Physical Restraints

 

Overview

 The Centre for Medicare and Medicare Services defines physical restraints as “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body”. Physical restraints include bedrails and other mechanical restraints designed to restrict mobility. The idea behind using these restraints is that by restraining residents, they cannot arise from a chair or transfer out of bed, and thus will not fall (or in the case of bedrails, they will not roll out of bed). However, research has supported the fact that restraints and side rails do not prevent falls (Capezuti et al., 1998).

Evidence of Effectiveness:

The idea that restraints may lead to adverse outcomes and their potential for harm is well documented. They include mobility limitations, muscle weakness and deconditioning which will increase the risk of falling (NRCSA, 2004), and serious injuries such as strangulation, and even death. Mahoney (1998) found that between 37% and 90% of falls from hospital beds occurred because of raised bed rails, and Oliver and colleagues (2000) confirmed that there is no evidence to support bedrails for falls prevention. Thus, federal guidelines now discourage the use of physical restraints except for limited types and bedrails. Gallinagh and colleagues (2002) found that only 35% of those restrained had a supporting rationale for restraint use documented. The most common reasons for restraint use were to prevent falls (58%), prevent wandering and to promote positional support. They suggested that a decrease in staffing levels might be associated with an increased use of restraints (including side rails). Agostini and colleagues (2001) identified six studies on physical restraints, two concerning bedrail interventions and four on mechanical restraint interventions. None of the studies found a statistically significant difference in falls between the intervention group and the control group. In fact, restrained patients seemed to have a modest increase in fall risk or fall injuries. Physical restraints may also contribute to potential harm by acting to limit the resident’s freedom, dignity, and quality of life. There is now growing evidence against the use of physical restraints: they do not eliminate falls and reducing their use may actually decrease the risk of falling. In fact, the risks of using restraints far outnumber the risks of not using restraints. The risks of using restraints are countless, including:  

• Falls
• Strangulation/death
• Pressure sores/skin abrasions
• Decreased mobility
• Abnormal changes in blood pressure, blood volume, and basal metabolic rate
• Lower-extremity edema
• Cardiac stress
• Incontinence
• Constipation
• Decreased muscle mass, tone, and strength
• Bone demineralization
• Stiffness
• Contractures
• Sensory deprivation
• Increased dependency
• Increased confusion
• Disordered sleep
• Depression
• Agitation
• Frustration
• Loss of dignity
• Changes in self-image

 

Guidelines

 

Bill 85 - Patient Restraints Minimization Act, 2001

 Because of the evidence of the harms of restraints, the government of Ontario issued Bill 85, known as the Patient Restraints Minimization Act in 2001. The purpose of this Act is to minimize the use of restraints on patients/residents and to encourage hospitals and facilities to use alternative methods. Under this Act, a hospital or facility shall not restrain, confine, or use a monitoring device on a patient or resident unless it satisfies section 5 (Enhancement of Freedom and Patient Consent) or section 6 (Prevention of serious bodily harm) of the Act. Every hospital or facility is thus required to establish policies to encourage the use of alternative methods; make its policies available to the public; train staff with respect to the restraining of patients; and keep records about the restraining, confinement, or monitoring of patients/residents. The full details of the Act are available at the following site by the Government of Ontario:
http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_01p16_e.htm

Registered Nurses’ Association of Ontario

 In their latest report on the Prevention of Falls and Fall Injuries in the Older Adult (2005), the Registered Nurses’ Association of Ontario stated their views on the use of restraints. Under their Least Restraint section, they recommended that nurses not use side rails as an intervention for falls prevention, but they do acknowledge that client factors may influence this decision. The authors cited a study by Capezuti and colleagues (2002) which found that there was no difference in the risk of falls or recurrent falls with bilateral side rail use among the nursing home clients they studied. RNAO also recommended that organizations establish a least restraint policy that guides staff on the use of physical and chemical restraints. The RNAO fall prevention guideline can be downloaded at: http://www.rnao.org/Page.asp?PageID=924&ContentID=810

 College of Nurses of Ontario - Report on Practice Standard of Restraints

 The College of Nurses of Ontario (CNO) defines restraints as “physical, chemical or environmental measures used to control the physical or behavioural activity of a person or a portion of his/her body.” Physical restraints (i.e. bed rails) limit a resident’s movement; environmental restraints (i.e. a secure unit or a seclusion room) control a resident’s mobility; and chemical restraints are any form of psychoactive medication used to intentionally inhibit a particular behaviour or movement.

The College endorses the least restraint approach and recommends that all possible interventions be exhausted before deciding to use a restraint.

The CNO agrees with the Registered Nurses’ Association of Ontario that in order for nurses to follow the least restraint policy, the organizations they work in should also support this policy. The CNO’s Restraints standard is consistent with the Patient Restraint Minimization Act of 2001 which includes components such as staff training, reassessment, record keeping, client consent, policy development relating to restraint use, and alternative methods. Their Restraints standard includes a list of nursing responsibilities that nurses should carry out to provide quality care for residents. They are: understanding the client’s behaviour, developing an individualized plan of care, working together with other members of the health care team, evaluating the plan of care and making changes if it is not effective, using the least restrictive restraints if restraints must be used, involving patients in making the care plan, and keeping in mind that restraint use is always a temporary solution and never a long-term intervention.

The following is a sample scenario the CNO provided in their Restraint guidelines on how to deal with restraint use:  

Scenario: A client is admitted into a long-term care facility that has a least restraint policy and does not use restraints. However, the family insists that their mother be restrained to protect her safety and tells the nurse that if they do not restrain their mother and she falls, they will initiate legal action.  

Discussion: When clients request nurses to perform an act that may cause serious harm, nurses need to inform clients in a non-judgmental manner of the potential risks and harms associated with the practice. If the family continues to request that restraints be used, the nurses should respect the family’s choice but needs to explain that because the facility has a no restraints policy, it does not have restraints available or the resources to use restraints safely. Knowing this information, the family can then make an informed decision about where to place their mother.

For more sample scenarios, click the following link to download to full report: http://www.cno.org/docs/prac/41043_Restraints.pdf

 

Alternatives

The following is a list of suggestions that can be used as restraint alternative interventions to prevent falls.

  Environment

• Reduce noise
• Maintain an even temperature
• Place necessary or desired objects within reach of the resident
• Maintain safe ground surfaces
• Keep exits and elevators locked with codes
• Use vision barriers to deter wandering
• Use appropriate lighting
• Adjust residents’ bed height to allow his or her feet to touch the floor with seated on the edge

Physical status

• Increase balance and ambulation skills: therapy, restorative walking programs
• Provide support devices to maximize function: walkers, grab bars, nonskid shoes
• Incorporate frequent toileting and individualized bowel and bladder programs

Cognitive Status

• Anticipate personal needs and interests
• Segment and simplify tasks
• Make adequate, appropriate stimulation available
• Introduce activities that create a sense of purpose

 

For More Ideas of Alternatives to Restraints, see following chart:

Alternatives
1.	Activity involvement	30.	Family education
2.	Appliances (i.e. glasses, hearing aide, brace, splints)	31.	Foods to promote relaxation
3.	Appropriate fitting clothing	32.	Items in reach
4.	Bedside commode, bedpan, urinal	33.	Lowering bed
5.	Built up toilet seat	34.	Massage, back rub
6.	Change of scene	35.	Mat on floor
7.	Company and conversation	36.	Medication reduction
8.	Educated to call before getting up	37.	Naps
9.	Grab bars	38.	Nonskid mat by bed
10.	Instructed on use of appliances	39.	Physician consultation
11.	Instructed on use of call light	40.	Pillows, bolsters
12.	Night light	41.	Range of motion program
13.	Non-glare, nonskid floors	42.	Rearrangement of furniture
14.	Nonskid shoes	43.	Relaxation tapes
15.	Redirection to activity	44.	Staff training
16.	Revised medication schedule	45.	Tinted windows to decrease glare
17.	Snakes	46.	Trapeze bar
18.	Toileting (retraining program)	47.	Visual reminders
19.	Transfer ambulation program	48.	Review of medications
20.	½ rails, 1 full rail, etc.	49.	Wander guard
21.	Alternative call light	50.	Orthotic devices
22.	Assistive devices (walkers, canes, grabbers, etc.)	51.	Change of treatment/medication time
23.	Bed alarm	52.	Fall prevention plan
24.	Behaviour management	53.	Buddy system
25.	Call light attached to clothing	54.	Over bed tables
26.	Carpet	55.	Noise reduction
27.	Chair with armrests	56.	Room identifiers
28.	Communication board	57.	Visual barriers to unsafe areas
29.	Exercise class	58.	Rest areas in “long” hallways

* This list is not exhaustive!

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Restraint-Free Care: Individualized approaches for frail elders

Strumpf, N.E., Robinson, J.P., Wagner, J.S., and Evans, L.K. (1998)

These authors favour restraint-free care, and view restraints as symbolizing a poor quality of care because it is a failure to address the real needs of the person. The philosophy of restraint-free care is to care for each person as a separate and unique individual and to respect their rights. Thus care should be directed towards to the maintenance of dignity, autonomy, self-esteem and physical well-being. Restraint use is inconsistent with the philosophy of individualized care.

 Impact of physical restraint on older adults and their nurses:

 Old adults have expressed many feelings to physical restraints and they include anger, fear, resistance, humiliation, demoralization, discomfort, resignation, denial, agreement, and betrayal. Nurses and other caregivers also feel the impact of restraining older adults and have expressed many concerns, including anxiety, sense of inadequacy, hopelessness or helplessness, frustration, guilt, fear, anger, sense of being overwhelmed, repugnance, and satisfaction. As can be seen from this list, the negative feelings expressed by both the caregivers and the restrained far outnumber any positive aspects of restraint use.

 Myths and Facts about Restraints:

 Below are three very common myths about the use of restraints that we feel should be made known to all caregivers, especially those who work in facilities that currently still support the use of restraints.

Myth 1: “The old should be restrained because they are more likely to fall and seriously injure themselves.”
Fact: Injuries can occur when restraints are used: clients can attempt to remove restraints, will try to climb over bed rails and thus even more serious harm

Myth 2: “The moral duty to protect patients from harm requires restraint.”
Fact: A physical restraint has no known therapeutic value and may actually be hazardous. Side effects of restraints include skin trauma, pressure ulcers, constipation, incontinence, decreased muscle strength, and psychosocial effects as well.

Myth 3: “No interventions for meeting client needs are available.”
Fact: Research shows that a range of individualized interventions have eliminated physical restraints (i.e. environmental modification, change in activity, exercise, etc)

Implementing a process of restraint-free care

The authors of this book also provided a list of guidelines for facilities to follow in order to implement a process of restraint-free care. They suggest that for facilities to successfully implement restraint-free care, this process should be targeted to the board of directors/owners, administration, medical staff, nursing staff, clients, as well as their family and friends. The following are the three main phases of the implementation process:

1. Unfreezing Phase:

• Develop a philosophy of restraint free care: staff need to feel commitment and support from the top.
• Copies of the facility’s philosophy should be circulated and discussed throughout the institution
• Identify leaders (those who are committed, credible, and have authority) responsible for the implementation
• Set clear, achievable goals
• Provide educational programs to the above targeted groups about restraint-free care
• Facilitate open communication regarding restraint-free care

 
2. Moving Phase:

• Become aware of people who are restrained, determine the reasons for each restraint
• Eliminate restraints on the easiest cases first (in consultation with clients, family and staff)
• Prohibit use of restraints once eliminated from a person or unit
• Develop a “no restraint” protocol for new admissions
• Establish a protocol for emergency response to specific risk factors (e.g. bed or chair alarm for fall risk)
• Create an evaluation or feedback system: track medication use, falls and injuries, and progress towards goals
• Provide continuing education to target groups
• Celebrate efforts and successes

 
3. Refreezing phase:

• Develop and refine policies and procedures to reflect changes and adhere to them

 

Alternatives of Side Rail Use

Strumpf et al. (1998) also provided the following list of interventions facilities can use to eliminate the use of side rails:

• place bed against wall
• bed monitors
• low bed or mattress placed on floor
• cushions or padding around bed
• bedside commode
• side rail use should be decreased in a gradual and systematic manner