Rounding out a successful first season, the final Toronto Academic Health Science Network (TAHSN) Nursing Grand Research Rounds for 2012/2013 took place at the Centre for Addiction and Mental Health (CAMH) on Tuesday, May 7, 2013. Engaging audience members and webcast attendees through their seminar on Preventing the Use of Restraints: Integrating Evidence into Practice, Bloomberg Nursing’s Adjunct Lecturer, Athina Perivolaris and Assistant Professor, Dr. Kristin Cleverley presented evidence with a focus on the client perspective.
Staff and students from CAMH (Queen Street and College Street Sites), University Health Network, St. Michael’s Hospital, and the University of Toronto listened attentively to the information presented. Perivolaris, Dr. Cleverley and CAMH Nursing Research Fellow, Sara Ling, led the audience on a journey describing the components of the CAMH Restraint Prevention Initiative that began in 2008.
“This research helps staff gain insight into the client perspective and the use of restraints,” said Dr. Cleverley who is the director, Practice Research and Innovation at CAMH. “It’s a systematic overview of how we can minimize and ultimately prevent the use of restraints with clients.”
Perivolaris stated that CAMH started the journey with clarifying and refining their restraint policies. The focus was to develop systems and processes to enable staff to support clients using alternatives. CAMH recognized that there are no controlled studies on the value of putting those with a serious mental illness in seclusion or restraints. There is, however, an abundance of evidence on the harmful effects of restraint use. “CAMH developed alternative methods to manage harmful and unwanted client behaviours by focusing more on trying to help the clients maintain control and prevent them from escalating to the point where the only course of action would be restraints,” said Perivolaris.
“There is often a goal of using restraints in a safe manner,” said Perivolaris, who is an advanced practice nurse, Professional Practice Office at CAMH. “We decided that prevention should be the top priority with 90 per cent of our efforts on developing systems and processes to prevent the use of restraints, 8 per cent on the de-escalation process and 2 per cent on restraint use as a last resort.”
Dedicating considerable attention to addressing the risks involved with using restraints, assessing with clients and family the behaviours causing concern, collaborating with the health team and updating client safety plans and use of restraints only as a last resort are some of the key activities of the journey of restraint prevention. Key changes to the restraint policy were highlighted as follows: the name of the policy was changed from Least Restraint to Emergency Restraint policy to reflect the intent of the restraint use – only in emergency situations; the maximum duration of the restraint order was decreased from 24 hours to 12 hours to increase the frequency of the assessments and the trial of alternative strategies; and the automatic notification of the Psychiatric Patient Advocates Office for clients experiencing a restraint event to provide advocacy , support and empowerment.
A client perspective from pre, present and post-restraint use was Dr. Cleverley’s research focus. Completing retrospective chart audits, provided surprising and useful clinical and research information. Many of the clients expressed a mixture of powerful emotions when their behaviour escalated and most felt that they would manage better through stronger relationships with clinicians. Dignity, respect, communication and therapeutic relationships were the core of client wishes on the audit charts.
“We want to sustain and build on best practices here at CAMH,” said Dr. Cleverley. “This research provided the team with an understanding of providing client-centred care, establishing and maintaining therapeutic relationships, as set out by the RNAO, while highlighting the importance of the client’s voice in the evaluation process.”
The 2013/2014 TAHSN Nursing Grand Research Rounds will begin in the fall of 2013. Please visit our website for updates on the topics and location of the next series.
To view the April Research Round on Rehabilitating Persons with Cognitive Impairment: Restoring Success Where Once Thought Only Failure Lay held at UHN please go here.
To view the January Research Round on Enhancing Care Transitions across the Healthcare System: Insights from Research and Innovation held at St. Michael’s Hospital please go to intro, Shari, Sonya, Lianne and Q&A.