Institutional policy: use of restraints in extended care and nursing homes

Programme d'intervention visant à réduire l'utilisation des contentions physiques dans des unités de soins de longue durée — mise en oeuvre et effets sur le personnel soignant

This study aimed at (a) developing a restraint reduction program, (b) describing its implementation in long-term care units, and (c) examining its effects on care staff's perceptions of and knowledge about the use of restraints. The program was composed of three parts: consciousness-raising meetings, staff education, and clinical follow-up. The study was a randomized, controlled clinical trial with eight intervention care units (five nursing homes) and 11 controls (five additional nursing homes). Care staff was surveyed at two time intervals over a 7-month period (pre- and post-test intervention; intervention care units: N = 171 [T0] and N = 158 [T1]; controls: N = 181 [T0] and N = 166 [T1]). The implementation of the program was successful and results showed significant changes in care staff perceptions of and knowledge about the use of restraints.

Nurses using physical restraints: Are the accused also the victims? - A study using focus group interviews

Background

To date, the literature has provided an abundance of evidence on the adverse outcomes of restraint use on patients. Reportedly, nurses are often the personnel who initiate restraint use and attribute its use to ensuring the safety of the restrained and the others. A clinical trial using staff education and administrative input as the key components of a restraint reduction program was conducted in a rehabilitation setting to examine whether there were any significant differences in the prevalence of restraint use pre- and post-intervention. Subsequent to the implementation of the intervention program, focus group interviews were conducted to determine the perspective of the nursing staff on the use of restraints and their opinions of appropriate means to reduce their use.

Method

Registered nurses working in units involved in the study were invited to participate in focus group interviews on a voluntary basis. Twenty-two registered nurses (three males [13.6%] and nineteen females [86.4%]) attended the four sessions. All interviews were audio taped and transcribed verbatim. Other than the author, another member of the project team validated the findings from the data analysis.

Results

Four themes were identified. Participants experienced internal conflicts when applying physical restraints and were ambivalent about their use, but they would use restraints nonetheless, mainly to prevent falls and injuries to patients. They felt that nurse staffing was inadequate and that they were doing the best they could. They experienced pressure from the management level and would have liked better support. Communication among the various stakeholders was a problem. Each party may have a different notion about what constitutes a restraint and how it can be safely used, adding further weight to the burden shouldered by staff.

Conclusion

Studies about restraints and restraint use have mostly focused on nurses' inadequate and often inaccurate knowledge about the use of restraints and its associated adverse effects. These studies, however, fail to note that nurses can also be victims of the system. Restraint use is a complex issue that needs to be understood in relation to the dynamics within an environment.

Reasons for physically restraining patients and residents: a systematic review and content analysis

OBJECTIVE

The purpose of this systematic review was to determine why people are physically restrained in the acute and residential care settings.

METHOD

A comprehensive search was undertaken of electronic databases to identify studies addressing the reasons for using physical restraint. Findings were synthesised using content analysis.

RESULTS

Twenty-three studies were identified. The most common reason for using restraints related to patient-oriented issues such as ensuring the safety of people. However, they are also commonly used to facilitate treatment, maintain the social environment and because of issues such as understaffing.

The use of physical restraints as a safety measure in the care of older people in four rehabilitation wards: findings from an exploratory study

We investigated the prevalence and type of physical restraint used with older persons on four rehabilitation wards in Northern Ireland. A longitudinal observational approach was used. One hundred and two patients were observed on four occasions over a three-day period. Most of the patients (68%) were subjected to some form of physical restraint, side-rails being the most commonly observed method. Those who were restrained were dependent on nursing care to meet their needs and received more drugs than those whose mobility was not restricted. No association was found between restraint use and nursing staffing levels, nor was there any association with the incidence of falls. Nurses rationalised their use of restraint as being linked to wandering and patient protection in cases of confusional type behaviours. An association was found between stroke and the maintenance of positional support through the use of restraints (side-rails and screw-on tabletops). Approximately, one-third of those restrained had this noted in their care plans, with concomitant evidence of patient/family involvement in the restraining decision.

Perceptions of physical restraint use and barriers to restraint reduction in a long-term care facility

The use of restraints in nursing homes has been curtailed in the United States since the passage of the 1987 federal legislation regulating restraint practices. This study used focus groups with administrators and nursing staff in a skilled nursing facility to examine their views of restraints and perceptions of conditions in the nursing home environment that affect restraint use. Although respondents lacked a shared definition of a "restraint," they did identify contextual factors that in combination with resident characteristics produced situations in which restraint use was justified. Implications of these findings for staff education on restraint reduction are discussed.

Perceptions of older people who have experienced physical restraint

It is well documented that the use of physical restraints on older people has been linked to negative clinical outcomes. However, less is known about the personal perspective of those who have been restrained. This study examines the perceptions of older people who have experienced physical restraints in a rehabilitation ward. A purposive sample was used of 17 male and female patients who were restrained. The patients were interviewed using the Subjective Experience of Being Restrained instrument (Strumpf and Evans, 1988) which is a semi-structured interview schedule. The most commonly used restraint devices included side rails, screw-on tabletops and reclining chairs. The data were analysed using content analysis. The results indicate mixed feelings regarding physical restraints. Patients' impressions of physical restraints included indifference of the devices to their perceived safety value. Overall, a minority of patients (n = 4) had positive feelings about physical restraints as they provided a sense of security to them. However, the negative comments of the patients were more prevalent and their responses were categorized in terms of institutional control, ritualised care, entrapment and discomfort, and possible alternatives.

Relatives' perceptions of side rail use on the older person in hospital

With an increasing emphasis on improving standards in the care of older people, the use of physical restraints has received growing attention in the nursing literature. Physical restraint use has been likened to abuse as it impedes the movement of a person, encourages dependence on staff and denies autonomy. Side rails (cot sides, bed rails) can be considered as a physical restrain device. The therapeutic use of restraint has not previously been adequately explained. Furthermore, there is a dearth of literature examining the personal experience of physical restraint use. The Family Interview Guide (Strumpf and Evans, 1988) was used to explore perceptions of nine relatives whose family had side rails used during their care in an older person ward. The findings of the study suggest that while families place value on the perceived safety function of side rails, they nonetheless have worries about their use. These pertain to the risk of patient entrapment and possible injury. Patients' relatives associated side rails with ritualized practice in gerontology and make suggestions for the re-design of side rails. The study also highlights the potential for increased family participation in the decision to use side rails.

Use of Physical Restraints on Hospitalized Psychogeriatric Patients

1. When making decisions about the use of physical restraints, minimizing the physical risk of patients was determined to be the most important obligation. 2. Nurses' understanding and consideration of important factors that influence restraint use are essential to its reduction. 3. Nurses should be aware of their ethical responsibilities to older patients and their families. They must ensure the patient's right to be informed and respect their dignity.

The use of physical restraints to psychogeriatric patients in Hong Kong

The use of physical restraint has been a controversial intervention in the nursing management of hospitalized elderly patients in many countries. This ethnographic study was conducted in one psychogeriatric ward in Hong Kong in order to explore what determines psychiatric nurses' decisions to use restraints on their elderly patients. By comparing the findings of three data sources, comprising semistructured interviews, observations, and clinical records, five main themes were identified with regard to the nurses decision of restraint use. They included the rationale of physical restraint, consideration of alternative measures, consideration of adverse consequences, ethical considerations, and policy and documentation of restraint use. The findings of this study demonstrate that nurses must question the established practice myths about restraint use being the best way to maintain patient safety. Most importantly, nurses need cognitive and ethical preparation to face different situations in which physical restraint may be used.

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.

Use of physical restraints on elderly patients: an exploratory study of the perceptions of nurses in Hong Kong

A qualitative study was designed to explore nurses' perceptions of the use of physical restraints on elderly patients in Hong Kong. Content analysis of semi-structured interviews with 20 registered nurses working in medical and geriatric settings of two regional hospitals revealed that although nurses generally had mixed feelings about the use of physical restraints on elderly patients, they did not question this 'routine' practice and their knowledge about the consequences and alternatives to the use of restraint was limited. It was found that nurses had an overriding concern in ensuring elderly patients' physical safety and using restraints therefore provided them with a sense of security. The deleterious impact of restraint on the care received by elderly patients was largely unrecognized. Implications for practice and future studies are discussed in the light of these findings.

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.

The effects of research on clinical practice: the use of restraints

The investigators have conducted a series of four descriptive, clinical studies to examine the nature of restraint use in extended care and nursing home units in a veterans' facility. Based on the findings of three of these studies, staff education and policy changes were implemented with the intent of decreasing the use of restraints. The present and fourth study in the series examines whether the use of restraints decreased from 1990 to 1993, after policy changes and staff education were initiated. Findings indicate that the frequency of restraint use decreased by almost half, from 25% to 14%. In addition, falls did not increase, but those falling were less likely to be restrained. These findings illustrate the importance of research in setting a course for positive change in clinical practice.

Involuntary transfers and discharges of nursing home residents under federal and state law

When, as projected, nearly one out of every four Americans is age sixty-five or more, one out of every four Americans over sixty-five will spend time in a nursing home, and caregiver families scarcely exist, we will no longer be able to avert our eyes from the grim options faced by our senior citizens. Nor will we be able to continue to operate under the comforting but often false illusion that our convenient dispositions are actually serving the best interests of the elderly.

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.

Extended care and nursing home staff attitudes toward restraints. Moderately positive attitudes exist

1. The average score on the Restraint Questionnaire for Staff indicated that the extended care and nursing home staff members in the study presented had moderately positive attitudes toward using restraints. 2. There were no significant differences in attitude scores based on gender, position, education, or clinical experience. 3. Collaborating with another professional, especially a physician, was related to a more positive attitude toward restraints; this effect approached statistical significance. 4. Sixty-five percent of the staff could offer no alternatives to restraining a patient; for those who could offer an alternative, increasing staff size was cited most frequently.

Patient and family perceptions of restraints

Based on a holistic philosophy that aging persons' most primary need is that of autonomy and freedom, this qualitative descriptive study examined patients' and their family members' perceptions of the restraint procedure. Twenty-five restrained patients were interviewed, and 19 of their family members completed mailed surveys to describe their perceptions about restraints. Results indicated that the majority of patients (52%) expressed negative feelings about being restrained. Family members expressed a wide variety of feelings and were ambivalent about seeing a loved one restrained. Implications are that nursing needs to become committed to the philosophy of autonomy and freedom for elderly persons.