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?