Development of a tool for risk assessment to ...

service development

Development of a tool for risk assessment to facilitate safety and appropriate restraint Catheryne Waterhouse is lecturer/practitioner, Ward N1, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF

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estraint is described in the Focus on Restraint guidelines of the Royal College of Nursing (RCN) (1992) as the ‘removal of personal liberty, institutionalisation of the worst kind’. However, a more comprehensive description, relevant to the use of restraint in nursing, would be that proposed by the RCN Scotland (1999): Any manual method or physical or mechanical device, material or equipment to involuntary restrain the movement of the whole or a portion of a patient’s body as a means of controlling his/her physical activities in order to protect him/her or others from injury.

In its more recent guidelines on restraint, the RCN (2004: 3) offers a more succinct definition as ‘restricting someone’s liberty or preventing them from doing something they want to do’. In the discussion of this definition, the aim of preventing damage to property is included as a reason for the use of restraint, in addition to preventing harm to the individual and/or others. It is also emphasized that a person who is restrained ‘is being denied a fundamental human right’ (RCN, 2004: 3). Nurses working in the field of mental health, learning disabilities and care of the elderly have carried out audits, research, and written reams on the subject of restraint, correlating the results with poor patient outcomes, higher mortality rates, increases in hospitalization, nosocomial infections, pressure sores and increased levels of confusion (Bray et al, 2000; Gallinagh et al, 2002; Martin, 2002; Hamers et al, 2004; Braine, 2005). Their work has consequently provided nurses with comprehensive direction on their legal, ethical and professional responsibility to refrain from restraining a patient unless there is appropriate and adequate clinical justification and that prior alternative interventions have been tried but deemed unsuccessful (Joint Commission Accreditation of Health Care Organisations, 1994). This guidance should be rigorously applied to all clinical settings including neuroscience units and yet on a daily basis, restraints remain commonplace and are applied to manage particular clinical events in neurosurgery and, more specifically, in neuro-critical care. Typically, the deployment of restraint devices is undertaken by staff to gain control over behaviour which is

British Journal of Neuroscience Nursing

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likely to cause serious injury to the patient, such as the extremely confused patients who continuously attempts to leave the safety of the ward, climb out of bed or remove their endotracheal tube, tracheostomy tube, invasive drains or intravenous central lines. The use of physical or mechanical restraints such as electronic tagging, lap belts or padded mittens prevents the patient from inadvertently self-harming or interfering with essential medical management. In contrast, chemical restraints such as benzodiazepines or major tranquillizers are occasionally used to modify extremely distressed, agitated or confused behaviour, and are instigated by medical staff as part of the patient’s therapeutic management plan. The national Neuroscience Nursing Benchmarking Group has explored issues related to restraint and made some key recommendations giving emphasis to the management of challenging behaviour and the prevention and reduction of the use of restrictive measures while continuing to maintain patient safety. The restraint benchmark has not yet been published but the final draft is currently out for discussion by the benchmark group. The dangers incurred as a result of restraining patients are well documented, and the Human Rights Act 1998 and the Mental Capacity Act 2005 are clear that, with limited exceptions such as reasonable defence, reasonable chastisement or

Abstract

Restraint is a method of involuntarily restraining the movement of the whole or a portion of a patient’s body to control behaviour and prevent injury to the patient or others. Restraint has been correlated with with poor patient outcomes, higher mortality rates, increases in hospitalization, nosocomial infections, pressure sores, and increased levels of confusion. It can often be extremely difficult to maintain patient safety without acting in a way that might provoke an allegation of abuse. The aim of this article is to discuss some of the difficulties that presented themselves to nurses in the Royal Hallamshire Hospital’s neuroscience unit following a decision to justify actions to use restraints. The development a functional risk assessment tool for use in cases of challenging behaviour is explained and its use discussed in relation to legal and consent requirements. Key words n Critical care n Restraint n Risk n Benchmarking Accepted for publication following double-blind peer review 3 September 2007

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service development reasonable everyday contact, to touch someone or cause someone to be touched against his/her will is unlawful. However, the Mental Capacity Act 2005 also provides for the use of force to restrain an incapacitated patient in his/ her best interests according to the ‘doctrine of necessity’. Therefore, because everyone has a basic human right to be free from the use of unacceptable force to restrict his/her freedom to move, the importance of completing a risk assessment to identify the benefits and risks associated with an intervention strategy cannot be over-emphasized and forms the cornerstone of the clinical governance agenda defined in the consultation document, ‘A first class service: quality in the new NHS’ (DH, 1998). A key component of clinical governance is detecting deficiencies or shortfalls in the provision of care and services through the use of clinical audit and risk assessments. Where a risk, in this case a neurosurgical patient with cognitive difficulties, attempts to disrupt his/her treatment, strategies must be put in place to prevent, minimize or manage the risk where it cannot be reduced, ensuring that safe, high quality care is delivered to the patient at the same time as maintaining the safety of the practitioners. It is not the intention in this article to review the literature relating to the use of restraints. This has been comprehensively presented in other papers (Bray et al, 2000; Gallinagh et al, 2002; Hamers et al, 2004; Braine, 2005). Instead, the aim of this article is to discuss some of the difficulties that presented themselves to nurses in the neuroscience unit at the Royal Hallamshire Hospital following a decision to justify actions to use restraints. As a result of this decision, the nurses developed a risk assessment tool to provide guidance about how to respond to cases of challenging behaviour in patients.

The need for risk assessment

The project to develop a risk assessment tool for the use of restraint began 6 years ago at the request of the unit matron following a complaint from a patient’s relative, who was upset when she found her husband’s hands restrained in bandages. The matron was also concerned at the high cost of providing cottonwool rolls, crêpe bandages and elastic tape to construct the protective gloves. Although the local benchmarking group was in its infancy, it was considered important to involve in the undertaking as many people as possible who were most likely to be affected by the issues raised so that the staff would accept the results of the investigation as a true representation of standard practice and not merely a ‘paper exercise’. The project began by assembling a taxonomy of factors that were considered to influence clinical decision-making. Initially these were divided into three categories: ■ The critically ill patient who becomes non-compliant with his/her medical treatment or tampers with his/her invasive medical devices ■ The cognitively impaired patient who is confused and likely to wander with little insight into his/her condition, or the patient that needs support to maintain his/her sitting position out of bed 422

■ The confused or disoriented patient whose behaviour put him/her or others at risk of injury, e.g. where there is a high risk of falling or of aggressive and violent outbursts. In each of the categories identified above it was possible to identify several distinct responsibilities that were considered necessary to address. Following a detailed literature search, the nurses on the unit wrote guidance for implementing restraint in neuroscience, incorporating a detailed flowchart for management. Despite the comprehensiveness of this guidance, in practice, few nurses adhered to the framework, and it was soon recognized that a more functional checklist was needed that was better suited to the realities of practice.

Development of a functional tool

Nurses do not intentionally set out to hurt their patients but trying to maintain patient safety without acting in a way that might provoke an allegation of abuse can be extremely difficult to achieve, even for the most experienced of nurses. On the ‘shop floor’ the nurses that most frequently apply restraints do so with the genuine belief that it is in the best interests of the patient (Strumpf et al, 1988; Gallinagh et al, 2002). In neuroscience there can be serious consequences for a practitioner’s indecisiveness, e.g. nosocomial infection and/or the need to remove an infected bone flap. There are other obvious critical consequences of failing to intervene. For example, few acutely ill neuroscience patients can manage their own airways without some kind of adjunct. The inadvertent removal of a post-surgical drain, a catheter to reduce intracranial pressure, or an intravenous central line for titrated doses of noradrenalin could easily be fatal. In such cases the nurse would be in breach of his/her duty of care and could even face the possibility of litigation for lack of professional judgment (RCN, 1992). The aim was to develop an instrument that was transparent in its intentions, clearly communicated and adopted by all staff on a day-to-day basis. Although the focus would always be on the needs of the patient, it was important not to lose sight of other pertinent issues such as the safety of clinical staff, other patients and carers. The Health and Safety Executive (HSE) (2006) states that: A risk assessment is simply a careful examination of what, in your work, could cause harm to people, so that you can weigh up whether you have taken enough precautions or should do more to prevent harm.

The five-step framework of the HSE guidance was used to guide our approach (Table 1).

Identifying the hazards and who is at risk Steps one and two involved identifying the hazards and deciding who might be harmed, bearing in mind that the law—the Health and Safety at Work Act, 1974 and the


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service development Management of Health and Safety at Work Regulations 1999—did not expect health professionals to be able to eliminate all risks, but to try to protect people as far as is ‘reasonably practicable’. Using the risk assessment document staff were asked to consider whether the patient was endangering his/her own safety or that of others. Given the nature of the client group the risk to patients was invariably high. The risks to staff were considerably less but the degree of risk to staff depended on the specific behaviours of the patients.

Evaluating the risks The next part of the assessment involved observing the nature of the altered behaviour and identifying possible causes for it. Some of the items listed were very basic such as recognizing that the patient has a full bladder or that the patient was in pain, while others were more difficult to ameliorate, e.g. alcohol or drug dependency. Only when this step of the process has been completed can practioners consider applying restraints. Even then, restraints should be used only when positive, non-restrictive procedures have failed to produce the desired behavioural change (RCN, 2004). The next section of the assessment presents a list of ‘minimum’ restraint measures that could be considered or applied to patients whose behaviour is putting themselves at risk or compromising their care. This list prompts the practitioner to try to distract the patient or defuse the episode, for example, by manipulating the environment to reduce the trigger factors. Examples may include moving the patient into or perhaps out of a side ward, providing a radio or a television, bringing the family in to calm the situation, or providing appropriate diversional activities. If simple strategies such as these are ineffective and the risk is still considered to be significant, restraint may be applied, but it should be regarded as a ‘last resort’ measure only implemented in extreme circumstances. This includes the use of cot-sides, hand restraints, electronic tagging and even one-to-one supervision. Referral to the neuropsychologists may be appropriate at this time. Use of a behavioural chart to identify the trigger factors for the challenging behaviour may also be helpful. Education is essential to the successful implementation of the tool and a significant amount of time must be invested in providing information, instruction and training to ensure that staff understand and recognize the possible

Table 1. Five steps to risk assessment Step 1

Identify the hazards

Step 2

Decide who might be harmed and how

Step 3 Evaluate the risks and decide on precaution Step 4 Record your findings and implement them Step 5 Review your assessment and update if necessary From: Health and Safety Executive, 2007.


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antecedents, attributes and consequences of applying restraints in line with step three of the HSE guidance.

Recording the findings Step four of the HSE’s risk management framework concerns documentation, recording and implementation. It can be argued that this section is the most important aspect of the approach. It entails a careful consideration of communication and consent. Whenever possible the agreement of the patient must be sought and he/she should be informed of the benefits that might be derived from the proposed measures. To give consent the patient must be of sound mind. Unfortunately, it is often the case that the patient is unable to give consent because of his/her confused mental state. Consultation and discussion with the patient and his/her carers at this point is essential as they need to understand the rationale for the use of the restraints and the potential consequences of not using such measures. In practice, this involves contacting the family at home as soon as practicable or reasonable to do so. At this time it is important to give the family the option of sitting with the patients as a possible alternative to restraint. In reality, however, few carers are able to commit to such intensive supervision but they feel reassured that they have at least been consulted. The Mental Capacity Act 2005 (sections 5 and 6; Code of Practice 6.11–6.19) now provides a comprehensive framework that gives greater structure and guidance for clinical staff on the use of restraints and ensures that the views of family members, carers and relevant people are more formally and legally taken into account. Until recently, it has been possible to apply the ‘reasonable person’ rule (DH, 2001), allowing the patient’s medical team to act appropriately on the patient’s behalf. However, this has always been controversial and in some cases open to abuse. This principle is now codified in the Mental Capacity Act 2005. The Mental Capacity Act 2005 also enshrines other principles that have become accepted practice and have been recommended in a number of clinical governance documents. It is important to consult and take into account the views of family members, carers and relevant people such as the independent mental capacity advocate who has an interest in the welfare of the patient. In practice this means involving the family in discussions about the rationale for the use of the restraint as soon as it is practicable or reasonable to do so and giving them the option of sitting with the patients as a possible alternative to restraint. In reality, few carers are able to commit to such intensive supervision but they feel reassured that they have at least been consulted.

Review and update The final part of the tool provides for ensuring that any restraint that has been agreed by the nursing staff or multidisciplinary team is the least restrictive necessary to achieve the desired result, and the reasons for its use must be recorded on the assessment tool and in the patient’s Vol 3 No 9

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424 Yes


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Ictal or postictal states Mental health problems Drug dependency or withdrawal Alcohol dependency or withdrawal Dementia or neurodegenerative disorder (especially Parkinson’s disease). Sleep deprivation

Confused

Agitated (may accidentally remove lines/tubes)

Disrupting essential therapy

Risk of falling

Disinhibition

Verbally aggressive

Other (describe)

Communication or memory Impairment

Wandering and may decide to leave the ward

Reason that restraint is required:

Environmental factors - noise, lighting.

Intracranial injury, space occupying lesions or infection.

Hypoxia

Electrolyte/metabolic imbalance

Pain

Bowel/bladder full

Pyrexia

Identify Possible Causes for Altered Behaviour

No

Anxiety or situational frustration.

Yes

Describe this behaviour: (this may be a combination of factors)

Endangers the safety of other patients/staff

Endangers his/her own safety

Is the patient exhibiting behaviour that:

Date:

Hospital number: Affix patient label

Patient name:

This record must be followed in the assessment, monitoring and evaluation of any patient who may require physical or chemical restraint in order to maintain the patient’s own safety or to protect patients and staff from harm.

CHALLENGING BEHAVIOUR RISK ASSESSMENT AND RECORD

No

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Respiration & circulation are not compromised Hygiene and toileting offered Food and fluids offered. Skin integrity checked. Assess on-going need for restraint CARE PLAN UPDATED

Provide orientating stimuli (e.g. clock).

Provide patient opportunity to control activity.

Offer or provide comfort measures.

Utilize direct observation, i.e. 1:1, or video monitor room

Remove harmful objects

Utilize verbal de-escalation techniques.

Manipulate the environment, e.g. music, video, change of room

Review drug therapy.

Provide appropriate diversional activities – describe:

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03.00 ………………………………16.00 ……………………………… 04.00 ………………………………17.00 ……………………………… 05.00 ………………………………18.00 ……………………………… 06.00 ………………………………19.00 ……………………………… 07.00 ………………………………20.00 ………………………………

Electronic tagging

Posey Mitt

Wrist restraint

Chemical restraint (refer to guidelines).

Cot sides

Yes

No

If the assessing nurse is unable to maintain patient safety through these strategies then the situation must be referred to the senior nurse on duty

11.00 ………………………………24.00 ………………………………

10.00 ………………………………23.00 ………………………………

09.00 ………………………………22.00 ………………………………

08.00 ………………………………21.00 ………………………………

02.00 ………………………………15.00 ………………………………

01.00 ………………………………14.00 ………………………………

00.00 ………………………………13.00 ………………………………

signature signature

EVALUATE RESTRAINT STRICTLY HOURLY

One-to-one supervision

Identify maximum restraint to be used.

Unable to utilize less restrictive alternatives – explain:

ENSURE :

Involve family or significant others to calm the situation.

Time restraint Implemented:

Consultation with Patient

Optimize environment to reduce triggers.

No Name of Relative/Carer consulted regarding use of identified restraint:

Yes

Try to diffuse situation using the minimum of staff

Identify minimum restraint to be used.

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service development care plan. The risk assessment prompts practitioners to frequently re-evaluate the continued need for the restraints as care continues. For instance, central lines or a tracheostomy might have been removed or the patient’s cognitive state might have significantly improved so that he/she is more compliant with care. The use of commercially produced restraints allows the nurse to readily assess the patient’s circulation and tissue viability without inflicting additional distress—a practically impossible task when bandages and tape are used. As a result of the process described, a tool for conducting risk assessments in cases of challenging behaviour was completed for use in the neuroscience unit at the Royal Hallamshire Hospital (Figure 1).

Conclusions

Step five of the HSE framework emphasizes the importance of reviewing an assessment tool from time to time to make sure that the guidelines are working effectively. The tool developed by the Royal Hallamshire Hospital’s neuroscience unit has undergone a couple of amendments and is likely to change again to bring it in line with the trust’s documentation framework. To work effectively and reduce the numbers of iatrogenic patient injuries, the risk assessment document must be fully embedded in the ward’s daily routine. It is has become custom and practice to complete an assessment on all patients throughout the neuroscience unit that need to be restrained. This applies to the use of Posey mitts, tagging systems, belts and sedation. While the original purpose for devising such a tool was to validate what was firmly believed to be the best and safest practice, the outcome ultimately yielded unexpected dividends. As a positive result of using the tool, there is anecdotal evidence to suggest that the number of patients that need to be restrained owing to non-compliance with

Key Points ■ Restraint is a method of involuntarily restraining the movement of the

whole or a portion of a patient’s body to control behaviour and prevent injury to the patient or others ■ Restraint has been correlated with with poor patient outcomes, higher

mortality rates, increases in hospitalization, nosocomial infections, pressure sores, and increased levels of confusion

medical management has significantly reduced. Restraints are rarely used to maintain the integrity of straightforward devices such as nasogastric tubes or indwelling catheters, and they are never used as an alternative to understaffing or sudden increases in patient acuity levels. This project has demonstrated the positive impact that a protocol or guideline can have in the practical management of patients. The tool developed serves to protect the best interests and safety of the patients, and nursing staff have welcomed the availability of unambiguous practical and realistic guidance. Conflict of interest: none declared Braine ME (2005). The management of challenging behaviour and cognitive impairment. British Journal of Neuroscience Nursing 1(2): 67–74 Bray K, Hill K, Robson W, Leaver G, Walker N, Leary M, Delaney T, Walsh D, Gager M, Waterhouse C (2004) British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nurs Crit Care 9(5): 199–211 Department of Health (1998) A first class service: Quality in the new NHS. HSC 1998/113. DH, London Department of Health (2001) Reference Guide to Consent and Examination or Treatment. 6 April. Gateway ref 2001. www.dh.gov. uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4006757 (accessed 14 August 2007) Department of Health, Home Office (2005) Mental Capacity Act. Stationery Office London Gallinagh R, Nevin R, McIlroy D et al (2002) The use of physical restraint in the care of older people in four rehabilitation wards: Findings from an exploratory study. Int J Nurs Stud 39: 147–56 Hamers JPH, Gulpers MJM, Strik W (2004) Use of physical restraint with cognitively impaired nursing home residents. J Adv Nurs 45(3): 246–51 Health and Safety Executive (2006) Five Steps to Risk Assessment. www.hse.gov.uk/risk/fivesteps.htm (accessed 14 August 2007) The Joint Commission Accreditation of Health Care Organisations (1994) Accreditation Manual for Hospitals. Vol 1: Standards. Oakbrook Terrace Illinois Strumpf N, Evans L (1988). Physical restraint of the hospitalised elderly: Perceptions of patients and nurses. Nursing Research 37(3): 133–7 Martin B (2002) Restraint use in acute and critical care settings: changing practice. AACN Clinical Issues 13(2): 294–306 Royal College of Nursing (1992) Focus on Restraint. Guidelines on the use of Restraint in the Care of Older People. 2nd edn. Bury St Edmunds Press Royal College of Nursing (1999) Guidance on Restraint: Issues for Nurses Working In Neuroscience Units in Scotland. RCN Scotland, Edinburgh Royal College of Nursing (2004) Restraint Revisited: Rights, Risks and Responsibilities. Guidance for Nursing Staff. RCN, London. www. rcn.org.uk/members/downloads/RestraintRevisited.pdf (accessed 28 August 2007)

■ A functional risk assessment tool for use in cases of challenging

behaviour was developed by the Royal Hallamshire Hospital’s neuroscience unit following a decision to justify actions to use restraints ■ The Royal Hallamshire Hospital’s tool adopts the five-step approach to

risk assessment recommended by the Health and Safety Executive ■ All steps of the risk assessment process must be recorded ■ Wherever possible the agreement of the patient must be sought and

the patient informed of the benefits that might be derived from any proposed measures

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Further reading National Patient Safety Agency (2004) Understanding the patient safety issues for people with learning disabilities. NPSA, London National Patient Safety Agency (2007) Advice on the safe use of bed rails. Device Bulletin 7729. NPSA, London Reigle J (1996) The ethics of physical restraint in critical care. AACN Clinical Issues 7(2): 23–6


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