The ethical problems of prolonged physical restraint

Nursing practice with hospitalised older people: Safety and harm

BACKGROUND

Nursing teams work with hospitalised older people in institutions, which prioritise a biomedical model of care. This model does not fit the needs of older people because it emphasises efficacy and a narrow definition of patient safety, but does not prioritise functional needs. Nursing care is provided around the clock within the context of fiscal restraints as well as negative societal and nursing perspectives about ageing and old people. Yet, nursing perceptions of managing safety and potential harms to older patients within these hospital institutions are not well understood.

METHODS

An integrative review was conducted to examine nursing perspectives of safety and harm related to hospitalised older people.

RESULTS

The majority of included papers focused on restraint use. Findings reveal that nurses are using restraints and limiting mobility as strategies to manage their key priority of keeping older patients safe, reflecting a narrow conceptualisation of safety. Policy, administrative support and individual nurse characteristics influence restraint use. Safety policies that nurses interpret as preventing falls can encourage the use of restraints and limiting mobility, both of which result in functional losses to older people.

CONCLUSIONS

This complex issue requires attention from clinical nurses, leaders, policy makers and researchers to shift the focus of care to preservation and restoration of function for older people in hospital as a safety priority.

IMPLICATIONS FOR PRACTICE

Clinical leaders and nursing teams should engage in developing processes of care that incorporate maintaining and restoring older people's function.

Ethical dilemmas in social work practice with disabled people: the use of physical restraint

This article discusses the use of restraint with disabled adults and children and uses a case study of one particular child to explore issues related to the use of restraint, including the consent of the person subjected to restraint, their human rights, and the balancing of these rights with the need to reduce the risk of harm. The case study involves a young woman who requested to be restrained in a particular way and the challenges this posed to the staff caring for her. The article concludes that in many complex situations there is no clearly right approach to take, and each situation involving restraint must be considered on an individual case-by-case basis.

Progress in ethical decision making in the care of the dying

Practitioners in critical care have made a significant progress in caring for dying patients in critical care by taking advantage of the suggestions from their professional groups. Progress has been made in responding to and controlling patients' pain. Major initiatives from the Joint Commission and the American Pain Society have helped direct this improvement. Palliative care consultations as well as ethics consultations have improved symptom control in the critically ill. Issues of consent have been problematic for dying patients in critical care especially in the area of discontinuing therapies. But, better policies related to advance directives have been developed to ensure good care. Spiritual care has received more attention, and now chaplains are recognized by the Society for Critical Care Medicine as integral to the critical care team. The American Association of Critical-Care Nurses has been a leader in improving end-of-life issues and continues to spearhead many projects to improve end-of-life care.

Nursing home staffing and training recommendations for promoting older adults' quality of care and life: Part 1. Deficits in the quality of care due to understaffing and undertraining

Caught between the inability or unwillingness of nursing home corporations and owners to redistribute revenue and the reluctance of federal and state agencies to increase payments to nursing homes, the nation's most vulnerable older adults are not receiving the care they deserve. Widespread recognition of substandard care and quality of life of older adults in nursing homes has existed for decades. In addition, there is substantial evidence that poor quality of care is related to inadequate numbers and training of nursing staff. Still, policy makers and nursing home owners have failed to take needed action. In the first article of this two-part series, major deficits in the care of older adult nursing home residents are reviewed, and research documenting the relationship between nursing home staffing and the quality of care and life of residents is summarized.

Falls in somatic and dementia wards at Community Care Units

INTRODUCTION

Falls and fall injuries are common problems for patients at nursing homes in Sweden. Impaired cognitive function, a poor sense of orientation and a high intake of medicine, can lead to an increase in falls among older people.

AIM

The objective of this study was to investigate the associations between falls and: fall risks, fractures, the use of physical restraints and the use of certain medications in somatic and dementia wards, respectively.

METHOD

The study design is ecological, and aggregated data regarding falls, fall risk assessments, fractures, the use of physical restraints and medication were collected between 2000 and 2003. The Pearson correlation analysis and regression analyses were used to investigate associations between fall risks, medication, fractures, wheelchair-bound situations, bed rails and falls.

RESULTS

The total number of reported fall incidents was 2651; of these, 737 incidents were registered in dementia wards and 1914 in somatic wards. Dementia wards and somatic wards differed regarding falls and fractures, as it was only in dementia wards that falls were associated with fractures. There was also a significant correlation between falls and assessed risk of falling, the use of certain medication, and physical restraints such as wheelchairs and bed rails in dementia wards. Falls at somatic wards were associated with the use of sleeping pills with benzodiazepines.

CONCLUSION

For dementia wards there were associations between falls and fractures, physical restraints and the use of certain medications. Fractures were associated with the use of neuroleptics, sleeping pills and sleeping pills with benzodiazepines. At somatic wards, falls correlated with the use of sleeping pills with benzodiazepines, and with the use of wheelchairs and bed rails.

Use of physical restraints in rehabilitation settings: staff knowledge, attitudes and predictors

AIM

This paper reports a study examining the knowledge, attitudes and practices of staff with regard to the use of restraints in rehabilitative settings, and quantifying the direct and indirect effects of the factors that influenced these practices.

BACKGROUND

Nursing staff hold many misconceptions that support the continued use of physical restraints as a desirable technique in clinical settings to control clients. A number of previous studies measuring the knowledge, attitudes and/or practices of nursing staff towards the use of restraints have been conducted in acute, elder care, or psychiatric settings. However, not many have examined the predictors of staff practices when restraints are applied. In the study reported here, physical restraint was defined as any manual method or physical/mechanical device, material or equipment attached to a client's body so that their free movement was restricted.

METHODS

A questionnaire was administered to 168 nursing staff in two rehabilitation centres in Hong Kong. The data were collected in 2002-2003 and the response rate was 80%.

FINDINGS

Inadequate knowledge and negative attitudes on the use of restraints were found among staff. Most believed that good alternatives to restraints are not available, or they underestimated the physical and psychological impact of restraints on clients. Path analysis indicated that staff attitudes and their clinical experiences had positive direct effects on restraint use. In addition, level of knowledge and clinical experience had a positive indirect effect on practice by influencing attitudes.

CONCLUSION

These data could serve as a basis for re-educating nursing staff on the subject. Staff with more clinical experience could give appropriate guidance to other members of staff on decisions to apply restraints. More effective alternative interventions to restraining clients should be explored. Once the gaps in knowledge are closed, more positive attitudes among staff towards the use of restraints can be cultivated, thus leading to a higher standard of nursing practice.

Use of restraints on dementia patients: an ethical dilemma of a nursing staff in Israel

This quality improvement project investigates the ethical dilemmas faced by nursing staff (ie, registered nurses, practical nurses, and nurse aids) using restraints for dementia patients in "realistic" and "idealistic" situations.

RATIONALE

There is a need to offer adequate care for a growing number of patients suffering from dementia and to ensure their safety. Restraints are a common practice for this purpose; however, they may inflict harm and contradict patient rights of freedom, autonomy, and respect. The issue becomes more complex in view of the multiple studies showing that the various justifications for using restraints are often based on caregiver interests and institutional considerations rather than on the patient's benefit.

DESIGN

The project was conducted on a sample of 200 Israeli nursing staff members, half from internal medicine wards of 3 hospitals and the other half from 3 psychogeriatric nursing homes, all treating dementia patients. The project used a questionnaire composed of demographic data and an ethical preference questionnaire built on 18 situations concerning restraints. Situations were categorized into 3 purposes: (a) patient's benefit, (b) other patients' benefit, and (c) institutional benefit. These situations referred to realistic (ie, expressing views of daily practice) and idealistic (ie, expressing personal and professional beliefs and values) situations.

RESULTS

The project exposes a discrepancy between the manner in which the nursing staff perceive use of restraints in an idealistic situation and in a realistic situation and the greater tendency to use restraints in the realistic situation than in the idealistic situation. The main contribution of the project is in revealing the conflict between the personal beliefs of the nursing staff and the nurses' perceptions of their institutional obligations.

CONCLUSIONS

The project uncovered a discrepancy among the beliefs, the personal and professional values of the nursing staff, and their perception regarding the actual use of restraints in the daily work routine.

The use of physical restraints for patients suffering from dementia

This study reviews the ethical dilemmas of nursing staff about using restraints on patients suffering from dementia in two types of health care settings in Israel: internal medicine wards of three general hospitals; and psychogeriatric wards of three nursing homes. The nurses' level of knowledge about the Patient's Rights Law, the Israeli Code of Ethics, and the guidelines on restraints was analysed. The purposes of restraints were defined as beneficial to: (1) the patient; (2) other patients; or (3) the institution. The concept was evaluated in a realistic situation (expressing views of daily practice) and in an idealistic situation (expressing personal and professional beliefs and values). It was shown that nurses in internal medicine wards of general hospitals agreed more with the use of restraints than those in psychogeriatric wards in nursing homes. Differences were more pronounced when restraints were beneficial to the institution. In addition, nurses working in psychogeriatric wards of nursing homes had more knowledge about the guidelines on restraints and were less inclined than their counterparts to agree with the use of restraints for the benefit of other patients or the institution.

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.

The effect of physical restraints on fall rates in older adults who are institutionalized

Since the Omnibus Budget Reconciliation Act (OBRA) of 1987, there has been a significant reduction in the use of physical restraints to prevent falls in older adults who are institutionalized because of the developing awareness of the physical and psychological problems associated with them. The purpose of this ex post facto descriptive study was to determine if there is a difference in falls when physical restraints are allowed or prohibited in one older adult population. Data from incident reports from a purposive sample of 97 older adults in one long-term care facility were analyzed before and after the implementation of a restraint-free policy. The results indicated no significant difference in the number of falls before and after the policy change. However, there was a significantly lower number of falls with injuries and a significantly higher number of falls without injuries. These findings suggest older adults will continue to fall with or without the use of physical restraints because of changes associated with the aging process and risk factors. Removing physical barriers from older adults and allowing freedom of movement may decrease the severity of injury sustained in a fall.

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.

Physical and pharmacologic restraints in long-term care facilities

This study examined the effects of education on the attitudes and practices of long-term care staff toward use of restraints. The intervention, a 1-day educational seminar, used a collaborative team of speakers from the Utah Survey Agency and medical professions. Seminar goals were threefold: first, to provide information about best practices for managing behaviors of individuals with dementia in long-term care settings; second, to provide an explanation of the Omnibus Budget Reconciliation Act regulations pertaining to restraint use; and third, to present alternative strategies to link best practice guidelines to the provision of care. Results showed significant changes in participants' attitudes toward use of restraints. Participants reported replicating the seminar for nursing home staff, revisiting facility policies on restraints, and modifying resident care plans.

Planned change to implement a restraint reduction program

Physical restraints have been the standard of practice to manage certain types of patient behavior, such as unstable mobility, wandering, agitation, and interference with medical treatment. However, this intervention is not without serious negative consequences. Patients with neurological disorders or injuries are often at high risk for being restrained. The need to change to a more positive, patient-focused, restraint-free model was the goal of this project. A convenience sample of adult patients who were admitted to a neurological unit were studied. Outcome data that were assessed included (1) staff nurses' perception of restraints, (2) fall rate, (3) fall rate with injury, and (4) tube/line loss rate. Staff perceptions of restraints were assessed by administering the Perception of Restraints Use Questionnaire (PRUQ) before and after implementation of the restraint-reduced environment. The results of the outcome data support the change to a more restraint-reduced environment, as indicated by fall rate, fall rate with injury, and tube/line loss. Additionally, nurses' perceptions of restraints, as measured by the PRUQ, indicated a trend toward less emphasis on the use of restraints to control specific unsafe or undesirable patient behaviors.

Comparative data analysis using collaborative skilled nursing/long-term care indicator assessment

This article describes a process developed by Eastern Mercy Health System (EMHS), headquartered in Radnor, PA, to identify opportunities for quality improvement using defined outcome-based indicators in skilled nursing and long-term care (SN/LTC). The model is built on collaboration among the system's freestanding and hospital-based facilities; it includes a cyclical approach to the exchange of information. The experiences of three of the system's members reflect how each has realized measurable benefits by applying to their unique settings the lessons learned through the collaborative process.

Being restrained: a study of power and powerlessness

Previous research about the use of restraints has mainly sought generalizations regarding (a) who is likely to be restrained, (b) the frequency of the use of restraints, and (c) the behavior that precipitates the application of restraining devices. Therefore, there has been a paucity of research that attempts to understand the impact of restraint on the restrained person. The purpose of this study was to understand the meaning of the experience of being restrained for 10 psychiatric patients who had been restrained in leather restraints. Participants were interviewed in unstructured interviews. The taped interviews were transcribed and analyzed by means of a modification of an eight-stage interpretive process, grounded in Heideggerian phenomenology. In this article the theme of power is reported and discussed.

The use of physical restraints in elder care in relation to fall risk

Physical restraints are a frequently used but disputed method to prevent falls. The aim of the present study was to investigate how the use of restraints in institutional elder care relates to previous falls and to the estimated fall risk of the individual patient. A total of 1142 patients, mean age 82 years, were included in the study. A questionnaire, the Multi-Dimensional Dementia Assessment Scale (MDDAS), was used to measure motor function, vision, hearing, ADL performance, behavioral symptoms, psychiatric symptoms, cognitive impairment and use of medication. Questions concerning the use of physical restraints and known previous falls were added to the instrument. Based on data from the questionnaire (MDDAS), a score on the Downton Fall Risk Index was calculated for each patient. All in all, 248 (22%) of the patients had been subject to restraints and for 155 of them (14%) such measures had been taken to prevent falls. Only weak connections were found between the restraining of patients to prevent falls and the prevalence of known previous falls during hospital stay (phi = 0.05), and estimated fall risk (phi = 0.07). The results indicate that the use of physical restraints is poorly connected with the estimated fall risk. Therefore, this study may point to a possible overuse of these measures.

Breaking loose. Use of physical restraints in nursing homes in Queensland, Australia

A survey was completed by 123/203 (61%). Directors of Nursing of Queensland's nursing homes, to obtain information about the use of physical restraints. Of a total of about 6500 (4693 females; 1807 males) nursing home residents in Queensland, Australia, 23.6% (1536) were reported to have been physically restrained at the time the survey was completed. Of this group, females comprised 72.9% (1120) and males 27.1% (416). The commonest forms of physical restraint were bedrails (38.2%) and restraining belts (23.7%). The commonest patient-oriented reason for using physical restraints was to "prevent falls" (85.4%) and the commonest nurse-oriented reason was "because no alternative exists" (39.8%). The correlation between the size of nursing homes (bed numbers) and the number of residents was strong and positive, indicating that Queensland nursing homes were functioning at full capacity (r = 0.999, a = 0.05). The correlation between the size of nursing homes (bed numbers) and the number of residents who were physically restrained was weak and negative (r = 0.002, a = 0.05), suggesting that nursing home size did not predict the use of physical restraints. Correlations between the total number of staff, the total number of untrained staff (assistants in nursing) and the number of residents who were physically restrained were also weak (r = 0.0427; 0.0695 respectively; a = 0.05), suggesting that these factors also had little predictive influence on the use of physical restraints. The findings of this research indicate that the extent to which physical restraints are currently being used in nursing homes in Queensland should be of concern, particularly in the context of a general, contemporary professional belief that the use of physical restraints in nursing homes should be minimised, if not entirely avoided.

Restraint-free care for acutely ill patients in the hospital

A growing body of empirical evidence documenting the negative effects and the limited effectiveness of physical restraints continues to shape policy and professional standards. In addition to occurrences of serious harm from restraint devices, ethical concerns about care with dignity have supported reevaluation of restraints in all settings for all patients. Lessons from considerable research conducted in nursing homes and clinical experience with restraint reduction in long-term care facilities are applicable to acute care settings, where restraint-free care can and should be embraced.

Physical restraints in geriatric care in Sweden: prevalence and patient characteristics

OBJECTIVE

Physical restraints are used frequently in geriatric care to promote the safety of frail older patients. This study investigated the prevalence of the use of physical restraints in geriatric care and the way in which patient characteristics are related to the use of physical restraints.

DESIGN

A point prevalence study of patients cared for in various types of geriatric settings.

SETTING

Eight nursing homes, 15 old people's homes, a somatic geriatric clinic, and a psychogeriatric clinic in a health care district in northern Sweden.

PARTICIPANTS

A total of 1325 patients, mean age 82 years, 64% of whom were women.

MEASUREMENTS

The Multi-Dimensional Dementia Assessment Scale (MDDAS) was used to measure motor function, vision, hearing, speech, ADLs, behavioral symptoms, psychiatric symptoms, use of psychoactive drugs, and the physical and psychological workload of the staff. In addition, questions concerning the use of physical restraints were added to the instrument.

RESULTS

Twenty-four percent of the patients were physically restrained. The highest prevalence was found in nursing homes and psychogeriatric care. Physical restraints were found to relate most strongly to cognitive impairment, impaired ADLs, and speech and walking ability. Ninety-four percent of the restrained patients were cognitively impaired. Other variables relating to the use of physical restraints were psychiatric symptoms and behavioral disturbances.

CONCLUSIONS

This study has shown that physical restraints are used frequently in geriatric care in Sweden and that cognitive and physical impairments relate very closely to the use of physical restraints.

Restraint-free care: how does a nurse decide?

Decisions by nurses to avoid physical restraint use in older adults is a complex process that requires individualized, comprehensive assessment and creative problem-solving. Institutional and social policy increasingly support a standard of restraint elimination influencing care decisions with frail older adults. It has become clear that the decision to avoid or use physical restraint is influenced as well by nurses' attitude or beliefs about the efficacy of restraint. To further understand how decisions are made to avoid physical restraint, it is important to also explore the degree to which nurses possess knowledge, autonomy, and accountability in this decision-making process. Understanding how decisions are influenced will advance the development of restraint-free care interventions for older adults.

Nurses' awareness of restraint use with elderly people in Greece and the U.K.: a cross-cultural pilot study

The use of restraints in hospitalised elderly people is a contentious but poorly-documented issue and many gaps remain in the literature. Despite the growth of the elderly population, there has been little attempt to safeguard their rights in relation to appropriate care whilst in hospital. Furthermore, little is known about the attitudes of nurses in the U.K. towards the use of restraints in the older population, and there is an almost total absence of cross-cultural studies. The current study is a small pilot study of nurses' attitudes towards and knowledge of restraint use with older patients. A structured questionnaire was given to 39 U.K. and 11 Greek trained nurses who were working in acute care settings where elderly patients were cared for, with the aim of identifying their perceptions and experiences of the use of restraints in their clinical settings. Although numbers were small, a number of differences between the two groups were found, and there were indications of further differences. These issues are examined, with particular reference to the need for education, restraint policies and multidisciplinary decision-making about restraint use. Some major principles which should be included in cross-cultural studies are also discussed.

Psychological Responses to Physical Restraint Use in Older Adults

A view of physical restraint in older adults as ineffective, harmful, and assaultive to the dignity of the individual rather than routine and efficacious, created a paradigm shift among consumers and professionals. Studies exploring the response to restraint and interventions to help a restrained individual resolve the trauma, the assault on their personal integrity, and the loss of control, are needed. Recognition that physical restraint can be traumatic for individuals warrants an assessment of psychological responses of restrained older adults by health professionals and supports the goal of restraint reduction or elimination

Analysis of restraint-free nursing homes

Administrators and key informants in restraint-free nursing homes participated in a telephone survey to improve understanding of the process, resources, and measures for successful adoption of restraint-free care. Respondents expressed a strong opinion that each facility must develop its own individualized approach to restraint removal. However, similar approaches were found which suggest that efficiencies in conversion may be gained through application of change theory informed by restraint removal experience.