course materials

1. Discussion: Relating a patient problem to an IOM/QSEN competency.
Discussion: Relating a patient problem to an IOM/QSEN competency. ON Discussion:
Relating a patient problem to an IOM/QSEN competency.INSTRUCTION: Write a paper of a
minimum of 12 pages in length, excluding title page, abstract, and references. The paper
must be constructed according to APA format (APA, 2010). Headings are to be included (see
below). See Rubric for point allocation & sample. Introduction: (i) Purpose
statement/research question· (ii) Significance of the patient problem, ed by the
literature. (iii) Select one IOM/QSEN Nurse Competency (Cronenwett et al., 2007)Review of
the Research Literature: This section includes a review of the 5 articles relating the patient
problem to an IOM/QSEN competency. (ie related to the purpose statement /research
question, and to substantiate the significance of the patient problem )Case Example: The
case example must exemplify the problem statement/research question and be related to
the identified IOM/QSEN competency. The case example should describe the patient
condition, disease(s), clinical issues, medications, nursing care, etc.Transition Theory (Im,
2006): frames the Capstone paper, and incorporating this theory is a required component of
the paper. The following question(s) must be addressed when incorporating Transition
Theory (Im, 2006):a) What transition(s) is the patient in?b) What are the facilitator’s and
inhibitors?c) What is or was the patient’s response?d) What was the nursing
intervention?Conclusion: Integrate nursing implications from your literature review and
relate them to your patient’s problem. Include nursing implications in these three areas:(a)
Practice: What is the best nursing practice for this issue?(b) Education: What are the
current guidelines for educating nurses, patients/families about care for this problem?©
Research: What are the priorities for further study (from a nursing perspective) related to
this problem?**PICO question: Among patients with type-2 diabetes, does patient education
improve compliance/self management?Article 1: Carpenter, R., Dichiacchio, T., & Barker, K.
(2019). Interventions for self-management of type 2 diabetes: An integrative
review. International Journal of Nursing Sciences, 6(1), 70-91.Article 2: Bagnasco, A., Di
Giacomo, P., Da Rin Della Mora, R., Catania, G., Turci, C., Rocco, G., & Sasso, L. (2014). Factors
influencing self?management in patients with type 2 diabetes: A quantitative systematic
review protocol. Journal of Advanced Nursing, 70(1), 187-200.Article 3: Brackney, D.
(2018). Enhanced self?monitoring blood glucose in non?insulin?requiring Type 2 diabetes:
A qualitative study in primary care. Journal of Clinical Nursing, 27(9-10), 2120-2131.Article
4: Chrvala, Sherr, & Lipman. (2016). Diabetes self-management education for adults with
type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient

2. Education and Counseling, 99(6), 926-943.Article 5: Boström, Isaksson, Lundman,
Graneheim, & Hörnsten. (2014). Interaction between diabetes specialist nurses and patients
during group sessions about self-management in type 2 diabetes. Patient Education and
Counseling, 94(2), 187-192.Article 6: Cronenwett, Sherwood, Barnsteiner, Disch, Johnson,
Mitchell, . . . Warren. (2007). Quality and safety education for nurses. Nursing Outlook,
55(3), 122-131.Article 7: ALLIGOOD, Martha R., TOMEY, Ann M. (2006). Nursing theorists
and their work. 6th ed. Philadelphia: Mosby Elsevier. ISBN: 978-0323030106FYI: Attached
is the sample of a nursing capstone paper, and the last 2 articles the QSEN and the IOM/
transition articlescapstone_exemplar.docxmeleis_chapter_20.pdfqsen.pdfUnformatted
Attachment PreviewRunning head: RESTRAINT USE AND PATIENT SAFETY Restraint Use
and Patient Safety: Nursing Care of Elderly Patients with Delirium in Acute Care Settings
University of Massachusetts Boston 1 RESTRAINT USE AND PATIENT SAFETY 2 Abstract
This capstone paper integrates the current clinical problem of delirium in the hospitalized
elderly patient with the associated QSEN nursing competency of safety by addressing and
exploring the following question: Among elderly inpatients with delirium in the acute care
setting, does the nurse’s use of alternative, restraint-free approaches to care as compared to
the use of physical restraints lead to increased patient safety? After an introduction of the
problem and its significance to patient safety, a review of current research literature that
addresses both the problem of delirium and its possible nursing interventions is presented.
Next, a case example of a patient cared for by the author during her senior preceptorship on
a general medicine floor at an acute care facility is presented and applied to the clinical
problem. The paper then concludes with a discussion of implications for future nursing
practice, patient education, and further research on the clinical problem. Keywords:
delirium, elderly, acute care, nursing, physical restraints, safety RESTRAINT USE AND
PATIENT SAFETY 3 Restraint Use and Patient Safety: Nursing Care of Elderly Patients with
Delirium in Acute Care Settings Introduction Delirium is a common patient problem in the
acute care setting, particularly among the elderly population. According to the United States
National Library of Medicine (2015). Discussion: Relating a patient problem to an
IOM/QSEN competency.delirium is a state of “sudden, severe confusion due to rapid
changes in brain function that occur with physical or mental illness” and individuals who
experience this acute change in mental status can often become agitated. The onset of
delirium signals the presence of other serious medical conditions or illness and nurses must
be able to identify delirium and intervene both quickly and appropriately to treat and
manage it (Chong, Chan, Tay, & Ding, 2014). At times, in an effort to ensure the safety of
both patient and nurse, physical restraints such as full bed rails, wrist and ankle restraints,
or vests are used. Physical restraints are defined as “any device attached to or adjacent to a
person’s body that cannot be controlled or easily removed by the person and deliberately
restricts a person’s freedom of movement” (Kwok et al., 2012, p. 645). Such restraints
should be viewed as a last resort intervention, as their use can itself become a safety issue,
often causing the patient additional distress and potentially resulting in injury (Cosper,
Morelock, & Provine, 2015). It is the duty of every nurse to provide his or her patients with
the safest possible care; therefore, the need for restraints should be carefully evaluated and
restraints used only if other less restrictive options are unable to patient safety. Safety is a

3. core nursing competency identified by the Institutes of Medicine and defined by the QSEN
Institute (2014) as providing care in a way that “minimizes the risk of harm to patients and
providers through both system effectiveness and individual performance”. Discussion:
Relating a patient problem to an IOM/QSEN competency.Competent nurses should always
strive to place patient safety at the center of their practice and RESTRAINT USE AND
PATIENT SAFETY 4 therefore, in light of the aforementioned concerns, the use of physical
restrains in current nursing practice should be explored by asking the following clinical
question: Among elderly inpatients with delirium in the acute care setting, does the nurse’s
use of alternative, restraint-free approaches to care as compared to the use of physical
restraints lead to increased patient safety? To address this question, a review of current
research literature that explores both the problem of delirium and related nursing
interventions is presented, followed by the presentation of a case example that highlights
the patient problem and a concluding discussion of implications for future nursing practice,
education, and research on the issue. Review of the Research Literature Patient Problem
The problem of delirium experienced by elderly patients in acute care settings is significant
and well-documented in the literature. To appreciate the problem, it is first important to
understand the incidence of hospitalization for elderly individuals. According to Krall et al.
(2012), the elderly are defined as individuals who are 65 years of age or older and a group
that accounts for 40 percent of acute care hospital admissions. This geriatric population has
unique needs and common cognitive impairments such as dementia and delirium
necessitate specialized care (Krall et al., 2012). Rice et al. (2011) noted that delirium is
recognized as the most common complication experienced by the hospitalized elderly
patient in the United States and accounts for 17.5 million extra days of inpatient stays
annually. More than 2 million older American adults suffer from episodes of delirium every
year and the estimated yearly costs of treatment and follow-up healthcare needs are
anywhere from $38 to $152 billion (Rice et al., 2011). Discussion: Relating a patient
problem to an IOM/QSEN competency.Research conducted in Singapore by Chong et al.
(2014) found that delirium is a significant problem seen frequently in the elderly
population in acute care hospitals; they report that 11-24% RESTRAINT USE AND PATIENT
SAFETY 5 of elderly inpatients are admitted with delirium and 5-35% more develop the
condition during the course of their hospitalization. According to Gillies, Coker, Montemuro,
and Pizzacalla (2015) elderly patients often have preexisting dementia and go on to develop
acute delirium during their hospital stay that can result in behaviors that are challenging for
nurses to manage, such as verbal outbursts, escape or elopement attempts, and resisting
necessary medical care or nursing interventions. A wealth of current evidence on the
incidence of delirium among elderly acute care inpatients strongly s the claim that it is a
significant clinical problem. To further appreciate the problem of delirium in the
hospitalized elderly population, it is vital to understand its potential outcomes and
implications for patient safety. The American College of Physicians has recognized its
clinical significance, noting that elderly patients who experience delirium are at greater risk
for developing complications like pneumonia and pressure ulcers, and according to First,
are three times more likely to be moved to a long term care facility, such as a nursing home,
on discharge and suffer a decline in their overall health status (as cited in Aguirre, 2010).

4. Further underscoring the seriousness of delirium as a clinical problem is the fact that the
Agency for Healthcare Research and Quality has identified it as a key indicator of quality
and safety in patient care (as cited in Rice, 2011). A study by Flaherty and Little (2011)
reported that delirium is a problem that cannot always be prevented and has multiple
detrimental sequelae for patients, including falls, injury, reduced capacity to perform
activities of daily living (ADL), increased length of stay in the hospital, and higher mortality
rates. Patients suffering from delirium require more intensive monitoring by nursing staff
and have a 25-33% mortality rate in the acute care setting, as well as a 35-40% rate by one
year after discharge (Chong et al., 2014). Discussion: Relating a patient problem to an
IOM/QSEN competency.These patients need to be closely monitored in order to ensure
their safety, an intervention that cannot always be achieved given typical nurse-patient
staffing RESTRAINT USE AND PATIENT SAFETY 6 ratios (Flaherty & Little, 2011). A study
by Cosper et al. (2015) noted that delirium often leads to agitation and the use of potentially
dangerous physical restraints if it is not diagnosed and treated quickly. Current evidence
clearly illustrates the significance of delirium as a clinical problem in the elderly and one
that has particularly important implications for patient safety. Nurses caring for delirious
patients must be able to implement the safest possible nursing interventions to protect said
patients from injury until the delirium resolves. Nursing Interventions Nursing
interventions for the management of delirium in elderly hospitalized patients in acute care
settings are extensively documented in the literature. Studies of both physical restraint use
and alternative, restraint-free approaches to care can be found. The decision to use
restraints is often motivated by the nurse’s desire to ensure patient safety. A systematic
review of the literature on nurses’ attitudes towards physical restraints conducted by
Möhler and Meyer (2014) revealed that concern for patient safety is a common theme
reported by registered nurses (RNs) caring for geriatric patients; despite having negative
feelings about physical restraint interventions, nurses identify their obligation to uphold
patient safety as paramount and the primary reason for using such restraints. Möhler and
Meyer’s research showed that most nurses believe physical restraints will help prevent
falls, injury, and interruptions of necessary medical interventions for delirious elderly
patients; however, the study noted that this belief is also affected by nurses’ lack of
knowledge regarding alternative approaches as well as the issue of high nurse-patient
ratios. Möhler and Meyer also found that most nurses do not routinely question physical
restraint use and view them as an accepted, common nursing intervention. A similar
descriptive case study of nurses’ and nursing assistants’ opinions of physical restraint usage
in older adults by McCabe, Alvarez, McNulty, and Fitzpatrick (2011) revealed RESTRAINT
USE AND PATIENT SAFETY 7 that overall, nursing staff are neutral to the use of restraints,
with nurses having a more negative opinion of their use than nursing assistants. McCabe et
al. also found that overall, interference with therapeutic interventions was identified as the
primary reason for implementing restraints although nurses in the emergency department
used restraints primarily for protecting themselves and other staff from combative patients.
According to McCabe et al., restraints continue to be used in an effort to promote patient
and staff safety despite research that shows restraint usage can have unintended negative
consequences for the patient, such as bone fractures and soft tissue damage, and actually

5. increase the elderly patient’s delirium and risk for falls and fall injury. Discussion: Relating a
patient problem to an IOM/QSEN competency.A case study by Krall et al. (2012) discussed
the implementation of an Acute Care for the Elderly (ACE) unit in one acute care hospital;
the goal of this intervention was to promote safe, patient-centered care to confused elderly
patients with delirium or dementia. Krall et al. described the ACE unit as a dedicated six-bed
area on a larger medical-surgical floor staffed by Geriatric Resource Nurses (GRNs), located
close to all supplies and the nurses station, with patients being observed by at least one
caregiver at all times and a policy of not using any physical restraints. Three months after
the ACE unit’s implementation, none of its patients had experienced a fall, whereas six falls
occurred on the larger unit (Krall et al., 2012). Other safety indicators included no pressure
ulcer development among ACE unit patients, prompt removal of restraints from restrained
patients transferred from other units, and a lower average length of stay of 3.18 days
compared to 3.90 days for the general unit (Krall et al., 2012). From a qualitative
perspective, both nurses and family members reported feeling that patients receive higher
quality and safer care on the ACE unit (Krall et al., 2012). Although there is concern among
nurses that avoiding physical restraints altogether is unsafe and could lead to delirious
patients suffering a fall injury, the ACE model illustrates that restraint-free care can actually
be safer. RESTRAINT USE AND PATIENT SAFETY 8 A similar case study by Flaherty and
Little (2011) involved the use of a dedicated four bed restraint-free Delirium Room (DR)
within an ACE unit in two different acute care hospitals; the DRs were designed to enable
constant observation by nursing staff and thus patient safety and eliminate the use of
physical restraints. According to Flaherty and Little, the use of physical restraints on
delirious elderly patients can exacerbate the severity of their delirium and should be
avoided at all costs. Flaherty and Little found that a “tolerate, anticipate, and don’t agitate”
approach in the DR led to better patient outcomes; by allowing patients to initially engage in
unsafe behavior with the nurse close by, the nurse could identify the potential unmet needs
that were the root cause of the unsafe behavior, such as climbing out of bed to void, and
thus intervene to resolve the issue without the use of restraints (p. S297). Flaherty and
Little’s study showed that a restraint-free environment does not lead to increased falls as
some fear it could; just two falls were reported in the DR in one year and 28 were reported
on the rest of unit. Discussion: Relating a patient problem to an IOM/QSEN competency.The
study also showed that length of stay and mortality rates for delirious patients in the DR
were comparable to those of non-delirious patients (Flaherty & Little, 2011). Again,
research shows that the fear of restraint-free care leading to an increase in falls is
unfounded and that patient safety is upheld in such an environment. Another case control
study of one acute care hospital by Chong et al. (2014) compared the outcomes of elderly
patients with delirium on a special Geriatric Monitoring Unit (GMU) to those in non-GMU
areas of the hospital. According to Chong et al., the GMU is a unique five bed unit designed
for the specialized care of elderly patients with acute delirium and has low nurse-patient
ratios to constant supervision. Results of the study showed that patients in the GMU
experienced no application of physical restraints and saw a fall rate of 1.3% even though
80% of said patients were experiencing hyperactive or mixed delirium, while the non-
RESTRAINT USE AND PATIENT SAFETY 9 GMU group had a much higher restraint usage

6. rate of 23.1% and a fall rate of 2.6%, with fewer patients (64%) classified as having
hyperactive or mixed delirium that can manifest as agitation and combativeness (Chong et
al., 2014). Once more, current research suggests that caring for delirious patients in ways
that do not involve physical restraints actually improves their outcomes and s their safety.
A case study by Cosper et al. (2015) involved a physical restraint reduction program that
was piloted in four separate acute care hospitals; it was noted that although patient safety is
improving and injury and mortality rates associated with restraint use have been declining
since 2009, such incidents are still among The Joint Commission’s 15 most commonly
reported sentinel events. The use of physical restraints is a safety concern and has been
associated with numerous types of injury including soft tissue damage, neuropathy,
ischemia, pressure ulcer development, increased falls and fall injury (Cosper et al., 2015).
By securing the of senior hospital administrators, having a restraint reduction leader on
each unit, promoting interdisciplinary rounds on delirious patients as well as hourly
nursing rounds, instituting twicedaily delirium screenings, providing staff education on
physical restraint usage (including legal and ethical considerations and potentially negative
sequelae), and making restraint-free alternatives like bed alarms more readily available, the
two larger hospitals saw a decrease in restraint use from 5.87% to 1.73% over two years
and the smaller hospitals declined to 0% and 1.95% (Cosper et al., 2015). Study results also
showed that neither fall rates nor rates of patient self-extubation increased after the use of
patient restraints declined (Cosper et al., 2015). In light of this evidence, committing to
restraint-free approaches to delirium management and obtaining multidisciplinary for
their use are clearly important steps that nurses can take to protect the safety of their
patients. Discussion: Relating a patient problem to an IOM/QSEN competency.RESTRAINT
USE AND PATIENT SAFETY 10 Finally, a retrospective case study by Kwok et al. (2012)
found that a similar restraint reduction initiative in a large acute care hospital in Hong Kong
led to a shorter length of stay in the facility for cognitively impaired patients, including
patients with delirium. Kwok et al. noted that length of stay is often used as an indicator of
quality care and so far no evidence exists to show that discharging patients sooner leads to
negative outcomes or safety issues. Results of the study showed that from 2007 to 2009, the
use of physical restraints with cognitively impaired patients decreased from 24.5% to 9%,
the average length of stay decreased from 17 days to 14 days, and fall incidents decreased
slightly from 1% to 0.5% (Kwok et al., 2012). Once again, the lack of physical restraints has
been demonstrated to positively impact the safety of the delirious patient. After a thorough
review of current research evidence it becomes clear that implementing restraint-free
approaches to the management of delirium in elderly acute care patients protects the safety
of said patients and demonstrates excellence in nursing care. Case Example The author is
currently completing a nursing preceptorship on a 25 bed general medicine unit at
Massachusetts General Hospital. The unit cares for patients with a wide variety of medical
diagnoses but often admits patients with delirium, the majority of them elderly, for medical
workup and resolution of their acute mental status changes. At times, such patients with
altered mental status become agitated, combative, or repeatedly attempt to get out of their
beds, thus placing themselves and their nurses in unsafe situations and at risk for injury. As
a result, physical restraints such as soft wrist and ankle restraints are used to keep the

7. patient in bed when nurses or other personnel are unable to be at the bedside around the
clock to intervene and redirect the patient. Discussion: Relating a patient problem to an
IOM/QSEN competency.RESTRAINT USE AND PATIENT SAFETY 11 On a night shift, a 76
year old male was admitted to the unit with the diagnosis of delirium after having arrived to
the emergency department from a long term care facility with hyperglycemia (blood
glucose in the low 400s) and an acute change in mental status. In the emergency
department, where he stayed for several hours, the patient received insulin and was then
sent to the unit for further monitoring and diagnostic workup of his delirium. The patient’s
medical history included diabetes mellitus, recurrent urinary tract infections, hypertension,
and multiple falls. Given his history of falls and current delirious state, the patient was
placed on fall precautions, which included padded floor mats and the use of a bed alarm.
Due to his need for a private room with contact precautions and bed availability constraints,
the patient was not placed in a room close to the nurses’ station; however, frequent safety
checks were made. Although he was confused, the patient was initially pleasant and
relatively cooperative with care and, when not, was easily redirected. However, as the shift
progressed he became increasingly agitated. The patient repeatedly attempted to get out of
bed and was no longer responding to redirection; he began yelling and cursing at the
nurses, refusing care, and attempting to remove necessary equipment such as his cardiac
monitoring leads, oxygen saturation probe, and intravenous lines. In his confused state, the
patient was convinced he was being held against his will without reason and that he needed
to either go home to his mother or get dressed and go to work. Unfortunately, the patient
had no family o