Methods to reduce restraints: process, outcomes, and future directions

Review of the Use of Physical Restraints and Lap Belts With Wheelchair Users

Wheelchair-related physical restraints, lap belts, and other alternatives are intended to provide safe and adequate seating and mobility for individuals using wheelchairs. Physical restraints and lap belts are also helpful for positioning people in their wheelchairs to reduce the risk of injury during wheelchair tips and falls. However, when used improperly or in ways other than intended, injury or even death can result. Although widely prescribed, little evidence is available to direct professionals on the appropriate use of these restraints and lap belts and for whom these restraints are indicated. The purpose of this study was to conduct a review of available literature from 1966-2006 to identify the risks and benefits associated with lap belts while seated in wheelchairs. Twenty-five studies that met the inclusion criteria were reviewed. Nine studies reported the frequency of asphyxial deaths caused by physical restraints, nine studies reported the long-term complication and indirect adverse effects of physical restraints and lap-belt use, and seven studies reported the benefits of physical restraints and lap belts with individuals using wheelchairs. Despite the weak evidence, the results suggest a considerable number of deaths from asphyxia caused by the use of physical restraints occurred each year in the U.S. The majority of the deaths occurred in nursing homes, followed by hospitals, and then the home of the person. Most deaths occurred while persons were restrained in wheelchairs or beds. Based on that, caution needs to be exercised when using restraints or positioning belts. In addition, other seating and environment alternatives should be explored prior to using restraints or positioning belts, such as power wheelchair seating options. Positioning belts may reduce risk of falls from wheelchairs and should be given careful consideration, but caution should be exercised if the individual cannot open the latch independently. Also, the duration of use of the physical restraint should be limited. Therefore, several factors should be considered when devising a better quality of physical-restraint services provided by health care professionals. These efforts can lead to improved safety and quality of life for individuals who use wheelchairs.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

Effect of a treatment interference protocol on clinical decision making for restraint use in the intensive care unit: a pilot study

The literature is replete with articles describing restraint reduction strategies used in long-term care settings, geriatric specialty units, and medical/surgical units in the acute care setting. The feasibility, effectiveness, and appropriateness of such strategies cannot be capriciously applied to the intensive care setting. This article provides an overview of the implementation and outcomes of a pilot study using an algorithmic approach that is clinically appropriate and justifiable for restraint use in the intensive care environment. It provides the critical care nurse with a standardized method for decision analysis when managing patients at risk for treatment interference.

Developing a restraint-reduction program for child/adolescent inpatient treatment

TOPIC

Meeting mandated guidelines to reduce, if not eliminate, the use of restraints with children and adolescents hospitalized on inpatient psychiatric units.

PURPOSE

To present eight promising options for restraint reduction with inpatient children and adolescents, and the research that supports their efficacy.

SOURCES

Review of the literature.

CONCLUSION

By combining what is known about child/adolescent restraint use with restraint-reduction research in the adult field, several options for restraint reduction can be derived.

Restraint reduction: research utilization and case study with cognitive impairment

Although great strides have been made in restraint reduction, restraints still present a challenge for long-term care facilities. Restraint reduction is particularly difficult with cognitively impaired residents. This article presents the implementation of a research-based approach to restraint reduction and a case study with a cognitively impaired resident. Two year after implementing the research-based approach, the restraint rate had decreased 28%. The case study with the cognitively impaired resident revealed an increase in nurse contacts but a decrease in nurse time after restraint reduction. Concern for the cognitively impaired resident's safety remained an issue for the staff. Discussion includes weighing the risk/benefit ratio of restraint use and considering dignity and quality of life.

Bedrails: choosing the best alternative

This article discusses the importance of resident assessment in the decision to use bedrails, highlights the importance of an interdisciplinary approach to decision-making, and offers a compendium of care plan interventions and devices that serve as alternatives to bedrails.

Physical restraints in nursing homes: a review of the literature since the Nursing Home Reform Act of 1987

The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.

The use of physical restraints in nursing homes: pre- and post-Nursing Home Reform Act

The purposes of this paper are: (1) to determine resident risk factors for the use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA) of 1987, (2) compare these results with resident risk factors for the use of physical restraints prior to the implementation of the NHRA, and (3) to identify facility characteristics associated with the use of physical restraints. The data used are from 4,215 nursing home residents in 268 facilities who were evaluated using the Minimum Data Set (MDS) in six month periods in both 1990 and 1993. Results indicate that the NHRA may have been successful in reducing the use of physical restraints; however, it would appear to have had less impact on the types of residents who are restrained. It is also shown that the use of physical restraints is associated with facility characteristics.

The use of restraint in the care of elderly patients

The use of physical and chemical restraint in elderly care settings to restrict mobility and control behaviour is not a new concept. However, until the 1980s, it was an area that was neglected in nursing research. In 1989, Evans and Strumpf carried out an extensive literature review on restraint in an attempt to consolidate the state of knowledge regarding its use in care of the elderly settings. This article aims to evaluate how far the discussion surrounding restraint has progressed since that time and in what direction. It also reviews the extent of restraint use and rationale for its application, the consequences of restraint and progress in developing alternatives.

Nursing knowledge and use of restraint alternatives: acute and chronic care

This descriptive study compares the types of restraints and alternatives to restraints used by nurses in the acute and chronic care setting. Significant results showed that chronic care nurses used fewer restraints and more alternatives than nurses in acute care. It is suggested by the findings stated above that the need is significant for additional and continued education in the acute care setting regarding restraints and alternatives to restraints.

Research-based practice: reducing restraints in an acute care setting--phase I

The purpose of this research utilization project was to select and implement a research-based Restraint Education Program for reducing the use of restraints in an acute care setting by changing the perception of the restraint coordinators about restraints in the direction of decreased importance. The Iowa Model, Research Based Practice to Promote Quality Care (Titler et al., 1994) was selected to guide the change process. A multidisciplinary team reviewed the restraint policy and procedure, new restraint products and alternative restraint methods. After a review of the literature on restraint education programs, the committee concluded that education was the key component in decreasing the use of physical restraints. The research-based Restraint Education Program developed by Drs. Strumpf and Evans was selected as the educational program. Education sessions were developed and a pilot study was conducted with the restraint coordinators. The Perceptions of Restraint Use Questionnaire (PRUQ) (Strumpf & Evans, 1988) was administered before and after the education sessions. The results of the t-test showed a decrease in the post-test mean scores on 7 of the 17 items indicating a less important perception by the staff about the use of restraints. Four items had an increase in mean scores on the post-test indicating the restraint coordinators increased their perception of the importance of physical restraints with these items. The restraint education program was presented to the nursing staff throughout the institution. Risk management and quality assurance will monitor patients restrained and evaluate the nursing staff with the PRUQ in 3 months.

Establishing alternatives to physical restraints in the acute care setting: a conceptual framework to assist nurses' decision making

Critical care and acute care nurses must determine ways to deliver optimal patient care without the use of physical restraints. This article explores the application of the clinical decision analysis model to the challenge of finding nonrestraint approaches to care. Clinical decision analysis is a structured, quantified approach for choosing an optimal course of action in a situation that involves tradeoffs among risks and preferences and when outcomes are uncertain. Decision analysis provides a graphic representation of the decision situation that facilitates evaluation of factors relevant to the situation and evaluation of the potential events and outcomes following a chosen strategy. The decision analysis model can be useful for determining guidelines for clinical practices, facilitating discussions among health care providers and patients, and determining areas in need of additional research.

Reducing the use of physical restraints in long-term care facilities

1. There has been increasing recognition of the role of education as a catalyst for changing restraint use practices and policies of long-term care facilities in Canada and other Western countries. 2. Findings of this longitudinal study documented the positive outcome of a structured restraint education program in reducing the use of physical restraints and promoting non-restrictive alternatives. 3. With continuing education and inservice programs, restraint-free elderly care can be attained in a cost-effective manner and without an increase in resident falls and injuries.

Nurses Helping Nurses Development of Internal Specialists in Long-Term Care

The prevalence of psychiatric disorders and behavioral disturbances among nursing home residents, combined with observed deficits in geriatric mental health/illness expertise among LTC staff, supports the need for creative approaches to improve the knowledge, understanding, and management of such problems among LTC providers. The train-the-trainer model described in this article proved to be a viable method to providing geriatric mental health consultation and training that targets both improved quality of life for residents and quality of work life for the staff in charge of residents' care. More collaborative efforts among nursing specialists, subspecialists, and generalists are needed to empower those who work in LTC to utilize strengths and abilities inherent to their positions. Nursing homes nurses, who are all too familiar with the problems and challenges of their patient population, may act not only as mental health trainers but also as resource persons, role models, liaisons with geropsychiatric specialists, and leaders in the application of geropsychiatric care principles to residents within their facility, thus promoting improved resident and staff care alike.

Nurses helping nurses: development of internal specialists in long-term care

1. Too often, expert assistance provided by psychiatrists and psychiatric nurse specialists to long-term care (LTC) providers of geriatric patients is short-lived and not effective in helping LTC staff deal with their patient's behavioral and psychological problems. 2. One of the main objectives of the study--and one that was found to have positive results--was to provide a mechanism by which LTC staff could develop their own expertise in the management of behaviorally difficult residents. 3. More collaborative efforts among nursing specialists, subspecialists, and generalists are needed to empower those who work in LTC to utilize the abilities and strengths inherent in their positions.

Delirium and physical restraint in the hospitalized elderly

Delirium or acute confusion increase the likelihood of physical restraint use and subsequent harmful physical and psychological effects. Assessment for delirium is presented as a conceptual framework to guide researchers, administrators, and clinicians in developing strategies to decrease the use of physical restraint and to support quality of life for hospitalized older adults.

Individualized care alternatives used in the process of removing physical restraints in the nursing home

OBJECTIVE

To describe the individualized care alternatives used during the process of removing physical restraints in a nursing home.

DESIGN

Descriptive survey.

SETTING

A non-profit geriatric long-term care facility.

SUBJECTS

Sixty-three physically restrained residents (mean age = 85.3 years).

MEASURES

Information regarding the different care alternatives used to replace physical restraints was obtained from the Gerontological Clinical Nurse Specialist implementing the process of removing restraints.

RESULTS

The physical restraints of six of the 63 participants were removed without implementing any care alternative. With the remaining 57 participants, an average of 3.3 different care alternatives were used (range 1-7 care alternatives). Environmental alternatives (such as wheelchair adaptations and alternative seating) were used with 86% of the restrained residents; alterations in nursing care (such as additional supervision and toileting schedules) were used with 77% of the participants. Psychosocial and physiological alternatives, as well as the use of structured activities, were used less frequently. At the end of the study period, five residents remained restrained.

CONCLUSIONS

This papers shows the complexity of the process of removing physical restraints in the nursing home. The need of an individualized approach is stressed.

Falls in the nursing home: preventable or inevitable?

1. Falls in the elderly are frequent occurrences and are usually a result of the complex interaction of environmental, physiological, and pathological variables. Fall-related injuries happen much less frequently. 2. Physical restraints have not been found effective in preventing falls and may be associated with increased risk of fall-related injury. 3. Because of the complex nature of falls in the elderly, fall prevention programs must emphasize the critical assessment of each resident's risks for falling with targeted interventions.

Reducing physical restraints: developing an educational program

1. Philosophical premises for an educational program aimed at restraint reduction include beliefs about quality of care, commitment to understanding the meaning of behavior, and desire to shift practice from control of behavior to individualized approaches to care. 2. If change is to occur, an educational program aimed at restraint reduction must recognize the potential contributions of all staff members, use an interactive teaching style, and promote discussion and problem solving. 3. Results of testing a Restraint Education Program suggested that altering staff beliefs and increasing knowledge produced a change in restraint practices, at least in the short term.