Pain Management / Sedation

Gorillas, restraints, and moral blind spots

Some years ago, I watched a movie in which the moviegoers were asked to count the number of times basketball players passed the ball to one another. I am proud to say that I counted them accurately. However, I missed the fact that in the middle of the basketball game a 500-pound gorilla entered the basketball court, beat on his chest, and then exited. I actually did not see the gorilla. Neither did anyone else.

I was so convinced that there was no gorilla that when they replayed the movie and showed it to me, I thought they had somehow substituted a different movie. But however much I swore I did not see the gorilla, it was there nonetheless. I did not see it because I did not expect to see it—and because I was concentrating on something else. Believe it or not, this can also be true with moral lapses. Consider the following case:

A patient was discharged from the hospital following hip surgery and admitted to the nursing home for rehabilitation. This is routine once the patient is “stable” enough to go home or to a rehabilitation facility to continue his or her treatment. At the time of the transfer, it had been documented that the patient was confused and unsteady on her feet. She was advised not to ambulate without her walker and identified as at “high risk” for a fall. She had a documented history of both confusion and noncompliance with these instructions while she was in the hospital, and her physician ordered restraints. Unfortunately, the physician merely ordered, “previous restraint orders should be continued.”

Upon admission, the patient was cooperative and did not seem to be confused. The nurse admitting the patient to the rehab unit noted that the orders were unclear at best, and invalid at worst. So, she called the physician to clarify matters. Meanwhile, she did not restrain the patient. While the nurse was waiting for the physician’s response, the patient attempted to get up. She fell and was found injured on the floor.

Chemical restraint involves the use of psychotropic drugs, sedatives, or paralytic agents. Physical restraint involves the use of physical or mechanical devices to restrain movement. Physical restraints may be cloth, leather, metal handcuffs or shackles, car seats, or seat belts. Forensic restraints are those applied by officers of the law only and they are not subject to the rules and regulations and standards that apply to hospitalized patients. Once the officer removes the restraint, however, all rules, regulations, and standards that apply medical restraints are in force. Behavioral restraints are used in psychiatric situations—and there are strict standards regarding their use. Medical restraints also are to be clearly ordered by an appropriate practitioner, and closely monitored by nurses. In this case, the use of restraints clearly fell under the “medical” rules.

As almost every practicing nurse can tell you, the uses of restraints—and the standards that apply to their use—are both complex and confusing. However, CMS (Centers for Medicare and Medicaid) is quite adamant about limiting the use of restraints of any kind. In general, restraints may be physical or chemical. The use of involuntary mechanical or human restraints or involuntary seclusion is only justified as an emergency safety measure in response to imminent danger to one’s self or others. Such measures can be justified only so long as, and to the extent that, the individual is a risk to herself and others. Moreover, restraint use has been strongly tied to abuse, misuse, death, and injury. Because of this public outcry, many nursing homes have adopted “restraint-free” policies. This nursing home had such a policy.

I can understand the nurse’s concern about using restraints without a clear, written order from the physician, but in this case, the patient’s record showed that she was noncompliant, at high risk, and her physician clearly wanted the restraints continued. Therefore, a prudent nurse would have applied at least minimal restraints, such as keeping an aide with her, until clarifying the situation with the physician. What was her “blind spot?” Perhaps the nurse followed policy blindly without thinking the issue through, or maybe she was angry because she believed the physician “knew better” than to write “continue previous orders” and wanted to call him on it. What she didn’t see was that it was the patient who would pay the price for her decision. This is what I think, what are your thoughts?

11 thoughts on “Gorillas, restraints, and moral blind spots”

  1. ScrubsRN says:

    If “patient was cooperative & did not seem to be confused” then applying restraints would be tantamount to assault, which is why the MD order for “previous restraint orders should be continued” requires clarification before it’s valid.How many other patients on the unit were confused that day? Was there extra staff to have someone stay with that patient until the MD returned the call? If the RN ends up in court many years from now she only has her THOROUGH charting about that day to back her up.

  2. JenniferRN says:

    Most errors happen on handoff…and handing off a patient from one facility to another is even more danger-prone. While I think restraining the patient is unreasonable when she appears cooperative, reading the patients immediate history may have indicated that the nurse should have taken some steps to assure patient safety while she clarified the physician’s intent…

  3. Pat RN says:

    Blaming the nurse is easy and equivalent to Monday morning quartering backing. There are factors not known. What did the nurse know about the patient before arrival? Restraining a patient who is cooperative and not confused is unreasonable. Perhaps transfer to a rehab unit in a nursing home, with one RN, was premature. This sure sounds like the Blame Culture. The nurse does not seem careless as the physician was called to clarify the orders. The nurse did not have a crystal ball to predict that

  4. MT says:

    CMS indicates the patient must be an immediate risk to themselves. Perhaps the staff had be disciplined prior to this for not “blindly” following policy. The article also does not indicate if the patient was assessed by the physician prior to the restraint order. The RN assessed her as cooperative and did not seem confused, so clarification of the order is prudent in my opinion. I wonder about the assumption the nurse may be angry. Assumptions without knowledge are rumors.

  5. Patrick says:

    A full assessment on admission should have been done. PRN restraint orders and resume orders are not acceptable. Nursing staff should have remained with the patient until the order could have been clarified. In extreme stiutations, a RN can place a patient in restraints pending a face to face LIP assessment (1 hr).SO! In this case:
    1) full RN assessment. 2) have a nsg staff with the patient until the order is clarified. 3) Use minimal restraint possible pending the face to face LIP evaluation.

  6. Anonymous says:

    I agree a full assessment of the patient was imperative. This would of certainly helped the nurse in question to see exactly what the patients needs were. Reality- while there may not always be time to do a full assessment there must be time set aside to do it anyway. Most certainly an aide could have been found to stay with the patient for the few minutes it would have taken to contact the physician to clarify. Either way the patients safety should always come first.

  7. hmhvalentine says:

    I think the issue here was the immediate safety of the patient. The patient should not have been left alone until a complete and proper assessment determined her ability to understand what activities posed a danger to her. You can’t do that in just the few minutes you spend with a patient when they first present. Besides the documentation from the hospital, did an appropriate hand-off occurr between facilities? Questions and answers?

  8. Leah Curtin says:

    Wow! Thanks for sharing wonderful perspectives with me. It makes me proud to be a nurse!I agree with all of you. Unfortunately neither CMS nor the Courts concur…And also, it is possible to use a ‘sitter’ and not to apply physical restraints at all. The presence of a person in the room to prevent falls also is a form of restraint but it is more respectful of a person’s dignity. Drugs, dementia, physical limits & stange places make one prone to falls & falls can be deadly.

  9. Anonymous says:

    I also disagree with Ms. Curtin. There is little to no evidence suggesting physical restraints protect our patients from falling. A full workup regarding the patients confusion was warranted and may have helped to prevent the injury

  10. Concerned ACNS-BC says:

    I respectfully disagree with Ms. Curtin. The evidence is clear that restraints do not protect our elderly patients from falling. What if that nurse had applied restraints and the patient was injured anyway? Then that nurse is legally liable for violating policy and could lose her job. Should the patient have been left alone without a staff or family member present? No, but the reality is that maybe no one was available. Should a non-punitive look at this through a RCA be done? Absolutely!

  11. Anonymous says:

    There is a guerrla in the room. It is called lack of consideration for human dignity. Restraints are never a solution to keeping the patient safe. The nurse in this situation was dealing with the downstream effect of our continuing to kid ourselves that we are restraining patients for their safety. We are restraining patients because we don’t have the resources to properly meet their needs and provide appropriate survellance and to protect the hospital’s liability. there are better solution

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