Date of Doctor of Nursing Practice Project Completion

Spring 5-5-2026

Faculty Advisor

Dr. Roussel, Linda

Abstract

Purpose: This quality improvement project aimed to improve nursing compliance with restraint care plan documentation standards using bundled interventions, including targeted education, electronic health record (EHR) prompts, and unit-based audit and feedback processes. The goal was to achieve at least a 70% improvement in documentation compliance within 12 weeks.

Background: Accurate restraint documentation is essential for patient safety, ethical practice, interdisciplinary communication, and regulatory compliance. Despite existing policies and education, institutional audits revealed compliance rates of 50% or less, demonstrating a persistent gap in practice and the need for structured interventions.

Methodology: The project used the Plan-Do-Study-Act (PDSA) framework across three implementation phases. A retrospective chart review of 55 restraint-order charts from March 2023 to January 2025 was completed. Pre- and post-intervention audits measured compliance using a customized data collection tool. Interventions included nursing education sessions, integration of a standardized restraint care plan template into the EHR, and real-time audit and feedback conducted by charge nurses. Compliance trends were analyzed using descriptive statistics and process charting.

Results: Compliance rates fluctuated throughout the study period, with the lowest scores observed between February and April, and improved performance noted in January 2025. Survey findings identified key barriers to documentation, including low restraint incidence (23.2%), heavy workload (19.0%), insufficient staffing (16.7%), lack of knowledge and forgetfulness (13.1% each), and short restraint duration (10.6%).

Conclusion: Streamlined, user-friendly documentation processes and leadership support are essential to sustaining compliance, improving patient safety, and strengthening regulatory readiness.

Keywords

Restraint documentation, Restraint use care plan compliance, quality improvement, patient safety, nursing practice, electronic health record.

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