Least Restraint Programs

1. Least Restraint Programs Presented by: Shirley L Robinson Leisureworld North Bay Family Council

2. Definition & Policy Direction Policy Direction: Least Restraint Least restraint means all possible alternative interventions are exhausted before deciding to use a restraint. This requires assessment and analysis of what is causing the behaviour. Most behaviour has meaning. When the reason for the behaviour is identified, interventions can be planned to resolve whatever difficulty the client is having that contributes to the consideration of restraint use. For example, if a client has poor balance or is frequently falling, interventions, such as giving the client a walker, can be developed to help protect the client’s safety while allowing freedom of mobility. A policy of least restraint indicates that other interventions have been considered and/or implemented to address the behaviour that is interfering with client safety. • What are Restraints? Restraints are physical, chemical or environmental measures used to control the physical or behavioural activity of a person or a portion of his/her body. Physical restraints limit a client’s movement. Devices such as a table fixed to a chair, tilt wheelchair or a bed rail that cannot be opened by the client, are physical restraints. Environmental restraints control a client’s mobility. Examples include: a secure unit or garden, seclusion or a timeout room. Chemical restraints are any form of psychoactive medication used, not to treat illness, but to intentionally inhibit a particular behaviour or movement. College of Nurses of Ontario Practice Standard: Restraints

3. Scenario A nurse in a long-term care facility is admitting a client who has been transferred from a local hospital. The facility has a least restraint policy and for the past year has used no restraints. It has a risk assessment protocol used on admission to help staff determine an appropriate plan of care that identifies behaviours that may lead to consideration of restraint use. Since implementing a least restraint policy, the facility has found that falls have not increased. The falls that have occurred have resulted in significantly less injury. Additionally, the incident of skin breakdown has declined by 50 percent. The family is insisting that their mother be restrained to protect her safety. They tell the nurse that if they do not restrain their mother and she falls, they will initiate legal action. Discussion This situation, like many involving the use of restraints, is an ethical dilemma. While nurses respect client choice, limits do exist. As explained in the Ethics practice standard, client choice might be limited by policies that promote health or by the resources available in a particular situation. When clients request nurses to perform an act that may cause serious harm, nurses need to inform clients in a non-judgmental manner of the potential risks and harm associated with the practice. The nurse in this scenario needs to explore the implications of the request. The family believes that if no restraint is used, their mother’s safety will be jeopardized. The nurse is able to provide education about the risks of restraint use and the alternatives available. If the family continues to request that restraints be used, the nurse respects the family’s choice but needs to explain that because the facility has a no restraints policy, it does not have restraints available or the resources to use restraints safely. Knowing this information, the family can then make an informed decision about where to place their mother. Client and family needs are best met when these discussions occur before the admission takes place. College of Nurses of Ontario Practice Standard: Restraints

4. T eresa Malotte, RN & Assistant Director of Care When first educated as management, rounds were done through the building and time was spent with the staff while they were on the units. Groups discussions were held about 15 - 20 min to discuss the changes as well as the policy, and each staff then signed their name to education sheets. Tracking was done to indicate who received the info. A lot of one on one education was provided to staff on the topic. Information was covered at staff meetings and brought oo our charge nurse meetings as well. Quarterly are audits were done at the beginning, but only a percentage, now we do them all. A review is done all the charts for those residents who have restraints. We ensure the consents and doctor orders are complete and current. We also check that the documentation is being done correctly. Our night staff check the restraint flow sheets and leave a memo for follow up. The managers then follow up with staff involved.

5. Friday April 3, 2009 -- Camille Jensen, Writer & Online Production Editor (axiomnews.ca)A new video on Leisureworld’s policy to minimize restraints in its 26 long-term care homes is being created in an effort to educate families on the importance of eliminating the use of restrictive devices.Developed by the education department in collaboration with a number of Leisureworld homes, the video will dispel myths about the safety of restraints and showcase the more proactive approaches for resident safety.Beverly Zangari, staff educator with Preferred Health Care Services which provides education to Leisureworld, says the organization has adopted a least restraint minimization policy and wants families to be aware of some of the negative implications of restraints. The video is encouraging greater communication with the resident's family to help Leisureworld staff learn more about the resident’s previous habits that can be incorporated into their care plan. The filming of the video took place at five Leisureworld homes — Richmond Hill, Scarborough, Tullamore, O’Conner Court and St. George — and features directors of administration and care, front-line staff and family members sharing their experiences on the subject. “The video is going to give many, many sides of the story of why zero restraint or restraint reduction is the goal of Leisureworld and making sure at the same time that the resident is as safe as possible.” Ruth Ramirez, communications specialist for Preferred Health Care Services and Leisureworld, produced the film and says the many testimonials gathered will send a powerful message on the need to find other ways to support residents.Once completed, Ramirez says the video will be used with families and at family council to help more people understand the need to decrease the use of restraints. Used by permission received from C. Jensen axiomnews.ca Apr.23/09

6. For more information and additional articles see our back info table for copies of more Least Restraint Articles profiled in the March 2009 Ontario Long Term Care Magazine. Thank you to OLTCA for permission to copy. You can also go the OLTCA Website if you wish to see contents of all of the March 2009 Magazine. www.oltca.com End of Presentation Thank you for the opportunity to share this information with all of you! College of Nurses of Ontario Practice Standard: Restraints