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APNA 29th Annual Conference Session 4015: October 31, 2015 Tomsic 1

Restraint Free Patient Care

Sustaining a Culture of Restraint‐Free Patient Care: A Collaborative Effort to Educate Military Healthcare Professionals in the Restraint‐Free Management of Patients

Joseph P. Tomsic, PMHNP‐BC, NEA‐BC Naomi L. Winterheld, ACCNS‐AG

Disclaimer

The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the United States Air Force, Department of Defense, nor the U.S. Government. Speakers have no conflicts of interest to disclose.

Objectives

• Objective 1: Identify warning signs and triggers in

patients with agitation, use appropriate calming mechanisms, understand decision‐making capacity, and apply LEAP communication methodology prior to the escalation of behavior that might lead

• Objective 2: Understand the concept of developing

restraint free patient care training that is interactive and targeted at level of learning that results in nursing practice change.

• Objective 3: Describe how to incorporate interactive

learning when designing training to change clinical practice

APNA 29th Annual Conference Session 4015: October 31, 2015 Tomsic 2

Enabling Objectives

• Background
• Research
• Key points
• Design of education plan

– Developing Levels of learning – Small group facilitated discussions – Triggers, warning signs and calming mechanisms (TWC)/exercises – Review scales to measure agitation – Explain decision‐making capacity (DMC) – Applying Listen‐Empathize‐Agree‐Partner (LEAP) – Review pharmacologic management – Review restraints as a last resort

• Conclusions/closing remarks

Background

• Royal Air Force Lakenheath Military Treatment

Facility

• “Restraint Free” added to policy in 2009
• Worked closely with the MTF Chief Nurse and

multi‐purpose ward clinical specialist

• Staff educated April 2014
• Restraint events: 2011‐3, 2012‐6, 2013‐3,

2014‐0, 2015‐0 (as of August)

– Approximately 65% initiated by RNs

Current Research

• To sum it up, restraints are…

– a low‐frequency, high‐risk patient care intervention – often avoidable

• Places to look for information

– Agency for Healthcare Research and Quality (2000+ articles

• http://www.ahrq.gov/index.html

– The Joint Commission (2700+ articles)

• http://www.jointcommission.org/

– National Guideline Clearinghouse (often overlooked)

• http://www.guideline.gov/

See Handout #4 for references

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Current Research (cont.)

• Serious injuries and even death have been

linked to the use of physical restraints.

• Chemical restraint may lead to over‐sedation,

the development of cardiorespiratory compromise, decreased gastrointestinal motility, DVT and other complications.

See Handout #4 for references

Key Points

Safety

Everything stops until safety can be established. What is the safest alternative? What is needed to provide the safest alternative?

Suicidal and Homicidal Ideations

Suicidal ideation is a medical emergency. Homicidal ideation is a medical emergency that carries a duty to warn for health care professionals.

Patient Assessment

Work quickly to determine cause of agitation, many diagnoses/substances can cause psychosis and/or agitation.

Developed by J. Tomsic

Levels of Learning: Cognitive Objectives

See Handout #1 for more on levels of learning

Evaluation: validate learning in the clinical setting Synthesis: generate new interventions to calm patients Analysis: relate learning to current practice Application: demonstrate the use of new interventions Comprehension: generalize the need to prevent restraint use Knowledge: identify triggers, warning signs and calming mechanisms Clinical practice change happens at the higher levels of learning Developed by J. Tomsic

APNA 29th Annual Conference Session 4015: October 31, 2015 Tomsic 4

Levels of Learning: Affective Objectives

See Handout #1 for more on levels of learning

Internalizing: Automatically considers calming mechanisms Organization: Values avoiding the use of restraints and organizes this into clinical priorities Valuing: Safe patent care is an important value Responding: Works with peers to discuss study questions and participates in role‐playing exercises Receiving: Is open to learning new interventions and skills to avoid using physical restraints Clinical practice change happens at the higher levels of learning Developed by J. Tomsic

Exercises

• Small Group Discussion

– What is your current attitude concerning the use

• f restraints?
• Case Studies

– When does a medication for agitation become a chemical restraint?

See Handout #2 for example questions

Triggers

Critical Triggers

Being Teased Being Yelled at Being talked down to Being Pressured Not Being Listened to Being Laughed at Not Being Taken Seriously Being told to stay in room

Medical Professional Induced Triggers

Boundary Invasion Lack of Privacy Touching Talking Down to patients Visiting Hours Repeated Questions Interruption s Medical Jargon

Common Triggers

Receiving Bad News Isolation Loneliness Fear Darkness Feeling Pressured Noise Not being in Control

Taylor‐Trujilio, A., & Seams, B. (2011). A Violence Prevention Model for Acute Behavior Health Care. Paper presented at the APNA, Anaheim, CA.

APNA 29th Annual Conference Session 4015: October 31, 2015 Tomsic 5

Warning Signs

Late Warning Signs

Making Threats Pacing Yelling Target Lock Bouncing Legs Shaking Rocking Clinched Fists

In the Middle Warning Signs

Walking away Not listening Not answering Demanding to leave Clenching Fists No eye contact Refusing PRN medications

Early Warning Signs

Clenching teeth Restless Wringing Hands Talking Fast Threatening to go AMA Refusing Care Poor Eye Contact Fidgeting

Taylor‐Trujilio, A., & Seams, B. (2011). A Violence Prevention Model for Acute Behavior Health Care. Paper presented at the APNA, Anaheim, CA.

Calming Mechanisms

Environmental Calming Mechanisms

Going for a walk Comfort Room Lying down Quiet Room Time alone Step Outside Take Hot or Cold Shower Change lighting or Temp

Individual Calming Mechanisms

Listen to music Deep breathing Spiritual Practices Exercise Journaling Molding Clay Meditation Reflection

Interpersonal Calming Mechanisms

Talking to family Calling family or friends Therapeutic Touch Speaking to Staff Gender Specific Support Getting a Hug Having Hand Held Command Support

Taylor‐Trujilio, A., & Seams, B. (2011). A Violence Prevention Model for Acute Behavior Health Care. Paper presented at the APNA, Anaheim, CA.

More About: Triggers, Warning Signs and Calming Mechanisms

• Incorporate into initial and ongoing

assessments

• Helps to provide patient‐centered care
• Should be reassessed frequently
• Can be assessed during patient rounding
• Powers Individual Agitation Prevention Plans
• Practice, Practice, Practice

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Small Group Exercise

Triggers and Warning Signs Calming Mechanisms Handout #3, TWC Learning Deck

Warning Signs Calming Mechanisms

Triggers, warning signs and calming mechanisms worksheet developed by J. Tomsic v1.1 What additional calming mechanisms do you think would be appropriate?

Case One: A patient lets the nurse know on admission that they do not like being in the hospital. The patient states they do not feel in control, hospitals are noisy and they never understand what nurses are saying. You find the patient the next day very upset and agitated after a lab technician draws a blood sample. The patient is yelling that the tech did not ask before touching her, does not understand why there are so many lab tests and is threatening to go AMA. You go to speak to her and explain in layman’s terms why the tests are needed, get her in contact with her family and make sure the room is quiet and comfortable. After a few minutes the patient calms down.

Handout #3, TWC Learning Deck

Warning Signs Calming Mechanisms

Being Touched Not being in Control Medical Jargon Threatening to leave Refusing Care Yelling Calming Enviroment Call Family Layman’s Terms

Triggers, warning signs and calming mechanisms worksheet developed by J. Tomsic v1.1 What additional calming mechanisms do you think would be appropriate?

Handout #3, TWC Learning Deck

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Scales to Measure Agitation

• Do not replace TWC skills
• Common Scales

– Positive and Negative Syndrome Scale (PANSS) – Behavioral Activity Rating Scale (BARS) – Overt Aggression Scale (OAS)

• Some consideration to adopt

– Agitated Behavior Scale (ABS)

• Simple and free to use
• Observational
• May be useful in populations outside of rehab

http://ohiovalley.org/informationeducation/agitation/abs/

Decision‐Making Capacity (DMC)

• Caregivers should balance the right to

autonomy while protecting the best interest of patients who lack the ability to make an informed decision require.

– Beneficence=doing good – Non‐maleficence=inflicting no harm

• Providers (attending physician) usually makes

the determination if a patient is able to make an “informed refusal.”

Adapted from Appelbaum PS. Clinical practice, Assessment of patients competence to consent to treatment. N Engl J Med. 2007;357(18):1834‐1840

DMC (cont.)

• Common diagnoses in which patients lack

DMC include delirium, dementia, and some psychiatric disorders

• DMC should be accessed in regards to specific

decisions

• It may be appropriate to not allow a patient to

leave AMA until DMC is established

• DMC should re‐assessed regularly
• Potential Medical Professional Trigger!

Adapted from Appelbaum PS. Clinical practice, Assessment of patients competence to consent to treatment. N Engl J Med. 2007;357(18):1834‐1840

APNA 29th Annual Conference Session 4015: October 31, 2015 Tomsic 8

Criteria for DMC

Decision making capacity

Demonstrates adequate understanding Demonstrates an appreciation of the risks/benefits

• f the choice

Understands

• ptions

Makes a consistent choice regarding wishes

Adapted from Appelbaum PS. Clinical practice, Assessment of patients competence to consent to treatment. N Engl J Med. 2007;357(18):1834‐1840

Pharmacologic Management

• Medications can be a useful intervention for

patients who do not respond to non‐ pharmacologic techniques.

• Common medications that can be given IM:

– Haloperidol – Abilify – Olanzapine – Geodon – Ativan

Assessment and emergency management of the acutely agitated or violent adult: UpToDate, Topic 291 Version 29.0

Pharmacologic Management (cont.)

• Antipsychotics and benzodiazepines are

agents of choice to manage acute agitation.

• Monitor for adverse effects and additive

adverse reactions.

Chemical restraint is the use of medications to immobilize or reduce the freedom of movement and may include the use of sedatives, tranquilizers or antipsychotic agents.

Assessment and emergency management of the acutely agitated or violent adult: UpToDate, Topic 291 Version 29.0

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Listen‐Empathize‐Agree‐Partner

• Gold standard for deescalating aggressive,

agitated, or uncooperative patients.

– Motivational Enhancement Therapy. – Developed over 20 years ago. – Motivational vs. confrontational approach. – Useful for patients in denial. – Useful for patients who abuse substances. – Few are trained in LEAP despite the fact it is proven to be effective. L E A P

Amador, X. (2010). I Am Not Sick I Don’ Need Help! How to Help Someone with Mental Illness Accept Treatment (10th ed.). New York: Vida Press. For more information read Dr. Amador’s book and/or go to http://www.leapinstitute.org/

Listen

• Don’t argue ‐ instead use reflective listening.

– Work to understand the patient’s point of view. – Reflect your understanding back to the patient. – Don’t react to what the patient feels, wants or believes. – Understanding the patient’s experience will provide a foothold to move forward. – If a patient believes you understand them they will be more open to what you have to say. L E A P

Amador, X. (2010). I Am Not Sick I Don’ Need Help! How to Help Someone with Mental Illness Accept Treatment (10th ed.). New York: Vida Press. For more information read Dr. Amador’s book and/or go to http://www.leapinstitute.org/

Empathize

• Empathizing will let the patient know you are

seriously considering their point of view.

– Empathize with the reasons why the patient does not want to accept treatment. – Empathize with the patient’s feelings connected to delusions (empathizing is not the same as agreeing beliefs are true). – Patients are more receptive to empathic care givers. L E A P

Amador, X. (2010). I Am Not Sick I Don’ Need Help! How to Help Someone with Mental Illness Accept Treatment (10th ed.). New York: Vida Press. For more information read Dr. Amador’s book and/or go to http://www.leapinstitute.org/

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Agree

• Find common ground and stake it out.

– Avoid coming to an impasse. – You may need to look closer for common ground. – Look for motivations of the patient to change. – Common ground always exists. – Acknowledge that the patient has a personal choice and responsibility for the decisions they make about their life. – Be a neutral observer, pointing out what you agree upon and the positive and negative consequences of the patient’s decisions. L E A P

Amador, X. (2010). I Am Not Sick I Don’ Need Help! How to Help Someone with Mental Illness Accept Treatment (10th ed.). New York: Vida Press. For more information read Dr. Amador’s book and/or go to http://www.leapinstitute.org/

Partner

• Form a partnership with the patient to achieve

shared goals.

– Areas to where you can partner with the patient:

• Discharge from the hospital
• Feeling better
• Getting back to work
• Recovery from illness

– More often than not these involve accepting treatment and services. L E A P

Amador, X. (2010). I Am Not Sick I Don’ Need Help! How to Help Someone with Mental Illness Accept Treatment (10th ed.). New York: Vida Press. For more information read Dr. Amador’s book and/or go to http://www.leapinstitute.org/

Restraints as a Last Resort

• It may be necessary if the patient is violent,
• vertly aggressive or their behavior

jeopardizes the immediate physical safety of the patients, staff members or others.

• If a patient is agitated and disrupting critical

medical treatment:

– Consider a constant observer. – Consider seclusion. – Advance to more restrictive physical restraints (violent

• r non‐violent) only as a measure of last resort.

APNA 29th Annual Conference Session 4015: October 31, 2015 Tomsic 11

Conclusions

• Restraint free patent care requires leadership

at all levels.

• Restraint free patient care is a realistic goal.
• Restraint free patient care will not happen

without changing how we practice.

• Restraint free patient care is evidence based.
• Restraint free patient care is supported by our

Air Force core values.

Closing Remarks

• Nurses should always document interventions

and the level of efficacy.

• Constant observation can in some cases

increase agitation.

• Constant observation is a valuable resource

and its use can be minimized with calming mechanisms.

• Consider treating your patients like your

relatives (if you like them).

Thanks for your time and attention!

Questions?

Contact Information

joseph.tomsic.1@us.af.mil or naomi.winterheld@us.af.mil More contact info joe_t26@yahoo.com https://uk.linkedin.com/pub/joe‐tomsic/28/691/12 See Handout #4 for references