Implementing and sustaining evidence-based practices in long-term care.

Alternative Approaches to the Use of Restraints

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    Nurses require knowledge and evidence on the use of alternative approaches to the use of restraints. The promotion of safe evidence based care is the goal to prevent the untoward incidents from the use of restraints. This guideline offers nurses a model which will help them to examine their approach to the use of restraints within their practice.

    Registered Nurses’ Association of Ontario. (2012). RNAO Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, ON: Author. Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

     This work is funded by the Ontario Ministry of Health and Long-Term Care

    Source: https://rnao.ca/bpg/guidelines/promoting-safety-alternative-approaches-use-restraints?_ga=2.257239755.1702348378.1602485970-1685849072.1567072300 

     

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    Restraint Gap Analysis

    An organizational assessment tool to assist with implementation and evaluation of the RNAO Promoting Safety: Alternative Approaches to the Use of Restraints by comparing current practice to evidence-based practice. 

    Registered Nurses' Association of Ontario's. (2012). Promoting Safety: Alternative Approaches to the Use of Restraints gap analysis. Toronto, ON: Long-Term Care Best Practices Program


     

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    This template is helpful in identifying and altering the antecedent and consequences to change behaviour.

    Registered Nurses’ Association of Ontario. (2012). Appendix L of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (p. 113). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Source: Omelan, C. (2006). CME: Approach to Managing Behavioural Disturbances in Dementia. Canadian Family Physician, February, 52, p. 193 Reprinted with permission from the Canadian Family Physician

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    This link takes you to the admission to a secure unit section 45 of the Long-Term Care Homes Act, 2007, S.O. 2007, c. 8. Government of Ontario. Retrieved from https://www.ontario.ca/laws/statute/07l08

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    This link takes you to the Health Canada website where you can access the guidance on hospital beds related to entrapment.

    Health Canada. (2006). Guidance Document: Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching Reliability, and Other Hazards. Author. Retrieved from https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/application-information/guidance-documents/guidance-document-adult-hospital-beds-patient-hazards-side-rail-other-hazards.html

     

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    This link takes you to the AdvantAge Ontario Website for implementation resources, you can scroll down to find a section on Minimizing Restraining and Use of Personal Assistance Services Devices (PASDs). Under this section there are documents related to: 1) Policy, procedure and training package and 2) Appendix materials, including: i) physical restraint monitoring, ii) restraint audit tool, and iii) least restraint, last resort training presentation.  

    AdvantAge Ontario. (2010). LTCHA Implementation resources. Retrieved from https://www.advantageontario.ca/MediaCentre2/LTCHomesActCentralseeSiteNavigation/LTCHA_Resources.aspx

    Copyright: AdvantAge Ontario 

    Website: www.advantageontario.ca   

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    The Alternative Approaches List is a table with examples and suggested alternatives and patient behaviours.

    Registered Nurses’ Association of Ontario. (2012). Appendix J of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 104-107). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    All request to adapt the Alternative Approaches to Restraint use must be directed to the Ottawa Hospital, Department of Nursing Professional Practice

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    This decision tree from The Ottawa Hospital provides a visual decision making guide to determine risk and restraint alternatives.

    Registered Nurses’ Association of Ontario. (2012). Appendix N of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author. (page 116). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    All requests to adapt the Alternative to Restraints Decision Tree must be directed to the Ottawa Hospital, Department of Nursing Professional Practice

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    This link takes you to the Alzheimer Society Canada publication which discusses types of restraints, least restraint for persons with dementia and what to do when restraint free strategies are ineffective.

    Alzheimer Society of Canada. (2007). Restraints. Toronto, Ontario, Canada: Author. Retrieved from http://www.alzheimer.ca/en/We-can-help/Resources/Alzheimer-Society-brochures-and-publications.

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    The Behaviour Monitoring Log from Penn Nursing Science helps determine the meaning of untoward events through examining patterns of behaviours/occurrences.

    Registered Nurses’ Association of Ontario. (2012). Appendix M of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 114-115). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Adapted from: Strumpf, N., Robinson, E.J.P., Wagner, J.S., & Evans L.K. (1998). Restraint-Free Care: Individual Approaches for Frail Elders. New York: Springer Publishing, pp. 44-46. Reprinted with permission from Penn Nursing Science.

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    A sample Jeopardy game illustrates a fun way to evaluate learning.  

    Registered Nurses' Association of Ontario. (2014). Best practice Jeopardy: Alternative to restraints edition. Long-Term Care Best Practices Program, Toronto, ON.

     

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    This tool is used to assess the residents’ level of confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects- as present or absent.

    Registered Nurses’ Association of Ontario. (2012). Appendix G of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 99-100). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Source: Almvik, R. & Woods, P. (April 2003). Short-Term Risk Prediction. The Broset Violence Checklist. Journal of Psychiatric and Mental Health. Nursing, 10(2), pp. 236-238

    Reprinted with permission from John Wiley and Sons

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    This tool is used to determine reasons caregivers attribute using physical restraints with the elderly.

    Registered Nurses’ Association of Ontario. (2012). Appendix K of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 108-110). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Developed by Lois Evans and Neville Strumpf (1986). University of Pennsylvania School of Nursing: revised 1990 & 2010.

    Website: www.nursing.upenn.edu
     

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    This tool helps the resident and caregiver discuss individualized behavioural triggers and preferred measures of response.

    Registered Nurses’ Association of Ontario. (2012). Appendix T of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (p. 125). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Reprinted with permission from St. Joseph`s Health Care. Hamilton, Ontario

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    The 5 questions in this tool are used to assess care preferences of patients if they become upset or have difficulty dealing with emotions.

    Registered Nurses’ Association of Ontario. (2012). Appendix I of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 102-103). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Copyright NY State Psychiatric Institute, Reprinted with permission from David J. Hellerstein, MD.

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    These tips and interventions help caregivers to examine their own practices and best strategies to prevent escalation of behaviours.

    Registered Nurses’ Association of Ontario. (212). Appendix U of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 126-127). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Provided by the Milwaukee County Mental Health Division, Milwaukee, WI

    Adapted from Dr. Gudeman's Interaction with Patient on Interventions with De-Escalating Patient 10/99

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    This debriefing tool provides examples of questions to ask the resident after they have been restrained or secluded.

    Registered Nurses’ Association of Ontario. (2012). Appendix X of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (p. 139). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Used with permission: Stone Institute of Psychiatry, Northwestern Memorial Hospital Chicago, IL

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    Practice standards are documents that help nurses understand their responsibilities and legal obligations to enable them to make safe, effective and ethical decisions when practising. This practice standard aims to help nurses understand the regulatory and legislative requirements for documentation.

    College of Nurses of Ontario. (2008). Documentation, Revised 2008. Toronto, ON: Author. Retrieved from http://www.cno.org/globalassets/docs/prac/41001_documentation.pdf


     

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    This interview guide Subjective Experience of Being Restrained (SEBR) can be used with patients in hospital and then in nursing homes.

    Registered Nurses’ Association of Ontario. (2012). Appendix E of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 94-96). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Copyright 1986 University of Pennsylvania School of Nursing

    Website: www.nursing.upenn.edu/

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    This assessment tool is used primarily by mental health professionals to “estimate” a persons’ probability of violence.

    Registered Nurses’ Association of Ontario. (2012). Appendix H of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (p. 101). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Reprinted with permission from Ronald Roesch, Professor, Director of Mental Health Law and Policy Institute, Simon Fraser University

    Website: http://kdouglas.wordpress.com/hcr-20/

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    The link takes you to the minimizing of restraining section 109 to 113 of the Ontario Regulation 79/10 made under the Long-Term Care Homes Act, 2007, Government of Ontario. Retrieved from https://www.ontario.ca/laws/regulation/r10079

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    This link takes you to the minimizing of restraining sections 29 to 36 of the Long-Term Care Homes Act, 2007, S.O. 2007, c. 8. Government of Ontario. Retrieved from https://www.ontario.ca/laws/statute/07l08

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    The Mutual Action Plan (MAP) takes into account the resident's individual style of learning and communicating.

    Registered Nurses’ Association of Ontario. (2012). Appendix O of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 117-118). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    MAP Behavioural Profile - Draft 2009/11/18 adapted from: Safe Management Group Inc. 2008. Copyright 2009, Ontario Shores Centre for Mental Health Sciences. All rights reserved.

    Reproduction in whole or in part by any means without written consent of Ontario Shores is prohibited by law.

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    This observation and documentation record is when chemical restraints, seclusion and/or mechanical restraint are used.

    Registered Nurses’ Association of Ontario. (2012). Appendix W of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 131-138). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Copyright Centre for Addiction and Mental Health (2009). This material is prepared solely for internal use at CAMH. No part of this document may be reproduced in any form for publication without the permission of CAMH

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    Les normes d’exercice informent les infirmières de leurs responsabilités et expliquent leur rôle au public. Le présent document a pour objectif d’aider les infirmières à comprendre leurs responsabilités et à prendre des décisions en matière de contention. La contention, qu’elle soit physique, environnementale ou chimique, est un moyen controversé visant à restreindre les mouvements d’un client ou à maîtriser son comportement.

    Copyright © Ordre des infirmières et infirmiers de l’Ontario, 2009.

    Ordre des infirmières et infirmiers de l’Ontario. (2006).  La contention. Toronto, ON, Canada: Auteur. Récupérée de http://www.cno.org/fr/exercice-de-la-profession/normes-et-directives-professionnelles/.

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    Organizational data collection tool that can be used when restraints are used as a “last resort”.

    Registered Nurses’ Association of Ontario. (212). Appendix Y of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 140-142). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    All requests to use or adapt the Appendix: The Ottawa Hospital Organizational Audit Form must be directed to the Ottawa Hospital, Department of Nursing Professional Practice for permission.

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    This website provides information and resources about the P.I.E.C.E.S.™ program. "Putting the P.I.E.C.E.S.™ Together" represents Physical, Intellectual, Emotional, Capabilities, Environment, Social, and are the cornerstones of the philosophy and care of the P.I.E.C.E.S.™ approach.

    P.I.E.C.E.S.™ (n.d.). P.I.E.C.E.S. website. Retrieved from http://pieceslearning.com/

     

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    This individualized de-escalation plan considers cause and effect and solutions focused on the resident’s strengths.

    Registered Nurses’ Association of Ontario. (2012). Appendix R of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 122-123). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Reprinted with permission from The Massachusetts Department of Mental Health

     

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    In Ontario, Canada the Patient Restraints Minimization Act asks healthcare settings to consider alternative approaches and only use restraints as a last resort when a person is at risk of harm to themselves and/or others.

    Registered Nurses’ Association of Ontario. (2012). RNAO Promoting Safety: Alternative Approaches to the Use of Restraints. [Fact sheet]. Toronto, ON: Author. Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints.pdf


     

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    This link takes you to the University of Iowa Geriatric Education Center website that provides you access to multiple resources. Follow the link to publications in infoconnect for restraint-free resident care.

    McKay, S. (n.d.). Info-connect: Restraint-free resident care. University of Iowa Geriatric Education Center. 

    Website: http://www.healthcare.uiowa.edu/igec/

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    This link takes you to the website of Executive office of Health and Human Services (EOHHS) with resources on Restraint/Seclusion Reduction Initiative and Boston Medical Centre Person De-escalation Plan and Intensive Residential Program.

    Commonwealth of Massachusetts. (n.d.). Restraint/Seclusion Reduction Initiative. Mass.gov. retrieved from https://www.mass.gov/service-details/restraintseclusion-reduction-initiative-rsri

    Website: http://www.mass.gov/eohhs/gov/departments/dmh/

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    This resource from Health Quality Ontario is designed to support providers with tools that assist change ideas linked to indicators and target measures. Under the Long-Term Care heading users will find resources to support least restraints programs including best practice tools, collection QI resources to measure restraint use and strategies to decrease restraint use.

    Web Address or Source: http://qualitycompass.hqontario.ca/

    Reference: Health Quality Ontario 2015, retrieved from http://qualitycompass.hqontario.ca/portal/long-term-care/Restraints#.WE6zfYWcHUs

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    Alberta Health Services presentation describing different types of restraints. Why restraints are used and possible side effects of restraint use.

    Alberta Health Services. (n.d.). Restraints as a last resort. [Presentation]. Retrieved from https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-srs-efc-restraints-notes.pdf

     

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    This document outlines interventions that can be used with residents exhibiting signs of aggression, disorientation, frequent falls and or inappropriate behaviours.

    Registered Nurses’ Association of Ontario. (2012). Appendix P of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 119-120). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Used with permission from Caressant Care

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    This tool helps the resident identify their responses to stress and their individualized coping strategies.

    Registered Nurses’ Association of Ontario. (2012). Appendix S of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (p124). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Copyright Centre for Addiction and Mental Health (2008). Reprinted with permission from CAMH

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    This tool evaluates the client risk and treatability related (i.e. violence, self-harm, suicide, absconding, substance use, self-neglect, and victimization).

    Registered Nurses’ Association of Ontario. (2012). Appendix F of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (pp. 97-98). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Reprinted with permission from British Columbia Mental Health & Addiction Services

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    This decision tree can be used to this determine if a siderail is a restraint or if alternatives are available.

    Registered Nurses’ Association of Ontario. (2012). Appendix Q of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (p. 121). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Source: Talerico, K. & Capezuti, E. Myths and Facts About Side Rails: Despite Ongoing Debates About Safety and Efficacy, Side Rails Are Still a Standards Component of Care in Many Hospitals. So How Do You Determine Their Safe Use? AJN: American Journal of Nursing, Volume 101, Issue 7, pp. 43-48. Reprinted with permission from Wolters Kluwer Health

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    This link included informaiton and documents to helps nurses understand their responsibilities and legal obligations to enable them to make safe, effective and ethical decisions when practicing. A link is included to the practice standard which aims to help nurses understand their responsibilities and make decisions regarding the use of restraints.

    College of Nurses of Ontario (2018). Understanding Restraints. Toronto, ON: Author. Retrieved from https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/restraints/