Thursday April 27th 2017

Beyond folding washcloths: An innovation for diversional activity

20161122_092429Finding ways to keep patients safe in today’s complex hospital settings is an ongoing challenge. RNs experience a multitude of daily pressures arising from regulations, standards and hospital initiatives. It is particularly challenging when nurses are faced with balancing the care of complex and often critically ill patients against meeting the needs of patients displaying cognitive changes who are at risk for injury.

Repetitive tasks like folding washcloths or towels or numbering papers are often a fallback for nurses struggling to find diversional activities for patients. A review of literature failed to define the most effective and creative type of diversional devices available. Finding essential diversional interventions for this population led us to re-examine items kept in our unit-based activity boxes. By thinking “out of that box,” we identified a low-cost tool that went beyond common diversional activities (e.g., puzzles, coloring items, stuffed animals, whistles, small purses with combs, mirrors and fingernail files).

This story describes the development by an interprofessional team of an effective, inexpensive, safe and suitable tool called an activity pillowcase to help patients who exhibit challenging behaviors. In a unique take on commercial pillowcases and/or activity aprons, we engaged volunteer services to modify pillowcases that fit our standard hospital pillows. Volunteers stitched on various tactile and visual objects, e.g., zippers, buttons, sensory patches with varied textures, shoelaces, ribbons and large beads. Special attention was given to the objects attached to the pillowcase, so items are easily manipulated but not easily removed since safety is paramount. Since the case fits over a standard pillow, the activities can be literally kept at patients’ fingertips whether they are in a bed or a chair.

The pillowcases were first piloted and evaluated on the oncology and palliative care unit after the same unit trialed commercially available sensory pillows. The trial results indicated that staff was concerned about small beads being removed by the patients and the need for dry cleaning after each use. A physical therapist with seamstress skills volunteered to produce a new activity pillowcase that has soft fabric pieces, a plastic zipper and a pouch to hold a picture. These specially created pillowcases received high satisfaction ratings from staff, patients and families and were implemented in all adult inpatient units.

Now the design and attachment of objects is carried out by a hospital volunteer with input from an interprofessional team called the Delirium and Acute Confusion and Restraint Reduction Committee. The primary volunteer is now a member of the committee, which is composed of a representative RN from each of the adult units, a physical therapist and a pharmacist, and is led by a clinical nurse specialist. The pillowcases are for single patient use only and are given to the patient on discharge, thus reducing concerns about cross-infection or need for laundering. The cost to produce each pillow is minimal as the pillowcases, the most expensive item, cost $1.30 each. The other items like spools of ribbon and buttons are bought in economical sizes that often can be used for creating many pillowcases. Pillowcases are located on each unit in the activity boxes, and hospital volunteers regularly stock and monitor the contents.

The pillowcases are used with patients who are confused or who are experiencing a combination of cognitive impairments, such as a patient with dementia and a superimposed delirium. We also found it a helpful aid for adult patients who have intellectual and developmental disabilities and are in need of distraction and sensory input or modulation. Frequently, the pillowcases serve as an adjunct treatment for patients in hospice care who are exhibiting terminal restlessness. Buttons, ribbons and zippers provide opportunities for tactile repetitive manipulation that patients find soothing or distracting, and can help redirect movements that might lead to pulling on tubes. A surprising finding is that the pillowcases help in our patient mobility program because the diversional activities make it easier for the patients to tolerate their out-of-bed time.

The pillowcase is an example of one strategy we have utilized to decrease restraint use. It aligns with the American Nurses Association Center for Ethics and Human Rights position statement on restraint reduction. The 2012 statement outlined the need for continued work to “…explore safe, appropriate and effective nursing responses to patient behaviors that continue to place patients at risk, and to the safety factors related to restraint and seclusion.” While we use a multimodal approach to restraint-reduction strategies, the use of the pillowcases is a welcomed diversional intervention. Our restraint usage is historically below the National Database Nursing Quality Indicators; beyond that, our overall restraint use continues to decline.

About the authors

By Jan Bahle, MSN, CNS, CTTS, CVN; Ruth Ludwick, PhD, RN-BC, CNS, FAAN; Gina Govazzi, BSN, RN; and Chris Faler, MPT

This four-person team is composed of a clinical nurse specialist, a nurse scientist, an RN and a physical therapist. All are employed at University Hospitals Portage Medical Center in Ravenna, OH. Jan Bahle, lead author, is a CNS and a member of the American Association of Critical-Care Nurses and the National Association of Clinical Nurse Specialists. Ruth Ludwick, nurse scientist, is a member of the Ohio Nurses Association, American Nurses Association, NACNS and ANA’s Delirium Work Group, and an editorial board member of the Online Journal of Issues in Nursing.
Acknowledgment: We recognize the early efforts of Karen Edge, MPT, and Amanda Seman, PTA, for assisting with the evolution of the pillowcases.


ANA resources

ANA position statement: Reduction of Patient Restraint and Seclusion in Health Care Settings

ANA and the ADS Delirium website:

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