Uses of and alternatives to restraints in pediatric settings

Clinical holding: ethical guidance for children's nurses working in the UK

This article explores ethical decision-making surrounding clinical holding of children and young people in healthcare environments with the aim of enhancing autonomy and engagement on their behalf. A considerable body of evidence, published over the last 20 years, suggests that this complex and challenging area of practice is not always well managed, with mixed messages about the nature of consent, choice and negotiated practice countered by best interests decisions taking precedence ahead of the child's wishes. An ethical framework is proposed comprising four levels of value-based interventions and how they may be applied in clinical practice, allowing for increased engagement, empowerment and support on behalf of children and young people in relation to clinical holding decisions.

Ethical considerations with regard to adolescent consent in the perioperative setting: Talking points for anaesthetic practitioners

The legal and ethical issues surrounding the care of children and young people in the perioperative setting are often vague and an anaesthetic practitioner could find themselves inadequately prepared for any issues that may arise. This paper details the case of an adolescent who withdrew her consent to surgery whilst in the anaesthetic room. It raises questions about Gillick Competency and whether the use of restraint is ever justified.

Physical Restraint during Procedures: Issues and Implications for Practice

Physical restraint or holding down a child or young person with cancer is generally accepted to ensure success in carrying out the various procedures involved throughout the disease trajectory. Over the past several years, health care staff have become more aware of the issues surrounding physical restraint. However, the research around the effects of being involved in physical restraint is extremely limited. Nurses continue to have little education in the pertinent issues, restraint techniques, and alternative strategies. This article aims to highlight areas that nurses caring for children and young people with cancer need to consider. Strategies for improving practice are also discussed with the thought that nurses will be stimulated to re-evaluate the use of physical restraint in this group of children and young people.

Child Restraint in the Acute Setting of Pediatric Nursing: An Extraordinarily Stressful Event

Lack of clarity regarding when or how to use restraint in pediatric nursing is in direct contrast to international legislation and children's rights activists, who continuously support increased safeguards to protect children and improved health-care services for children. The aim of this article is to present a review of available literature with the purpose of stimulating discussion on the topic of this extraordinarily stressful event in the lives of hospitalized children and their parents. Studies for this literature review were identified using library catalogues and computerized searches of the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Mbase, psychLIT, and Medline. Keywords used included restraint, immobilisation, acute restraint, child restraint, p(a)ediatric restraint, and elderly restraint. The majority of the articles reviewed were secondary sources that advocated awareness and encouraged the use of restraint alternatives when managing the care of a child during a procedure. The results of the review accentuates the dearth of research in relation to the use of restraints in pediatric nursing, and highlights the need for pediatric nurses and allied health-care professionals to explore this sensitive topic further. By failing to address these issues, it could be argued that researchers in child health are ignoring an extraordinarily stressful event in pediatric health care.

Child and adolescent inpatient restraint reduction: a state initiative to promote strength-based care

OBJECTIVE

To reduce the use of restraint and seclusion with children and adolescents in psychiatric inpatient units by promoting a preventive, strength-based model of care.

METHOD

The State Mental Health Authority used data analysis, quality improvement strategies, regulatory oversight, and technical assistance to develop and implement system change over a 22-month period. No changes in regulation or policy were undertaken.

RESULTS

Comparative data collected before and after the interventions demonstrated substantial reductions in the use of restraint and seclusion. Child units (age 5-12) decreased from 84.03 to 22.78 episodes per 1,000 patient days (72.9%), adolescent units from 72.22 to 37.99 episodes (47.4%), and mixed child/adolescent units from 73.37 to 30.08 episodes (59%).

CONCLUSIONS

The use of restraint and seclusion in child and adolescent inpatient settings can be reduced through a systems approach, which may have applicability to other settings and systems.

Restraint use in acute and critical care settings: changing practice

Reduction of physical restraint use in the acute and critical care setting is a complex issue. Ethical considerations, regulatory and professional standards, legal liability concerns, healthcare team members' knowledge and attitudes, and unit culture and practice traditions must all be considered. Restraint reduction programs may use a process improvement format that engages the support of the organization's leadership. Specific interventions for restraint reduction, such as understanding the meaning of a patient's behavior, using a team approach, and involving the family can be evaluated and modified for application in the acute and critical care setting. Successful initiatives to decrease the use of restraint in this setting require an understanding of the many factors that support and oppose this practice.

Improving patient care through implementation of nurse-driven restraint protocols

Nationally, much attention has been placed on the indiscriminate application and abuse of restraint usage. This was the impetus for health care institutions across the country to relook at the policy, practices, and procedures regarding restraints. Our health care system made changes to our restraint policy, practice guidelines, and procedures in an effort to assure protection of the patients' health and safety while preserving their dignity, rights, and well-being. The mission was to pursue a restraint-appropriate environment by restraining only those patients who were assessed as being at risk of harming self and to protect the patient or others from injury. Our overall goal was to reduce restraint usage. This article describes the current policies, practice guidelines, and procedures for identifying clinically appropriate and adequately justified situations for restraint usage. The focus is on implementation of nurse-driven restraint protocols to improve patient care. All efforts directed at improvements in restraint usage and management of a patient in restraints has reduced our overall numbers of patients in restraints as well as significantly reduced risk of incidence for patients in restraints.