I was having lunch with my good friends from the Risk Management Department this past Thursday.
We had our usual chit-chat at lunch and I was the only one at the table who was not of that department. I have a particularly good relationship with these people as one of their members is actually one of my Student Pilots. She and I discuss elements of Risk Management all the time…both of Healthcare and Aviation.
I am not alien to Risk Management because my job the first 17 years or so of my Healthcare Career were in Clinical Engineering, a Department wholly designed to insure Patient and Staff Safety in the Healthcare Environment.
Another member of the team is a person who is an Ordained Minister who has performed a wide range of jobs in Healthcare over the years. He is a very approachable man and very jovial. I always enjoy my time spent with him. He is a very honest soul. The final member of the team in attendance at lunch is a seasoned Risk Management RN.
The discussion, among the three of them, were discussions of Patient Restraint Protocols.
In the hospital environment, restraints of course are used to prevent injury of one’s self or staff in the event the patient loses control. These are referred to as “behavioral restraints”. The other types are “restraints of necessity” for person’s who may get out of bed and be unstable, or may pull out breathing tubes and IV tubing due to disorientation.
The guidelines are clear: You must have a Physicians Order to apply restraints and that order must be reissued or reviewed with the Physician every 24 hours. You must always have the patient in clear sight of monitoring by Healthcare Staff and you must inspect the tightness of restraints and the condition of the patient every 15 minutes when a patient is in behavioral restraints and is otherwise not sedated and is clearly intent on harming themselves or others.
There must also be a certain degree of slack in the restraints…a quarter inch around limbs and two to four inches of slack in the bed bindings themselves.
Chemical restraints, as well, require a great deal of checks and balances to be applied and maintained on a patient. You cannot leave a patient helplessly restrained and unmonitored. You must provide any and all necessary services for that patient, including a means to use the bathroom and also to have time out of restraints as appropriate so that the patient can walk and not obtain blood clots that could kill them.
For the staff, restraints are a pain in the ass. The documentation protocols are even more robust than the actual physical protocols.
There have been a number of courses (some of which I have taken) that encourage “restraintless control” measures. As an example: Staff are equipped with whistles that they blow when an escape attempt is made or a patient becomes disoriented or combative that can provide a needed and strong physical and Psychological response from staff to manually restrain the patient and place them back into bed or back into a seclusion room.
The central issue is about providing control that the patient does no longer have.
When a patient is properly restrained…either mechanically or chemically…the patient should be in some relative sense of control and, ironically, comfort. I’ve actually seen patients, in some cases teenagers, actually thankful and comforted by being in restraints. It’s wild, but they sometimes will tell you that they mimick a sense of being held and being focused upon and they know they are no longer a danger to themselves on some level.
Mild sedation is almost always given alongside behavioral restraints. It would be unfair to leave a patient comfortless and feeling helpless in this kind of situation. After all, it is not usually their fault they are out of personal control.
I am of the belief that during those earliest phases of life outside the womb, when a child is not properly held by a caretaker, that a lack of security and a deep sense of vulnerability is obtained in the child. Native American women would wrap their children very tightly in a papoose so that they could work and travel on foot. The famous “swaddling clothes” of the Middle East were tight wrappings of cloth that secured the new born infant and provided that sense of enclosure…much as the womb of their mother did before birth.
But, what if you were to use a logging chain to bolt someone down, perhaps naked, to a dungeon floor? What if you were to tie cords around a persons limbs and throat and tie them so tightly that the circulation or even perhaps breath was restricted in the person who provided any kind of struggle?
How traumatic would that be??
Would that not create the incentive for panicked escape?? Have you ever heard the term “chewing through the restraints”??
Measures of control go very far in the lives of children who have controlling and overbearing parents. The demands placed upon the child, often to become what the parent could not possibly become, are a type of prison whereby the child can simply NOT be themselves. The dynamics get very deep and there is a host of controlling behaviors that arise in the minds of overbearing parents.
Doesn’t society itself not already have enough controls for an individual? Aren’t we in enough prisons already in today’s society??
In the work environment, when you get a micromanaging and controlling boss who leaves you with the impression that you are disposable (not safe) and that your job could be on the line at anytime for any of his whims…you might say…the controlling restraints placed upon you are just too tight.
Punitive thinkers…control freaks…place too tight of controls upon you…and you can’t find the needed sustenance and comfort from the source of the control that should be required.
The scales have tipped and the controlling person no longer is being responsible for seeing to it that your basic needs are met within the environment of control.
Control should be provided for safety. As in an aircraft: Control should be provided to the pilot so that positive performance can be obtained from the aircraft.
Control is about safety and positive performance. If’s it’s anything other than this, it’s abuse.
In lawful terms for Medical Personnel, this places the decision maker in a legally liable standpoint.
There is a responsibility that goes along with management and it’s a trait more and more being forgotten by management. You can have plenty of management and not an ounce of leadership. Leadership means you lead…you draw people toward something…so that you can guide them in a more constructive and less constrictive way so that there can always be a good outcome. It seems to me as though Leadership anymore is by leash.
Leadership with a leash is no leadership at all. You can drag someone on a leash.
Management has forgotten the higher order of servitude and responsibility that goes along with the added rewards for the job.
(This one-way pathway is the pathway of Narcissism, by the way)
Over control and needless control is abuse.
As in Hospital Restraints, control should always be to ensure safety for all considered and to set parameters of behavior so that a positive outcome can be derived for all, if possible.
But, if you place the restraints too tightly…in a work environment, in a marriage, or on your children…it’s only going to provide the impetous for them to chew through the restraints and attempt/complete escape. That escape may be physical, but it can also be emotional or mental in nature. That defiance you see, in that red faced teenager, is a sign that you or someone placed too tight of controls upon them.
I’ve found that children who were overly controlled oftentimes go on to become control freaks and tyrants themselves.
Over control is not love and is not a substitute for love.
Think about this: Indulgence of a child is another form of control.
Like feeding a hungry child candy canes exclusively…it may appear from the outside as being preferential treatment. But, more often than not, indulgence is an attempt by the parent to “buy off” and deflect the child’s true, wholesome needs and the child is thus inadvertently placed in a control system via neglect of their needs. A child cannot provide for their own welfare…it is the parent responsibility. If the parent is irresponsible, the child suffers.
Just as a child will suffer health problems from continuously eating hastily and repetitively provided candy canes and not getting the nutrition they need…the indulged child is being robbed of the cuddling attention, limit setting and validation of a present parent…of which there is no substitute.