NR 556 Week 8 Policy Implementation Plan Example

Implementation Plan: Rolling Out the Approved Restraint Release Trial Requirement on Two Medical Units, Everyone It Binds, the First Month in Intervals and What Will Show Whether It Holds

Student Name

College of Nursing, Chamberlain University

NR 556: The Nurse Leader and Health Policy

Instructor Name

Month Day, Year

Implementation Plan: Rolling Out the Approved Restraint Release Trial Requirement on Two Medical Units, Everyone It Binds, the First Month in Intervals and What Will Show Whether It Holds

The Change and Its Authority

The nursing policy committee approved an amendment to the hospital's restraint and seclusion policy at its meeting this month, and the chief nursing officer signed it the same week, together with $46,000 for a six-month trial of virtual monitoring. The amendment requires that, for non-violent restraint of adult inpatients, a release trial be documented within each shift before the restraint is renewed, defines a release trial as removal of the restraint under direct or virtual observation for at least 15 minutes while the patient is awake, and clarifies that brief release for care does not count as discontinuation. It takes effect on the two adult medical units on the first of next month and will extend hospital-wide after a six-month review. This plan describes how the change will be carried out.

Everyone the Decision Binds

The groups bound by the change are listed explicitly, because the groups omitted from a plan are the ones that later break it.

Registered nurses on all three shifts on both medical units, including part-time and per diem staff, who carry out and document trials.

Float pool nurses assigned to the units, who may not attend unit meetings.

Agency and travel nurses, who receive a short orientation and may be on the unit for only a few weeks.

Charge nurses, who will check trial documentation at the end of each shift.

Patient care technicians, who often notice when a patient is calmer and can alert the nurse.

Hospitalists and nocturnists, who write renewal orders and will now see a trial documented before renewing.

Central telemetry monitoring technicians, who will watch patients during virtual trials.

Informatics, who must add a release trial field to the restraint flowsheet and a prompt in the renewal order.

Pharmacy, because the restraint order set is maintained with the pharmacy order set team, and the line allowing reapplication without a new order must be removed.

The emergency department, because patients boarded there before admission may arrive restrained and must be assessed under the new rule on arrival.

The First Month, in Intervals

Four to two weeks before go-live. Informatics builds the flowsheet field and order prompt and tests them. The reapplication line is removed from the order set. Camera units are delivered and tested. The clinical nurse specialist runs 30-minute education sessions for nurses on each shift, repeated so that night staff can attend, covering the two categories of restraint, the definition of a release trial, how to time a trial, how to request virtual monitoring or a sitter and how to document a trial judged unsafe. Hospitalists receive a one-page summary at their monthly meeting.

Two weeks to go-live. Charge nurses are briefed on the shift-end check. Float pool and agency coordinators add a one-page sheet to orientation packets. Telemetry technicians are trained on the camera system and the alert script. The emergency department nurse manager is briefed.

Go-live week. The clinical nurse specialist is on each unit at the start of every shift for the first three days, including nights, to answer questions and help with the first trials. The manager checks every restraint record daily.

Weeks two to four. Daily checks drop to three times a week. A short huddle at each shift change reviews any trial that could not be done and why. At the end of week four, the clinical nurse specialist and the manager review all restraint episodes, trial documentation, restraint durations and any unplanned line removals, and report to the Nursing Practice Council.

What Could Break the Change

Implementation research describes how characteristics of the intervention, the setting, the individuals involved and the process of implementation together shape whether a change takes hold (Damschroder et al., 2009). Several risks follow. Staff may document trials that did not happen, to satisfy the requirement; the manager's review will compare documented trials with virtual monitoring logs where cameras were used. Night staffing may make trials impossible on some nights; the documentation of trials judged unsafe will show how often, and that data will inform the permanent decision on sitters or cameras. Agency staff may not receive the orientation sheet; the charge nurse check will catch missing documentation from any nurse. And hospitalists may renew by phone out of habit; the order prompt asks whether a trial was documented before the renewal can be signed.

What Will Show Whether It Holds

Four measures will be reported monthly for six months: the share of renewals preceded by a documented trial, target 90% or higher; median restraint duration, target under 24 hours, compared with the baseline of 41 hours; lines or tubes pulled out during a trial or in the hour following a trial, as a safety check; and the share of trials that had camera or sitter support. Restraint remains a common intervention in acute care (Minnick et al., 2007), and a reduction in duration without an increase in line removals would show that the change is safe and effective. At six months, the Nursing Practice Council will decide whether to extend the requirement hospital-wide and whether to make virtual monitoring permanent.

How the Plan Serves the Rule

Every step in this plan serves the federal requirement that restraint come off at the first safe opportunity (Condition of Participation: Patient's Rights, 2024). The release trial is the means of showing that the requirement is being met, the flowsheet field is the evidence, and the charge nurse check makes sure the evidence exists. If a surveyor asks how the hospital knows restraints are not kept on longer than needed, the answer will be a documented trial before each renewal and a monthly report on duration.

Keeping the Change

After six months, the release trial requirement will be written into the unit's annual competency review, the flowsheet field will become permanent and the quarterly restraint review will be added to the unit's quality dashboard. The oral rule that began this work, that restraints simply need a new order every 24 hours, will be replaced by a written one that staff helped shape, which is the best protection against the old version returning.

The plan will be revisited at the six-month review, with any changes approved by the same committee.

References

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

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50

Minnick, A. F., Mion, L. C., Johnson, M. E., Catrambone, C., & Leipzig, R. (2007). Prevalence and variation of physical restraint use in acute care settings in the US. Journal of Nursing Scholarship, 39(1), 30-37. https://doi.org/10.1111/j.1547-5069.2007.00140.x