Disclosure Discussion of Background and Purpose Review of Materials - - PDF document

Constance Noll DNP, MA, CRNP, PMHNP-BC Janet McMillan DNS, APRN, PMHNP-BC University South Alabama

Disclosure

The speaker has no conflicts of interest to disclose.

Restraint Reduction Interventions:

A Quality Improvement Initiative Considering Nurse Stress Acknowledgements

Christina Cafeo DNP, RN, CENP Project Mentor

Images contained in this presentation are displayed with written permission or are of public domain

Objectives

Discussion of Background and Purpose Review of Materials & Methods Review of Results Discussion & Conclusions

APNA 30th Annual Conference Session 2041: October 20, 2016 Noll

INTRODUCTION Psych Nurse

in the ICU

Image credit: Conn Health I-Team 5/31/14

Restraint Use is Problematic

American Nurses Association advocates for restraint free care with evidence-based guidelines to prevent multiple patient injuries from psychological trauma to death (ANA, 2011) Restraining or secluding patients is viewed as contrary to the fundamental goals & ethical traditions in nursing It was frequently thought that without effective restraints, patients were in danger of injuring themselves or others Restraints have been used based on beliefs, not evidence, that patient safety is promoted

Image used with permission from Microsoft

BACKGROUND Restraint Rates

Rates of restraint

• nurse sensitive measurements
• amenable to performance improvement

(Kleinpell, 2013)

Cultures in critical care areas have been

• reluctant to embrace paradigm shift
• maintain restraint use as a safe practice

(Cosper et al., 2014; King & Elliot, 2012; Lach et al., 2016; Stintson, 2016)

Culture & Nurse Stress

Violence, patient agitation & aggression

• related to resisting care
• trying to get OOB, leave hospital
• precipitates “safe" restraint use

(Gillies, 2015; McNett et al., 2012; Yont et al., 2014)

Nurses obliged to

• engage in self-care
• manage stress
• maintain therapeutic relationships

(APNA, 2014)

APNA 30th Annual Conference Session 2041: October 20, 2016 Noll

Relationship: Nurse Stress & Restraints

Nurses apply restraints emergently after exhausting less restrictive measures Dynamics involved in the nurse/patient relationship are therefore crucial Providing RNs with stress management strategies- peer support and mindfulness

• enhances communication skills for effective

interventions in high emotive interactions

(Clerico et al., 2015; Orly et al., 2012; Rose et al., 2013; Seys et al., 2013; Yang et al., 2014)

Evidence Gap

A review of evidence revealed a gap: Educational strategies related to restraint reduction did not include mitigation of nurse stress

Project Question

Can significant Restraint Reduction

• ccur through educational

interventions that include techniques for decreasing nurse stress?

Project Goals

1) Restraint volume reduction 2) Increased nurse knowledge: a) negative restraint sequelae b) restraint alternatives c) stress- effects & mitigation 3) Reduction of nurse stress

APNA 30th Annual Conference Session 2041: October 20, 2016 Noll

METHODS

Collection of non-patient specific restraint volumes

• Academic, urban 700 bed Medical Center
• MICU setting
• January to May 2016

Email Survey Monkey requests

• 120 RNs, anonymous identifier
• Two weeks prior & following a series of three

educational presentations

• Completion implied voluntary participation &

informed consent Survey

• Perceived Stress Scale (PSS-10) (Lee, 2012)
• Demographic information
• Knowledge items

Perceived Stress Scale Items PSS-10

• 1. In the last month, how often have you been upset because of

something that happened unexpectedly?

• 2. How often have you felt that you were unable to control the

important things in your life?

• 3. How often have you felt nervous and "stressed"?
• 4. How often have you felt confident about your ability to handle your

personal problems?

• 5. How often have you felt that things were going your way?
• 6. How often have you found that you could not cope with all the

things that you had to do?

• 7. How often have you been able to control irritations in your life?
• 8. How often have you felt that you were on top of things?
• 9. How often have you been angered because of things that were
• utside of your control?
• 10. How often have you felt difficulties were piling up so high that you

could not overcome them?

___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often

Perceived Stress Scale PSS-10

Scoring

• Item value ranges zero to 4
• Summed according to + or – wording
• Scores range zero to 40
• Scores of 13- average
• Scores of 20- high stress range
• High scores- advised to review stress

management strategies

Educational Presentations

1) Negative Consequences of Restraint Use/Influences of Staff Stress 2) Restraint Alternatives/Mitigation of Staff Stress 3) De-escalation Communication/Plan for Personal Stress Management

APNA 30th Annual Conference Session 2041: October 20, 2016 Noll

Analysis

Convenience sample

• 14 RNs matched in pre & post PSS-10 enrolled

Small sample size

• non-normal distribution
• required categorical data treatment

Descriptive statistics

• means, standard deviations, frequencies,

percentages

RESULTS Sample Characteristics

Female nurses (92.9%) Baccalaureate preparation (78.6%) 50% were between 26 to 35 years of age 50% had two years or less of RN experience Baseline PSS-10 average score 15.71 ± 5.76 Correct knowledge questions 2.23 ± 0.60

Pre and Post PSS-10 Results

Wilcoxon signed rank test

• no overall statistically significant

finding however: Nurse stress and feelings of nervousness were significantly reduced

Pre and Post PSS-10 Results

PSS-10 items

Median Z p

In the last month Before intervention After intervention

• 1. How often have you been upset because of something

that happened unexpectedly? 2.00 2.00

• 1.25

.212

• 2. How often have you felt that you were unable to

control the important things in your life? 2.00 1.50

• 0.28

.782

• 3. How often have you felt nervous

and "stressed"?

3.00 2.00

• 2.11
• 4. How often have you felt confident about your ability to

handle personal problems? 3.00 3.00 .00 1.000

• 5. How often have you felt that things were going your

way? 3.00 3.00 .00 1.000

• 6. How often have you found that you could not cope with

all the things that you had to do? 1.50 2.00

• 0.33

.739

• 7. How often have you been able to control irritations in

your life? 3.00 3.00

• 0.38

.705

• 8. How often have you felt that you were on top of things?

3.00 3.00 .00 1.000

• 9. How often have you been angered because of things

that were outside of your control? 2.00 1.00

• 1.51

.132

• 10. How often have you felt difficulties were piling up so

high that you could not overcome them? 1.00 1.00

• 0.51

.608

• APNA 30th Annual Conference

Session 2041: October 20, 2016 Noll

Restraint Volumes

83.7% decrease in restraint volumes occurred in 20 weeks Decreased nurse stress was favorably associated with decreased use of restraints

Graphic Summary

MICU restraint volumes: baseline, during, and post intervention with significant PSS-10 values

• DISCUSSION

OVERALL FINDING Decreased nurse stress positively associated with decreased restraint use

Image used with permission from Microsoft

Suggestions Implied by Project

Replication * Multiple units & hospital systems * Longer duration establish sustainability Results support other findings: * Nurse emotions have role in de-escalating, demanding situations * Increased ability for nurse empathy results in reduced restraints

(Farquharson et al., 2013; Stintson, 2016; Yang et al., 2014)

APNA 30th Annual Conference Session 2041: October 20, 2016 Noll

Clinical Relevance

Contributes to body of evidence regarding patient restraints as nurse driven effort Nurse stress has a role in clinical decision making patient restraint use Inclusion of mitigation of nurse stress in educational efforts for Restraint Reduction may enhance desired

• utcomes

Future Implications

Research on recognition of stress as an essential part of improving patient outcomes is in its infancy Future studies needed to explore evidence- based strategies for practice (Pont & Koppel, 2015) Encouraging nurses to mitigate stress may enhance personal health & contribute to more positive patient outcomes Unwavering goal - continued efforts to minimize and eliminate patient restraints

Questions?

Thank you for your time and attention!

References

• ANA. (2011). 2011 ANA health and safety survey. Nursing World.

Retrieved from http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Heal thy-Work-Environment/SafeNeedles/2011-HealthSafetySurvey.html.

• APNA. (2014). APNA Position Papers: Position Statement on the Use of

Seclusion and Restraint. Retrieved from http://www.apna.org/files/public/APNA_SR_Position_Statement_Fin al.pdf Burk, R. S., Grap, M. J., Munro, C. L., Schubert, C. M., & Sessler, C. N. (2014). Predictors of agitation in critically ill adults. American Journal

• f Critical Care, 23(5), 414-423. doi: 10.4037/ajcc2014714

Cosper, P., Morelock, V., & Provine, B. (2014). Please release me: Restraint reduction initiative in a health care system. Journal of Nursing Care Quality, 30, 16-23. doi: 10.1097/NCQ.000000000000074 Enns, E., Rhemtulla, R., Ewa, V., Fruetel, K., & Holroyd-Leduc, J., M. (2014). A controlled quality improvement trial to reduce the use of physical restraints in older hospitalized adults. Journal of the American Geriatric Society, 62, 541-545. doi: 10.1111/jgs.12710

APNA 30th Annual Conference Session 2041: October 20, 2016 Noll

References

Farquharson, B., Bell, C., Johnson, D., Jones, M., Schofield, P., Allan, J.,...Johnson, M. (2013). Nursing stress and patient care: real time investigation of the effect of nursing tasks and demands on psychological stress, physiological stress and job performance: Study

• protocol. Journal of Advanced Nursing, 69(10), 2327-2335. doi:

10.1111/jan.12090 Gillies, L., Coker, E., Montemuro, M., & Pizzacalla, A. (2015). Sustainability of an innovation to support and respond to persons with behaviors related to dementia and delirium. Journal of Nursing Administration, 45, 70-73. King, J. N., & Elliott, V.A. (2012). Self/unplanned extubation: safety, surveillance, and monitoring of the mechanically ventilated patient. Critical Care Nursing Clinics North America, 24, 469-479. Kleinpell, R. M. (2013). Outcome assessment in advanced practice nursing, (3rd ed.). New York, New York: Springer. Lach, H. W., Leach, K. M., & Butcher, H. K. (2016). Evidence-based practice guideline: changing the practice of physical restraint use in acute care. Journal of Gerontological Nursing, 42(2), 17-26. doi: 10.3928/00989134-20160113-04

References

McNett, M., Sarver, W., & Wilczewski, P. (2012). The prevalence, treatment and outcomes of agitation among patients with brain injury admitted to acute care units. Brain Injury, 26, 1155-1162 doi: 10.3109/02699052.2012.667587 Orly, S., Rivka, B., Rivka, E., & Segal-Engelman, D. Are cognitive- behavioral interventions effective in reducing occupational stress among nurses? Applied Nursing Research, 25, 152-157. doi: 10.1016/j.aprn.2011.01.004 Rose, J., Mills, S., Silva, D., & Thompson, L. (2013). Client characteristics, organizational variables and burnout in care staff: The mediating role of fear in assault. Research in Developmental Disabilities, 34, 940-947. doi: 10.1016/j.rdd.2012.11.014 Seys, D., Wu, A. W., Van Gerven, E., Vleugels, A., Euwerma, M., Panella, M.,…Vanhaecht, K. (2013). Health care professionals as second victims after adverse events: A systematic review. Evaluation and the Health Professions, 36, 135-162. doi: 10:1177/0163278712458918 Stintson, K. J. (2016). Nurses’ attitudes, clinical experience, and practice issues with use of physical restraints in critical care units. American Journal of Critical Care, 24(1), 21-26. doi: 10.4037/ajcc2016428

References

Verhaeghe, S., Duprez, V., Beeckman, D., Leys, D., Van Meijel, B., & Van Hecke, A. (2014). Mental health nurses’ attitudes and perceived self-efficacy toward inpatient aggression: a cross- sectional study of associations with nurse-related characteristics. Perspectives in Psychiatric Care, 52(1), 12-24. doi/10.1111/ppc.12097 Wilson, M. P., Pepper, D., Currier, G. W., et al. (2012). The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA psychopharmacology workgroup. Western Journal of Emergency Medicine, XIII(1):26-34. Retrieved from: escholarship.org/uc/uciemwestjem Yang, C. P., Hargreaves, W. A., & Bostrom, A. (2014). Association of empathy of nursing staff with reduction of seclusion and restraint in psychiatric inpatient care. Psychiatric Services, 65(2), 251-254. Retrieved from http://www.psychiatrictimes.com/ Yont, G. H., Korhan, E. A., Dizer, B., Gumas, F., & Koyuncu, R. (2014). Examination of ethical dilemmas experienced by adult intensive care unit nurses in physical restraint practices. Holistic Nursing Practice, 28(2), 85-90. doi: 10.1097/HNP.000000000000013

APNA 30th Annual Conference Session 2041: October 20, 2016 Noll