Adult-Dnp-Staff Education About Tic-2018

TRAUMA-INFORMED CARE 1
STAFF EDUCATION ABOUT TRAUMA-INFORMED CARE TO REDUCE RESTRAINT

AND SECLUSION
by
Anita Iyengar
Capstone Paper submitted in partial fulfillment of the

requirements for the degree of
Doctor of Nursing Practice
Chatham University
August 23, 2018
Signature Faculty Reader Date
Signature Program Director Date

Acknowledgments
I would like to thank my family and friends for their many acts of encouragement. I am
especially grateful for the support of my mother and sister-in-law, Louise. I appreciate the
classmates who were always there for me, no matter how busy they were.
I would like to acknowledge Lisa for patiently paving the way at the clinical site, Dr. K.
Clark for sharing her knowledge and dedication to behavioral health nursing, and Dr. A.
O’Sullivan for her mentorship and confidence building. I have been fortunate to experience the
expertise and commitment of the Chatham faculty. I would like to specially thank Dr. Michelle
Doas, Dr. Melissa Popovich, and Dr. Kathleen Spadaro.

Dedication
This project is dedicated to the nurses and other people who work in acute behavioral
health care, and the people they serve.

Abstract
The usage of restraint and seclusion (RS) in acute psychiatric settings is a serious health care
problem in the United States. The practice is dangerous, unethical, and financially burdensome.
Restraint and seclusion is overused and preventable. Staff education about trauma-informed care
(TIC) is an evidence-based intervention for the reduction of RS usage. An evidence-based
practice change project was implemented in the psychiatric department of a mid-Atlantic urban
hospital. The purpose of the project was to determine if a TIC educational intervention increased
the nursing staff’s knowledge of TIC and confidence in implementing it. A pretest-posttest
design was used. The data were analyzed using descriptive and comparative statistics. The
intervention was determined to increase the participants’ knowledge of TIC and confidence in
implementing it.
Key words: Restraint and seclusion, trauma-informed care

Table of Contents
Acknowledgments..................................................................................................................2
Dedication ..............................................................................................................................3
Abstract ..................................................................................................................................4
Chapter One: Overview of the Problem of Interest ..............................................................9
Background Information ............................................................................................9
Significance of the Problem .......................................................................................10
Question Guiding Inquiry (PICO) .............................................................................11
Variables of the PICO question .....................................................................12
Summary ....................................................................................................................12
Chapter Two: Review of the Literature/Evidence ................................................................13
Methodology ..............................................................................................................14
Sampling strategies ........................................................................................14
Inclusion/Exclusion criteria ...........................................................................14
Literature Review Findings........................................................................................15
Discussion ..................................................................................................................21
Limitation of literature review. ......................................................................21
Conclusions of findings .................................................................................21
Potential practice change ...............................................................................22
Summary ....................................................................................................................22
Chapter Three: Theory and Model for Evidence-based Practice ..........................................23
Theory ........................................................................................................................23
Application to practice change.......................................................................24

Model for Evidence-Based Practice ..........................................................................24
Application to practice change.......................................................................25
Summary ....................................................................................................................25
Chapter Four: Pre-implementation Plan ...............................................................................26
Project Purpose ..........................................................................................................26
Project Management ..................................................................................................26
Organizational readiness for change ..............................................................26
Inter-professional collaboration .....................................................................27
Risk management assessment ........................................................................27
Organizational approval process ....................................................................28
Use of information technology ......................................................................28
Materials Needed for Project .....................................................................................29
Plans for Institutional Review Board Approval .........................................................29
Plan for Project Evaluation ........................................................................................29
Plan for demographic data collection ............................................................30
Plan for outcome data collection and measurement ......................................30
Plan for evaluation tool ........................................................................30
Plan for data analysis ...........................................................................31
Plan for data management ..............................................................................31
Summary ....................................................................................................................32
Chapter Five: Implementation Process .................................................................................33
Setting ........................................................................................................................33
Participants…………………………………………………………………………..33
Recruitment ................................................................................................................34
Implementation Process .............................................................................................34
Plan Variation ............................................................................................................35
Summary ....................................................................................................................35
Chapter Six: Evaluation and Outcomes of the Practice Change ...........................................37
Participant Demographics ..........................................................................................37
Figure 1 ..........................................................................................................38
Table 1 ...........................................................................................................39
Outcome Findings ......................................................................................................39
Outcome One .................................................................................................39
Table 2………………………………………………………………………40
Outcome Two.................................................................................................40
Table 3 ...........................................................................................................41
Summary ....................................................................................................................41
Chapter Seven: Discussion ...................................................................................................43
Recommendations for Site to Sustain Change .........................................................43
Plans for Dissemination of Project ..........................................................................44
Project Links to Health Promotion/Population Health ............................................44
Role of DNP-Prepared Nurse Leader in EBP ..........................................................45
Future Projects Related to Problem .........................................................................46
Implications for Policy and Advocacy at All Levels ...............................................46
Summary ..................................................................................................................47
Chapter Eight: Final Conclusion ...........................................................................................49

Clinical Problem ........................................................................................................49
Evidence Base ............................................................................................................50
Theory and Model for Evidence-based Practice ........................................................50
Project Management ..................................................................................................51
Project Implementation ..............................................................................................52
Outcome Findings ......................................................................................................52
Discussion Summary .................................................................................................53
Final Conclusions...................................................................................................................54
References ..............................................................................................................................55
Appendix A: Johns Hopkins Nursing Evidence Based Practice Model ..............................61
Appendix B: Knowledge of Trauma-Informed Care and Confidence in Implementation Test
................................................................................................................................................62
Chapter One: Overview of the Problem of Interest
Restraint and seclusion (RS) is a practice used to prevent patient harm to self and others
when alternative interventions have failed (Jovanovic & Johnsen, 2006). There is no evidence
that the practice has any treatment value (American Psychiatric Nurses Association [APNA],
2018, Carlson & Hall, 2014). Restraint and seclusion usage causes the risk of physical and
emotional harm to patients and staff, as well as financial burden to the health care institution
(Carlson & Hall, 2014). The usage of RS presents an ethical dilemma for nurses (American
Nurses Association [ANA], 2012). The usage of RS in psychiatric health care settings is a
serious clinical problem. This paper will introduce an evidence-based (EBP) change project
aimed at reducing RS usage.
Background Information
Violence is an international health care problem and is pervasive in mental health settings
(Carlson & Hall, 2014). It is “the portal to restraint and seclusion use, while, conversely restraint
and seclusion use contributes to workplace violence” (Carlson & Hall, 2014, p. 2). The
Substance Abuse and Mental Health Services Administration [SAMHSA] (2015) voiced
commitment to the eradication of RS in the treatment of people with mental health and substance
use disorders in the United States (US). The Department of Health and Human Services [DHHS]
(2006) endorsed all hospitalized patients’ right to freedom from unnecessary restraint. The
National Alliance on Mental Illness [NAMI], (n.d.), a consumer group, wrote that RS should be
used on a limited basis, only when there is strict justification.
National nursing organizations have recommended the reduction of RS usage in patient
care. The ANA (2012) advised that registered nurses (RNs) participate in RS reduction. The
APNA expressed commitment to the reduction, and eventual elimination, of restraint (2018).
The Emergency Nurses Association [ENA] (2013) identified the occurrence of violence and the
reduction of RS usage as essential practice issues. At the setting of the EBP change project, a
teaching hospital in a mid-Atlantic state, nurse leaders identified RS usage as a safety problem.
A behavioral emergency quality improvement initiative that included the goal of RS reduction
was under development. The nurse managers were recommending multi-disciplinary
collaboration in the effort (Nurse Manager, personal communication, December 14, 2016).
At the hospital, the occurrences of RS were summarized in a behavioral event report.
The report covered July 2015 through September 2016 and included the three psychiatric units.
In the crisis center, the monthly number of restraint episodes ranged from six to 37 and the
monthly number of seclusion usages ranged from zero to three. For one inpatient unit, the
restraint use ranged from zero to six monthly episodes and zero to seven for seclusion. For the
other inpatient unit, the range was from zero to two per month for both restraint and seclusion
usage. No trends were apparent in the behavioral health findings (Hospital X, 2016).
Significance of Clinical Problem
The usage of RS at the EBP change project setting was problematic for ethical, safety and
financial reasons. In its Reduction of Patient Restraint and Seclusion in Health Care Settings
position statement, the ANA (2012) noted that RS poses physical danger. The ANA (2012)
stated that restraints are “contrary to the fundamental goals and ethical traditions of the nursing
profession which upholds the autonomy and inherent dignity of patients” (para. 2). The practice
of RS is coercive (SAMHSA, 2015).
The usage of RS is physically and psychologically dangerous. In U.S. psychiatric care,
there were 142 known patient deaths associated with the use of RS between 1988 and 1998
(Jovanovic & Johnsen, 2006). The staff injury rates in psychiatric treatment settings that use RS
are greater than those of employees in other high-risk industries (SAMHSA, 2015). Restraint
and seclusion usage has the potential to be emotionally harmful to patients and staff (Carlson &
Hall, 2014; Jovanovic & Johnsen, 2006). The usage can “trigger a recapitulation of traumatic
experiences” (Jovanovic & Johnsen, 2006, p. 1) in patients. In nursing staff, RS usage can result
in anxiety, fear and guilt (Moran et al., 2009). The physical and psychological toll of violence
on the nursing staff was a concern at the setting (Nurse Manager, personal communication,
January 19, 2017).
Nationally, the usage of RS is expensive. An estimated $375 million dollars is spent
annually on the after-effects of conflict and containment in U.S. inpatient psychiatric settings
(Carlson & Hall, 2014). At the EBP change project setting, workers’ compensation costs related
to workplace violence were being analyzed. There were potential financial benefits to RS
reduction.
Question guiding inquiry (PICO). Evidence-based practice (EBP) “is key to
delivering the highest quality of healthcare and ensuring the best patient outcomes at the lowest
costs” (Melynk & Fineout-Overholt, 2015, p. 3). The components of EBP include external
evidence, clinical expertise, and patient preferences and values. A targeted search is essential to
the identification of evidence that thoroughly addresses a clinical question. The PICO format is
a vehicle for formulating a thorough question to direct this search. The PICO acronym refers to
population or disease, intervention or issue of interest, comparison intervention or issue, and
outcome (Melynk & Fineout-Overholt, 2015). The PICO question identified for this clinical
problem was: “Does education about trauma-informed care increase nursing staff’s knowledge
of the intervention and their confidence in implementing it on adult inpatient and crisis
psychiatric units?”
Variables of the PICO question. The population for this project was the nursing staff of
an acute psychiatric service in a mid-Atlantic urban teaching hospital. The intervention was
education about trauma-informed care (TIC). The comparison was the population’s knowledge
about TIC, and confidence in implementing it, before and after the intervention. The intended
outcomes were increased knowledge of TIC, and confidence in implementing it.
Summary
The usage of RS was identified as a serious clinical problem by federal agencies, national
nursing organizations, a national consumer group, and the setting of the EBP change project.
Patient and staff safety, nursing ethical standards, and organizations’ finances are being
threatened by RS usage in psychiatric health care. The project evaluated whether staff education
about TIC increased knowledge of TIC and confidence in implementation. The next chapter
will discuss a review of the literature that supported staff TIC education as an evidence-based
intervention for reducing RS in acute adult psychiatric settings.

Chapter Two: Review of the Literature
The use of restraint and seclusion (RS) in psychiatric clinical settings is a safety problem.
Restraint and seclusion is a practice that should be used as a last resort, to prevent patient harm
to self and others, when alternatives have failed (Jovanovic & Johnsen, 2006). The practice is
overused, violent, and preventable (National Association of State Mental Health Program
Directors [NASMHPD], 2016). Restraint and seclusion perpetuates further violence, causes the
risk of physical and emotional danger to patients and staff, and is financially burdensome to the
health care institution (Carlson & Hall, 2014). There is no evidence that RS has therapeutic
value (American Psychiatric Nurses Association [APNA], 2018; Carlson & Hall, 2014).
Approximately 90% of the people receiving public psychiatric services have histories of
psychological trauma. Based on the recognition of this high prevalence, trauma-informed care
(TIC) is aimed at preventing the re-infliction of trauma during the provision of services. In
addition to the awareness of the prevalence of trauma, sensitivity to the effects of trauma, and the
provision of physically and psychologically safe environments are fundamental to TIC
(NASMHPD, 2016). The TIC model acknowledges that health care personnel that have trauma
histories can be re-traumatized in the workplace, and that employers have a responsibility for
employee safety as well as patient safety (Isobel & Edwards, 2017). Trauma-informed care is a
framework for the agency-wide application of six core principles: safety, transparency, peer
support, collaboration and mutuality, empowerment, and acknowledgement of the unique effect
of cultural, historical, and gender issues on individuals (Substance Abuse and Mental Health
Services Administration [SAMHSA], 2015). The purpose of this chapter is to present the
findings of a literature review that was done to investigate TIC staff education as an evidence-
based intervention for reducing RS usage in acute adult psychiatric health care settings.
Methodology
A literature search was conducted to find evidence-based interventions to reduce RS
usage. The selected databases were: Cumulative Index of Nursing and Allied Health Literature
(CINAHL) with Full Text, Cochrane Central Register of Controlled Trials, Cochrane Database
of Systematic Reviews, Medline, and PsycINFO. Medline and CINAHL are comprehensive
scientific health care databases. The Cochrane Database of Systematic Reviews is an important
source for intervention-related information. The Cochrane sources include references from the
grey literature. PsycINFO is a database that addresses mental health and behavioral sciences
(Melnyk & Fineout- Overholt, 2015).
Sampling strategies. Key words for the search were: restraint, seclusion, prevention,
reduction, trauma-informed care, education, inpatient and crisis. The terms were related to
potential interventions for the evidenced-based practice (EBP) change project, which was aimed
at the clinical problem of restraint and seclusion in inpatient and crisis psychiatric settings. Peer-
reviewed current publications from January 2010 to March 2017 were sought.
Inclusion/Exclusion criteria. A seven-level hierarchy of evidence provided guidance
about the reliability of the evidence in answering the clinical question. The hierarchy was used
to evaluate the strength of the evidence, and relatedness to the problem, population, and setting.
In the hierarchy Level I had the strongest evidence. Level VII had the weakest evidence. The
levels and sources of evidence were as follows: Level I from systematic reviews or meta-
analyses of randomized controlled trials (RCTs), Level II from well-designed RCTs. Level III
from well-designed, non-randomized studies, Level IV from well-designed cohort and case-
controlled studies, Level V evidence from descriptive and qualitative study systematic reviews,
Level VI evidence from single descriptive or qualitative studies, and Level VII from authority
opinions and expert committees (Melnyk & Fineout-Overholt, 2015). There is a paucity of
higher-level evidence related to interventions for RS reduction (Bak, Brandt- Christensen,
Sestoff & Zoffmann, 2011; Borckardt, et al., 2011). Additionally, inpatient mental health TIC
information is minimal and much of the TIC material is in the grey literature (Muskett, 2014).
Because of these limitations, all levels of evidence were accepted. The next section is a
description of the articles that were chosen to support TIC staff education as an intervention for
the reduction of RS usage in the acute psychiatric health care setting.
Literature Review Findings
A comprehensive review of the literature indicated that a variety of interventions have
been identified to reduce RS in acute psychiatric settings. Empirical evidence about the
effectiveness of the interventions in comparison to one another is limited. Identified
interventions included: patient assessment protocols, de-escalation techniques, adjustments to the
physical environment, and medications. Combined strategies have also been identified. These
combined strategies include staff education, cultural changes to the treatment environment, and
patient empowerment (Bak et al., 2011). The involvement of administrators after RS
occurrences combined with routine patient assessment using the Broset Violence checklist, staff
TIC and crisis response training, and improvements to the physical environment have been
suggested as RS reduction strategies (Blair et al., 2017). Trauma-informed care was identified as
an intervention for RS reduction. In the United States (US) the inclusion of trauma-informed
staff education has been identified as a strategy for successful TIC implementation (Muskett,
2014). Staff education about trauma-informed care is the intervention that will be the focus of
this literature review.

Borckardt et al. (2011) conducted an RCT to examine the effect of a four-branched
engagement model on the rate of RS usage at an inpatient psychiatric hospital. The interventions
were TIC training, rule and language changes, environmental adjustments, and patient
involvement in treatment planning. A variant of the multiple-baseline design was used.
Randomized assignment was made to the order in which the four interventions were
implemented on each of five nursing units. The RS rate was reduced by 82.3%. The
environmental changes were the one intervention associated with the reduction in RS usage. The
changes included painting the walls in warm colors, the addition of throw rugs and plants, re-
arrangement of the furniture to encourage more patient-patient and patient-staff interaction, and
regular patient-staff meetings. One limitation of this study was the possible failure of full
implementation of the three other interventions. A second limitation was that the trial was
conducted in a single agency. The generalizability of the findings was not tested (Borckardt et
al., 2011). The study did provide evidence that TIC was positively associated with RS reduction.
A systematic review of publications related to mechanical restraint was done to identify
nursing interventions for reducing restraint usage, and the interventions’ effectiveness relative to
one another (Bak et al., 2011). The authors used over 50 key words in different combinations.
The search included papers published between 1998 and April 2009. Original peer-reviewed
papers in English, Danish, Swedish and Norwegian with English abstracts, and references to
physically restrained adult psychiatric inpatients were included. Among the 32 databases
reviewed were CINAHL and the Allied and Complementary Medicine (AMED)/EBSCO host.
The search yielded 2885 papers that were read for relevance and eligibility, leaving a sample of
268. The remaining papers were further appraised, resulting in a final sample of 59. In the final
sample, 48 studies were quantitative and 11 were qualitative. The findings were graded
according to the Danish Reference Programme Secretariat. Results indicated that among the 27
identified interventions, the three most likely to reduce the number of restraint occurrences in
clinical settings included trauma-informed components. Staff education was one of the elements
of the combined strategies in the second ranked intervention.
Muskett (2014) conducted a systematic review of literature about TIC practices in acute
mental health settings. The search was done through the Psychology and Behavioural Sciences
and Nursing and Allied Health Comprehensive and Biomedical Collections databases. Primary
search terms were trauma-informed and adult or youth inpatient mental health/psychiatric care.
The search was inclusive of January 2000 through June 2011 and was limited to peer-reviewed
journals and full-text English articles. The 116 identified articles were screened for those with
the following: qualitative or quantitative studies about treatment in adolescent or adult inpatient
and forensic mental health settings or related to trauma-informed patient care. Most articles
were ruled out due to their non-inpatient settings leaving 13 remaining articles, one of which was
an RCT. The other articles offered lower levels of evidence. Trauma informed care, in
particular the NASMHPD six core strategies for the reduction of RS, was positively correlated
with decreased RS (Ashcraft & Anthony, 2008; Azeem. Aujla, Rammerth, Binsfield & Jones,
2011; Barton, Johnson & Price, 2009; Borckardt, et al., 2010). The NASMHPD six core
strategies for reducing seclusion and restraint use are: active and direct senior leadership
involvement, data-informed practice, workforce development, RS prevention tools, formal
consumer roles within health care agencies, and debriefing post -RS event (Muskett, 2014;
NASMHPD, 2016).
In reviews of quality assurance data from January 2000 through October 2004, Ashcraft
and Anthony (2008) found that a zero monthly seclusion rate occurred in two psychiatric crisis
services after the implementation of an RS elimination initiative. The interventions were like
those in the NASMHPD’s curriculum for reducing violence and RS and included staff training in
TIC. Seclusion and restraint was eliminated. The smaller crisis unit reached the absence of RS
before the larger one did. The authors speculated that the comfortable and spacious physical
environment and the less pressured pace of the smaller unit allowed for faster development of an
improved healing environment than happened in the larger one. Weaknesses of the study were
that the duration of the RS elimination was not reported, and that chemical restraint utilization
was not specifically tracked (Ashcraft & Anthony, 2008). This study indicated a positive
correlation between TIC and RS elimination.
Azeem et al. (2011) conducted a study to investigate the effect of TIC -based strategies
on reducing RS usage in children and adolescents in psychiatric hospitals. The method was a
retrospective medical record review of 458 youth who had been admitted to a state psychiatric
hospital between July 2004 and March 2007. In March 2005, the senior leadership and clinical
staff were trained in the trauma-informed NASMHPD six core strategies for RS reduction.
During the first 6-month period for which the records were reviewed, there were 93 episodes of
RS. In the last 6-month interval, there were 31 episodes. A limitation of the study was a
simultaneous dialectical behavioral therapy initiative on one of the units, which could have
contributed to the reduction in RS. Another limitation was the limited period that the baseline
data covered (Azeem et al., 2011). This study showed a correlation between TIC and a
downward trend in the numbers of RS episodes.
A 26-bed psychiatric unit implemented a restraint elimination quality improvement
project based on the NASMHPD six core strategies for reducing RS, and the Mental Health
Recovery Model. The project’s two interventions were staff TIC training and the conversion of
the seclusion room to a comfort room. The seclusion room had never been used for seclusion.
The purpose of the comfort room was to provide a non-restrictive intervention for anxiety and
agitation. The room was painted in soft colors and offered soothing sensory stimulation. The
staff training addressed the prevalence of trauma, the neurobiological effects of trauma, and
person-centered relationships. The training was based on the NASMHPD principles.
Elimination of restraint usage was accomplished. During the 6-year period preceding the start of
the initiative, the number of restraint episodes had ranged from nine to 19 annually. The
elimination of restraint had been maintained for over a year at the time that the article was
written. A second outcome was that nurses and nursing assistants expressed confidence in TIC,
and commitment to continued zero restraint usage. A third outcome was a reduction in
psychotropic medication utilization. An additional finding was that statistical information about
the prevalence of trauma and responsiveness to participants’ emotional reactions were essential
components for the success of the training (Barton et al., 2009).
The Positive Alternatives to Restraint and Seclusion (PARS) project was a four-year
grant funded performance improvement initiative implemented in three facilities in New York.
The facilities were: a private psychiatric hospital for children and adolescents, a state-operated
children’s psychiatric center, and a psychiatric residential center for children. Each of the three
agencies had the discretion to develop its own program in keeping with the NASMHPD six core
RS reduction strategies. Consultation was provided by NASMHPD experts. Quantitative data
were collected by the state’s event reporting system. Linear regression was done to trend the RS
data against time. Qualitative data obtained from consultant observations, site communications
with the Office of Mental Health, and site reports were analyzed looking for themes. There were
significant decreases in restraint episodes per patient day in each of the three facilities. For
Facility 1 the reduction was 62% (R2 = .27, p = .019), for Facility 2 it was 86% (R2 = .50, p =
.001), and for Facility 3 it was 69% (R2 = .29, p = .007). A key finding was that sustained
commitment to understanding and operationalizing the core strategies was necessary from all
levels of staff for the interventions to be successfully implemented. One limitation of this project
was the inclusion of only voluntarily participating agencies. Another limitation was that the
population included youth only. The generalizability of the results is not known. Each
organization reported that NASMHPD strategies were essential to RS reduction and chose to
continue the effort when the grant ended (Wisdom, Wenger, Robertson, Van Bramer & Sederer,
2015).
The literature review identified support from the discipline of nursing. Of the seven
sources of evidence, six included nurse authors. Five of the sources of evidence were nursing
journals. The disciplines of psychiatry and public health were also represented in the selected
articles. The reference without nurse authors was from a psychiatry publication, written by two
non-psychiatrists with mental health expertise. Because TIC prescribes organization-wide
implementation ad a collaborative approach, multidisciplinary participation is indicated
(SAMHSA, n.d.). The selection of the study from outside of the discipline of nursing is
justified.
An advantage of the findings was that the trauma-informed NASMHPD core strategies
for RS reduction were utilized in four of the seven studies, all of which suggested a positive
correlation between TIC and restraint reduction. A fifth study noted the similarity of its RS
reduction strategies to the NASMHPD strategies. Another advantage was the finding that TIC is
a preventive approach against physical and emotional harm to patients and staff, as well as an
evidence-based intervention for the problem of RS (Muskett, 2014). A potential disadvantage of

the findings were the obstacles to thorough implementation of TIC training, which one article
alluded to without elaboration.
Discussion
Limitations of literature review. Limitations of the literature review included the small
amount of available higher-level evidence. One Level II source was found. The rest of the
evidence was obtained from two Level V and four Level VI sources. Another limitation was that
an article beyond the selected 7-year search period was included. The article had evidence that
supported TIC for RS reduction in crisis centers. Crisis center staff were part of the population
at the clinical setting where the EBP change project was implemented. A third limitation was the
inclusion of two studies of child and adolescent populations. These studies were included for
their evidence about TIC interventions, although the project setting had an adult population.
Conclusion of findings. The evidence from the literature review suggested that TIC is a
RS reduction strategy. Staff education about TIC was identified as an intervention in the studies.
The evidence supported the proposed intervention for the EBP change project. Additionally,
implementation of TIC and other psychosocial interventions to reduce RS were not believed to
cause harm, whereas RS was known to be dangerous (Bak et al., 2011). An advantage of the
findings was that the trauma-informed NASMHPD core strategies for RS reduction were utilized
in four of the seven studies, all of which suggested a positive correlation between TIC and
restraint reduction. A fifth study noted the similarity of its RS reduction strategies to the
NASMHPD ones. Another advantage is the finding that TIC is a preventive approach against
physical and emotional harm to patients and staff, as well as an evidence-based intervention for
the problem of RS (Muskett, 2014). A potential disadvantage of the findings is the possible
obstacles to thorough implementation of TIC training, which one article alluded to without
elaboration.
Potential project. Staff education about TIC was indicated for the problem of RS in
inpatient and crisis psychiatric settings. The findings supported the proposed intervention:
education about TIC for psychiatric inpatient and crisis staff. The NASMHPD core principles
for RS reduction were identified as a basis for the planning of the intervention.
Summary
An integrative literature review was conducted to explore evidence about staff TIC
education as an intervention to reduce RS usage in adult inpatient psychiatric settings. Multiple
databases were searched with keyword terms based on the clinical problem, setting, and
population. Identified articles were evaluated for the strength of the evidence and the relatedness
to the clinical problem. The studies chosen for further review indicated that TIC had a positive
correlation with the reduction of RS in the inpatient setting. Staff TIC training was an identified
strategy in the studies. Support from the discipline of nursing for TIC intervention was clearly
documented. There was evidence to support nursing staff education about TIC as an intervention
for this EBP change project, aimed at the reduction of RS usage in an acute psychiatric setting.
The next chapter will discuss the concept, nursing theory, and the EBP model that provided the
structure for the development and implementation of this EBP change project.
Chapter Three: Theory and Model for Evidence-based Practice
Concepts are experiential formulations that convey the abstract ideas within theories
(Chinn & Kramer, 2015). Theories provide discipline-specific frameworks for practice (Fawcett
& DeSanto-Madeya, 2013). Models guide the design and implementation of strategies for
evidence-based practice (EBP) changes within organizations (Melnyk & Fineout-Overholt,
2015). The purpose of this chapter is to describe the concepts, theory, and EBP model that were
guides for the development of this EBP change project.
Concepts
While the experts had not formulated a definition of trauma-informed care (TIC),
unifying themes were documented in the literature. These themes included physical and
emotional safety, collaboration with consumers and families, understanding the unique impact of
trauma on individuals, strengthening consumer and service provider resilience, and building
linkages across services (Wilson, Pence & Conradi, 2013). Chinn and Kramer wrote that in
nursing “knowledge refers to knowing in a way that can be shared or communicated with others”
(2015, p. 3). The concept of TIC knowledge is the communication of knowing of TIC.
Confidence is a subjective measure of belief in one’s own abilities, and is context dependent
(Perry, 2011). The concept of confidence in implementation of TIC is the self-measure of
confidence in implementing TIC.
Theory
Jean Watson’s Theory of Human Caring has an interpersonal focus (Fawcett & DeSanto-
Madeya, 2013). A foundational ethic of the theory is that human-centered and relationship-
centered care are essential to healing (Watson, 2006). The model’s 10 Clinical Caritas Processes
provide a structure for nursing processes that support healing for the patient and the nurse
(Fawcett & DeSanto-Madeya, 2013).
Application to practice change. The caritas processes offered translation of the TIC
concepts to practical interventions. One example was that trust and mutuality are core
components of TIC (Substance Abuse and Mental Health Services Administration [SAMHSA],
2015). The Watson model prescribes the development of trusting relationships (Cara, 2006). A
second example is that safety is a tenet of TIC (SAMHSA. 2015). The inclusion of safety in
nursing environments is a component of the caritas processes (Fawcett & DeSanto-Madeya,
2013). A third example is that TIC includes the awareness of the unique effects of culture,
history and gender on individuals (SAMHSA, 2015). The caritas processes include working
within others’ contexts (Cara, 2006). A fourth example is that mutuality and collaboration are
fundamental to TIC (SAMHSA, 2015). Co-participatory staff-patient relationships are included
in the Watson model (Cara, 2006).
The caritas processes include nurse involvement in teaching and learning. The processes
also address the importance of a communicable sense of confidence by nurses (Fawcett &
DeSanto-Madeya, 2013). Teaching, learning, and nurse confidence supported the EBP change
project’s staff education intervention.
Evidence-Based Practice Change Model
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model helps nurses at
the bedside translate evidence into clinical practice. The model is based on three phases: practice
question, evidence, and translation [PET] (see Appendix A). The PET process is iterative. The
aims of the model include nurse autonomy, leadership, and interdisciplinary engagement
(Melnyk & Fineout-Overholt, 2015).

Application to practice change. The JHNEBP Model was applicable to the project and
project setting. The participants included bedside nurses working on acute psychiatric units in an
American Nurses Credentialing Center (ANCC) Magnet® -recognized hospital. The translation
of evidence to practice and staff empowerment are Magnet® principles (Delaney & Lynch,
2008).
The PET phases provided a structure for the practice change process. A practice question
related to TIC as an intervention for the problem of restraint and seclusion (RS) was identified
and refined. Thorough a literature review, evidence was found, appraised, and summarized. A
recommendation for staff education about TIC was established. A translation plan for providing
staff TIC education through a method that was appropriate to the participants’ roles and the
settings’ resources was developed and implemented. The outcomes were evaluated, and a
dissemination plan was formulated.
Summary
The concepts of knowledge of TIC and confidence in implementation, and the Watson
Theory of Human Caring, provided a framework for the development of the EBP change project.
The theory was applicable to the TIC practice change because the caritas processes provided a
structure for the interpretation of core TIC principles. The JHNEBP model provided
organization for the application of the evidence to practice. The steps of this model informed the
design, implementation and evaluation. The next chapter will describe the pre-implementation
planning for this EBP change project.

Chapter Four: Pre-implementation Planning
Successful project planning includes the assessment of the setting and the coordination of
project actions (Harris, Roussel, Dearman, & Thomas, 2016). The purpose of this chapter is to
present the design of the evidence-based practice (EBP) change project. The intervention was
staff education about trauma-informed care (TIC) for the clinical problem of restraint and
seclusion (RS) in psychiatric settings.
Project Purpose
The purpose of this EBP change project was to evaluate a TIC educational intervention.
The intervention was evaluated to determine if it increased the nursing staff’s knowledge of TIC,
and their confidence in implementing it. The evidence supported staff education about TIC as an
intervention for RS reduction.
Project Management
The initial processes of project management include planning. Planning includes the
addressing of details so that a meaningful project is created. Environmental assessment and
strategy development are important components of planning (Harris, et al., 2016). The pre-
implementation planning of the EBP change project included: an assessment of the project
setting, obtaining approval from the organization and institutional review board (IRB),
determining the role of information technology (IT), creating a list of materials, and developing a
plan for data collection and evaluation.
Organizational readiness for change. The awareness of conditions, influences, and
trends can provide the project manager (PM) with insight into the setting’s readiness for change
(Harris et al., 2016). The setting of the EBP change project had a hospital-wide initiative to
increase safety related to patient behavioral events. Restraint and seclusion utilization had been
identified as one of the problem areas (Hospital X, 2016). The nursing department’s strategic
imperatives included building a culture of safety, strengthening the healing environment, and
improving the patient experience (Hospital X, March 2017). The psychiatric nurse manager was
committed to safety, relationship-based care, restraint and seclusion (RS) reduction, and staff
development (Nurse Manager, Personal Communication, April 4, 2017).
Inter-professional collaboration. Interdisciplinary teams provide knowledge and
expertise that is greater than that of any single discipline (Ogrinc, et al., 2012). For this EBP
change project, team membership included the nurse manager, the nurse educator, and the project
manager (PM). A website designer and a medical librarian provided consultation.
Risk management assessment. The anticipation and addressing of factors that can
support or hinder a planned change are important steps in project management. A strengths,
weaknesses, opportunities and threats (SWOT) analysis is a method to identify these factors.
Strengths and weaknesses are influences internal to the setting. Opportunities and threats are
external (Harris, et al., 2016).
Strengths at the setting included a hospital-wide RS reduction initiative, and American
Nurses Credentialing Center (ANCC) Magnet® recognition. Magnet® requirements support
EBP (Wilson et al., 2015). Another strength was stakeholder support. The nurse manager was
committed to RS reduction and staff development, and the nurse educator was supportive of TIC
and of the educational presentation. An additional strength was that the hospital had continuing
education provider status through the state nurses' association.
Among the weaknesses was the absence of financial resources for staff coverage for
training sessions. Participants had to complete the session during their usual work time or on
their personal time. The strategy to address this weakness was a web-based presentation of the
educational intervention that the participants accessed individually. A second weakness was that
the intervention took place during a period when the staff was responsible for completing
mandatory competencies. The project's educational session therefore competed for the
participant pool's availability. A strategy to encourage participation was the availability of
continuing education credit for the nurses.
There were opportunities and threats that were identified by the SWOT analysis. An
opportunity was that the parent company of a major regional third-party payer had a trauma-
informed philosophy. A potential threat was the regional reallocation of behavioral health
services, causing the potential for changes to the patient population and resource allocation at the
setting.
Organizational approval process. The organizational approval for the EBP change
project had two steps. The first step was nurse manager approval. This approval was obtained
through two meetings between the PM and nurse manager. The initial discussion included: the
PM’s interest in the RS clinical problem, the EBP practice change project requirements, the
nurse manager’s goals for the unit, and the organization’s nursing priorities. During the second
discussion, the plan for a TIC educational presentation was presented and supported, contingent
on an electronic format that allowed for independent individual participation. The second step in
the organizational approval process was for the PM to secure a letter of intent to participate prior
to implementation.
Use of information technology. Information technology (IT) is a significant enabler of
project success (Harris, et al., 2016). For the planning of the EBP practice change project, the
PM completed literature reviews with the use of IT. Electronic mail (e-mail) was used for
communication among team members and between team members and the participant pool.
Microsoft Office Word software was used for the documentation of the evidence, and creation of
the cover letter, test, and demographic survey. A content management system and web hosting
platform were used for the creation and delivery of the educational presentation. Video clips
from the Internet were embedded into the presentation. An online survey service was used for the
collection of pretest, posttest, and participant demographic data. The data were recorded and
analyzed using Microsoft Excel software.
Materials Needed for Project
Materials for the project were a password-protected computer, internet access, email, a
printer, paper, pens, black ink cartridge, web-based survey provider, a content management
system, and hosting platform. A Microsoft Office package with Excel and Word software were
used. A letter of intent to participate from the clinical setting, participant cover letter, participant
demographic form, TIC presentation, Trauma-Informed Care Knowledge and Confidence in
Implementation Test, and continuing education evaluation form were also needed. Telephone
access and a locked filing cabinet were used.
Plans for Institutional Review Board Approval
The IRB is a committee that reviews proposed research plans. The purpose of the review
is to ensure that the plans meet federal ethical requirements for the protection of human subjects
(Polit & Beck, 2012). The PM submitted a quality improvement determination form to the IRB
at the setting of the EBP change project. The IRB determined that the project was a quality
improvement/assessment initiative and that no IRB review was necessary.
Plan for Project Evaluation
Project evaluation is aimed at measuring the change that results from the impact of the
project (Harris et al., 2016). The expected outcomes of the project were increased knowledge of
TIC and increased confidence in implementing it in nursing staff. Benchmarks were set for both
outcomes.
Plan for demographic data collection. Demographic information was self-reported by
the project participants using an online survey. The information included: gender, age, ethnicity,
education level, number of years of health care employment, number of years in psychiatric
health care, and job category. Participants’ names were not collected. The data points were
analyzed for numbers and percentages using the survey service’s software. The information
about the participants’ ages was presented in a table. The information about the participants’
numbers of years of health care employment were presented in a bar graph.
Plan for outcome data collection and measurement. The analysis of outcomes is
critical to health care improvement (Ogrinc et al., 2012). The intended outcomes of the EBP
change project were an increase in nursing staff knowledge of TIC and confidence in
implementing TIC. Trauma-informed care knowledge and confidence in implementation were
measured before and after the TIC educational intervention. Knowledge of TIC was measured
by multiple choice questions. Confidence in providing TIC was measured with a five-point
Likert scale. The benchmark for knowledge of TIC was a minimum score of 80% in 75% of the
participants that completed the posttest. Eighty percent was the minimum passing score for staff
training at the setting where the EBP change project was implemented. The benchmark for
confidence in implementing TIC was a posttest score of four of higher in 80% of the participants.
The tool that was used to measure TIC knowledge and confidence in implementation were
developed by the PM.
Plan for evaluation tool. The knowledge of TIC evaluation tool was a self-developed
questionnaire based on the Substance Abuse and Mental Health Administration (SAMHSA)
Guiding Principles of Trauma-Informed Care. These principles had provided a framework for
the content of the educational TIC presentation. The content validity of the tool was determined
through review by a psychiatric mental health nurse practitioner with a trauma-informed
practice, and a doctoral prepared psychiatric mental health clinical nurse specialist. The tool was
comprised of 10 multiple choice questions and was scored by assigning one point for each
correct answer (See Appendix B). The possible range of scores was from 0 to 10.
The measurement of the confidence level in the TIC evaluation tool was a one-item
question that focused on measuring the participant’s confidence in providing trauma-informed
care in the clinical setting. The response was based on a five-point Likert scale with 1 – not at
all confident, 2 – not confident, 3 – neither confident or not confident, 4 – confident, and 5 –
very confident.
Plan for data analysis. The aggregate means of the pretest and posttest scores of
knowledge of TIC were calculated. A two-tailed t-test was done to determine whether the
difference between the aggregate means was statistically significant. The aggregate means of the
pretest and posttest scores of confidence in implementation of TIC were calculated. A two-tailed
t-test was completed to determine whether the difference between the aggregate means was
statistically significant. The mean and t-test calculations were completed using Microsoft Excel.
The results were displayed in tables.
Plan for data management. The pretest, posttest, and demographic survey were
created using a password protected account with a cloud-based survey service. Participants
accessed the surveys through links on a private website. The surveys were completed
anonymously. The data collected from the surveys were added to a Microsoft Excel
Spreadsheet. The spreadsheet was kept on a password-protected computer belonging to the PM.
The printed Excel copies were stored in a locked cabinet in the PM’s office. Data records will be
kept for five years after the completion of the project. The hard copy records will then be
shredded and disposed of confidentially. Electronic records will be deleted and cycled through
the trash bin.
Summary
The pre-implementation planning phase of the EBP change project was described in this
chapter. The purpose of the project was identified. Organizational approval was obtained, an
organizational risk management assessment was completed, and an IRB determination was
applied for and obtained. A complete list of materials was assembled. A plan for evaluating the
project was developed. The pre-implementation phase included inter-professional collaboration
and the use of IT. The next chapter will discuss the implementation process.
Chapter Five: Implementation Process
Restraint and seclusion (RS) usage in psychiatric health care settings is a serious problem
in the United States [US] (Carlson & Hall, 2014). The usage of RS was also identified as a
clinical problem at the hospital where the evidence-based practice (EBP) change project was
implemented (Hospital X, 2016). The evidence from a literature review supported trauma-
informed care (TIC) staff education as an intervention for the problem of RS in psychiatric
clinical settings (Ashcraft & Anthony, 2008; Azeem, Aujla, Rammerth, Binsfield & Jones, 2011;
Bak, Brandt- Christensen, Sestoft & Zoffmann, 2011; Barton, Johnson & Price, 2009; Borckardt
et al., 2011; Muskett, 2014; Wisdom, Wenger, Robertson, Van Bramer & Sederer, 2015). The
purpose of the EBP change project was to determine if an educational intervention about TIC
increased the nursing staff’s knowledge of trauma-informed care (TIC) and confidence in
implementing it. This chapter discusses the implementation process of the project.
Setting
The setting of the EBP change project was the psychiatric department of a 500-bed mid-
Atlantic urban hospital with an academic affiliation. The department included a crisis center and
two adult inpatient units. The hospital had American Nurses Credentialing Center (ANCC)
Magnet® recognition.
Participants
The participants were 20 nursing staff members that worked in the psychiatric division of
an acute care hospital. The potential pool had 101 people. The nursing staff included registered
nurses (RNs), direct care workers, and social service clinicians. The participants were all adults,
18 years and older, with no restriction on gender, race, or ethnicity. Both full-time and part-time
employees were invited to participate, regardless of their level of experience.

Recruitment
During the week before project implementation began, the nurse manager introduced the
project in staff meetings and encouraged participation. On June 1, 2018, the first day of
implementation, the nurse educator (NE) emailed the cover letter and a flyer to the nursing staff
with a message inviting participation. At the end of Weeks 1, 2, and 3 the NE sent email
reminders with further encouragement to participate. The messages were sent on Thursdays
since the units’ weekend workflow was anticipated to be more conducive to participation than
the weekday workflow. During Week 4, the NE again invited participation through an in-person
announcement at staff meetings. During Week 5, on July 3rd, the NE sent an email reminder to
support the participation of those working on the July 4th holiday. On July 9, 2018, the final day
of implementation, the NE sent an additional email invitation to participate. Because convenient
access to the website’s hyperlink was considered a facilitator to participation, it was included in
the cover letter, flyer, and emails. The closing date of the intervention was also included in the
communications. Continuing education (CE) credit was provided to registered nurse (RN)
participants after the submission of an evaluation form. The CE offer was noted in the
recruitment communications.
Implementation Process
Participation in the EBP change project included: the independent study of a TIC
educational presentation, the Knowledge of Trauma-Informed Care and Confidence in
Implementation pretest and posttest, and the demographic survey questions. The participants
independently accessed the educational material on a private website. The educational content
was delivered though text and video clips. Each of the three surveys was linked to the
website. Participants had the option to use work computers or their own electronic devices. The
estimated time for completing the presentation and the three surveys was 50
minutes. Participation in the demographic survey and tests provided implied
consent. Participation was anonymous. Registered nurses that were seeking CE credit submitted
a paper evaluation of the presentation to the NE. The project was implemented over a five-and-
a-half-week period. The project manager (PM) and NE communicated weekly about the
progress of the project. The PM was available to the participants and prospective participants by
telephone and email.
Plan Variation
A variation was made to the project plan. The variation involved the collection of the
participants’ posttests and demographic surveys. Of the 20 participants, 14 took the posttest.
Thirteen participants took the demographic survey. During the implementation phase of the EBP
change project two mandatory staff trainings were unexpectedly assigned to the nursing staff.
The two trainings were in addition to the completion of annual competencies that were also
required during the project’s implementation. To avoid increasing the time burden for the staff,
the PM did not pursue the collection of the remaining posttests and demographic surveys.
Summary
The usage of RS in psychiatric health care settings was a documented clinical problem in
the US and in the psychiatric division of a mid-Atlantic hospital that was the setting for the EBP
change project. Staff education about TIC was identified as an evidence-based intervention to
address the problem. An EBP change project was implemented at the hospital to determine if a
TIC educational intervention increased the nursing staff’s knowledge of TIC and confidence in
implementing it. The voluntary participation in the intervention was supported by the
departmental nursing leadership. The NE was the primary recruiter. The web-based intervention
was a single-session TIC educational presentation that the participants accessed independently.
The participants provided demographic information. The participants’ knowledge of TIC and
confidence in implementation were measured by a test before and after the presentation. The
tests and demographic survey were done online. There was a total of 20 participants. Twenty
participants took the pretest, 14 participants took the posttest, and 13 participants took the
demographic survey. Due to the addition of mandatory nursing staff trainings during the
implementation phase, the PM did not pursue the completion of the missing posttests and
demographic surveys. The next chapter will discuss the data analysis and results of this EBP
change project.
Chapter Six: Evaluation and Outcomes of the Practice Change
Data -driven evaluation of evidence-based practice (EBP) outcomes is essential to the
improvement of health care (Melnyk &Fineout-Overholt, 2015). In the acute psychiatric service
of a general hospital, restraint and seclusion (RS) usage had been recognized by the nursing
department as an area for improvement. Through a literature review by the project manager
(PM), staff education about trauma-informed care (TIC) was identified as an evidence-based
intervention for the problem of RS usage in acute psychiatric health care settings. The purpose
of this EBP change project was to evaluate whether a TIC educational intervention increased the
nursing staff’s knowledge of TIC and confidence in implementing it. This chapter describes the
analysis of the data, and the conclusions and outcomes of the project.
Participant Demographics
The participant demographic data points were: gender, age, ethnicity, education level,
number of years of health care employment, number of years in psychiatric health care
employment, and job category. The information was self-reported through an anonymous web-
based survey. The data were collected and analyzed by the project manager (PM) using the
survey service’s software. Thirteen of the 20 participants provided demographic data. Twenty-
nine percent (n=4) were male, 71% (n=9) were female, and none were gender diverse. Twenty-
nine percent (n=4) of the participants were African- American or Black and 64 % (n= 9) were
White. None of the participants were: Hispanic or Latino, Native American or American Indian,
or Asian or Pacific Islander. One participant (7%) reported being of an ethnicity other than those
listed. Sixty-four percent of the participants (n=8) had bachelor’s degrees as their highest level
of education. Thirty-six percent (n=5) had graduate degrees as their highest level of education.
The data about the participants’ numbers of years of health care employment were collected in
ranges and analyzed using numbers and percentages (see Figure 1). One of the respondents did
not answer this question.
Figure 1
Number of Years of Participant Health Care Employment
70.00%
n=7
60.00%
50.00%
40.00%
30.00% n=3 Responses
20.00%
n=1
n=1
10.00%
0.00% 0.00%
0.00%
0-1 year 2-5 years 6-10 11-15 16-10 21 years
years years years or more
Twenty-three percent (n=3) of the participants reported having been employed in
psychiatric health care for 6-10 years, 15 % (n=2) had been employed in psychiatric health care
for 11-15 years, 15 % (n=2) had been employed in psychiatric health care for 16-20 years, and
46 % (n=6) had been employed in psychiatric health care for 21 years or longer. Seventy-nine
percent (n=11) of the participants were registered nurses, 14% (n=2) were direct care workers,
and none of the participants were social service workers. Seven percent (n=1) reported being in
a job category other than the three that were listed. The data about participants’ ages were
collected by age group and analyzed using numbers and percentages (see Table 1).
Table 1
Age of participants
Age in Percent of Number of

years participants participants
20-30 7% 1
31-40 21% 3
41-50 7% 1
51-60 36% 4
61 or 29% 4
above
Outcome Findings
The intended outcomes of the evidence-based practice (EBP) change project were
increased nursing staff knowledge of TIC and increased confidence in implementing it. The
nursing staff’s knowledge of TIC and confidence in implementation were measured before and
after a web-based TIC educational intervention. The PM used Microsoft Excel software for data
collection and the descriptive and comparative statistical calculations.
Outcome one. The nursing staff’s knowledge of TIC was measured by the completion of
10 multiple choice questions. The benchmark for the nursing staff’s knowledge of TIC was a
score of 80% or higher on the posttest in 75% of the participants. Ninety-three percent of the
participants that took the posttest scored 80% or higher. The benchmark for knowledge of TIC
was exceeded.
The aggregate means of the pretest and posttest knowledge of TIC scores were
calculated. The aggregate mean of the posttest scores was greater than the aggregate mean of the
pretest scores. Twenty participants answered the knowledge of TIC questions on the pretest.
Fourteen participants answered the knowledge of TIC questions on the posttest. A p-value of ≤
0.05 was set as the threshold for statistical significance of the difference between the aggregate
means. This value is within the range that can be considered as a cutoff for statistical
significance (Salkind, 2017). A two-tailed t-test was conducted on the pretest and posttest
aggregate means. The test determined that the difference between the aggregate means of the
knowledge of TIC pretest and posttest scores was statistically significant (see Table 2).
Table 2
Knowledge of TIC Scores
Pretest Posttest Two-tailed

aggregate mean aggregate mean significance
Knowledge 63% 81% .009
Outcome 2. The nursing staff’s confidence in TIC implementation was measured by
one question using a five-point Likert scale. The benchmark was a minimum score of four on
the posttest confidence measure in 80% of the participants. One hundred percent of the
participants that took the posttest scored four or higher. The benchmark was exceeded.
The aggregate means of the pretest and posttest confidence in TIC implementation scores
were calculated. The aggregate mean of the posttest scores was greater than the aggregate mean
of the pretest scores. Twenty participants completed the confidence scale on the pretest.
Fourteen participants completed the confidence scale on the posttest. A p-value of ≤ 0.05 was
set as the threshold for statistical significance of the difference between the aggregate means. A
two-tailed t-test was conducted on the pretest and posttest aggregate means. The test determined
that the difference between the aggregate means of the confidence in TIC implementation pretest
and posttest scores was statistically significant (see Table 3).

Table 3
Confidence in Implementation of TIC
Pretest Posttest Two-tailed

aggregate mean aggregate mean significance
Confidence 3.9 4.4 .047
Summary
The EBP change project for the clinical problem of RS usage was implemented in the
acute psychiatry department of a general hospital. The intervention was focused on staff
education about TIC. The intended outcomes were increased nursing staff knowledge of TIC
and increased confidence in implementing it. The participants’ knowledge of TIC pretest and
posttest scores were collected and analyzed. Ninety-three percent of the participants that took
the posttest scored 80% or higher. The benchmark of a score of 80% or higher in 75% of the
participants was exceeded. The aggregate mean of the posttest scores was greater than the
aggregate mean of the pretest scores. The two-tailed significance of the difference was .009,
indicating statistical significance. The intended outcome of increased knowledge of TIC in the
nursing staff was met. The participants’ confidence in implementation of TIC pretest and
posttest scores were collected and analyzed. One hundred percent of the participants that took
the posttest scored four or higher. The benchmark of a minimum score of four in 80% of the
participants was exceeded. The aggregate mean of the confidence in implementation of TIC
posttest scores was greater than the aggregate mean of the pretest scores. The two-tailed
significance of the difference was .047, indicating statistical significance. The intended outcome
of increased confidence in implementation of TIC in the nursing staff was met. Based on the
analysis of the knowledge of TIC and confidence in implementation scores, the project
intervention was determined to have been effective. The next chapter will discuss:
recommendations for sustaining the EBP practice change, the dissemination plans, the links of
the project to health promotion and population health, the role of the Doctor of Nursing Practice
graduate in EBP, ideas for future projects related to the clinical problem of RS, and policy
implications.
Chapter Seven: Discussion
The creation of cultures that sustain EBP and the dissemination of new evidence are
essential to the improvement of patient outcomes (Melnyk & Fineout-Overholt, 2015). The
Doctor of Nursing Practice (DNP) prepared nurse is responsible for advancing EBP, health
promotion, and population health. All advanced practice nurses (APNs) should be policy
advocates (Chism, 2016). The EBP change project addressed the clinical problem of restraint
and seclusion (RS) usage in an adult psychiatric setting. The intervention was focused on staff
education about trauma-informed care (TIC). This chapter will discuss: the recommendations
for sustaining the EBP change, the plan for the dissemination of the project results, the project
linkages to health promotion, population health, and policy, and the APN and DNP roles in the
EBP change.
Recommendations for Site to Sustain Change
The translation stage of the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP)
Model addresses the importance of a plan that includes the attainable implementation of
recommendations based on new evidence (Melnyk & Fineout-Overholt, 2015). One
recommendation for the project setting was that it continue the inclusion of TIC in the
orientation aggression management class and the annual updates. The classes were established
events on the training calendar. A second recommendation was for the hospital to provide
continuing education (CE) credit to registered nurses (RNs) for participation in additional TIC
educational programs. The hospital had CE provider status through the state nurses’ association
(SNA). The application to the SNA for CE credit would not incur additional cost. A third
recommendation was that the hospital track the amount of RS usage in relation to the
implementation of TIC interventions. The potential benefits of RS reduction include fewer staff
and patient injuries as well as cost savings (Flood, Bower, & Parkin, 2008).
Plans for Dissemination of Project
The communication of new evidence is necessary to maximize its impact on health care
quality (Melnyk & Fineout-Overholt, 2015). Plans for dissemination of the project results at the
organizational, local, and national levels were developed. A summary of the EBP change project
including the purpose, results, conclusions, and recommendations was provided to the nurse
educator (NE) at the practice site. The project manager (PM) contacted other local hospitals
through a national nursing organization to offer TIC training sessions to clinical nurses after the
project ended. The nurse manager, NE, and PM planned to present a poster with the project
results at the annual conference of a national nursing organization.
Project Links to Health Promotion/Population Health
Clinical prevention includes health promotion as well as risk and illness prevention for
individuals and families. Population health includes: community, environment, culture, and
socioeconomics. Nurses are qualified to intervene in clinical prevention and population health
(Chism, 2016).
The EBP change project had links to health promotion and the reduction of risk and
illness. Restraint and seclusion usage is associated with the risk of physical and emotional harm
to patients and psychiatric staff members (Carlson & Hall, 2014). A reduction in RS usage had
the potential to reduce danger to the patients and staff. In addition, TIC supports patient
adherence to treatment plans (Machtinger, Cuca, Khanna, Rose, & Kimberg, 2015). The
intervention thus had the potential to support illness prevention.

The EBP change project had links to population health. Moral distress, which can cause
burnout and job dissatisfaction, is pervasive in nurses. Moral resilience provides resistance to
moral distress. Ethical practice environments support moral resilience (Hylton Rushton,
Schoonover-Shoffner, & Kennedy, 2017). The usage of RS presents an ethical dilemma to
nurses (American Nurses Association [ANA], 2012). A reduction in RS usage had the potential
to support moral resilience by reducing ethical conflict in the practice environment.
Collaborative organizational cultures also support moral resilience (Hylton Rushton et al., 2017)
Collaborative relationships are a foundation of TIC (Substance Abuse and Mental Health
Services Administration [SAMHSA], 2015). Safety supports moral resilience (Hylton Rushton
et al., 2017). The TIC model recognizes that organizations are responsible for employees’ safety
(Isobel & Edwards, 2017). The implementation of TIC and a reduction in RS usage had the
potential to support moral resilience in the nursing community at the setting of the EBP change
project.
Role of DNP-Prepared Nurse Leader in EBP
The American Association of Colleges of Nursing (AACN) Essentials of Doctoral
Education for Advanced Practice Nursing include clinical scholarship and analytical methods for
EBP. Graduates of Doctor of Nursing Practice (DNP) programs should have expertise in
evaluating, translating, integrating, and applying EBP (Chism, 2016). Through participation in
the EBP change project the PM practiced these four skills. During the pre-implementation stage,
the literature was evaluated for applicability to the evidence base of the intervention. The
identified evidence was integrated into the project plan. The evidence-based intervention was
translated into practice, incorporating the preferences and requirements of the setting. The
results of the project were evaluated.

Graduates of DNP programs are responsible for promoting efficient health care (Chism,
2016). The EBP change project had implications for cost containment. Nurse retention could
have been positively affected through the prevention of moral distress and job dissatisfaction.
Improved nurse retention contributes to cost savings for health care organizations. Nationally
the cost of replacing a staff nurse is estimated at $22,000 to $64,000 (Robert Wood Johnson
Foundation, 2018). A second possible financial benefit was related to the costs of physical
patient containment methods, including RS. These methods are expensive to organizations
(Carlson & Hall, 2014). Staff injuries and special patient observations contribute to the expenses
(Bowers et al., 2008). A reduction in RS usage had the capacity to decrease the costs associated
with staff injuries and the staffing for special observation levels.
Future Projects Related to Problem
A possible future project that was related to the problem of RS usage was the
development of additional TIC educational interventions at the project setting. Affiliating
students were a potential resource for this work. Multidisciplinary collaboration is a component
of TIC (SAMHSA, 2018). The student groups included the disciplines of Nursing, Medicine,
Social Service, and Pastoral Care. Students in a DNP program were part of the available pool.
A second possibility for a future project was to expand TIC education to the nursing staff in the
clinical areas beyond the psychiatric department. The existing cloud-based training system and
the hospital’s CE credit provider status were potential resources for this effort. The projected
benefits of these two future projects included: the meeting of the Magnet® EBP requirement,
illness prevention, risk reduction, and intervention for RS reduction.
Implications for Policy and Advocacy at All Levels

Though policy influences daily practice and has the potential to improve health care,
many practitioners take a passive approach. Advanced practice nurses (APNs) have the
responsibility to be health policy leaders. Current health policy development is focused on
health promotion and illness prevention (Goudreau & Smolenski, 2018).
The EBP change project had policy implications for the setting. The RS policy and
procedure could have included TIC as an alternative to physical containment. The Centers for
Medicare and Medicaid (CMS) Conditions of Participation state that RS should be used with
patients only to prevent physical harm to a person when less restrictive alternatives have failed
(Missouri Hospital Association, 2014). The setting was a Medicare participating provider.
Federal policy makers recognized the importance of trauma-informed services. The
volume of proposed legislation related to trauma-informed services had increased since 2010. In
the years 2010 through 2012, no trauma-informed bills were proposed. In 2015, 28 bills with
trauma-informed implications were proposed (Purtle & Lewis, 2017). Senate Bill 774 and the
identical House Bill 1757, entitled the Trauma-Informed Care for Children and Families Act of
2017, had provisions for Department of Health and Human Services (DHHS) involvement and
multigenerational interventions in health care, education, and social services. The bills were
introduced, and further congressional action was pending (Library of Congress, n.d.).
Summary
For the improvement of patient outcomes, evidence dissemination and cultures that
support EBP are necessary (Melnyk & Fineout-Overholt, 2015). The PM identified actions to
support the continuation of the EBP change at the project setting. The recommendations were
congruent with the translation phase of the JHNEBP model. Potential future projects related to
the problem of RS using existing resources were identified. The PM identified linkages of TIC
and RS reduction with health promotion, illness prevention, and population health. These links
had possible benefits for individuals and the nursing community. The role of the DNP-prepared
nurse in EBP was demonstrated through clinical scholarship, analytic methods, and the provision
of effective health care. The policy implications included clinical procedure at the project setting
and national legislation. The implications for nursing advocacy included the targeted
dissemination of the project results at the organizational, local, and national levels. The next
chapter will discuss the final conclusions about this EBP change project.
Chapter Eight: Final Conclusions
Evidence-based practice (EBP) improves patient outcomes (Melnyk & Fineout-Overholt,
2016). The EBP change project for the clinical problem of restraint and seclusion (RS) was
implemented at a mid-Atlantic adult acute psychiatric setting. The intervention was nursing staff
education about trauma-informed care (TIC). Staff TIC education is an evidence-based
intervention for RS reduction (Wisdom, Wenger, Robertson, Van Bramer & Sederer, 2015). The
purpose of the EBP change project was to determine whether the intervention increased the
nursing staff’s knowledge of TIC and confidence in implementing it. This chapter will
summarize: the clinical problem, the evidence base for the intervention, the concept, theory and
EBP model used in project development, the project management and implementation, and the
outcome findings.
Clinical Problem
Restraint and seclusion (RS) usage in psychiatric clinical settings is a serious health care
problem for safety, ethical, and financial reasons. Restraint and seclusion usage is preventable
and overused (National Association of State Mental Health Program Directors [NAMSMHPD],
2016). Restraint and seclusion promotes further violence, is physically and emotionally
dangerous to the patients and staff, and financially burdensome to health care organizations
(Carlson & Hall, 2014). Patient deaths have resulted from RS usage (Jovanovic & Johnsen,
2006). The use of RS violates nursing ethical standards (American Nurses Association [ANA],
2012). There is no evidence that RS has any treatment value (American Psychiatric Nurses
Association [APNA], 2018). The nursing department at the setting of the EBP change project
identified the reduction of RS as a safety and quality improvement goal (Nurse Manager,
personal communication, January 19, 2017).

Evidence Base
A literature search was conducted to find evidence-based interventions to reduce the
usage of RS in acute adult psychiatric clinical settings. The databases used included the
Cumulative Index of Nursing and Allied Health Literature (CINAHL) with Full Text, Cochrane
Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline, and
PsycINFO. The key words utilized for the search included restraint, seclusion, prevention,
reduction, trauma-informed care, education, inpatient and crisis. Peer-reviewed current
publications from January 2010 to March 2017 were sought. All levels from a seven-level
hierarchy of evidence for intervention-related questions were accepted.
The literature review indicated that TIC had a positive correlation with the reduction of
RS in acute psychiatric clinical settings. In the studies, staff TIC training was an identified
component of the intervention (Ashcraft & Anthony, 2008; Azeem, Aujla, Rammerth, Binsfield
& Jones, 2011; Bak, Brandt- Christensen, Sestoft & Zoffmann, 2011; Barton, Johnson & Price,
2009; Borckardt, 2011; Muskett, 2014; Wisdom et al., 2015). The evidence supported TIC staff
education as an intervention for an EBP change project for the clinical problem of RS usage.
Theory and Model for Evidence-Based Practice
The EBP change project was developed within a framework provided by the concepts of
knowledge of TIC and confidence in the implementation of TIC, and the Watson Theory of
Human Caring. The theory was applicable to the practice change because the caritas processes
provided a structure for the application of the TIC guiding principles. The Johns Hopkins
Nursing Evidence Based Practice (JHNEBP) model outlined an organized process for the
application of the evidence to practice. There are three phases in this model: practice question,
evidence, and translation (Melnyk & Fineout- Overholt, 2015). The phases informed the design,
implementation, and evaluation of the project.
Project Management
Project management includes assessment (Harris, Roussel, Dearman, & Thomas, 2016).
During the pre-implementation stage of the EBP change project, the project manager (PM)
assessed the readiness of the organization for the change. This organizational readiness was
supported by the identification of RS usage as a problem by the nursing department at the project
setting. The pre-implementation assessment included a risk management assessment to identify
factors that could support or impede the change process. This organizational assessment looked
at strengths, weaknesses, opportunities, and threats (SWOT). The identified strengths and
weaknesses were used in the planning of the project. Strengths included: the RS reduction
initiative at the setting, the Magnet® EBP requirement, support from the nurse manager and
nurse educator, and the hospital's continuing education (CE) provider status through the state
nurses’ association. The identified weaknesses were the absence of financial support for staff
coverage for the educational session and the coincident timing of the intervention with the
renewal of annual mandatory staff competencies. Strategies to address the weaknesses were the
web-based delivery of the intervention and CE credit for RN participants.
Planning is an important process in project management (Harris et al., 2016). The pre-
implementation planning of the EBP change project included several steps. Organizational
approval for the project was obtained. The nurse manager gave approval for the project after the
implementation plan was agreed to, and provided a letter stating the organization's intent to
participate. The role of information technology (IT) was reviewed, and included literature
searches, team communications, word processing, development and delivery of the intervention,
and data collection and analysis. A list of project materials was created. A quality improvement
determination form was submitted to the project setting's institutional board (IRB). The IRB
determined that the project was a quality assessment/quality improvement effort and that no
review was necessary. A plan for the evaluation of the project was created. The plan included:
demographic data collection, outcome data collection and measurement, data analysis, and data
management. A team with representatives from the disciplines of Nursing, IT, and Library
Sciences collaborated on the planning of the project and development of the intervention.
Project Implementation
The intervention was a single session web-based presentation. The nurse manager
supported participant recruitment by announcing the project at staff meetings and encouraging
participation during the week prior to the start of implementation. On the first day of
implementation the nurse educator (NE) circulated the PM's cover letter and a flyer inviting
participation to the nursing staff. Throughout the implementation phase, the NE encouraged
participation through emailed messages to the staff, and personally at the staff meeting that
occurred during implementation. The 20 participants accessed the presentation independently
through a private website on the work computers or their personal electronic devices.
Participation was anonymous and included a pretest, posttest, and demographic survey as well as
the presentation. The presentation included text and video clips. The registered nurse (RN)
participants had the option of receiving continuing education credit after completing an
evaluation of the presentation. The PM was available by telephone and email for participants'
questions.
Outcome Findings
The intended outcomes of the EBP change project were increased nursing staff
knowledge of TIC and increased confidence in implementing it. Twenty participants took the
pretest and 14 participants took the posttest. Microsoft Excel software was used for the data
analysis. Ninety-three percent of the participants scored 80% or higher on the knowledge of TIC
posttest. The benchmark of a score of 80% or higher in 75% of the participants was met and
exceeded. The aggregate mean of the knowledge of TIC pretest scores was 63%. The aggregate
mean of the knowledge of TIC posttest scores was 81%. The significance of the difference
between the pretest and posttest aggregate means was .009. The difference was statistically
significant. One hundred percent of the participants that took the confidence in implementation
of TIC posttest scored four or higher. The benchmark of a score of four or higher in 80% of the
participants was met and exceeded. The aggregate mean of the confidence in TIC
implementation pretest scores was 3.9. The aggregate mean of the confidence in TIC
implementation posttest scores was 4.4. The significance of the difference between the
confidence in TIC implementation pretest and posttest aggregate mean scores was .047. The
difference was statistically significant. The data analysis showed that the project intervention
was effective.
Discussion Summary
Evidence-based practice is essential to the improvement of health care outcomes (Melnyk
& Fineout-Overholt, 2015). The usage of RS is a threat to the quality of psychiatric care. The
physical and psychological safety of the patients and nursing staff is in jeopardy when RS is used
(Carlson & Hall, 2014). Restraint and seclusion usage presents an ethical dilemma for nurses
(ANA, 2012). Staff education about TIC is an evidence-based intervention for the reduction of
RS (Muskett, 2014). An EBP change project to address the problem of RS usage was
implemented in the psychiatric department of a general hospital. The hospital had identified the
reduction of RS as a quality improvement goal. The concepts of knowledge of TIC and
confidence in the implementation of TIC and the Watson Theory of Human Caring provided a
framework for the development of the project. The JHNEBP model supplied an organized
process for the application of the evidence to practice. The pre-implementation phase of project
management included: organizational assessment and approval, an IRB determination, inter-
professional collaboration, planning for IT use, and creating a list of needed materials. During
the implementation phase, the participants studied the web-based TIC presentation
independently, and took the demographic survey, pretest, and posttest. The NE actively
supported participant recruitment throughout the phase by email and personal contact with the
nursing staff. Continuing education credit was offered to RN participants. When the
implementation phase ended, the PM analyzed the data. The results indicated that the
intervention was effective in increasing the nursing staff's knowledge of TIC and confidence in
implementing it.
Final Conclusions
The usage of RS in psychiatric clinical settings is a critical and preventable clinical
problem. Staff education about TIC is an evidence-based intervention for the reduction of RS
usage in psychiatric clinical settings. An EBP change project was implemented for the problem
of RS usage in the acute psychiatric department of an urban general hospital. The intervention
was a web-based educational session about TIC for the nursing staff. The purpose of the project
was to determine if the intervention increased the nursing staff’s knowledge of TIC and
confidence in implementing it. The intended outcomes of increased nursing staff knowledge of
TIC and confidence in implementation were met.

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Appendix A
The Johns Hopkins Nursing Evidence-Based Practice Model
Practice
Evidence Translation
Question
©The Johns Hopkins Hospital/The Johns Hopkins University. Implied consent for use was
granted upon registration to receive the material.

Appendix B
Knowledge of Trauma-Informed Care and Confidence in Implementation Test
and Posttest Knowledge of Trauma-Informed Care and Confidence in Implementation
Knowledge of Trauma-Informed Care and Confidence in Implementation Test
Knowledge
1. According to the Adverse Childhood Experiences (ACE) study, what percentage of adults
reported at least one Adverse Childhood Experience?
A. 67%
B. 89%
C. 43%
D. 16%
2. The risk of which health problem(s) increases with the number of Adverse Childhood
Experiences (ACEs) that a person has experienced?
A. Depression only
B. Heart disease only
C. Suicidality only
D. A and C only
E. A, B, and C
3. The effects of persistent childhood trauma include all EXCEPT

A. Changes to the hippocampus that affect memory
B. Strengthened immunity from adaptation to stress
C. Automatic reactions based on past experiences
D. Extreme behaviors for self-protection
4. Cortisol, triggered by the fight or flight, response
A. Interferes with learning only
B. Increases cholesterol levels
C. Interferes with memory only
D. A and C
E. A, B, and C
5. Which is true about secondary trauma?
A. Secondary trauma results from exposure to another person’s trauma experience
B. Secondary trauma results from direct trauma that occurs repeatedly
C. Secondary trauma is not relevant to the provision of trauma-informed care
D. None of the above
6. Which action is trauma informed?
A. Applying Universal Trauma Precautions only
B. Staff participation in policy development only
C. A and B
D. Neither A or B
7. Which of the following illustrates a trauma-informed care guiding principle?
A. Collaboration among health care professionals and consumers
B. Minimizing power differentials throughout the organization
C. A compliance focused treatment setting that values hierarchy
D. A & B
E. All of the above
8. Trauma-informed care includes
A. Recognition of symptoms as survival mechanisms from the past
B. Awareness that recovery from trauma happens quickly with treatment
C. Deficit-focused patient assessments
D. None of the above.
9. Which verbalization to a trauma survivor best reflects trauma-informed theory?
A. “Time heals all wounds”
B. “Don’t talk about it or you’ll get upset.”
C. “What happened to you?”
D. “What’s wrong with you?”
10. According to the trauma-informed care model, the primary reason that staff self-care is
important is
A. Staff satisfaction
B. Safety
C. Role modeling
D. B and C
Confidence
I am confident in my ability to implement trauma-informed care in my practice
1. Strongly disagree
2. Somewhat disagree
3. Neither agree or disagree
4. Somewhat agree
5. Strongly agree

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TRAUMA-INFORMED CARE 1

STAFF EDUCATION ABOUT TRAUMA-INFORMED CARE TO REDUCE RESTRAINT

Capstone Paper submitted in partial fulfillment of the

Doctor of Nursing Practice

August 23, 2018

Signature Faculty Reader Date

Signature Program Director Date

Doas, Dr. Melissa Popovich, and Dr. Kathleen Spadaro.

health care, and the people they serve.

(TIC) is an evidence-based intervention for the reduction of RS usage. An evidence-based

Key words: Restraint and seclusion, trauma-informed care

Chapter One: Overview of the Problem of Interest ..............................................................9

Background Information ............................................................................................9

Significance of the Problem .......................................................................................10

Question Guiding Inquiry (PICO) .............................................................................11

Variables of the PICO question .....................................................................12

Chapter Two: Review of the Literature/Evidence ................................................................13

Sampling strategies ........................................................................................14

Inclusion/Exclusion criteria ...........................................................................14

Literature Review Findings........................................................................................15

Limitation of literature review. ......................................................................21

Conclusions of findings .................................................................................21

Potential practice change ...............................................................................22

Chapter Three: Theory and Model for Evidence-based Practice ..........................................23

Application to practice change.......................................................................24

Model for Evidence-Based Practice ..........................................................................24

Application to practice change.......................................................................25

Chapter Four: Pre-implementation Plan ...............................................................................26

Project Purpose ..........................................................................................................26

Project Management ..................................................................................................26

Organizational readiness for change ..............................................................26

Inter-professional collaboration .....................................................................27

Risk management assessment ........................................................................27

Organizational approval process ....................................................................28

Use of information technology ......................................................................28

Materials Needed for Project .....................................................................................29

Plans for Institutional Review Board Approval .........................................................29

Plan for Project Evaluation ........................................................................................29

Plan for demographic data collection ............................................................30

Plan for outcome data collection and measurement ......................................30

Plan for evaluation tool ........................................................................30

Plan for data analysis ...........................................................................31

Plan for data management ..............................................................................31

Chapter Five: Implementation Process .................................................................................33

Implementation Process .............................................................................................34

Plan Variation ............................................................................................................35

Chapter Six: Evaluation and Outcomes of the Practice Change ...........................................37

Participant Demographics ..........................................................................................37

Outcome Findings ......................................................................................................39

Outcome One .................................................................................................39

Chapter Seven: Discussion ...................................................................................................43

Recommendations for Site to Sustain Change .........................................................43

Plans for Dissemination of Project ..........................................................................44

Project Links to Health Promotion/Population Health ............................................44

Role of DNP-Prepared Nurse Leader in EBP ..........................................................45

Future Projects Related to Problem .........................................................................46

Implications for Policy and Advocacy at All Levels ...............................................46

Chapter Eight: Final Conclusion ...........................................................................................49