Pulling together for restraint reduction: submitted by Botsford Continuing Care Corporation - The 1996 Optima Awards: Resident-Focused Care - Cover Story

Nursing Homes, Sept, 1996 by Linda S. Mlynarek, Linda C. Mondoux

Comment from the Beverly Foundation:

Two medical directors and a psychologist wrote recently that "with common expectations, support and guidance, the talent in a facility can be focused on understanding behavior and responding to it in productive ways."(*) Here is a wonderful case in point. The facility made a direct link between restraint reduction and a corporate philosophy that promises the best possible care in a supportive and comfortable environment. It then developed a comprehensive, flexible approach that integrated multiple sources of input. Even staff resistance and the uneasiness of family members were transformed into opportunities for education, greater understanding and, ultimately, a more effective caregiving team.

Many facilities these days have attempted restraint reduction, but few have known at the outset the effort involved. In our Optima Awards submission describing our own experience, we have chosen to follow the outline developed by the co-sponsoring Beverly Foundation. Therefore:

I. Problem

What were the circumstances before the program commenced and what led you to focus on this need or problem? What convinced you that a change was necessary or desirable?

Even though OBRA requires facilities to achieve 0% physical restraint usage and a reduction in medications at least twice yearly, we were not yet in compliance with these mandates. For instance our 1995 survey referred to residents on our dementia unit exhibiting episodes of extreme agitation and, as of March 1995, 19% of those residents were receiving psychotropic meds without close supervision for reduction of medications.

With the onset of OBRA, we had been faced suddenly with the challenge of removing physical restraints and with the fear that residents would sustain injuries because, we felt, we would no longer be able to protect them. Interviews with residents and their families brought to light the human dignity side of the question, however. One female resident, when asked why she wore a restraint, responded, "I don't know, but I must have been bad." This was only the first of many eye-opening and poignant statements we heard from our restrained residents as we began to include them in the process of change...hopefully, to 0% restraint usage in our 179-bed facility.

As for those residents who were chemically restrained without a reduction in medication over a period of time, the facility did not have on staff a board-certified psychiatrist available for follow-up with these residents. We had a psychiatrist who was affiliated with our organization, but who was very inaccessible. Mental health screenings were very difficult to arrange in a timely fashion.

Use of psychotropic drugs, both in quantity and number of residents, actually increased from March to July 1995. Further investigation of these residents' history indicated psychotropic drug use dating back to 1993 without reduction.

What resources initiated, were consulted, or helped in definition of the problem?

Staff assisted in counting and identifying numbers and types of physical restraints. We considered a variety of assessment tools, finally deciding on merging the "best" of each into a comprehensive initial assessment and quarterly review plan. Staff also developed a checklist of environmental and physical factors that could affect residents' behavior.

To address use of chemical restraints, we turned to the community at-large. Though we encountered little enthusiasm from advocate agencies for assisting nursing home residents suffering from dementia, we interviewed psychiatrists who expressed an interest in working with our population. We searched specifically for an individual or individuals who shared our commitment to finding alternative methods to manage resident behavior so that it would be less disruptive to other residents and more supportive of the resident's quality of life. The psychiatrist whom we subsequently engaged was affiliated with an academic setting, and was well-known and respected nationally in the geriatric psychiatry field.

II. Objectives

What led you to choose the approach you selected?

Having learned that restraints of a physical and chemical nature were used for many reasons, we believed an interdisciplinary team approach would put us in the best possible position to identify the core reason that a restraint was being used, and then address that reason specifically. On this team we included representatives from occupational and physical therapy, nursing and social work, with other departments included as needed. Prior to beginning the program, we decided how the resident would be assessed, and how we would evaluate the resident's progress in order to identify possible strategies to eliminate or reduce problem behaviors.

What did you expect to accomplish?

Our corporate philosophy states, "...we will provide an environment in which clients will receive personal attention by health care professionals dedicated to maintaining their health, safety, independence, comfort and dignity during their residence through state-of-the-art medical, nursing, dietary, therapeutic, recreational, spiritual and quality of life programs within aesthetically pleasing facilities and grounds." In line with this, we hoped to create a calmer living environment for our residents. We desired to reduce, and eliminate over time, physical restraint usage and to have medications, particularly psychotropic drugs, monitored for utilization, with a goal of reduction/elimination as early as feasible.