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Dalton EM, Worsley D, Krass P, Kovacs B, Raymond K, Feudtner C, Shea JA, Doupnik SK. Factors influencing agitation, de-escalation, and physical restraint at a children's hospital. J Hosp Med 2023; 18:693-702. [PMID: 37401165 PMCID: PMC10529788 DOI: 10.1002/jhm.13159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/30/2023] [Accepted: 06/14/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Children hospitalized in medical hospitals are at risk of agitation. Physical restraint may be used to maintain patient and staff safety during de-escalation, but physical restraint use is associated with physical and psychological adverse events. OBJECTIVE We sought to better understand which work system factors help clinicians prevent patient agitation, improve de-escalation, and avoid physical restraint. DESIGN, SETTING, AND PARTICIPANTS We used directed content analysis to extend the Systems Engineering Initiative for Patient Safety model to clinicians working with children at risk for agitation at a freestanding children's hospital. INTERVENTION, MAIN OUTCOME, AND MEASURES We conducted semistructured interviews to examine how five clinician work system factors affected patient agitation, de-escalation, and restraint: person, environment, tasks, technology and tools, and organization. Interviews were recorded, transcribed, and analyzed until saturation. RESULTS Forty clinicians participated in this study, including 21 nurses, 15 psychiatric technicians, 2 pediatric physicians, 1 psychologist, and 1 behavior analyst. Work system factors that contributed to patient agitation were medical tasks like vital signs and the hospital environment including bright lights and neighboring patients' noises. Supports that helped clinicians de-escalate patients included adequate staffing and accessible toys and activities. Participants indicated that organizational factors were integral to team de-escalation, drawing connections between units' teamwork and communication cultures and their likelihood of successful de-escalation without the use of physical restraint. CONCLUSION Clinicians perceived that medical tasks, hospital environmental factors, clinician attributes, and team communication influenced patients' agitation, de-escalation, and physical restraint. These work system factors provide opportunities for future multi-disciplinary interventions to reduce physical restraint use.
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Affiliation(s)
- Evan M. Dalton
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Futures and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Diana Worsley
- Clinical Futures and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Polina Krass
- Clinical Futures and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brian Kovacs
- Department of Nursing and Clinical Care Services, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathleen Raymond
- Department of Nursing and Clinical Care Services, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Futures and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Judy A. Shea
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
- Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Philadelphia, Pennsylvania, USA
| | - Stephanie K. Doupnik
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Futures and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Yilmaz Kurt F, Aytekin Ozdemir A, Atay S. The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-Behavioral Intervention Package. Pain Manag Nurs 2019; 21:594-600. [PMID: 31628067 DOI: 10.1016/j.pmn.2019.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 04/27/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Invasive interventions can produce fear, anxiety, and pain in children. This may negatively affect the children's treatment and care. AIM This study was conducted to determine the effects of procedural restraint (PR) and cognitive-behavioral intervention package (CBIP) on venipuncture pain in children between 6-12 years of age. DESIGN Quasi-experimental study. SETTINGS The study was conducted in the pediatric blood collection service of the hospital in Turkey between October 1, 2015, and April 1, 2016. PARTICIPANTS/SUBJECTS The population of the study consisted of children admitted to the blood collection service during the study period who met the inclusion criteria. METHODS The children included in the study were divided into two groups. Group 1 (n = 31) received PR in accordance with routine clinical practice. Group 2 (n = 30) received the CBIP. The data were collected by the researchers using a questionnaire, the visual analog scale (VAS), and the Wong-Baker FACES (WB-FACES) Pain Rating Scale. RESULTS The children in the PR group had a mean VAS score of 5.90 ± 3.22 and a mean WB-FACES score of 8.70 ± 2.22. The children in the CBIP group had a mean VAS score of 2.43 ± 2.02 and a mean WB-FACES score of 2.80 ± 2.49. A statistically significant difference was found between the mean VAS and WB-FACES pain scores of the groups (p < .05). CONCLUSIONS The results of this study showed that the children in the CBIP group had a lower pain level during venipuncture compared to those restrained for the procedure.
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Affiliation(s)
- Fatma Yilmaz Kurt
- Department of Child Health Nursing, School of Health, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Aynur Aytekin Ozdemir
- Department of Nursing, Faculty of Health Sciences, Istanbul Medeniyet University, Istanbul, Turkey.
| | - Selma Atay
- Department of Fundamentals of Nursing, School of Health, Canakkale Onsekiz Mart University, Canakkale, Turkey
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Lombart B, De Stefano C, Dupont D, Nadji L, Galinski M. Caregivers blinded by the care: A qualitative study of physical restraint in pediatric care. Nurs Ethics 2019; 27:230-246. [PMID: 30975025 DOI: 10.1177/0969733019833128] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The phenomenon of forceful physical restraint in pediatric care is an ethical issue because it confronts professionals with the dilemma of using force for the child's best interest. This is a paradox. The perspective of healthcare professional working in pediatric wards needs further in-depth investigations. PURPOSE To explore the perspectives and behaviors of healthcare professionals toward forceful physical restraint in pediatric care. METHODS This qualitative ethnographic study used focus groups with purposeful sampling. Thirty volunteer healthcare professionals (nurses, hospital aids, physiotherapists, and health educators) were recruited in five pediatric facilities in four hospitals around Paris, France, from March to June 2013. The data were processed using NVIVO software (QSR International Ltd. 1999-2013). The data analysis followed a qualitative methodological process. ETHICAL CONSIDERATIONS The research was conducted in compliance with the Declaration of Helsinki. Written informed consent was collected systematically from participants. FINDINGS This study provides elements to help understand why restraint remains common despite its contradiction with the duty to protect the child and the child's rights. All participants considered the use of forceful physical restraint to be a frequent difficulty in pediatrics. Greater interest in the child's health was systematically used to justify the use of force, with little consideration for contradictory or ethical aspects. Raising the issue of forceful restraint always triggered discomfort, unease and an outpour of emotions among healthcare professionals. The findings have highlighted a form of hierarchy of duties that give priority to the execution of the technical procedure and legitimize the use of restraint. Professionals seemed to temporarily suspend their ability to empathize in order to apply restraint to carry out a technical procedure. This observation has allowed us to suggest the concept of "transient empathic blindness." CONCLUSION Using physical restraint during pediatric care was considered a common problem by participants. This practice must be questioned, and professionals must have access to training to find alternatives to strong restraint. Conceptualizing this phenomenon with the concept of "transient empathic blindness" could help professionals understand what happens in their minds when using forceful restraint.
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Affiliation(s)
- Bénédicte Lombart
- Assistance Publique - Hôpitaux de Paris (AP-HP), France; Laboratoire Interdisciplinaire d'étude du Politique Hannah Arendt (LIPHA Paris Est), France
| | - Carla De Stefano
- Assistance Publique - Hôpitaux de Paris (AP-HP), France; Université Paris 13, France; Sorbonne University, France
| | | | - Leila Nadji
- Laboratoire Interdisciplinaire d'étude du Politique Hannah Arendt (LIPHA Paris Est), France
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Miller JA, Hunt DP, Georges MA. Reduction of Physical Restraints in Residential Treatment Facilities. JOURNAL OF DISABILITY POLICY STUDIES 2016. [DOI: 10.1177/10442073060160040101] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Children and adolescents with severe emotional and behavioral problems in residential settings can become so aggressive that physical restraints are utilized to keep them and others safe. Recently, the use of physical restraints in residential treatment facilities for school-aged children has come under increased scrutiny, and there have been legislative mandates that the use of physical restraints be reduced. This article describes a quasi-experimental field study conducted to examine the effectiveness of a 2-phase (organizational and milieu) physical restraint reduction intervention in a multisite residential treatment center. Results provide support for the effectiveness of organizational-level and milieu interventions for restraint reduction. Overall, restraint rates were reduced by 59% using these interventions.
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Valenkamp M, Delaney K, Verheij F. Reducing seclusion and restraint during child and adolescent inpatient treatment: still an underdeveloped area of research. JOURNAL OF CHILD AND ADOLESCENT PSYCHIATRIC NURSING 2014; 27:169-74. [PMID: 25100241 DOI: 10.1111/jcap.12084] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PROBLEM Half of all youth hospitalized in inpatient psychiatric facilities manifest aggressive behavior. When aggression escalates to the point of danger, measures must be employed to guarantee safety of both patients and staff. In this paper, the current empirical evidence for intervention models to reduce restriction and restraint utilization in children and adolescents is reviewed. METHOD PubMed and PsycINFO were searched for English-language articles published between 2006 and 2013. Included were empirical studies of child or adolescent inpatient populations using a pretest and posttest design. FINDING Included in this review are three empirical papers describing two different intervention models that met the inclusion criteria. CONCLUSIONS The review indicates there are two empirical supported intervention models that are helpful in reducing seclusion and restraint utilization in children and adolescents. The promising empirical findings support evidence and application to the child/adolescent population for at least three of the six National Association of State Mental Health Program Directors core strategies for restraint reduction. The modest number of empirical papers reflects that reducing restrictive measures in child/adolescent inpatient treatment remains an underdeveloped area of research.
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Affiliation(s)
- Marije Valenkamp
- Department of Child and Adolescent Psychiatry, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; VanMontfoort Consultancy, Woerden, The Netherlands
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Kangasniemi M, Papinaho O, Korhonen A. Nurses’ perceptions of the use of restraint in pediatric somatic care. Nurs Ethics 2014; 21:608-20. [DOI: 10.1177/0969733013513214] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The interest in the children’s role in pediatric care is connected to children’s health-related autonomy and informed consent in care. Despite the strong history of children’s rights, nurses’ role in the everyday nursing phenomenon, that is, restraint in somatic pediatric care, is still relatively seldom reported. Aim: The aim of this study is to describe nurses’ perceptions of the use of restraint in somatic pediatric care. The ultimate aim is to deepen the understanding of the phenomenon of restraint, whose previous study has been fragmented. Methods: Qualitative approach was selected because of the lack of previous information. Due to the sensitivity of the research question, individual interviewees were selected among voluntary nurses (n = 8). All participants were registered nurses with general work experience as nurses of 5–16 years on average and specifically 1.5–10 years in pediatric nursing. Inductive content analysis was used for aiming to produce a synthesis of the research phenomenon. Ethical considerations: The research received organizational approval by the university hospital, and informed consent and confidentiality were ensured. Results: Restraint in pediatric nursing was process-like, but occurred without advanced planning. The restraint-related process included five categories: (a) identification of the situations where restraint may occur, (b) finding preventive methods, (c) identification of different forms of restraint, (d) rationing the use of restraint, and (e) post-restraint acts. Restraint was seen as a part of pediatric nursing which occurred daily and involved several professionals. According to the nurses’ illustrations, restraint means doing things even when a child is not agreeable. Conclusion: Restraint is part of somatic pediatric nursing, described as the last, but in some cases, the only resort for carrying out care or treatment. Restraint is not a goal in itself, but an instrumental tool and procedure in carrying out care. In the future, more information about nurses’ role and the use of restraint in pediatric nursing is still needed.
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Brenner M. A Need to Protect: Parents’ Experiences of the Practice of Restricting a Child for a Clinical Procedure in Hospital. ACTA ACUST UNITED AC 2013; 36:5-16. [DOI: 10.3109/01460862.2013.768312] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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LeBel J, Nunno MA, Mohr WK, O'Halloran R. Restraint and seclusion use in U.S. school settings: recommendations from allied treatment disciplines. THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY 2012; 82:75-86. [PMID: 22239396 DOI: 10.1111/j.1939-0025.2011.01134.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Restraint and seclusion (R&S) are high risk, emergency procedures that are used in response to perceived violent, dangerous situations. They have been employed for years in a variety of settings that serve children, such as psychiatric hospitals and residential treatment facilities, but are now being recognized as used in the public schools. The field of education has begun to examine these practices in response to national scrutiny and a Congressional investigation. The fields of mental health and child welfare were similarly scrutinized 10 years ago following national media attention and have advanced R&S practice through the adoption of a prevention framework and core strategies to prevent and reduce use. A review of the evolution of the national R&S movement, the adverse effects of these procedures, and a comprehensive approach to prevent their use with specific core strategies such as leadership, workforce development, and youth and family involvement in order to facilitate organizational culture and practice change are discussed. Proposed guidelines for R&S use in schools and systemic recommendations to promote R&S practice alignment between the child-serving service sectors are also offered.
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Affiliation(s)
- Janice LeBel
- Commonwealth of Massachusetts, Department of Mental Health, 25 Staniford St., Boston, MA 02114, USA.
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Brenner M. Child Restraint in the Acute Setting of Pediatric Nursing: An Extraordinarily Stressful Event. ACTA ACUST UNITED AC 2009; 30:29-37. [PMID: 17613140 DOI: 10.1080/01460860701366658] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Maria Brenner
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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Nunno MA, Holden MJ, Tollar A. Learning from tragedy: a survey of child and adolescent restraint fatalities. CHILD ABUSE & NEGLECT 2006; 30:1333-42. [PMID: 17109958 DOI: 10.1016/j.chiabu.2006.02.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Revised: 02/03/2006] [Accepted: 02/24/2006] [Indexed: 05/12/2023]
Abstract
OBJECTIVE This descriptive study examines 45 child and adolescent fatalities related to restraints in residential (institutional) placements in the United States from 1993 to 2003. METHOD The study team used common Internet search engines as its primary case discovery strategy to determine the frequency and the nature of the fatalities, as well as the characteristics of the children and the adolescents involved. RESULTS Male children and adolescents were over-represented in the study sample. Thirty-eight of the fatalities occurred during or after a physical restraint, and 7 fatalities occurred during the use of mechanical restraints. Twenty-eight of the deaths occurred in a prone restraint. In 25 of the fatalities, asphyxia was the cause of death. CONCLUSION In the 23 cases in this study where information is available, none of the child behaviors or conditions that prompted the restraint would meet the standard of danger to self or others: the commonly accepted criteria for the use of a restraint. The study points to deficiencies in fatality reporting, recommends reporting fatalities to established state child fatality review boards, and reinforces that restraints be governed by strict protocol and monitoring. The study also urges caution to policymakers in substituting or changing restraint procedures based on the incomplete data reported in this study.
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Affiliation(s)
- Michael A Nunno
- Residential Child Care Project, Family Life Development Center, College of Human Ecology, Cornell University, Ithaca, NY 14853, USA
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Review of Restraint Data in a Residential Treatment Center for Adolescent Females. CHILD & YOUTH CARE FORUM 2006. [DOI: 10.1007/s10566-006-9021-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Day DM. Examining the therapeutic utility of restraints and seclusion with children and youth: the role of theory and research in practice. THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY 2002; 72:266-278. [PMID: 15792066 DOI: 10.1037/0002-9432.72.2.266] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Restraining and secluding children living in residential facilities, though controversial, are commonly practiced by staff to manage disruptive behavior. In an effort to address some of the ongoing issues about the practice, this article examined the reasons for their use, their theoretical underpinnings, and extant empirical evidence in support of the theories. It is suggested that the current array of theories be updated and comprehensive research programs be encouraged to assess their clinical utility with various populations in a variety of settings.
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Affiliation(s)
- David M Day
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada.
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