Restraints

Module 1 - The Foundation of Safe and Ethical Care

Module Objective: To establish a strong philosophical, ethical, and regulatory foundation for restraint use, ensuring all staff understand that restraint is a high-risk, last-resort clinical intervention that must be governed by a culture of safety, patient rights, and strict adherence to BCMCH policy.

1.1. Welcome & Institutional Commitment

Senior Leader's Opening Remarks (Example Script):
"Good morning, everyone. Thank you for being here today for this critical training. At Believers Church Medical College Hospital, our mission is built on a foundation of compassionate care and uncompromising patient safety. The topic of patient restraint touches the very core of that mission.

This is not simply a procedural training. It is about our culture. It is about how we protect the dignity and rights of every single patient, especially our most vulnerable. The decision to restrain a patient is one of the most serious clinical actions we can take, and it carries immense responsibility.

I want to be clear: our institutional goal is to reduce the use of restraints to the absolute minimum. We achieve that by becoming experts in prevention, de-escalation, and alternative interventions. This training, and the policy behind it, is our commitment to you. We are committing to providing you with the knowledge, skills, and support to handle these challenging situations safely, ethically, and effectively. Your engagement today is vital to the safety of your patients, your colleagues, and yourselves. Thank you."

Facilitator:
"Thank you, [Senior Leader's Name]. As was just stated, this is a topic of profound importance. Before we dive in, let’s get a sense of where we are.

Let’s do a quick word association. When I say the words 'patient restraint,' what is the first word or feeling that comes to your mind? Just call it out. (Facilitator listens and can write key words on a whiteboard, e.g., 'Safety,' 'Control,' 'Sad,' 'Necessary,' 'Last Resort,' 'Dangerous,' 'Failure').

Thank you. As you can see, there are many different and often conflicting feelings associated with this. Our goal today is to align our understanding and our actions with a single, unified approach: the BCMCH approach.

Over the next few hours, we will cover the core philosophy of care, the specific definitions we must all use, the details of our hospital's policy, and the practical skills you need. We are here to create a shared sense of confidence and competence."

1.2. The Core Philosophy: A Culture of Safety & Least Restrictive Environment

Facilitator:
"The most important concept we need to grasp is that restraint is not a routine procedure. It is a failure of other, less invasive strategies. Our entire approach must be built on the philosophy of the Least Restrictive Environment.

What does this mean? It means we must always use the minimum level of intervention necessary to maintain safety. Think of it as a ladder of interventions:

• Bottom Rung (Least Restrictive): Verbal reassurance, reorientation.

• Next Rung: Environmental changes, reducing stimuli.

• Next Rung: Offering diversions, involving family.

• Higher Rung: Providing a 1-to-1 sitter or observer.

• Near the Top: Using a single, targeted physical restraint (e.g., one wrist).

• Top Rung (Most Restrictive): Full four-point physical restraints or seclusion.

Our job is to solve the problem on the lowest possible rung. We only climb the ladder when all lower rungs have been tried and have failed to ensure the patient's immediate safety. This is a fundamental paradigm shift from the old way of thinking. We are moving from:

• 'How do we control this patient?'

• To: 'What does this patient need that is causing this behavior?'

Trauma-Informed Care: A Crucial Lens
A critical part of this philosophy is Trauma-Informed Care. We must assume that any patient in our hospital could have a history of significant trauma—physical, emotional, or psychological. The act of being physically held down or restrained can be intensely re-traumatizing. It can trigger feelings of helplessness, panic, and terror associated with past events.

How does this change our practice?

• It means we communicate with extra care, explaining every single step of what we are doing and why.

• We use a calm and reassuring tone, even when the situation is tense.

• We acknowledge the patient's fear and distress. Saying, 'I can see this is very frightening for you' can make a world of difference.

• It reinforces why restraint is a last resort, because we are actively trying to prevent further psychological harm."

1.3. Defining Restraint: What It Is and What It Isn't

"To apply our policy correctly, we must have a crystal-clear, shared understanding of what constitutes a restraint. Ambiguity here can lead to patient harm or non-compliance.

Physical Restraint:
This is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely.

• Key Characteristic: It is attached or adjacent to the patient's body so they cannot easily remove it, and it restricts freedom of movement.

• Concrete Examples:

  • Wrist or ankle restraints (soft or leather).

  • Vest or jacket restraints.

  • Mitts that are pinned or tied down to the bed.

  • A bed sheet tucked in so tightly the patient cannot move.

  • All four side rails in the 'up' position. This is considered a restraint because it physically prevents a patient from voluntarily getting out of bed. (Note: Having 2 or 3 side rails up for mobility assistance or fall prevention is generally not a restraint).

  • A lap buddy or tray on a wheelchair that the patient cannot remove.

Chemical Restraint:
This is a drug used as a restriction to manage a patient's behavior or restrict their freedom of movement, which is not a standard treatment or dosage for the patient's medical or psychiatric condition.

• Key Characteristic: The primary intent is to control behavior, not treat a diagnosed condition.

• Scenario 1 (NOT a restraint): A patient with diagnosed schizophrenia is experiencing acute psychosis and is given their standard, prescribed dose of Haloperidol to treat the psychosis. This is treatment.

• Scenario 2 (IS a restraint): An elderly patient with dementia is agitated and repeatedly trying to get out of bed. They are given Haloperidol to sedate them and stop the behavior. This is chemical restraint and requires the same documentation and justification as a physical restraint.

What is NOT a Restraint:
It is just as important to know what is not a restraint to avoid unnecessary protocols. These are considered standard medical practice:

• An IV arm board used to protect a catheter site.

• Temporarily holding a patient still for a procedure (like drawing blood or placing a line).

• Post-operative positioning devices.

• Orthopedic devices like casts or splints.

• Having two side rails up to help a patient reposition themselves.

• A seatbelt on a wheelchair used for postural support that the patient can easily remove."

1.4. The BCMCH Policy & Regulatory Framework

"Our practice is not based on opinion; it is governed by law, accreditation standards, and our own hospital policy. This ensures a consistent standard of care for every patient.

link to bcmch restrain policy

This is BCMCH/POL/1002.12: Policy on care of patients under Restraints. This is our guiding document. It is not optional. Adherence is a condition of our practice at this hospital.

Let's look at a key part of this policy: Section 2.1, Interface: COP 16. What does this mean? 'COP' stands for 'Conditions of Participation.' These are health and safety standards set by national regulatory and accreditation bodies (like the National Accreditation Board for Hospitals & Healthcare Providers - NABH). This line in our policy tells us that our internal rules are designed to meet or exceed these high-level national standards. We are holding ourselves to the highest benchmark.

The Consequences of Non-Compliance: The 'Why'
Why are we so strict about this? The consequences of getting it wrong are severe and impact everyone.

• For the Patient (The Highest Cost):

  • Physical harm: Strangulation, nerve damage, pressure sores, muscle atrophy.

  • Psychological harm: Trauma, depression, fear, loss of dignity.

  • In the most tragic cases, death.

• For the Staff Member:

  • Moral and emotional distress.

  • Personal liability and legal action.

  • Disciplinary action.

• For Believers Church Medical College Hospital:

  • Legal liability and significant financial penalties.

  • Loss of accreditation from bodies like NABH.

  • Severe damage to our reputation and the community's trust in us.

Module 2 - Preventing Restraint Through Proactive Care & De-escalation

Objective: Equip staff with a "toolbox" of preventative strategies and de-escalation techniques.

Core Concept: Shift mindset from being reactive (applying restraints) to proactive (preventing the need for them). Success is measured by how often we make restraints unnecessary.

2.1. Become a Clinical Detective: Find the "Why"

• Key Message: A patient's behavior (agitation, confusion, combativeness) is a form of communication. It's a symptom of an underlying problem. Our job is to diagnose the cause, not just silence the symptom.

• Trainer Mantra to Emphasize: "THINK MEDICAL FIRST!" Before assuming a behavioral issue, rule out a physiological crisis.

• [Trainer Note]: Use the analogy of a "Check Engine" light. Restraining a patient without finding the cause is like putting tape over the light. The problem is still there.

A. Physiological Causes (The Body's Distress Signals)
* Pain: The #1 overlooked cause.
* Signs: Grimacing, guarding, moaning, restlessness, changes in vital signs.
* [Ask group]: "What are other non-verbal signs of pain you've seen?"
* Hypoxia: Lack of oxygen.
* [Critical Safety Point]: "Restraining a hypoxic patient can be fatal. Always check O2 saturation immediately when a patient has an acute mental status change."
* Hypoglycemia: Low blood sugar.
* Action Step: A quick finger-stick blood sugar test can resolve a major behavioral crisis.
* Infection: Especially UTIs in the elderly or sepsis.
* Delirium: Acute confusion with a rapid onset. Often caused by one of the above.
* Withdrawal: From alcohol or drugs.
* Electrolyte Imbalance: Sodium, calcium, etc.
* Physical Discomfort: Too hot/cold, hungry/thirsty, need for repositioning.

B. Psychological Causes (The Mind's Distress Signals)
* Fear/Anxiety: The hospital is a terrifying environment. Patients have lost control.
* Psychosis: Patient is responding to hallucinations/delusions we cannot see.
* Frustration/Powerlessness: Inability to communicate needs (e.g., post-stroke, intubated).
* Confusion/Disorientation: Waking up in a strange place with alarms and tubes.

C. Environmental Causes (The Setting's Distress Signals)
* Over-stimulation: Constant noise, alarms, lights.
* Under-stimulation: Isolation, no clock, no window.
* Loss of Privacy & Unfamiliarity: Feeling exposed and in a strange place.

2.2. The Toolbox of Alternatives: The First Line of Defense

• Key Message: These are the actions we must attempt and document before considering restraints.

• [Interactive Element]:

  • [Ask group]: "Based on the causes we just discussed, what are some simple, practical things we can do to help a distressed patient?"

  • [Whiteboard their answers, guiding them into the categories below.]

Toolbox Categories:

• 1. Address Physical Needs (The 3 P's):

  • Pain: Assess and treat effectively.

  • Potty: Offer proactive toileting.

  • Positioning: Reposition for comfort, offer pillows, warm blankets.

• 2. Modify the Environment:

  • Reduce stimuli: Dim lights, lower TV volume, move to a quieter room.

  • Provide orientation: Open blinds to show daytime, provide a clock/calendar.

• 3. Use Therapeutic & Social Interventions:

  • Family presence (if a calming influence).

  • Sitter/Observer: 1-to-1 companionship and redirection.

  • Diversional activities: Music, TV, folding towels, looking at photos.

  • Frequent, calm reorientation.

• 4. Address Sensory Deficits:

  • Ensure the patient has their glasses and hearing aids.

• [Key Takeaway]: "DOCUMENT ALL ATTEMPTS. In a review or a legal case, if your use of alternatives wasn't documented, it's considered that it wasn't tried."

2.3. Verbal & Non-Verbal De-escalation: Your Calm is Contagious

• Key Message: In a tense moment, you are the thermostat. You set the temperature in the room. Your calm can de-escalate a situation faster than anything else.

A. Non-Verbal Communication (Your Actions)
* Personal Space: Maintain a safe distance (leg-length away). Don't crowd the patient.
* Body Posture: Stand at an angle (less confrontational). Keep hands open and visible.
* Facial Expression: Keep it neutral or empathetic. Avoid showing anger or fear.
* Tone of Voice: Low and slow. A raised voice is fuel for the fire.

B. Verbal Communication (Your Words)
* Validate Feelings: This is the most important skill.
* DON'T say: "You need to calm down," or "There's no reason to be upset."
* DO say: "I can see this is very frustrating for you. Help me understand what's happening."
* Use Reflective Listening: Show you're hearing them.
* Patient: "You all are just ignoring me!"
* Staff: "It sounds like you feel like you're being ignored. That must be very upsetting."
* Set Clear, Calm Limits: Use the "I can't... but I can..." model.
* DON'T say: "If you get out of bed again, I'll have to restrain you!" (Threat).
* DO say: "For your safety, I can't let you walk to the bathroom alone right now, but I can get the commode for you right here."
* Offer Choices: Gives back a sense of control.
* "Would you prefer water or juice?"
* "Would you like me to turn the light on or leave it dim?"

2.4. Empowering Patients & Families (BCMCH Policy 3.5)

• Key Message: Our hospital policy mandates that we communicate clearly with patients and families. This is a non-negotiable step that builds trust and promotes partnership.

• [Trainer Instruction]: Display BCMCH Policy Point 3.5 on the screen. Go through each sub-point methodically.

• 3.5.1. Reason for restraint.

  • Goal: Be direct, honest, and link the action to a specific safety concern.

  • [Example Script]: "Mr. Kumar, we need to use these soft reminders on your wrists. The only reason is to keep you from pulling out the breathing tube that is helping your lungs heal."

• 3.5.2. How the patient/family can avoid restraint.

  • Goal: Frame it as teamwork. Give the patient a path to avoiding restraint.

  • [Example Script]: "Mrs. Das, we can avoid using these if we can agree that you will use your call light when you need something instead of trying to climb over the rail. Can we work on that together?"

• 3.5.3. Criteria necessary for release from restraint.

  • Goal: Provide a clear, achievable goal. This offers hope and clarity.

  • [Example Script]: "As soon as you are able to show us that you will not pull at your IV lines, we can take these off. Our goal is to remove them as soon as it is safe to do so."

• [Module Closing Takeaway]: "By mastering these preventative and de-escalation skills, you are not just following policy—you are providing higher quality, more compassionate, and safer care. You are preventing trauma for your patients and promoting a culture of safety for everyone."

Module 3 - The BCMCH Restraint Process: Indications, Orders, and Application

Objective: To ensure all staff understand the precise BCMCH criteria, roles, and procedures for initiating and ordering restraints. This module covers the critical decision-making phase when de-escalation has failed and restraint is being considered.

Core Concept: The decision to apply a restraint is a significant medical intervention, not an ancillary task. It requires a valid clinical reason, a proper order, and a safe, team-based application process. There is no room for shortcuts.

3.1. Approved Indications for Restraint at BCMCH

• Key Message: Restraints are only permitted for a specific and limited set of reasons. Using them for any other purpose (e.g., staff convenience, punishment) is a serious policy violation and can be considered abuse.

• [Trainer Instruction]: Display BCMCH Policy Point 1.1 on the screen. Go through each point deliberately. (link tot he policy)

• "Let's review the only approved 'gateways' to restraint at our hospital, as defined by our policy."

• 1. To prevent interference/obstruction with medical treatments.

  • Examples: Self-extubation of an endotracheal tube, pulling out a central line, disrupting a chest tube.

  • [Emphasize]: "The keyword here is 'interference.' The patient is actively and physically trying to remove life-sustaining or medically essential devices."

• 2. To protect medical devices.

  • Examples: Repeatedly pulling at IV lines, in-dwelling urinary catheters, or feeding tubes.

  • [Clarification]: "This is for situations where removal of the device would cause harm or seriously interrupt treatment, not just mild annoyance."

• 3. To prevent falls and injury.

  • Examples: A severely delirious patient who is impulsively trying to climb out of bed despite all other interventions (sitter, bed alarm, low bed height).

  • [Cautionary Note]: "This is a high-risk area. Research shows restraints can sometimes increase the risk of serious injury from a fall if a patient gets entangled. This must be a last resort after all other fall-prevention strategies have failed."

• 4. To control disruptive behavior (agitation, wandering, combativeness).

  • [Critical Link to Safety]: "This is only a valid reason when the behavior poses an imminent and serious threat of physical harm to the patient, staff, or others. Simply being loud or uncooperative is NOT an indication for restraint."

• 5. To preclude the possibility of harming self, staff, and other patients.

  • Examples: A patient who is actively hitting, kicking, or biting staff; a patient who is banging their head against the wall. This is the "violent/self-destructive" category.

• [Module Checkpoint]: "Before anyone on your team even considers reaching for a restraint, ask this question: 'Which one of these five approved reasons are we meeting right now?' If you can't clearly name one, you must stop and re-evaluate."

3.2. The Physician's Order: Rules and Exceptions

• Key Message: A restraint is a medical treatment that requires a medical order. The ordering process is strict, time-limited, and has specific exceptions you must know.

The General Rule [BCMCH Policy Point 3.1]

• "Restraints can be applied only with a physician's order."

• In an acute emergency where the patient is an immediate danger to self or others, the team may apply the restraint and obtain the physician's order immediately after. The clock for the face-to-face assessment starts at the moment of application.

Physician Documentation Requirements [BCMCH Policy Point 3.2]

• An order for restraint is incomplete and invalid unless it contains all of these elements:

  1. Reason for restraint: (Must align with one of the 5 approved indications).

  2. Alternatives tried: (Briefly, e.g., "verbal de-escalation, sitter at bedside failed").

  3. Type of restraint: (e.g., "soft wrist restraints bilaterally," "vest restraint").

  4. Duration: This is time-limited.

Order Validity [BCMCH Policy Point 3.3]

• "All standard restraint orders are valid for only 1 calendar day."

  • This means an order written at 11:00 PM expires at midnight. A new order is required for the new day.

  • [CRITICAL POINT]: "'PRN' or 'as-needed' restraint orders are STRICTLY PROHIBITED. There is no such thing as a PRN restraint."

CRITICAL POLICY EXCEPTIONS: The Dialysis Unit

• [Trainer Note]: "This next section is especially critical for our staff working in or with the Dialysis Unit. These are unique rules in our policy that deviate from the general standard. You must know them."

Dialysis Exception 1 (Nurse/Technician Initiated) [BCMCH Policy Point 3.1.1]

• The Scenario: A patient is having their Arteriovenous Fistula (AVF) cannulated for the first, second, or third time AND the patient is in a normal sensorium (i.e., not confused or delirious).

• The Rule: In this specific situation, the nurse or technician in charge can initiate restraint WITHOUT a prior physician's order.

• The Rationale: This is a high-risk moment for the fistula. An accidental movement can cause infiltration, hematoma, and damage to a new, precious access site. This policy empowers the frontline staff to protect the access preemptively during its most fragile stage.

[Interactive Scenario Drill]:

• [Ask group]: "A patient is here for their fourth AVF cannulation. They are anxious. Can the dialysis tech apply a restraint without a doctor's order?"

  • (Answer: No. The rule only applies to the first 3 times.)

• [Ask group]: "A new patient is here for their first cannulation, but they are delirious from an infection. Can the nurse apply a restraint without an order under this policy?"

  • (Answer: No. The patient must be in a 'normal sensorium'. This patient's delirium requires a standard physician's order.)

Dialysis Exception 2 (Extended Validity) [BCMCH Policy Point 3.3.1]

• The Scenario: A patient is on maintenance hemodialysis (HD) and has a confirmed diagnosis of dementia or chronic metabolic encephalopathy.

• The Rule: For these specific patients, a physician's order for restraint during each dialysis session is valid for 1 MONTH.

• The Rationale: This acknowledges that these patients have a chronic, irreversible condition that makes them unable to cooperate or remain still for the duration of dialysis. It prevents the need for daily, repetitive orders for a predictable and ongoing safety need.

• [Clarification]: "This does not mean the patient is restrained for a month. It means the order allowing for restraint during dialysis sessions is valid for a month. The patient must still be monitored hourly and the restraint removed at the end of the dialysis treatment."

3.3. Safe Application Technique: A Team Sport

• Key Message: Applying restraints is a high-risk, hands-on procedure. It must be done as a coordinated team to ensure the safety of both the patient and the staff.

Step 1: Assemble the Team

• Gather enough staff. A good rule of thumb is one person per limb plus one person to lead and communicate with the patient.

• Designate a leader. This person is the only one who speaks to the patient. They explain what is happening and why, calmly and clearly. The other team members remain quiet and focus on their assigned task.

Step 2: Communicate with the Patient

• The team leader should use a script like: "Mr. Kumar, we cannot allow you to pull out your breathing tube. For your safety, we are going to place soft reminders on your hands. This is to keep you safe. We will remove them as soon as we can."

Step 3: The Application Process (Physical Demonstration)

• [Trainer Note]: Use a mannequin or a willing volunteer for this demonstration. Have restraint kits available.

• Secure the Torso First: If possible, have one person gently but firmly hold the patient's torso/shoulders to prevent them from sitting up.

• Apply Limb Restraints: Each team member works on one limb simultaneously and quickly.

• Check for Fit: The "Two-Finger" Check.

  • Slide two fingers (yours, not the patient's) between the restraint and the patient's skin. If you cannot fit two fingers, it is too tight and poses a risk to circulation. Loosen it immediately.

• Use a Quick-Release Knot.

  • [Demonstrate slowly]: Show how to tie a slip knot or other approved quick-release knot. Emphasize that it must be able to be released with a single pull, even with weight on it.

  • [Have participants practice]: Pass around ropes and have participants practice tying the knot.

• Attach to the Bed Frame, NOT the Side Rails.

  • [CRITICAL SAFETY POINT]: "This is a life-or-death detail. NEVER, EVER attach a restraint to a movable side rail. If the rail is lowered, the patient can be choked or seriously injured. Attach straps only to the solid, non-movable part of the bed frame."

• [Module Closing Takeaway]: "The moment of application is tense and high-risk. By following these steps—having a team, a leader, and using precise, safe technique—we transform a potentially chaotic event into a controlled, safe, and professional clinical procedure."

Module 4 - Monitoring, Documentation, and Discontinuation

Objective: To master the critical tasks required after a restraint has been applied to ensure continuous patient safety, meticulous documentation, and timely discontinuation, all in full compliance with BCMCH policy.

Core Concept: The application of a restraint is not the end of the intervention; it is the beginning of a period of heightened responsibility and vigilance. Our duty of care is elevated, not lessened, when a patient is in restraints.

4.1. Continuous Monitoring and Assessment: The Patient's Lifeline

• Key Message: Once a patient is in restraints, they are completely dependent on us for their safety and basic needs. Frequent and thorough checks are not just policy—they are the patient's lifeline. Complacency can be fatal.

• [Trainer Instruction]: Display BCMCH Policy Point 3.4 on the screen.

• "Our policy gives us a clear minimum standard for monitoring. Let's look at BCMCH Policy Point 3.4: 'Patients shall be monitored at least every hour...'"

• [Clarification]: "What does 'at least' mean? It means hourly checks are the absolute floor, not the ceiling. For a patient who is highly agitated, violent, or medically unstable, your clinical judgment must tell you to monitor them more frequently—perhaps every 15 minutes, or even continuously with a 1-to-1 sitter. The patient's condition, not just the clock, dictates the frequency."

• What to Assess and Document at Every Single Check:

  • [Trainer Note]: Frame this as a systematic "head-to-toe" check for the restrained patient. Use a mnemonic like "CIRCLES" to make it memorable.

  • C - Circulation:

    • Check skin color, temperature, and capillary refill on the restrained extremities.

    • Look for signs of duskiness, paleness, coolness, or swelling.

    • Check for a distal pulse if possible.

• • I - Integrity (Skin):

    • Briefly remove the restraint (one at a time) to inspect the skin underneath for redness, chafing, or breakdown.

• • R - Repositioning & Range of Motion:

    • Reposition the patient to relieve pressure points.

    • Briefly remove the restraint (one at a time, as safety allows) and perform passive or active range-of-motion exercises. Document this release.

• • C - Comfort & Care Needs:

    • Assess for pain.

    • Offer fluids for hydration.

    • Offer food if appropriate.

    • Crucially, offer toileting. Many patients become agitated simply because they need to use the bathroom.

• • L - Level of Consciousness & Continued Need:

    • Assess the patient's alertness and psychological state. Are they calmer? More agitated?

    • Ask the critical question every time: "Does the patient still meet the criteria for restraint right now?" If the answer is no, you must begin the discontinuation process.

• • E - Extremity Sensation/Motion:

    • Ask the patient if they have any numbness or tingling ("pins and needles").

    • Ask them to wiggle their fingers or toes.

• • S - Safety of Device:

    • Check that the knots are still quick-release and secure.

    • Confirm straps are still attached to the non-movable bed frame.

4.2. Meticulous Documentation: If It Wasn't Documented, It Wasn't Done

• Key Message: In the eyes of regulators, accreditors, and the law, your documentation is the only proof of the quality and safety of care you provided. Incomplete or missing documentation implies that the care was not given.

• [Trainer Instruction]: Display BCMCH Policy Point 3.4 again.

• "Our policy is explicit about where this documentation must live: '...the same shall be documented in the nurse's chart available in the patient chart.'"

• [Trainer Note]: At this point, pull up a screenshot or a physical copy of the hospital's specific Restraint Flowsheet (whether it's an electronic health record module or a paper form). Walk through it section by section.

Essential Elements of Restraint Documentation:

• 1. The Initial Event Note: This is the narrative that sets the stage. It must include:

  • The specific patient behavior that necessitated the restraint (e.g., "Patient became acutely agitated, yelling, and attempted to pull out endotracheal tube with both hands").

  • A list of all the alternatives that were tried and failed (e.g., "Verbal de-escalation, presence of family, and 1:1 sitter all attempted without success").

  • The time the restraints were applied and the time the physician was notified/the order was received.

  • The education provided to the patient and family (as per Policy 3.5).

• 2. The Hourly (or more frequent) Flowsheet Entries:

  • This is where you document your "CIRCLES" assessment for every check.

  • The flowsheet should have checkboxes and narrative sections for:

    • Circulation, Skin Integrity, Range of Motion.

    • Provision of food, fluids, and toileting.

    • The patient's psychological state and behavior.

    • The assessment of continued need.

    • The safety check of the device itself.

  • Every entry must be timed and signed.

• [Interactive Drill]:

  • [Ask group]: "You go in for your hourly check. The patient is calm and sleeping. Their skin and circulation are fine. What do you document?"

    • (Guide them to understand that even a 'no change' assessment must be fully documented. You can't just write 'stable'. You must show you performed the full assessment.)

  • [Ask group]: "You offer the patient a drink of water and they take it. You assist them with a urinal. Do you need to document that?"

    • (Answer: Absolutely. It proves you are meeting their basic human needs, which is a critical part of safe restraint care.)

4.3. Discontinuation and Debriefing: Closing the Loop Safely

• Key Message: Our goal is always to get the restraints off as soon as it is safe to do so. Removing them and debriefing the event are as important as applying them.

A. Criteria for Removal:

• The process begins the moment the patient no longer meets the original criteria for application.

• The patient is calm, cooperative, and able to follow commands.

• They are no longer a danger to themselves or others.

• They are no longer interfering with essential medical devices.

B. The Process of Gradual Release:

• Don't just remove all restraints at once, especially if the patient was highly agitated.

• Trial a gradual release: Remove one restraint (e.g., on the non-dominant hand). Observe the patient's reaction for a period (e.g., 15-30 minutes).

• If they remain calm, remove the second restraint.

• A physician's order is required to discontinue the restraint order.

C. Debriefing: A Critical Step for Learning and Support

• Debriefing with the Patient:

  • When the patient is calm and able to participate, a staff member should talk to them.

  • Purpose: To reduce psychological trauma, explain what happened, listen to their perspective, and rebuild the therapeutic relationship.

  • Example Script: "Mr. Kumar, I am so glad we were able to remove those. I know that was a difficult experience. Do you remember what was happening that made us need to use them?"

• Debriefing with the Staff Team:

  • This is essential for team well-being and performance improvement.

  • Gather the staff involved in the event.

  • Ask three simple questions:

    1. What went well? (e.g., "The team assembled quickly.")

    2. What could we have done differently or better? (e.g., "We could have tried offering music before the situation escalated.")

    3. How is everyone doing? (These events are stressful for staff, too. Provide support.)

• [Module Closing Takeaway]: "By mastering monitoring, documentation, and discontinuation, you ensure that a necessary safety intervention does not turn into an unsafe or punitive experience. You protect your patient, you protect your license, and you uphold the high standards of Believers Church Medical College Hospital."

Module 5 - Special Populations and Scenarios

Objective: To apply the core principles of restraint safety to specific, high-risk patient populations, recognizing that a "one-size-fits-all" approach is insufficient and potentially dangerous.

Core Concept: While our core principles of "least restrictive," "last resort," and "medical necessity" are universal, their application must be thoughtfully adapted to the unique physiological, psychological, and developmental needs of different patient groups.

Introduction to the Module:

"In the previous modules, we established the foundational rules for restraint use. Now, we're going to add layers of nuance. We will explore how to apply these rules with heightened sensitivity and specialized knowledge for some of our most vulnerable patients. For these populations, the risks associated with restraint—both physical and psychological—are significantly magnified."

5.1. Pediatric Patients: Protecting Our Smallest Patients

• Key Message: Restraining a child is a profoundly serious event with the potential for long-lasting psychological trauma. Family involvement is not just an option; it is an essential component of care.

• Developmental Considerations:

  • Infants/Toddlers: Cannot understand verbal explanations. Their primary source of comfort and security is their caregiver. Separation is a major stressor.

  • Preschoolers: Have magical thinking and may believe the restraint is a punishment for being "bad." Fear of bodily harm is intense.

  • School-Age Children: Can understand simple explanations but still have significant fear. Loss of control is a major issue.

  • Adolescents: Issues of autonomy, control, and dignity are paramount. Being restrained can feel deeply humiliating and may trigger extreme opposition or aggression.

• Specialized Strategies and Adaptations:

  • Family as Partners:

    • The default position should be to have a parent or caregiver present. They are often the most effective de-escalation tool.

    • Coach the parent on how to provide comfort and distraction.

    • If the family's presence is escalating the situation (a rare occurrence), they may be asked to step out briefly, but this should be explained carefully.

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  • "Therapeutic Holding" as an Alternative:

    • This is a structured, safe hold by trained staff or parents to provide comfort and security while a brief procedure is done.

    • [Distinction]: "Therapeutic holding is meant to be comforting and brief. It is NOT the same as a prolonged, forceful manual restraint to control behavior. It's about 'hugging' for safety, not 'pinning down' for control."

• • Communication is Key:

    • Use age-appropriate language. To a 5-year-old: "We need to put these 'sleeve hugs' on your arms to help you remember not to touch your owie."

    • To an adolescent: "I know this feels awful. We need to do this to keep your IV line safe so we can get you better and out of here. What can we do to make this more tolerable for you?"

• • Environmental & Diversional Tactics:

    • These are even more effective in children. Use distraction cards, bubble wands, iPads with games/videos, or music.

• • Legal & Consent Issues: Involve parents/legal guardians in the decision-making process for restraint whenever possible, explaining the rationale and alternatives.

• [Critical Safety Point]: "A child's physiology is more fragile. Risks of positional asphyxia, nerve damage, and circulatory compromise are higher. Monitoring must be exceptionally diligent."

5.2. Geriatric Patients: The High Risk of Frailty

• Key Message: For elderly patients, especially those with frailty and multiple comorbidities, a restraint is a high-risk intervention that can trigger a cascade of negative outcomes, including functional decline, delirium, and serious injury.

• Unique Risks in the Geriatric Population:

  • Fragile Skin: High susceptibility to skin tears, pressure ulcers, and bruising.

  • Decreased Muscle Mass (Sarcopenia): Leads to faster deconditioning and loss of function when immobilized.

  • High Risk of Delirium: Restraints are a known precipitating factor for delirium. They increase confusion, fear, and agitation.

  • Increased Risk of Injury: An agitated elderly patient fighting against a restraint can suffer fractures, dislocations, or entanglement leading to asphyxiation.

  • Polypharmacy: Multiple medications increase the risk that a new chemical restraint will have dangerous interactions.

• Specialized Strategies and Adaptations:

  • Prioritize a Thorough Medical Workup:

    • Delirium in an older adult should be considered a medical emergency until proven otherwise. Aggressively search for underlying causes (infection, hypoxia, electrolyte imbalance, medication side effects).

    • "Treating the cause of the delirium is the best way to treat the agitation."

  • Focus on Fall Prevention Alternatives:

    • Use bed alarms, low beds, and floor mats as primary tools.

    • Ensure frequent and scheduled toileting.

    • Involve physical/occupational therapy early for mobility and safety assessments.

  • Sensory Aids are Crucial:

    • Ensure the patient has their glasses on and hearing aids in and working. Sensory deprivation is a powerful driver of confusion.

  • Medication Review: Scrutinize the medication list (MAR) for any drugs that could be causing or exacerbating confusion (e.g., anticholinergics, benzodiazepines, opioids).

  • Gentle, Frequent Reorientation: Reality orientation is paramount. Use clocks, calendars, and frequent, calm reassurance.

• [Clinical Pearl]: "For a geriatric patient, the question is not just 'Is this restraint necessary?' but also 'Is this restraint more dangerous than the behavior it's intended to prevent?' Sometimes the answer is yes."

5.3. Psychiatric Patients: The Shadow of Trauma

• Key Message: For patients with a primary psychiatric diagnosis, restraints must be integrated into a broader therapeutic plan and applied with an acute awareness of their potential to re-traumatize.

• Unique Considerations:

  • Trauma History: Assume that any patient with a significant mental health history may also have a history of physical, sexual, or emotional trauma. The act of being restrained can be a powerful trigger, replicating past traumatic experiences and worsening their condition.

  • Loss of Therapeutic Alliance: The use of force can severely damage the trust between the patient and the clinical team, making future therapeutic engagement more difficult.

  • Behavior as a Symptom: The patient's agitation is often a direct symptom of their illness (e.g., paranoia from schizophrenia, impulsivity from bipolar mania). The goal is to treat the illness.

• Specialized Strategies and Adaptations:

  • Integration with the Treatment Plan: The decision to restrain should be made in consultation with the psychiatric team whenever possible. The restraint is a temporary safety measure, not a replacement for psychiatric treatment.

  • Heightened Emphasis on De-escalation: Staff working with this population need advanced skills in verbal de-escalation, validation, and limit-setting.

  • Post-Restraint Debriefing is MANDATORY:

    • Once the patient is calm and safe, it is essential to process the event with them.

    • Purpose: To help them understand why it happened, allow them to express their feelings about it, identify triggers, and collaboratively plan how to avoid it in the future. This is a therapeutic opportunity to repair the alliance.

    • Example: "That was a really difficult situation earlier. Let's talk about what was happening for you right before you felt you were losing control. What can we do to help you recognize those feelings earlier next time?"

• [Ethical Consideration]: "Restraint can never be used as a punishment for difficult behavior or as a means of coercion. Its sole purpose is the imminent safety of the patient or others."

5.4. Patients with Cognitive Impairment (Dementia/Delirium)

• Key Message: For these patients, behavior is almost never willful; it is a manifestation of brain failure. Our approach must be rooted in compassion, redirection, and environmental management, not confrontation.

• Differentiating Dementia vs. Delirium:

  • Dementia: Chronic, progressive, slow onset. The patient's baseline is confused.

  • Delirium: Acute, rapid onset, fluctuating course. This represents a change from the patient's baseline and signals an underlying medical problem.

• Specialized Strategies and Adaptations:

  • Investigate All Behavior: Don't just label it "dementia." A patient with dementia can still get a UTI, become hypoxic, or be in pain.

  • Use Redirection, Not Reorientation:

    • For a patient with delirium, you reorient them to reality ("You are in the hospital").

    • For a patient with advanced dementia, arguing with their reality is fruitless and escalating. Instead, you validate their feeling and redirect their action.

    • Example: Patient with dementia insists, "I have to go home to cook dinner for my husband!"

      • Wrong Approach (Arguing): "You don't have to cook dinner. Your husband passed away 10 years ago and you live in a nursing home now." (This is cruel and will cause agitation).

      • Right Approach (Validate & Redirect): "It sounds like you are a wonderful cook and you take great care of your husband. That's lovely. Tell me, what's his favorite meal? Why don't we go for a short walk down the hall while you tell me about it?"

• • Environmental Cues: Use large-print signs (e.g., "STOP," picture of a toilet on the bathroom door).

  • Create a Calm Environment: Reduce noise, clutter, and the number of people interacting with the patient at one time.

• [Module Closing Takeaway]: "By tailoring our approach to these special populations, we move beyond simply following rules. We demonstrate clinical excellence, empathy, and a profound commitment to the dignity and safety of every single patient, no matter their age, condition, or circumstance."

Module 6 - Practical Skills Workshop & Competency Validation

Objective: To move from theoretical knowledge to practical application. This module provides hands-on practice in a safe, simulated environment, allowing staff to build muscle memory and confidence in critical skills. Competency will be formally assessed and validated.

Core Concept: Reading about a skill is not the same as performing it under pressure. This workshop is where we bridge the gap between knowing what to do and knowing how to do it. This is about building competence and confidence through practice.

Introduction to the Module:

"Welcome to our final interactive module. For the next hour, we are moving out of the lecture format and into a hands-on workshop. You've learned the 'why' and the 'what' from our BCMCH policy and best practices. Now, we're going to focus on the 'how.'

We have set up three stations, each focused on a critical skill. You will rotate through each one. The goal here is not to test you, but to let you practice in a safe space where you can ask questions, make mistakes, and get feedback. At the end of each station, a facilitator will validate your competency, ensuring you leave here today feeling prepared and confident in your abilities."

[Trainer Instruction]: Divide the training group into three smaller, manageable groups. Assign each group to a starting station. Explain that they will rotate every 15-20 minutes until everyone has completed all three stations. Ensure each station is staffed by a trained facilitator/instructor.

Station 1: De-escalation Role-Play

• Station Objective: To practice using verbal and non-verbal de-escalation techniques in a realistic, face-to-face scenario.

• Setup: A small, semi-private area. The station facilitator will act as the "agitated patient" or will coach a standardized patient/actor. Provide a simple scenario prompt.

• Facilitator Role: To act out the scenario realistically but safely, and to provide immediate, constructive feedback.

Facilitator's Guide for Station 1:

1. Briefing the Participant (1-2 minutes):
* "Welcome to the de-escalation station. Your goal here is not to 'win' the argument, but to lower the emotional temperature of the room and build a rapport with the patient. Remember your non-verbal cues and your verbal techniques."
* Provide the Scenario: "Here is the situation: I am Mr. Gupta, a 72-year-old man who had hip surgery yesterday. I am confused, in some pain, and I keep trying to get out of bed, saying I need to go home to feed my dog. Your goal is to de-escalate me and keep me safe without touching me."

2. The Role-Play (3-5 minutes):
* The facilitator (as Mr. Gupta) begins: (Pulls at gown, looks agitated) "Where are my clothes? I have to get out of here. My dog, Sheru, hasn't been fed! I need to go home RIGHT NOW!"
* Facilitator should escalate or de-escalate based on the participant's approach:
* If the participant is confrontational ("Mr. Gupta, you can't go home!"), the facilitator becomes more agitated ("Don't you tell me what I can't do!").
* If the participant uses good techniques, the facilitator becomes calmer.
* Things to look for from the participant:
* Good Non-Verbal: Maintains safe distance, open posture, hands visible.
* Good Verbal:
* Validation: "It sounds like you're very worried about Sheru. You must love him very much."
* Reflective Listening: "So you're feeling trapped here because you need to get home to your dog."
* Offering Choices: "I can't let you walk home, but how about I get you some water, and we can call a family member to check on Sheru for you? Would you like me to do that?"
* Redirection: "Tell me about Sheru. What kind of dog is he?"

3. Debrief and Feedback (5-7 minutes):
* Stop the role-play. Ask the participant first: "How did that feel? What do you think went well? What was challenging?"
* Provide specific, constructive feedback:
* "I noticed you kept your hands open and your voice calm, which was excellent. That really helped me feel less threatened."
* "When you immediately validated my concern for my dog instead of just telling me I couldn't leave, that was the turning point. Great job."
* "One thing to try next time is to offer a small, immediate choice. Even asking 'water or juice?' can help give back a sense of control."

4. Competency Validation:
* The facilitator signs off on the participant's training passport/checklist, confirming they have demonstrated basic de-escalation skills.

Station 2: Safe Application & Knot Tying

• Station Objective: To physically demonstrate the correct, safe application of a soft limb restraint, including the two-finger check and the quick-release knot.

• Setup: A hospital bed with a mannequin (or a volunteer participant acting as a passive patient). Have several sets of soft restraints and some practice ropes available.

• Facilitator Role: To demonstrate the correct technique, observe the participant's practice, and provide tactile correction.

Facilitator's Guide for Station 2:

1. Demonstration (3-5 minutes):
* "Welcome to the hands-on application station. We are going to practice the psychomotor skills of safely applying a restraint."
* Slowly and deliberately, demonstrate the entire process on the mannequin.
* Narrate every step: "First, I select the padded part of the restraint. I place it over the wrist, ensuring the soft side is against the skin. I loop the strap through the D-ring..."
* Emphasize the two-finger check: "Now, the critical safety check. I slide two of my fingers underneath. See how they fit comfortably? It's not too tight, not too loose. This ensures circulation is not compromised."
* Demonstrate the Quick-Release Knot: "Now for the knot. We do NOT tie a double-knot or a square knot. We use a quick-release knot. Watch how I do this..." (Demonstrate the knot slowly). "The most important part is that I can release it with a single pull, even if there's tension on the strap."
* Show correct attachment point: "And finally, I am attaching the other end of the strap to the solid, non-movable part of the bed frame. I am checking to make sure it is NOT the side rail."

2. Participant Practice (7-10 minutes):
* "Now it's your turn." Hand a restraint to the participant. "Show me how you would apply this to the mannequin's other wrist."
* Observe their technique closely. Provide corrective feedback in the moment:
* "That's a bit too tight. Let's loosen it and try the two-finger check again."
* "You've attached it to the side rail. Let's find a better, safer spot on the bed frame down here."
* Hand them a practice rope. "Okay, now show me the quick-release knot three times."

3. Competency Validation:
* Once the participant can correctly and independently:
1. Apply the restraint to the correct tightness.
2. Tie a functional quick-release knot.
3. Identify the correct attachment point on the bed.
* The facilitator signs off on their competency checklist.

Station 3: BCMCH Policy & Documentation Drill

• Station Objective: To apply knowledge of BCMCH policy and documentation requirements to realistic clinical scenarios.

• Setup: A table with chairs. Provide participants with laminated copies of the BCMCH restraint policy, blank copies of the hospital's restraint flowsheet, and scenario cards.

• Facilitator Role: To present scenarios, ask probing questions, and evaluate the participant's ability to navigate the policy and correctly complete documentation.

Facilitator's Guide for Station 3:

1. Briefing (1-2 minutes):
* "Welcome to the policy and documentation station. Here, we connect the rules to the real world. I'm going to give you a scenario, and using the BCMCH policy and this flowsheet, you'll tell me what you would do and what you would document."

2. Scenario Drill (10-12 minutes):
* Scenario Card 1 (Dialysis Exception): "A 45-year-old patient is in the Dialysis Unit for his second-ever AVF cannulation. He is alert, oriented, and extremely anxious about the large needles. The technician is worried he will jerk his arm during cannulation. Question: What are the technician's options regarding restraint according to BCMCH policy? If a restraint is applied, what must be documented?"
* Correct Answer: Per policy 3.1.1, because it's one of the first 3 cannulations and the patient is in a normal sensorium, the nurse/tech can initiate restraint without a prior physician's order to protect the fistula. They must document the reason, the application time, and begin hourly monitoring.

Generated code

     *   **Scenario Card 2 (Invalid Order):** "You are a nurse on the medical ward. The night-shift physician writes an order in the chart that says: 'Soft wrist restraints PRN for agitation.' **Question:** Is this a valid order? What is your next action?"

    *   **Correct Answer:** Per policy 3.3, this is an invalid order. PRN restraint orders are prohibited. The nurse's next action is to contact the physician, inform them that the order is not compliant with hospital policy, and request a proper, time-limited order if a restraint is currently needed.

*   **Scenario Card 3 (Documentation):** "You've just applied bilateral soft wrist restraints to a delirious patient who was pulling at their central line. **Question:** Using this flowsheet, show me where and what you would document for the initial application and for your first hourly check."

    *   **Correct Answer:** The participant should point to the initial narrative section and state they would document the precipitating behavior (pulling at line), the alternatives tried (e.g., verbal redirection), and the patient/family education. They should then point to the hourly checklist and correctly fill out the "CIRCLES" assessment (Circulation, Skin, Comfort, etc.) for the first check.

3. Competency Validation:
* When the participant can correctly answer the policy questions and identify the correct way to document on the flowsheet, the facilitator signs off on their competency checklist.