Effectiveness of Restraint Use for Preventing Falls and Injuries in the Older Adult

Abstract: The focus of this review is to examine the effectiveness of physical restraints in preventing falls and injuries in the geriatric population. Falls are the most reported incidence in acute care settings, often resulting in injury, decreased level of functioning, and psychosocial decline among adults.1 The occurrence of falls is highest in adults over 65 years of age. Interventions for maintaining patient safety and the prevention of falls have become a widely researched and debated topic.2 This article will compare the use of physical restraints to other common interventions in acute care settings in the prevention of falls and fall related injuries. Implications of restraint use and the challenges for the patient, health care providers, and individuals involved are explored.

The World Health Organization (WHO) reports that falls are the most common adverse event reported in acute care settings.1 Adults over the age of 65 are at the highest risk for falls, with 30% experiencing at least one fall annually. This number increases to over 40% for populations older than 85.1,2 Falls in the older adult negatively impact the physical, mental, and emotional wellbeing of the individual because of the injuries sustained and the subsequent consequences.3 Hip fractures resulting from falls account for 20% of deaths that occur within a one year period post fall.2 In addition, many patients have difficulty restoring to their previous level of functioning.2 Falls are associated with poorer patient outcomes and longer length of hospital stay.1 Geriatric and rehabilitation units, on average, have the highest incidence of falls.3 Emphasis on identifying risk factors associated with falls and implementing interventions to prevent their occurrence are essential to maintaining patient safety.3 The majority of falls occur due to a combination of factors which makes it difficult to identify one predisposing component.3 New risk factor assessment and screening tools have been utilized in conjunction with nursing interventions to decrease the incidence of falls.1,2,3 Studies completed in acute and mixed care settings have been able to identify appropriate interventions hospital staff can apply to their practice and their effectiveness.3 Common applications such as use of physical restraints, bed alarms, physical therapy, and the introduction of pharmacological therapies are just some of the interventions that will be examined in this review.

Identifying risk factors for falls is often difficult for many practitioners who see their patients infrequently in between visits.2 Studies show that 37% of patients do not report falls to their primary care doctors if asked due to fear and embarrassment of the incident.2 There are currently no specific tools that have shown to accurately predict the risk for falls, however single and multicomponent interventions have been able to decrease the amount of falls.2,3 Those most at risk for falls are those with Parkinson’s Disease, arthritis, cognitive impairment, incontinence, fall history, dementia, gait abnormalities, history of stroke and/or heart attack, use of sedatives and anti-hypnotics, weakness, and age over 65.2,3,4 Transient conditions such as altered mental status, as seen in older adults in cases of infection, are also considered to increase the risk of falling in the geriatric population.3,4 A decline in functional status and being able to complete activities of daily living have been shown to be contributing factors in falls. These can be a result of the transient conditions mentioned.3,4

Interventions and Fall Prevention

New studies on the older adult population have led to the formation of numerous nonpharmacological techniques to prevent falls.3 The introduction of the interventions in acute care settings have been based off of the works of Optimal Evidence-based Non-drug Therapies in Older People (ONTOP).3 ONTOP provides recommendations based on available evidence from primary trials through systematic reviews concerning non-drug interventions that are useful in treating common geriatric conditions.3 ONTOP has reported on the increasing morbidity and mortality of falls as well as determining adequate therapies for those most at risk in acute care and community settings.

 Most fall interventions are not implemented until an individual experiences their first fall. 1,2,3 For a vast majority of hospitalized patients, the addition of physical therapy or an exercise program is often mandated and geared towards preventing falls.1,2,3 Studies have implemented combinations of exercises such as aerobic conditioning, strength training, and yoga on medical-surgical and rehabilitation units.1 The single addition of exercise was shown to have no significant impact on the number of falls on the wards.1 A varied addition of weekly exercise was also shown to be insignificant.1,2,5  However, the addition of yoga and tai chi were shown to increase the confidence of patients and decrease the fear of falling in 66%.2 Strength training in patients with cognitive impairments and dementia were shown to decrease the prevalence of falls by 11%.3 Although ONTOP states that exercise is the most effective intervention in reducing fall rates in older adults, not all types of exercise were equally effective.3

There is a lack of current studies that evaluate the effectiveness of other common nursing interventions when decreasing the risk for falls.2,3,4,5 The utilization of fall risk identification bands, bed and chair alarms, hourly rounding, non-skid socks and keeping the bed in the lowest position were not proven to have a significant reduction in the number of falls.2,3 Multiple studies have cited that the implementation of a vitamin D supplement once daily decreased the amount of falls in individuals over the age of 65.1,2,3,4,5In addition, providing education to patients regarding medication management and safety awareness decreased the rate of falls post discharge by over 15%.3

The Use of Mechanical Restraints

When researched, the most common reason for physical restraint use was fall prevention.4,6,7 Mechanical restraints have been made standard practice for patients that display disruptive, wandering, or unsafe behaviors.8 The Center for Medicare and Medicaid Services (CMS) define physical restraints 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.”8 However, it is important to note that support for restraint use has been on the decline because of regulations by the Joint Commission passed in 1987.9 The focus on patient rights has taken priority, which has made the use of restraints the last measure nurses should utilize for an intervention.10 According to the existing literature, the most common mechanical restraints in studies were: the raising of all siderails, wrist, chest, and ankle straps, vests, safety release belts, and hand mits.6,7,8,9

Researchers reviewed the medical records of elderly adults on a rehabilitation ward of a teaching hospital and discovered that residents in restraints were twice as likely to experience and fall with a more serious injury than those unrestrained.6 In 25% of the fall cases, patients were in wrist or vest restraints the day prior to or the day of the event.6 It was concluded that the use of restraints was ineffective as an intervention for falls.6 The data shows that up to 47% of patients that fall are in restraints with intermittent use being the most exacerbating  factor.7 The addition of physical restraints led to an increase of indirect injuries not caused by fall.6,8,9 Deconditioning, loss of muscle strength, decrease in coordination and balance, decrease in bodily movement, contractures and skin breakdown were all  highly attributed to the increase of injuries reported during restraint use.6,9

Another comprehensive study concluded that over 25% of patients over 60 years of age were restrained for a period during their hospitalization.7 Altered mental status, difficulty ambulating, and repeat falls were the top reasons patients were restrained for fall prevention and behavior management.7 Comparison studies have suggested elderly individuals will continue to fall with or without restraints in place because of associated changes related to the aging process.9 When hospitals initiated a no restraint policy over a 6 month period, there was no significant difference in the number of falls that occurred.9,10 There were, however, less falls that resulted in serious injury, such as fractures, and a higher incidence of falls without minor injury such as hematomas.9,10 Removing physical barriers and allowing patients freedom of movement decreased the severity of injury sustained and fear of falling.10 Because of the risk of secondary injury related to restraint use, over 15% of the hospitals that participated in restraint reduction programs continued with the new practices.9,10,11

Little is documented about the nurse’s decision-making process regarding which patient to restrain and what alternatives to restraints can be utilized.8 One theory that has been said to aid in understanding this process in Ajzen and Fishbein’s theory of reasoned action (TRA).7 The TRA aims to explain how individuals decide to perform certain behaviors which can parallel how the attitudes and knowledge of nurses effect the use of physical restraints.7,8,9 In short, the theory suggests that behavior is determined by one’s attitude towards a behavior and the intention to perform it.7,8 The beliefs held by an individual are formed by experience, knowledge, and perceptions of those around them.8 Nurses are educated in ethics and possess the ability to think critically and should, therefore, be able to consider the benefits and consequences of restraining a patient.7,8,9 The attitudes, moral obligations, perception of others, and intentions of nurses were assessed in questionnaires in order to determine the likelihood of restraint use.7 The use of restraints was associated with higher scores on the questionnaires which also coincided with lower levels of education regarding restraints.7 The theory of reasoned action has not been explored in many studies pertaining to nursing although it provides great perspective regarding action and behavior. However, in order to better understand the reasoning of restraint use and the decision-making process of nurses, more data would be needed in order to determine correlation.

Challenges Associated with Restraint Use

 Literature reviews have demonstrated the hardships of maintaining the balance of legal and ethical issues surrounding restraint use.8 The Joint Commission and CMS have instituted regulations in order to assure that the rights of the patient are upheld.8 Strict monitoring and documentation of the restrained patient, correct fit and placement of the device in use, scheduled release times, and correct order for use are all necessary in order to avoid litigation.8,9 For example, physical restraints must be released every two hours while the patient is awake and direct observation is required.8,9,10 The use of mechanical restraints threatens 3 principles of ethics: beneficence, non-maleficence, and autonomy.9 Health care providers are morally obligated to protect the patient from harm while maintaining their dignity and personal rights. Due to inadequate education among nurses, this does not always take priority, which contributes to the harmful misperceptions about restraint use.7,8

In order to protect the rights of the individual, an assessment to determine the appropriateness of restraint use is necessary. One of the greatest factors in deciding to restrain a patient at risk for falls was behavior management.9 More than 72% of restrained older adults were found to have disruptive behaviors, cognitive impairment, dementia, or low impulse control.8,9,10 Studies have shown that restraint use was ineffective in redirecting inappropriate patient behaviors and increased agitation which lead to patient injury in 12% of cases.6,7,9 Alternative interventions both pharmacological and non-pharmacological were exhausted in less than 10% of restrained individuals in acute care settings.10 Researchers hypothesized that this could be related to nurse-patient ratios and understaffing. However, when reviewing the facility staffing records and nurse answered surveys, there was no correlation between understaffing and increased restraint use.7,8,9,12 Based off of the answers received, it was determined that the continued use of restraints in inappropriate settings was because of perceptions held by staff and family members.

 One of the most common perceptions among nurses and family members is that restraints reduce the risk of injury in acute care settings.8 To gain insight on the thoughts, opinions, and emotions of nurses, family members, and the patients themselves, there have been studies that developed questionnaires and initiated interviews for these populations.8,9,11,12 It was found that the opinions of nurses and family members did not have as great of a difference as previously projected.7,8 In a study of over 235 critical care nurses, only 56% stated that patients can refuse restraint placement.8 Interestingly enough, over 75% recognize feelings of guilt and embarrassment when they must utilize mechanical restraints in patient care. When it came to other interventions, 77% of nurses said they tried alternate measures and 83% stated that they would rather chemically sedate a patient.8,10, Based off of the answers given by staff, restraints were seen as unfortunate but necessary in regard to their role in patient care.10 Family members of restrained patients reported feeling divided on their use.7,8,10,12 The results showed, family members struggled the most with unease of having loved ones restrained, anger towards the patient’s behavior or towards staff, and feelings of their family member being held a prisoner.12 However, it is important to note that the family members scored almost just as high as the nurses during the test.10,12 The families of the patients agreed that accepting the fact their family member is restrained helps them cope because the patient can undo it or refuse at any time.8,12 The vast majority claimed they are “better” than sedatives and can support the reasoning behind restraint use.7,8,10,12 During the interview process, over 70% of families stated that they were the least supportive of indirect forms of restraint such as not adequately clothing a patient to prevent wandering and by removing assistive devices from the patient’s reach.12 The patients interviewed in this study agreed with this sentiment.12 Indirect forms of restraints led to increase feelings of mistrust of staff, increased frustration, loneliness and despair.10,12 The answers received by the patients, however, were not as positive as those of the nurses and families.10,12 Over 79% of the patients interviewed indicated they would rather risk injuring themselves (via wandering) than have a restraint in place.12 Over 82% stated they harbored negative feelings and decreased their confidence during the healing process.8,12 As a result of these studies, it became obvious to researchers that a knowledge deficit existed across the board pertaining to restraint use.8,9,10,12 Many institutions have used this as an opportunity to incorporate more staff education, review of policies, and family teaching to further improve and maintain the safety of the patients.7,8,9,10

 The consequence of the numerous studies regarding attitudes of those involved or affected by restraint use has led to reforms in acute care settings to increase patient safety and awareness.8 A mixed research study compiled a list of main points that have been individually chosen based off of the results of their own data and other pertinent studies to create a basic educational guideline to act as starting point for institutions.8 Education remains one of the greatest factors that can prevent falls and injury in the elderly associated with restraint use.8,9 Acute care providers, administration included, should be able to identify the risks and benefits of restraint use, recognize incorrect information of their use, become sensitized to the experience of being restrained, discuss personal attitudes of use with administration, describe legal and ethical implications, and discuss alternative therapies that are safe, cost effective, easy to implement, and preserve the patient’s diginity.8

The decline of restraint use can be directly attributed to the results studies have yielded and improved staff education gained from evidence based practice.8,9,12 It is generally agreed upon that utilizing physical restraints is no longer an acceptable practice unless other options have been exhausted or the patient is a threat to themselves or others.7,12 Although many of the studies reviewed revealed inconclusive data pertaining to other interventions, such as bed alarms and non-skid socks, to prevent falls, education on safety awareness has proven to improve patient outcomes among high fall risk patients.1,3,4 By continuing to conduct more research on the topic and adapting policies and guidelines to support the latest evidence, nurses can continue to decrease the rate of falls and risk for injury in the geriatric population.

References

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11. Capezuti E, Strumpf NE, Evans LK, Grisso JA, Maislin G. The Relationship Between Physical Restraint Removal and Falls and Injuries Among Nursing Home Residents. J Gerontol A Biol Sci Med Sci. 1998 Jan 1;53A(1):M47–52.
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