6.0. Documentation Refer to restraint of patient policy at Hong Kong Adventist Hospital 7.0. Revision & Approval History Date Revision No. Author and Approval 8.0. Reference list Bryant, H. & Fernald, L., 1997. Nursing knowledge and use of restraint alternatives: acute and chronic care. Geriatric Nursing, Volume 18, pp. 57-60. Gastmans, C. & Milisen, K., 2006. Use of physical restraint in nursing homes: clinical‐ethical considerations. Journal of medical ethics, 32(3), pp. 148-152. Joanna Briggs Institute, 2002. Physical Restraint-Pt 2: Minimisation in Acute and Residential Care Facilities. Best Practice, 6(4), pp. 1-6. Kwok, T. et al., 2012. Effect of Physical Restraint Reducation on Older Patients Hospital Length of Stay. JAMDA, Volume 13, pp. 645-650. Lai, C. K. Y., 2007. Nurses using physical restraints: Are the accused also the victims? – A study using focus group interviews. BioMedCentral Nursing , 6(5), pp. xxx-xxx. Nurses Working for Nurses, 2003. Guideline on the Use of Restraint in care of older person, Ireland: Nurses Working for Nurses. Qureshi, H., 2009. Report 26: Restraint in Care Homes for Older People: A Review of Selected Literature, Great Britain: Social Care Insitute of Exellence. Ralph, M. & Gabriele, M., 2013. Attitudes of Nurses towards the use of physical Restraints in Geriatric Care: A Systematic Review of Qualitative and Quantitative Studies. International Journal of nursing Studies, pp. xxx-xxx. Schnelle, J., Ouslander, J. & Cruise, P., 1997. Policy Without Technology: A Barrier to Improving Nursing Home Care. Oxford Journals: The Gerontologist, 37(4), pp. 527-532. Texas Department of Aging and Disability Services, 2014. Mechanical restraint reduction: Evidence-based best practices. [Online] Available at: http://www.dads.state.tx.us/qualitymatters/qcp/restrainreduction/index.html [Accessed 27 May 2014]. The Australian Councils for Healthcare Standards or ACHS, 2013. Report on Pilot Scheme of Hospital Accredation. Sydney, Steering Committee on Hospital Accredition. Zencirci, A. D., 2012. Use of Physical Restraints in NeuroSurgery: Guide for Good practice. In: F. Signorelli, ed. Explicative Cases of Controversial Issues in Neurosurgery. United States: InTech, p. 534. Read More