Best Practices in Nursing: Elderly Wellness and Restraint Alternatives

The use of restraints in health care settings has been a long debated topic. Restraints are used in every arena of patient care, including acute care settings, long-term care, pediatrics, and especially geriatrics. Although the use of restraints is ordered by a physician, nurses are often the caregivers who apply the restraints and care for the patient, while the restraints are in place.

Nurses have an ethical and professional responsibility to their patients during their care. Often their own beliefs relating to restraints will shape their decision making and actions regarding their patient’s care. Further education on the use of restraints and possible alternatives to their use has proven to influence nurses in their care practices. By minimizing the use of physical restraints, overall patient wellness has improved in elderly populations and their care settings.
Physical restraints have been defined as limiting a person’s freedom of movement by specific devices such as wheelchairs, safety vests, a room with closed doors and bed rails (Hantikainen, 1998, p. 331). The Health Care Financing Administration further defines a physical restraint as “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body” (Janelli, Stamps, & Delles, 2006, p. 163). Medications such as tranquilizers and sedatives are used as chemical restraints, which will treat behavioral symptoms by altering their mental state (NCCNHR, para. 1). Physical restraints are the most often used.
In 1987, Congress passed the Nursing Home Reform Act. The Act was prompted by prior studies that found nursing home residents to be abused and neglected. This act aims to provide quality care which in turn will lead residents to live at their optimal physical and mental state. To ensure these rights, the Act contains a Resident’s Bill of Rights, which specifically states residents have the right from freedom of physical restraints. States have a certification process which monitors homes and holds them to the standards set forth by this act. If standards are met, the homes will receive government funding (Klauber & Wright, 2001, para. 1-7)
In response to neglect, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also has a set of standards for restraint use. JCAHO is one of the primary organizations that aim to constantly provide quality care while safely protecting the patient. JCAHO is asking hospitals to implement interventions to decrease patient restraint use. Also, if restraints are warranted under their standards, they are requesting an increase in patient monitoring (Janelli et al., 2006, p. 163).
The utilization of restraints in the elderly population often receives the most attention, as they require extensive care for a wide variety of conditions and diseases. Due to their reduced independent capacity to care for and protect themselves, elderly choose to move into long-term care settings. The responsibilities of the patient’s health and security have now shifted to their nurses, whom have become their primary caregivers (Hantikainen, 1998, p. 343). Nurses care for the elderly in nursing homes for lengthy periods and also in acute care settings, when their medical needs exceed what the nursing home can provide.
In order to protect the elderly from potential harm to themselves, numerous types of restraints are used. Myers et al. (2001) states types of restraints used during their study were numerous, and the most common restraints used in the past year were jacket restraints, wrist/hand restraints, belt restraints, and secured table (30-31). Bed rails, wheelchairs, and waist restraints were other frequently used devices (Hantikainen, 1998, p. 332, & Liukkonen & Laitinen, 1994, p.1084).
The reasons these restraints were used on patients were widespread. Myers et al. (2001) stated patients were restrained in acute care settings primarily for preventing falls, limiting wandering, controlling disruptive behavior and to avoid interfering with medical devices (p. 29). In long-term care settings, often the reduced physical and cognitive state of residents is the reason for restraint. This must be done in order to protect the resident, to allow the nurse to complete basic care, and for time management of all nursing duties (Liukkonen & Laitinen, 1994, p.1083).
Outcomes of restraint use are rarely positive. While the nurse is capable of accomplishing more tasks, this is often at the detriment of the patient. The National Citizens’ Coalition for Nursing Home Reform [NCCNHR], (2007) cited that restrained individuals experience physical changes that include, decreased circulation, skin breakdown, ulcer formation, incontinence, constipation, muscle atrophy, weakened bones, increased risk of urinary tract infections and pneumonia (para. 5) Risk for falls and death by strangulation are also possible physical risks (Myers, 29). Of equal importance, the quality of the patient’s life is diminished by being physically restrained. The patient will experience depression, sleep disturbances, increased anxiety, and loss of independence and will become socially withdrawn from their environment (NCCNHR, 2007, para. 5)
Nursing response on the ethics of restraints is ambiguous. While Myers et al. (2001) cited nurses had a slightly positive attitude toward the elderly on all three scales of measurement, they indicated restraint use was acceptable in circumstances in which they were protecting their patients from harm and preventing injury (p. 31-32). Liukkonen & Laitinen (1994) also points out that physical restraints create a perpetual ethical dilemma for nurses. Restraints directly interfere with the nursing objective of patient autonomy. While trying to support their independence, nurses find the effect of restraints as “dehumanizing” to the patient and themselves (p. 1082). Hantikainen (1998) reported that nurses felt “ambiguity, frustration, sadness, powerlessness, strain and dissatisfaction” related to restraint use (p. 341). Liukkonen & Laitinen (1994) noted that the nursing staff in each research group was “considering the use of restraint as a difficult ethical problem which needed to be brought into open discussion on the wards.” While restraints were still applied to patients, their use is often questioned, leaving the use of alternatives more prevalent (p. 1085).
Janelli et al. (2006) stated 77% of the nurses in their study indicated they would attempt to use alternative measures before applying restraints to a patient (p. 165). Alternatives most attempted by the nurses were one-on-one observation, sedation, diversional activities and bed/chair alarms (p. 166). Both Hantikainen (1998) and Liukkonen & Laitinen (1994) stated the staff in their studies most frequently tried to comprehend patient behavior, used therapeutic touch and listening, and complied with resident’s requests that deviated from their daily schedule as substitutes for restraint use (p. 338 & p. 1082).
In their literature review, Evans, Wood, & Lambert (2002) found
a common restraint minimization technique to be staff teaching in conjunction with expert clinical consultation (p. 616). Different studies, conducted in acute and long-term settings, proved a decrease in restraint of patients using nursing education in conjunction with “multiple restraint-minimization activities” (pg. 619). Education topics included resident’s rights, risk and results of physical restraint, myths of restraint use, law based on restraint use, behaviors that are predictors of restraint and alternatives to restraint (p. 621). Evans et al. (2002) identified the best results occurred with gradual change that involved an interdisciplinary approach (p. 622).
When education and consultation are implemented in long-term care, overall results were successful. Residents restrained dropped from 41% to 4.05% when education was introduced (p. 619). Restraint use in long-term care was reduced without a rise in resident falls and major injury (p. 619). Nursing attitudes after alternative measures were not reported in any study. Additional studies must be conducted to explore nurses’ attitudes toward the implementation of restraint alternatives. As the debate over restraints continues, more research and education is needed to improve nursing practice.


Intervention 1 - Knowledge Deficit
i. Disadvantage 1 – Emphasis on Prior Experience
In several studies, when nurses were questioned on the use of restraints, nurses found restraint use to be an integral part of patient care. Many nurses did not feel restraints were a violation of patient rights, rather a means of patient safety. Nurses admitted that they often restrained residents of their long-term care facility for unclear reasons and without physicians’ orders. Restraints were used more often as routine practice rather than a reaction to a specific situation. Over one half of these nurses had more than six years of nursing experience (Hantikainen, 1998, p. 331-6). Concern for patient protection and safety was the prevailing primary reason nurses used restraints on their patients. (Liukkonen & Laitinen, 1994, p. 1084, Hantikainen, 1998, p.338). In a study by Myers, Nikoletti, & Hill (2001), nurses with an average of fifteen years experience were in agreement that restraints were used to protect patients from falls and injuries from interfering with therapeutic devices (p. 32).
ii. Disadvantage 2 – Lack of Training
As care facilities differ in their focus of care, staff for each type of facility varies. Acute care settings generally require nursing staff with more professional licensure (RNs, LPNs, and CNAs), many long-term care facilities have more unlicensed assistive personnel (Hantikainen, 1998, p.334). Uncertified staff are often uneducated in specific aspects of care, like restraint use. Without proper teaching, correct implementation of patient restraint use cannot be expected, even for licensed personnel. Liukkonen & Laitinen (1994) stated that more than 60% of nurses in one study stated they had received no instruction at all on the use of physical restraint while working in a geriatric ward (p. 1085). Furthermore, Evans, Wood, & Lambert (2002) found little evidence of the minimization of restraint use after an educational program was implemented. Over a year after restraint intervention and alternatives had been taught in an acute care setting, restraint use was over fifty percent, which was twenty percent higher than the pre-intervention level (p. 618).
Intervention 2 - Discrimination
Disadvantage 1 – Dislike for the elderly
Negative feeling regarding the elderly has been a theory as to the widespread use of restraints in this aged population. A study that examined the relationship between attitudes toward the elderly and attitudes toward restraint use did find a significant relationship between these negative attitudes toward older people and positive attitudes toward restraint use. (Myers, Nikoletti, & Hill, 2001, p. 29-30). This correlation may explain why up to eighty-five percent of elderly nursing home residents have been restrained at least once while living in the facility (Hantikainen, 1998, p. 331).
Disadvantage 2 – Dislike for the Mentally Ill
Caring for patients with mental illness results in may challenges, in addition to a nurse’s regular duties. With mentally ill patients, nurses face problems with “verbal and non-verbal communication, nutrition, physical functioning, safety, perceptual and motor difficulty, memory loss, and social isolation, “all in addition to other disease processes. With the addition of these factors to the nurses’ duties, some nurses grow to dislike their patients and treat them with less respect. Decreased understanding of demented patient’s behavior may contribute to nurses’ negative reactions in difficult care situations. (Liukkonen, 1994, p. 1086).


References

Evans, D., Wood, J., & Lambert, L. (2002). A review of physical restraint
Minimization in the acute and residential care settings. Journal of Advanced Nursing, 40(6), 616-625. Retrieved July 5, 2007 from
Academic Search Premier Database.
Hantikainen, V. (1998). Physical restraint: a descriptive study in Swiss
nursing homes. Nursing Ethics, 5(4), 330-346. Retrieved July 12, 2007 from Academic Search Premier Database.
Janelli, L. M., Stamps, D., & Delles, L. (2006). Physical restraint: a
nursing perspective. MEDSURG Nursing, 15(3), 163-167. Retrieved July 12, 2007 from Academic Search Premier Database.
Klauber, M. & Wright, B. (2001, February). The 1987 Nursing Home
Reform Act. AARP. Retrieved August 7, 2007 from
http://www.aarp.org/research/longtermcare/nursinghomes/aresearch
-import-686-FS83.html
Liukkonen, A. & Laitinen, P. (1994). Reasons for uses of physical restraint
and alternatives to them in geriatric nursing: a questionnaire study among nursing staff. Journal of Advanced Nursing, 19, 1082-1087. Retrieved July 12, 2007 from Academic Search Premier Database.
Myers, H., Nikoletti, S., & Hill, A. (2001). Nurses’ use of restraints and
their attitudes toward restraint use and the elderly in an acute care setting. Nursing and Health Sciences, 3, 29-34. Retrieved July 15, 2007 from Academic Search Premier Database.
National Citizens’ Coalition for Nursing Home Reform. (2007). Fact sheets: restraint use. Retrieved August 7, 2007 from
http://www.nccnhr.org/public/50_156_451.cfm