Testimony
presented to:
Joint Commission
on the
Accreditation of
Healthcare Organizations
Behavioral Healthcare Restraint Task Force

delivered by:
Elissa Brown, MSN, RN, CS
San Francisco, California - March 29, 1999

Beatrice A. Yorker, MS, JD, RN, FAAN
Atlanta, Georgia - April 6, 1999

Catherine F. Kane, PhD, RN, FAAN
Washington, District of Columbia - April 13, 1999

EXECUTIVE SUMMARY

The American Nurses Association

The American Nurses Association is the only full-service professional organization representing the nation's 2.5 million Registered Nurses through its 53 constituent associations. As the voice for professional nursing, ANA is critically concerned with issues related to patient safety and the quality of nursing care. The provision of individualized care through the reduction of restraint usage, both physical and chemical, in the behavioral health care and other settings, is one such issue.

A survey by the Hartford Courant revealed at least 142 deaths related to the use of physical restraints or seclusion since 1988. The report also noted that the true number of deaths is much higher since many such deaths go unreported. Since the articles were published, the National Alliance for the Mentally Ill (NAMI) has received reports from fifteen states about 24 incidents related to the use of restraints and/or seclusion...ranging from a sixteen year old in California who died while restrained by four staff members to an Ohio man who died in restraints running a temperature of 108 degrees. Situations such as these can not be allowed to continue.

Background

American Nurses Association (ANA) representatives Elissa Brown, MSN, RN, CS, First Vice President of ANA\California; Beatrice A. Yorker, MS, JD, RN, Fellow of the American Academy of Nursing; and, Catherine F. Kane, PhD, RN, FAAN, former ANA Representative to and Chairperson of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Behavioral Healthcare Professional Technical Advisory Committee (PTAC) presented testimony on behalf of ANA at the spring 1999 nationwide series of JCAHO-sponsored public hearings on the use of restraint and therapeutic holding in behavioral healthcare settings. These hearings were conducted as part of the Joint Commission's continuing commitment to improvements in its standards and survey process. The American Nurses Association testimony was prepared by Rita Munley Gallagher, PhD, RN, C under the direction of Eileen Sullivan-Marx, PhD, RN, FAAN and Neville Strumpf, PhD, RN, FAAN.

In testimony delivered at Fall 1997 Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) hearings, the American Nurses Association noted its support of the implementation of Joint Commission standards which require that the use of physical restraint be eliminated. The previous testimony noted as critical the active involvement of licensed independent practitioners in the evaluation of clinical circumstances surrounding patient behavior, a position currently espoused by ANA. Furthermore, ANA wishes to reaffirm its previously stated position: "Only when no other viable option is available should restraint be employed," especially in behavioral health care settings where the patients are among the most vulnerable of individuals. In those instances where physical restraint or therapeutic holding is determined to be "clinically appropriate and adequately justified," registered nurses, who possess the necessary knowledge and skills to effectively manage the situation, must be actively involved in the assessment, implementation and evaluation of the selected intervention. Not just anybody is qualified to apply restraints and situations such as those reported to NAMI can not be allowed to continue.

Of Particular Concern to JCAHO

While ANA applauds the perspectives put forth by JCAHO in the existing standards related to special treatment procedures which encompass seclusion and restraint, ANA is supportive of the inclusion of "restraint use" as a core indicator in ALL settings. Furthermore ANA believes that seclusion and/or restraint-related deaths must be included within the list of 'reportable' sentinel events as defined by JCAHO.

There are a variety of alternatives to restraint use. Physiologic approaches include such efforts as pain relief, comfort measures, or investigating symptoms indicative of developing complications, such as hypoxia or fever. Psychosocial interventions focus on the meaning of patient behavior and address that need, e.g. is the agitated patient fearful of impending surgery? Activities can include physical exercise/therapy, meaningful distraction, or contact with familiar persons or places, even by telephone. Environmental adjustments may range from simple use of light to facilitate vision to specifically designed units that reduce the hazards of falling. To foster transition to reduced restraint care and sustain lasting change beliefs must be altered and knowledgeable practice enhanced through education, intensive clinical evaluation, and consistent reinforcement of standards and policy.⁽¹⁾

One primary means for conducting on-site evaluations would be to ensure that behavioral health care surveyors possess actual inpatient psychiatric nursing experience. Furthermore, it is critically important that such surveyors have in-depth training in the evaluation of programming related to the effective models of therapeutic holding and/or restraint reduction. The importance of surveyors spending sufficient time to obtain adequate information regarding the therapeutic holding and/or restraint program being employed cannot be underestimated. There is a need to fully evaluate the philosophy of the program as well at the manner in which it is being implemented in staff training, milieu management, and interventions with clients. Incident reports should be reviewed to determine whether staff injury rates are increasing, related to lack of appropriate use of therapeutic holding and/or restraint.

Of Specific Relevance to Professional Nursing

Of particular relevance to professional nursing is determination of the most appropriate role for nursing staff in limiting restraint use, and in the unusual circumstances where they are used, working closely with physicians and others to have them removed as quickly as possible. Nursing has a history of being involved with attempts at reduction in the use of restraint going back well over one hundred years. Frequently, when restraint was employed it was in the belief that such action would promote patient safety. It has been noted that without effective seclusion and restraint practices, patients can be injured by other, assaultive patients. Likewise nursing staff can also be injured. Clearly adequate staffing is essential with this population.

Summary

In summary, the American Nurses Association is supportive of the implementation of Joint Commission standards which support the perspective that "Only when no other viable option is available should restraint be employed," especially in behavioral health care settings where the patients are among the most vulnerable of individuals. In those instances where physical restraint or therapeutic holding is determined to be "clinically appropriate and adequately justified," registered nurses, who possess the necessary knowledge and skills to effectively manage the situation, must be actively involved in the assessment, implementation and evaluation of the selected intervention. Once again, not just anybody is qualified to apply restraints and situations such as those reported to NAMI can not be allowed to continue.

ANA, encourages the establishment and use of behavioral health care interventions based on clinical judgement, accurate interpretation of behaviors and individualization of care. It would be the association's pleasure to continue to assist JCAHO in the development of such standards.

STATEMENT

The American Nurses Association

The American Nurses Association is the only full-service professional organization representing the nation's 2.5 million Registered Nurses through its 53 constituent associations. ANA advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress on health care issues affecting nurses and the public. As the voice for professional nursing, ANA is critically concerned with issues related to patient safety and the quality of nursing care. The provision of individualized care through the reduction of restraint usage, both physical and chemical, in the behavioral health care and other settings, is one such issue.

A 50-state survey recently conducted by the Hartford Courant (Connecticut) newspaper, revealed at least 142 deaths related to the use of physical restraints or seclusion since 1988. The report also noted that the true number of deaths is much higher since many such deaths go unreported. The database documents 142 deaths from 1988 to the present, as identified by public agencies, advocacy offices and news accounts. One of them, a patient at Virginia's Central State Hospital, died after being restrained for 300 hours, including two intervals of approximately 110 hours each. Others, young men in Pennsylvania and North Carolina died shortly after being physically restrained by people who were supposed to be caring for them. According to statistical projections commissioned by The Courant and conducted by the Harvard Center for Risk Analysis, between 50 and 150 such deaths occur every year across the country. Since the articles were published, the National Alliance for the Mentally Ill (NAMI) has received reports from fifteen states about 24 incidents related to the use of restraints and/or seclusion...ranging from a sixteen year old in California who died while restrained by four staff members to an Ohio man who died in restraints running a temperature of 108 degrees. Situations such as these can not be allowed to continue.

The American Nurses Association is pleased to have been given the opportunity to provide testimony. The association's comments will begin by responding to the areas of particular concern as stated by the Joint Commission. Finally, comments will be made on related issues which are of particular relevance to professional nursing.

In testimony delivered at Fall 1997 Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) hearings, the American Nurses Association noted its support of the implementation of Joint Commission standards which require that the use of physical restraint be eliminated. Adaptation of the clinical care environment's philosophy in order to allow for the availability of professional staff must be considered of prime importance in decreasing the need for therapeutic holding and/or physical restraint. Adequate professional staff must be available in order to make the necessary assessments to individualize patient care and take the necessary actions to resolve the patient's problem(s). The previous testimony noted as critical the active involvement of licensed independent practitioners in the evaluation of clinical circumstances surrounding patient behavior, a position currently espoused by ANA. Furthermore, ANA wishes to reaffirm its previously stated position: "Only when no other viable option is available should restraint be employed," especially in behavioral health care settings where the patients are among the most vulnerable of individuals. In those instances where physical restraint or therapeutic holding is determined to be "clinically appropriate and adequately justified," registered nurses, who possess the necessary knowledge and skills to effectively manage the situation, must be actively involved in the assessment, implementation and evaluation of the selected intervention. Not just anybody is qualified to apply restraints and situations such as those reported to NAMI can not be allowed to continue.

Of Particular Concern to JCAHO

Adequacy of current JCAHO standards relating to restraint use and therapeutic holding

While ANA applauds the perspectives put forth by JCAHO in the existing standards related to special treatment procedures which encompass seclusion and restraint, ANA is supportive of the inclusion of "restraint use" as a core indicator in ALL settings. Furthermore ANA believes that seclusion and/or restraint-related deaths must be included within the list of 'reportable' sentinel events as defined by JCAHO.

Criteria for the use of restraint in individuals with mental illness

Decisions regarding restraint use or avoidance in individuals with mental illness (as well as in those with no such diagnosis) are highly complex and require consideration of clinical and environmental factors based on empirical knowledge and within ethical norms. Empirical knowledge of restraint effects and alternative interventions based on individualized approaches to care frame decisions to avoid restraint use. Ethical questions of benefit versus burden and conflicts of patient autonomy versus paternalism undergird decisions regarding restraint.

Dilemmas in patient care situations are an inevitable consequence of professional accountability. With regard to use of restraints, nurses struggle with conflicts stemming from patients' rights of freedom, nurses' feelings of obligation to "protect" patients, and family and peer pressure to use restraints. In overcoming these competing expectations and the dilemmas raised, nurses report distancing themselves from the patient, an action that ultimately diminishes individualized care.

A common situation, often in early evening or at night, is the patient who becomes agitated or confused. Ludwick and O'Toole's (1996) survey found that 84% of hospital nurses reported that the last confused patient in their care was restrained, often based on the recommendation of another nurse, suggesting a routine use of restraints in response to confusion. Response to a change in the patient's cognitive status requires the same urgent, careful assessment and diagnosis that is almost automatic when a patient develops chest pain or threatens suicide. A coordinated team effort that evaluates the cause of new agitation, explores the meaning of the patient's behavior, and applies appropriate interventions fosters quality care without restraints.

Because nurses have a continuous relationship with the patient and provide constant monitoring of responses to illness, they are in the best position to meet the challenges of reduced restraint care.

Effective alternatives to the use of restraint

To achieve reduced restraint care, formal mission statements and policies that clearly state the intent to promote a reduced restraint environment for patients must be adopted. Such statements must include a focus on: 1) intention to comply with policy standards; 2) environmental designs to facilitate restraint reduction; and 3) implementation of an individualized approach grounded in the following principles: 1) all behavior has meaning; 2) patient needs are best met when behavior is understood; and 3) a systematic approach of assessment, intervention, and evaluation is the best means to respond to behavior.

When instituting change toward reduced restraint care, initial educational efforts must address fundamental components of such care. Open communication and dialogue at board and highest administrative levels, and including staff from all disciplines, as well as community representatives, and staff are essential to implementing change. Early success with less complex problems, such as eliminating restraints for positional support with substitution of wedge or roll cushions, fosters confidence for handling more difficult situations. If systems lack internal resources to provide education and specialist intervention, independent nursing consultation services can be contracted to provide for these needs.

Targeting specific units or groups of patients, such as all new admissions, and then identifying those who are restrained and why lays the groundwork for interventions aimed at eliminating restraints. Interventions may take the form of actions categorized as physiologic, psychosocial, activity or environment.

Physiologic approaches include such efforts as pain relief, comfort measures, or investigating symptoms indicative of developing complications, such as hypoxia or fever. Psychosocial interventions focus on the meaning of patient behavior and address that need, e.g. is the agitated patient fearful of impending surgery? Activities can include talking with the patient, physical exercise/therapy, involvement in activities, meaningful distraction, or contact with familiar persons or places, even by telephone. Environmental adjustments may range from simple use of light to facilitate vision, relocation of the patient to another bed or room, to specifically designed units that reduce the hazards of falling. To foster transition to reduced restraint care and sustain lasting change beliefs must be altered and knowledgeable practice enhanced through education, intensive clinical evaluation, and consistent reinforcement of standards and policy.⁽²⁾

Finally, it must be recognized that psychotropic medications are not merely 'chemical restraints' but treatment strategies which can result in a decreased need for therapeutic holding and/or physical restraint. However, it goes without saying, that there must be an adequate number of professional nurses available to provide the necessary care. They must be educated in the use of alternatives to restraint and such alternatives must be made available to them both through organizational policy and in fact. Only then, can the safety and quality of patient care be assured.

Effective means for conducting on-site evaluations

One primary means for conducting on-site evaluations would be to ensure that behavioral health care surveyors possess actual inpatient psychiatric nursing experience. Furthermore, it is critically important that such surveyors have in-depth training in the evaluation of programming related to the effective models of therapeutic holding and/or restraint reduction. The importance of surveyors spending sufficient time to obtain adequate information regarding the therapeutic holding and/or restraint program being employed cannot be underestimated. There is a need to fully evaluate the philosophy of the program as well at the manner in which it is being implemented in staff training, milieu management, and interventions with clients. Incident reports should be reviewed to determine whether patient and staff injury rates are increasing, related to lack of appropriate use of therapeutic holding and/or restraint.

There is also concern that psychotropic medications are being over-prescribed to control behavior in lieu of psychosocial interventions. Information related to this issue could be determined by interviews with clients, family members and staff and by record review to elicit information related to dramatic increases in the prescribing of sedatives and other psychotropic medications. Reviewing documented patient behavior and target symptoms for which patients are being medicated, and outcomes, should be continued. This is a complicated issue and is one additional reason that surveyors must be thoroughly trained, since such medications can be effective methods for helping clients to control abusive impulses.

Of Specific Relevance to Professional Nursing

Of particular relevance to professional nursing is determination of the most appropriate role for nursing staff in limiting restraint use, and in the unusual circumstances where they are used, working closely with physicians and others to have them removed as quickly as possible. Nursing has a history of being involved with attempts at reduction in the use of restraint going back well over one hundred years. Frequently, when restraint was employed it was in the belief that such action would promote patient safety. It was this belief, in part, which led to the increase in restraint use in the nursing home population. As concern about the quality of patient care in that setting rose the Nursing Home Reform Act (a part of the Omnibus Reconciliation Act of 1987) was adopted into law. The results of this law, which greatly affected the quality of care received through increased assessment of and care planning for the patient as well as through reduction of both physical and chemical restraint, have implications for individuals with mental illness as well.⁽³⁾

Advanced practice registered nurses (APRNs), as licensed independent practitioners, must be granted full privileges in behavioral health care settings. Psychiatric APRNs are specifically skilled in de-escalating situations, and in making assessments of changes in client conditions. When employed in inpatient settings they are frequently responsible for developing programs and providing continuing education to other staff. APRNs are most likely to be available to emergent situations, because they work on the units and are frequently responsible for the milieu, whereas physicians are generally focused on particular patients. Full privileging of APRNs can do much to promote the reduction of therapeutic holding and/or restraint use in psychiatric inpatient environments.

When the use of physical restraint has been determined by a licensed independent practitioner to be the most appropriate intervention, emphasis must remain on the availability of professional presence and adequate staffing. Nursing staff must be allowed to exercise clinical judgement and be provided with the supports necessary to act on that judgement.

It has been noted that without effective seclusion and restraint practices, patients can be injured by other, assaultive patients. Likewise nursing staff can also be injured. Organizational concerns must focus not only on protection of the rights of the assaultive individual. There must also be an appreciation of the rights of others (both patients and staff) in the environment to be protected from assault. Psychiatric units often are repositories for individuals who have been (or should be) incarcerated for some violent behavior (not always attributable to psychiatric illness). Nevertheless they are placed on psychiatric units for evaluation. Effective seclusion and restraint practices must be employed in order to manage these clients. Clearly adequate staffing is essential with this population.

In order to accomplish a reduced restraint care environment there must be administrative support to:

1. Enable the implementation of an individualized care plan;

2. Provide for sufficient continuing education for staff;

3. Engender the support of medical colleagues;

4. Ensure adequate professional staffing;

5. Provide appropriate environmental adaptation; and,

6. Make available necessary equipment.

Only in the presence of a philosophy devoted to enabling the above can a reduced restraint environment become a reality.

Often it is unclear which mode of intervention (therapeutic holding or application of physical restraints) is least restrictive. Some clients are said to find seclusion less confining while others indicate physical restraints to be less confining. Therefore it is not helpful to direct a standard hierarchy or protocol of interventions. Rather, development of individualized care plans which assist clients to engage in non-threatening and non-assaultive behavior must be employed thus reducing the need for therapeutic holding and/or application of physical restraints.

The American Nurses Association is critically concerned with issues related to patient safety and the quality of nursing care. In response to that concern, ANA has launched Nursing's Quality Report Card OUTCOMES Project which was developed as an educational program designed to inform nurses about health care quality outcomes measurement and nursing's quality indicators. Crafted around nursing's quality indicators, the program is based on the premise that nurses, in every role and setting, must acquire knowledge related to the measurement, improvement, and bench marking of seven nursing-specific clinical cost, quality and outcomes indicators. In addition to patient satisfaction two other indicators are of relevance to the discussion of restraint use. The first, Patient Injury Rate, identifies the rate at which patients fall and incur physical injury during the course of their hospital stay, a statistic frequently correlated with restraint use. The second, Maintenance of Skin Integrity, considers the rate at which patients develop pressure sores during the course of their hospital stay also of pertinence to restraint use. It is activities such as Nursing's Quality Report Card OUTCOMES Project which speak to ANA's ongoing concern with patient safety and the quality of professional nursing care. The original indicators are currently in the process of reformulation to address the needs of patients beyond the acute care setting.

Summary

In summary, the American Nurses Association is supportive of the implementation of Joint Commission standards which support the perspective that "Only when no other viable option is available should restraint be employed," especially in behavioral health care settings where the patients are among the most vulnerable of individuals. In those instances where physical restraint or therapeutic holding in "clinically appropriate and adequately justified," registered nurses, who possess the necessary knowledge and skills to effectively manage the situation, must be actively involved in the implementation and evaluation of the selected intervention. Once again, not justanybody is qualified to apply restraints and situations such as those reported to NAMI can not be allowed to continue.

ANA, encourages the establishment and use of behavioral health care interventions based on clinical judgement, accurate interpretation of behaviors and individualization of care. It would be the association's pleasure to continue to assist JCAHO in the development of such standards.

Once again, the American Nurses Association is grateful for the opportunity to provide testimony to the Joint Commission on the Accreditation of Healthcare Organizations on issues related to the use of restraint. If you have questions or if the American Nurses Association may be of any assistance to you, please feel free to contact Rita Munley Gallagher, PhD, RN,C, Senior Policy Fellow in the Department of Nursing Practice, at (202) 651-7062 or by E-mail rgallagher@ana.org, at your convenience.

REFERENCES

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