Use of Restraints in Elderly Nursing Care

Diana Liu

Concept Paper: Reaching for the Belt

Due to the rapidly increasing population of aging individuals globally, different safety approaches are delivered to address health concerns and promote the wellbeing in the geriatric patient. Peer-reviewed publications related to patient safety practices include topics such as medication, physical restraints and alternative therapies. Evidence based research will allow healthcare professionals, such as nurses, to fuel and shape confident, knowledgeable nursing care and interventions. This literature review will present current research and aggregate common themes/significant differences between the articles regarding the application of restraints. In addition, further examination of whether applying physical restraints maintain patient safety (ex: falls prevention) in long-term care settings or if it increases agitation and aggressiveness for the resident.

Clearly & Prescott (2015) defines restraints as “any manual method or physical or mechanical device, material or equipment attached to or adjacent to the body that the individual cannot easily remove which restricts freedom of movement or normal access to one’s body”. The increased prevalence of restraints used in long term settings is evident and concurrent with the variety of illnesses within the geriatric population. Healthcare workers should be sensitive and recognize that the elderly residents in long-term care homes are being displaced and introduced to a foreign environment which interrupts their daily routines.

The most common reason for restraining an elderly individual in a long term setting would be due to age-related behavioural patterns. “The prevalence of dementia among hospitalized patients ranges from 8% to 27%” (Cheong et al., 2016). The result of different behavioural illnesses can exhibit or impact risks relating to increase agitation and interruption of health treatments. An example is the presence of sundowning syndrome in dementia patients. Sundowning syndrome refers to a group of symptoms such as confusion, anxiety, aggression, or ignoring directions, which usually occurs at a specific time of the day.

Types of Restraints

Pharmacological

Antipsychotic (AP) drugs are often in the elderly population residing in long term care facilities. The treatment of agitated behaviour causes pharmotherapy to be initiated. There is no evidence as to how drives the restraint choice of physical, pharmacological or concurrent from the healthcare provider. Research shows that nurses have a tendency to choose AP medication restraint when there is little control in workplace environment and time management (Foebel et al., 2016).

Physical

Physical restraints should be closely monitored and re-evaluated hourly. In addition, the patient should be assessed every 15 minutes to determine whether removal of the restraints should be an option. One literature found that American had a positive view towards restraints usage and it was seen as beneficial for the patient (Masters, 2017). In juxtaposition, several research literature such as Cosper, Morelock and Provine (2015) revealed common negative effects which may include: lacerations, bruising, nerve injury, ischemic injury, asphyxiation, pressure ulcers, falls or possibly even mortality.

Ethical Concerns of Applying Restraints

Nurses in studies revealed that they have an overwhelming of guilt when applying restraints on individuals. Guilt resulting from restricting of freedom patients’ ability to become mobile. Other studies showed that nurses feel that it is their responsibility to carry out the doctor’s or institutional order to keep the patient safe from fall injuries and (taking out IV). In one literature, researchers referenced California SB-130, which state “that restraint is not treatment and does not alleviate human suffering or positively change behaviour” (Clearly & Prescott, 2015).

Research shows that there is a correlation between the increase use of restraints and staff shortage with time pressure to complete nursing duties (Dierckx de Casterlé, Goethals & Gastmans, 2015).

Considerations such as a patient’s autonomy and dignity as healthcare workers recognize and respect that we are dealing with individual human beings. Autonomy refers to one’s ability to make their own decision regardless how staff members perceive good/bad choice. Dignity refers an individual’s value and rights being respected as a whole. Health care professionals have also expressed applying restraints to patients impacts them personally. These workers expressed that they felt a disconnected with physician ordering restraint use and this can cause a breakdown in team moral and distrust.

Financial Costs Associated with Restraints Use

Reducing the use of restraints better preserve dignity of residents and minimize costs associated with increasing dependency of AP medications (Foebel et al., 2016). This dependency may be the medicinal effects of individuals or healthcare workers’ primary solution in the workplace. Some financial costs associated with restraints include medication supply, hospitalization resources and potential lawsuits against institutions for improper decision making. Family members sometimes insist that their loved ones to be restrained to prevent falls or self harm. However, these demands may cause detrimental outcomes to patient’s health.

According to Clearly and Prescott (2015), there is a fear of liability and being held legally due to failure to restrain may be the caregiver’s justification restraint intervention. In the same study, the authors conducted a cost analysis and determine it was less costly to restrain and using alternative approaches and implement restrain reduction program.

Alternatives to Restraints Implementation

Therapeutic Touch

Research shows that, therapeutic touch (TT) is a non-pharmacological option for intervention in agitated elderly individuals that is widely used in both clinical practice and research settings (Cai & Zhang, 2015). TT may be categorized into three types such as: caring touch, protective touch, and task touch. Studies shows that simple touch not only relieve pain and anxiety, promote patients to relax, and improve the quality of life, but it can contribute in disease treatment by enhancing immune function.

Creative Music/Art Therapy

Creative music therapy (CMT) can enhance patient engagement and mood, therefore ameliorating potential agitated and resistive behaviours. “Music therapy is a goal-directed process where the therapist assists a patient to improve, maintain, or restore a state of well-being” (Cheong et al., 2016). Long-term benefits of regular CMT can maintain physical and mental well-being. Additional benefits include increased engagement and mood due to the effects of music on attention, general well-being, and quality of life. Familiar music can trigger memory recall and elicit memories associated with positive feelings. This can also fulfill a person’s unmet needs for self-expression, achievement, meaning and purpose.

Environmental Factors

Numerous restraint alternatives can be implemented to adjust patients’ environment. Some environment changes can include bed position in room, adjustable beds, anti-slip and/or padded mats, hip protectors, motion devices, and position alarms (Clearly & Prescott, 2015).

Education

Research shows that nurses felt that their decision-making process is influenced by the different contextual factors such as inter-personal network and procedural-legal context (Dierckx de Casterlé et al., 2017). Routine staff training on appropriate use of restraints and alternatives, documentation of rationale to support the decision of nursing intervention. Various interdisciplinary professionals can also bring their expertise and support nurses to become empowered and work together collaboratively.

Literature Findings

Overall, the literature reviewed concluded that use of pharmacological or physical restraints does not decrease the incidence of agitation. In fact, there are many negative outcomes associated with restraints use. Some negative outcomes may include increased agitation, medication overdose, injury and may even result of patient death. Research suggests to implement alternatives to restraining patients. Such as options may increase quality of life, promote health and wellness and shorten hospital stays.

Conclusion

The use of restraints should be applied after all other options are exhausted. The use of restraints should not be a solution to the ongoing nursing shortage issue. It appears that many nurses revealed that there is a lack of education on restraint and the alternatives. Long-term care workers should not make assumptions that restraints is the only and best option in keeping a patient safe.

Exemplary nursing care can only begin when nurses and other healthcare professionals demonstrate sound rationale to practice and explore all outlets.

References

Weiner, C., Tabak, N., & Bergman, R. (2003). The use of physical restraints for patients suffering from dementia. Nursing Ethics, 10(5), 512-25. http://dx.doi.org/10.1191/ 0969733003ne633oa