Paper Example on Psychiatric Care: Examining Physical Restraint Practices

Abstract

The use of physical restraints within psychiatric units is problematic since it raises a range of legal, ethical, and clinical questions (American Psychiatric Nurses Association, 2014). The use of physical restraint has become a common practice in many psychiatric units despite the negative effects associated with its use. Selecting strategies such as verbal de-escalation to manage aggressive psychiatric inpatients shows promise with patients when used by providers and staff in mental health facilities. The purpose of this evidence-based project was to introduce and train staff to utilize the Modified Overt Aggression Scale (MOAS) and verbal de-escalation in psychiatric units in a residential psychiatric treatment center with aggressive female inpatients aged 13-17 years. The primary objectives were to reduce the selection of physical restraints and time used to restraint to less than an hour, assess 100% of the target population, educate providers/staff the use of MOAS and verbal de-escalation, and review intervention choices selected by staff. The intervention included implementing MOAS scale, training staff to use verbal de-escalation, and pre/posttest surveys to evaluate the effectiveness of verbal de-escalation techniques. Between January and April 2019, 20 patients met the inclusion criteria. Following the intervention, documented physical restraints decreased by 89%, time spent in restraints decreased to 10 minutes, 100% of the staff was trained, 18 patients were assessed, and 18 intervention choices were reviewed. Results suggest that a combination of MOAS scale along with staff training on verbal de-escalation can influence and reduce the selection of physical restraints in the inpatient psychiatric unit.

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Keywords: physical restraints, verbal de-escalation, training, aggression.

Physical restraint is a powerful intervention that is often used in mental health facilities (Hadi, Khosravi, Shariat, & Nadoushan, 2015). The primary objective of using physical restraint in a psychiatric unit is to protect patients from harming themselves or others. Therefore, the use of physical restraints is inevitable in some situations, even though it is highly disputed. According to Hadi et al. (2015), the use of physical restraint may lead to complications and problems for both patients and staff. Additionally, physical restraints may decrease positive behavior, whereas escalating negative behavior among mental health patients (Darwin, McGowan & Edozien, 2013). In the most extreme cases, physical restraint may cause death for some patients (Hadi et al, 2015). It is, therefore, desirable to reduce the use of physical restraint to the minimum as possible. Hadi et al. (2015) suggests that it is possible to prevent approximately 75% of physical restraints through the implementation of appropriate interventions such as determining factors that lead to aggression and training providers and staff how to perform de-escalating techniques. According to Margari et al. (2005), the Modified Overt Aggressive Scale (MOAS) plays a significant role in measuring several types of aggressive behaviors including verbal aggression, aggression against properties, auto-aggression, and physical aggression, observed over the past week. Introducing the MOAS tool and evidence-based verbal de-escalation techniques in a psychiatric unit provides the best intervention to reduce the selection of physical restraints.

Statement of the Problem

In the United States, many psychiatric units continue using physical restraints despite potential negative effects associated with the use of this intervention (Masters, 2017). According to Vedana et al. (2018), patients in mental health facilities often experience physical restraints as coercion and trauma, and this affects nurse-patient relations. To reduce excessive use and selection of physical restraints and its associated risks, providers and staff in the psychiatric unit need to familiarize themselves with the MOAS tool to predict and assess aggressive behavior together with the application of verbal de-escalation technique.

Background and Significance

Approximately 10 to 20 percent of individuals with mental health disorders engage in challenging behaviors such as aggressiveness, destructiveness, and self-injurious actions (Volavka, 2014). These aggressive behaviors, especially in psychiatric units, push providers and staff to utilize physical restraints as an intervention strategy to manage aggressive patients. Moreover, providers and staff often use physical restraints to protect and prevent harm to aggressive patients as well as prevent them from harming others (Garriga et al., 2016). The excessive and unnecessary use of physical restraints creates potential danger and even becomes fatal to the patients (Joint Commission, 2016).

It is important to perform an individual assessment of each patient to determine whether alternative interventions exist, such as verbal de-escalation, before implementing physical restraints. Most psychiatrists will utilize physical restraints when patients are aggressive and threaten to harm themselves or other individuals (Masters, 2017).

According to Huang et al., 2009, the MOAS is an inpatient rating scale that assesses four categories: verbal aggression, aggression against property, auto aggression and physical aggression. For each category of aggressive behaviors, the rater checks the highest applicable rating point to describe the most serious act of aggression during the specified observation period. Each is weighted using a psychometrically validated method developed by the MOAS authors. According to Margari et al. (2005), the MOAS scale has good psychometric properties. Patient assessment is essential since it helps to identify risk factors, as well as promote best intervention practices, by providers and staff that minimize adverse events, such as staff injury by the patient, patient seclusion, and restraint usage (Sands, Elson, Gerdtz, & Khaw, 2012). According to Griffith et al. (2016), employing the MOAS in psychiatric units supports the caregivers to assist in implementing appropriate interventions to patients who are likely to become aggressive, preempting this behavior to prevent excessive use of potentially harmful physical restraints that can negatively impact patients' well-being. In addition to the MOAS, the ten domains of the de-escalation strategies by the American Association for Emergency Psychiatry (AAEP) Project BETA de-escalation workgroup were utilized. The domains of de-escalation listed the following: Respect Personal Space, Do not be Provocative, Establish verbal contact, be concise, Establish wants and feelings, Listen closely to what the patient is saying, agree or agree to disagree, Lay down the Law and set clear limits, offer choices and optimism and debrief the patient and staff (Richmond et al., 2012).

Assessment

The residential psychiatric treatment center assessed in the project is in a metropolitan area in central Texas within the 76708 zip code. Demographic data available from the Census Bureau shows that the population in this zip code is approximately 27,172 (TX Hometown Locator, 2018). The median age of the population living in the 76708 zip code is 34.3. The median age of men is about 17.3 percent smaller than that of women (Town Charts, 2018). The average family size of a typical family in this zip code is 3, and 71 percent of families are a husband and wife family. This zip code contains 10,558 housing units. The median household income is $47,574, and 81 percent of the population is high school graduates. There are 563 people per square mile in this zip code, and the community is predominantly white 50.6 percent and 31.7 percent Hispanic (TX Hometown Locator, 2018).

This residential psychiatric treatment center was founded in the year 1919 as a state home for dependent and neglected children. This residential psychiatric treatment center offers services to the entire state of Texas. The services offered include mental health/psychiatric residential treatment to adolescent patients aged 13 and 17 years suffering from severe emotional/behavior disorders and serious dysfunctional family issues. The treatment services offered include psychiatry, nursing, psychotherapy, nutrition, spiritual, habitation, and Texas Education Agency (TEA) approved education services. A report from the hospital administration where the project took place reported that this facility plays a significant role in providing medical nursing and social worker training opportunities to local colleges and universities.

This residential psychiatric treatment center is situated in a large expanse of land, which is approximately 47.19 acres. There are 46 structures that include storage buildings, pavilion,

living units, cafeteria, school buildings, administrative offices, auxiliary service buildings, horse barn, 2 large buildings that are currently out of service, and four structures planned for repurposing. This facility has a total bed capacity of 78 beds. The average length of stay as on September 30, 2018 was 161 days. The average daily census as at August 31, 2018 was 72. Additionally, 100 percent of the patients are voluntary admissions.

This facility had a budget of $11,895,000.00 for the fiscal year 2017. The average daily cost of the stay as of September 30, 2018, was $469.00 while the average cost per patient was $27,109. The general revenue from the state of Texas, Medicaid, and private third party/insurance finances this facility. The last time the Joint Commission accredited this facility was in August 2016, and the next accreditation will be due in August 2019. This facility received patients from 60 different counties within Texas in the fiscal year 2018, which ended August 31, 2018. A report from the hospital administration reported that this facility's admissions come from all counties within Texas with 8.4 % being the highest from Tarrant, 6.3% from Bell, 5.6% from Collin, and 4.9% from Dallas.

This psychiatric treatment center has six units: two for girls and four for boys. The basic criteria for admission in this center include the fact that patients must be between 13 and 17 years old, psychiatrically diagnosed as emotionally and/or behaviorally disturbed, and a history of behavior adjustment problems. Adolescent patients ad...