NR 556 Week 4 Organizational Policy Review Example

Organizational Policy Review: The Hospital's Restraint and Seclusion Policy Read Section by Section, Its Lapsed Review Date, the Situations Its Wording Never Addresses and One Line That Conflicts With Federal Rules

Student Name

College of Nursing, Chamberlain University

NR 556: The Nurse Leader and Health Policy

Instructor Name

Month Day, Year

Organizational Policy Review: The Hospital's Restraint and Seclusion Policy Read Section by Section, Its Lapsed Review Date, the Situations Its Wording Never Addresses and One Line That Conflicts With Federal Rules

The Identifying Block

Title: Restraint and Seclusion. Owner: Department of Nursing, with the Medical Executive Committee as co-approver. Last approved: three years and four months ago. Review cycle: every three years. Scope: all inpatient units except the behavioral health unit, which has its own policy. Referenced standards: Medicare's hospital patients' rights rule and the accrediting organization's restraint standards.

The first finding comes from the block itself: the policy is four months past its required review date. A lapsed review does not make the policy invalid, but it means the text has not been checked against current practice, current guidance or the hospital's own restraint data for more than three years.

What the Text Says

Section 1, Purpose and definitions. Defines physical restraint, distinguishes restraint for non-violent, non-self-destructive behavior, described as restraint to support medical healing, from restraint for violent or self-destructive behavior, and defines seclusion.

Section 2, Least restrictive alternatives. Requires staff to consider and document alternatives before applying restraint, such as family presence, reorientation, covering lines and a sitter.

Section 3, Orders. Requires an order from a physician or other authorized practitioner; states that orders forbids standing and as-needed orders; allows the registered nurse to apply restraint in an emergency and obtain an order promptly.

Section 4, Non-violent restraint. Requires renewal each calendar day based on the practitioner's evaluation and nursing assessment; monitoring at least every two hours, including circulation, skin, hydration, toileting and the continued need for restraint.

Section 5, Violent or self-destructive restraint. Sets age-based limits on order length and requires the patient to be seen in person within the hour.

Section 6, Discontinuation. States that restraint must end as early as it safely can and that the registered nurse may discontinue restraint when criteria are met.

Section 7, Documentation and reporting. Lists documentation requirements and requires reporting of deaths associated with restraint.

Gaps

Release trials are not defined. Section 4 requires assessment of "the continued need for restraint," and Section 6 requires discontinuation at the earliest possible time, but no section says how continued need should be tested. A nurse could document "continued need" every two hours without ever removing the restraint to see what happens. This gap is the policy-level root of the renewal problem identified on the medical unit.

Temporary release is not addressed. The policy does not say whether removing a restraint briefly for care, such as bathing or repositioning, counts as discontinuation, which would require a new order to reapply. Federal surveyor guidance treats temporary release for care as different from discontinuation, but staff on our unit believe any removal requires a new order, which discourages release trials.

Nothing on delirium. Most non-violent restraint on medical units is for patients with delirium, yet the policy does not mention delirium screening or management, although restraint can worsen delirium (Inouye, 2006).

No data requirement. The policy does not require units to review their restraint episodes or report duration, only deaths.

A Contradiction

Section 3 prohibits as-needed orders, in line with federal rules (Condition of Participation: Patient's Rights, 2024). But Appendix B, an order set template attached to the policy, includes a line reading "Restraint may be reapplied if patient resumes pulling at lines," which in practice functions as an as-needed order: it allows reapplication without a new order based on a future contingency. The template appears to predate the current policy text. A surveyor reading the two together would find a conflict, and staff using the order set are following a line the policy itself prohibits.

How the Policy Compares With Practice

Set against the unit review, the policy's gaps line up with the practice problems almost exactly. The absence of a release trial definition matches the 12 episodes renewed without a documented trial. The silence on brief release for care matches staff belief that any removal requires a new order, which discourages trials. The appendix line allowing reapplication matches what night staff describe doing: taking restraints off for care and putting them back without calling. The one area where practice exceeds policy is monitoring, where two-hourly checks are well documented.

That match is itself a finding. It suggests that most of the practice problem is not staff ignoring the policy, but staff filling the policy's silences with habit. A review that stopped at checking compliance with what the text says would have found the unit largely compliant and missed the problem.

Who Should Review It

The overdue review should be led by the nursing policy committee but should include a hospitalist, because renewal orders are central; a clinical nurse specialist in gerontology, because most patients involved have delirium; a night charge nurse, because most restraints are applied at night; and the patient safety officer. The review should also compare the order set with the policy line by line, since the contradiction found here lay in an appendix that no one had read alongside the text.

What the Review Recommends

Four changes are recommended for the overdue review. First, define a release trial in Section 4, for example removing the restraint under direct observation for at least 15 minutes at least once per shift when the patient is awake, and require it to be documented before daily renewal. Second, clarify in Section 6 that brief release for care is not discontinuation and does not require a new order to reapply. Third, add a section on delirium, requiring screening and a delirium management plan for any patient in non-violent restraint. Fourth, remove the reapplication line from Appendix B and require units to review restraint duration quarterly.

All four changes fall inside what the nursing policy committee can approve with the chief nursing officer, identified in the policy ladder as the right rung for change. They are consistent with federal and accreditation requirements and, if anything, make compliance easier to demonstrate. The evidence that restraint devices are associated with injury (Evans et al., 2003) supports tightening the process for keeping them on.

The review is also a chance to align the policy with the language staff actually use, so that the written rule and the spoken one say the same thing.

Each recommendation points to a numbered section, so the committee can act on them one at a time.

References

Condition of Participation: Patient's Rights, 42 C.F.R. § 482.13 (2024).

Evans, D., Wood, J., & Lambert, L. (2003). Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing, 41(3), 274-282. https://doi.org/10.1046/j.1365-2648.2003.02501.x

Inouye, S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354(11), 1157-1165. https://doi.org/10.1056/NEJMra052321