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PubMed2006

Use of physical restraint in nursing homes: clinical-ethical considerations.

This article gives a brief overview of the state of the art concerning physical restraint use among older persons in nursing homes. Within this context we identify some essential values and norms that must be observed in an ethical evaluation of physical restraint. These values and norms provide the ethical foundation for a number of concrete recommendations that could give clinical and ethical support to caregivers when they make decisions about physical restraint. Respect for the autonomy and overall wellbeing of older persons, a proportional assessment of the advantages and disadvantages, a priority focus on the alternatives to physical restraint, individualised care, interdisciplinary decision making, and an institutional policy are the central points that make it possible to deal responsibly with the use of physical restraint for older persons in nursing homes.

Aged↗

PubMed2001

Nursing staff members' intentions to use physical restraints with older people: testing the theory of reasoned action.

AIM OF THE STUDY: To examine nursing staff members' attitudes, subjective norms, moral obligations and intentions to use physical restraints, using the Theory of Reasoned Action (TRA). RATIONALE: During the last two decades an extensive body of research has examined nurses' attitudes as one of the main factors affecting the decision to use or not to use physical restraints with older persons. However, no studies have examined empirically the antecedents to nurses' intentions to use physical restraints within a theoretically based framework. METHOD: A correlational design was used with 303 nursing staff members from an 800-bed elder care hospital in central Israel. Participants completed a questionnaire including questions based on the TRA as well as socio-demographic and professional characteristics. RESULTS: Regression analyses found attitudes, subjective norms and moral considerations to be significantly associated to intention to use physical restraints with older people. The TRA explained 48% of the variance in nurses' intentions. CONCLUSIONS: The TRA proved to be a useful framework for examining nurses' intentions to use physical restraints. Nurses' attitudes, beliefs and expectations of significant others should be examined before implementing educational programmes regarding the use of physical restraints.

Adult↗

PubMed1983

Suppression of pica using brief-duration physical restraint.

The present study supported the finding of Bucher et al. (1976) that physical restraint can control pica. However, unlike the earlier study which additionally used a verbal reprimand, physical restraint alone was shown to be effective. Further, this study showed that while all three durations of physical restraint suppressed pica, the duration of 10 s was more effective than either 30 s used with one subject, or 3 s used with the other in alternating treatments designs. The procedure proved simple to use, took minimal staff training time, and required no equipment. During treatment some increase in pica was observed in settings where treatment had not yet been applied but later treatment in these settings quickly controlled the behaviour. Collateral behaviours were largely unaffected except for picking and handling, a precursor for pica, which showed variable changes, with reductions being the only large changes.

Adult↗

PubMed1993

Asphyxial deaths due to physical restraint. A case series.

OBJECTIVE: To assess the common factors and the pattern of deaths related to the use of physical restraints. DESIGN: Case series. PARTICIPANTS: The chief death investigators of 37 large jurisdictions were sent questionnaires for all cases of restraint-related deaths. Sixty-three questionnaires from 23 jurisdictions were returned. MEASURES: The questionnaires allowed us to determine the restraint type used, the age and sex of the deceased, the furniture type with which restraints were used, the type of facility where the deceased was restrained, and whether the application of restraints was incorrect. RESULTS: We report 63 cases of asphyxial deaths from the use of physical restraints. Ages of decedents ranged from 26 weeks to 98 years. The greatest number of deaths occurred in the 80- to 89-year-old patients. There is a higher frequency for females of all ages, but the distribution for males and females is roughly the same for all age groups. Deaths occurred while the patient was restrained in a chair (wheelchair or geriatric recliner) or a bed. Most chair-related deaths (six of 19) and bed-related deaths (16 of 42) involved the use of vest restraints. Thirteen of the 42 bed-related deaths involved bedrails. The majority of deaths (61%) occurred in nursing homes and 57 of these 63 cases occurred while restraints were properly applied. CONCLUSIONS: Our report of 63 cases is an underrepresentation of the true number of restraint deaths. Our finding that the vast majority of restraint deaths occurred while restraints were correctly applied implies an inherent danger in the use of physical restraints. The safety of restraining patients and the efficacy of physical restraint needs to be examined and alternate means of assuring the safety of patients need to be developed.

Adolescent↗

PubMed2002

Perceptions regarding the use of physical restraints with elderly persons: comparison of Israeli health care nurses and social workers.

In view of the difficulty involved in decision-making regarding the use or removal of physical restraints and the recent pattern encouraging the use of interdisciplinary teams for elder care issues, the present study compared the perceptions of Israeli nurses and social workers in health care settings regarding the use of physical restraints. Data were collected from a convenience sample of 50 nurses and 69 social workers working in long-term and acute care settings. The findings indicated that participants in all professions attributed moderate to low importance towards the use of physical restraints. Social workers' perceptions were similar to those of nurses in psychiatric hospitals and slightly more favourable to the use of physical restraints than those of nurses in nursing homes. Patients' safety (as reflected in the scores of the items related to protecting an older person from falling and protecting an older person from pulling out a catheter) was the most important reason for using physical restraints for both groups. Increased attention should be given to the role of social workers as team members in the process of decision-making regarding the use or removal of physical restraints, especially as mediators between the elderly person, family members and staff members.

Aged↗

PubMed1978

The role of physical restraint in the treatment of psychiatric illness.

Although physical restraint is a widely used and possibly hazardous form of treatment, few guidelines for its use appear in the recent psychiatric literature. An approach is described in which physical restraint is considered to be a specific therapeutic technique with definable indications, "dosages", contra-indications, and side effects. A method of initiating and terminating this treatment modality is presented and the indications for its use are discussed. These include the presence of violent behavior during a psychotic illness; the presence of agitation or confusion when the use of antipsychotic medication is limited by physical illness; the presence of severe psychotic symptoms in conjunction with severely regressed, socially aversive behavior; the need to reduce excessive external stimuli; and the request for restraint by the patient. Possible side effects and contra-indications are also discussed and criteria for evaluating the duration and effectiveness of the treatment are proposed.

Evaluation Studies as Topic↗

PubMed2004

Physical restraint use among nursing home residents: A comparison of two data collection methods.

BACKGROUND: In view of the issues surrounding physical restraint use, it is important to have a method of measurement as valid and reliable as possible. We determined the sensitivity and specificity of physical restraint use a) reported by nursing staff and b) reviewed from medical and nursing records in nursing home settings, by comparing these methods with direct observation. METHODS: We sampled eight care units in skilled nursing homes, seven care units in nursing homes and one long-term care unit in a hospital, from eight facilities which included 28 nurses and 377 residents. Physical restraint use was assessed the day following three periods of direct observation by two different means: interview with one or several members of the regular nursing staff, and review of medical and nursing records. Sensitivity and specificity values were calculated according to 2-by-2 contingency tables. Differences between the methods were assessed using the phi coefficient. Other information collected included: demographic characteristics, disruptive behaviors, body alignment problems, cognitive and functional skills. RESULTS: Compared to direct observation (gold standard), reported restraint use by nursing staff yielded a sensitivity of 87.4% at a specificity of 93.7% (phi = 0.84). When data was reviewed from subjects' medical and nursing records, sensitivity was reduced to 74.8%, and specificity to 86.3% (phi = 0.54). Justifications for restraint use including risk for falls, agitation, body alignment problems and aggressiveness were associated with the use of physical restraints. CONCLUSIONS: The interview of nursing staff and the review of medical and nursing records are both valid and reliable techniques for measuring physical restraint use among nursing home residents. Higher sensitivity and specificity values were achieved when nursing staff was interviewed as compared to reviewing medical records. This study suggests that the interview of nursing staff is a more reliable method of data collection.

Journal Article↗

PubMed1998

Survey findings describing the use of physical restraints in nursing homes in Victoria, Australia.

Directors of Nursing of nursing homes in Victoria, Australia were asked to complete a 48 item survey designed to obtain information about the use of physical restraints. Responses were obtained from 272/420 (64.8%) DONs. Of approximately 10,065 (7326 females; 2739 male) nursing home residents, 25.5% (2568) were physically restrained at the time the survey was completed. Of this group, females comprised the largest number (1840; 71.6%) vs 728 (28.4%) males. Bedrails (39%) and restraining belts (29%) were the most commonly used types of physical restraints. "Preventing falls" (80.9%) and "because no alternative exists" (34.6%) were the main patient-oriented and nurse-oriented reasons respectively, for applying physical restraints. Weak correlations were noted between: the number of residents who were physically restrained and the size of nursing homes (r = 0.3313, alpha < 0.05); the total number of staff (r = 0.3031; alpha < 0.05) and the total number of untrained staff (Assistants in nursing) (0.2885; alpha < 0.05), suggesting that these factors had little predictive influence on physical restraint use. The extent that physical restraints are being used in nursing homes in Victoria is high, particularly in the context of a general view in the literature that their use should be minimised, if not avoided entirely.

Accidental Falls↗

PubMed1989

Social behavior and physical restraints.

This paper addresses the question: Are physical restraints related to decreased social behavior among nursing home residents? Data collected from 112 nursing home residents suggest that low social performance puts a resident at risk of being restrained, but more frequently the use of a restraint hampers a resident's performance of social behavior.

Aged↗

PubMed1996

The advanced practice nurse and changing perspectives on physical restraint.

Regulatory changes concerning the use of physical restraints in nursing homes have stimulated an examination of restraint use practices in other care settings. Caregivers are receiving mixed messages about appropriate restraint use in the hospital. Legal decisions are ambiguous in terms of the nurse's liability for restraint decisions, and the use of restraints may create a conflict between respecting patient autonomy and acting in the patient's best interest. Recent research does not support the belief that restraint use prevents patient injuries, but continues to document the untoward effects of restraints. Restraint reduction efforts have been successful in nursing homes, and many strategies can be adapted in acute care. As the movement to integrated systems of care places increased emphasis on continuity of services across settings and improved client outcomes, restraint practice is one area where interinstitutional collaboration and coordination must occur. The advanced practice nurse is in a key role to facilitate continuity of restraint reduction efforts.

Continuity of Patient Care↗

PubMedDate not supplied

Use of physical restraints. 1: consequences.

The use of physical restraints, e.g., cotsides, has become a routine procedure in many UK geriatric wards. However, it is associated with numerous adverse physical and/or psychological effects. Although restraints may be indicated in some cases, the nurse should be aware of the possible consequences. Ethical dilemmas may arise. This article, the first in a two-part series, discusses the consequences of restraint use, so that the nurse can balance the potential benefits and risks before deciding upon their use.

Accidental Falls↗

PubMed1998

Use of physical restraints in nursing homes in New South Wales, Australia.

A 48 item postal survey was completed voluntarily by 285/445 (64%) Directors of Nursing (hereafter DONs) of nursing homes in New South Wales, Australia, to obtain information about the use of physical restraints. Of a total of approximately 16,397 (11,719 females; 4678 males) residents of nursing homes from which information was obtained, 15.3% (2516) were physically restrained. Females comprised 11.2% (1839) and males 4.1% (677) of this group. The commonest forms of physical restraint were vests (25.3%), restraining belts (18.9%), bedrails (17.2%), lap trays (14.4%) and gerichairs (10.5%). The commonest patient-oriented reason for using physical restraints was to 'prevent falls' (84.2%) and the commonest nurse-oriented reasons were 'because no alternative exists' (39.6%) and 'to reduce legal liability' (20%). The correlation between the size of nursing homes (bed numbers) and the number of residents who were physically restrained was weak (r = 0.1771, alpha = 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 = 0.1792; 0.0921 respectively; alpha = 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 New South Wales should be of concern.

Accidental Falls↗

PubMed2000

Differences in nursing homes with increasing and decreasing use of physical restraints.

OBJECTIVES: This article examines the organizational characteristics of nursing homes associated with increasing and decreasing use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA) in 1991. METHODS: Nationally representative data from the 1992 and 1997 On-Line Survey Certification of Automated Records are used first to provide descriptive analyses and second for multinomial logistic regression analyses of organizational factors associated with an increase or decrease in physical restraint use. RESULTS: The results show that 2,331 nursing homes increased their use of restraints by >4% and 2,100 decreased their use of restraints by >3%. Ownership, Alzheimer's special care units, and average occupancy rates have bidirectional influence and are associated with both decreases and increases in restraint use, depending on their values. Chain membership and staffing levels of rehabilitation services are associated with increases in restraint use, whereas Medicaid census and private-pay census are associated with decreases in restraint use. Change factors were also important. An increase in Medicaid census and a change to chain membership since 1991 have an unsettling effect on care practices, increasing restraint use. CONCLUSIONS: Although the period used in this analysis represents a time frame in which the restraint reduction mandates of the NHRA were in effect, these results show that some nursing homes have increased their use of physical restraints. The organizational characteristics of these nursing homes differ from those that decreased their use of physical restraints.

Data Collection↗

PubMed1994

Delirium and physical restraint in the hospitalized elderly.

Delirium or acute confusion increase the likelihood of physical restraint use and subsequent harmful physical and psychological effects. Assessment for delirium is presented as a conceptual framework to guide researchers, administrators, and clinicians in developing strategies to decrease the use of physical restraint and to support quality of life for hospitalized older adults.

Aged↗

PubMed2006

The conceptualization of physical restraint as a nursing-sensitive adverse outcome in acute care psychiatric treatment settings.

The occurrence of physical restraint episodes in psychiatric settings is a major public health issue because the therapeutic utility of this form of behavior control has not been substantiated empirically. The purpose of this article was to examine the extant literature to determine if evidence supports the conceptualization of a physical restraint episode as an adverse client outcome that is sensitive to the organization of nursing care in psychiatric settings. An adapted version of the Quality Health Outcomes Model (Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality Health Outcomes Model. Image Journal of Nursing Scholarship, 30, 43-46) was used as the conceptual model to guide this inquiry. The databases Cumulative Index to Nursing and Allied Health Literature, Health and Psychosocial Instruments, HealthSTAR/Ovid and Healthstar, Medline, and psychINFO were searched from 1990 to 2005. There are 101 sources in this review. Evidence strongly suggests that a physical restraint episode is an adverse outcome that is sensitive to the organization of nursing care. A systematic exploration of the specific structures and processes of the organization that affect adverse outcomes, such as physical restraint episodes, is lacking in the United States.

Hospitals, Psychiatric↗

PubMed1998

The use of physical restraints in nursing homes: pre- and post-Nursing Home Reform Act.

The purposes of this paper are: (1) to determine resident risk factors for the use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA) of 1987, (2) compare these results with resident risk factors for the use of physical restraints prior to the implementation of the NHRA, and (3) to identify facility characteristics associated with the use of physical restraints. The data used are from 4,215 nursing home residents in 268 facilities who were evaluated using the Minimum Data Set (MDS) in six month periods in both 1990 and 1993. Results indicate that the NHRA may have been successful in reducing the use of physical restraints; however, it would appear to have had less impact on the types of residents who are restrained. It is also shown that the use of physical restraints is associated with facility characteristics.

Facility Regulation and Control↗

PubMedDate not supplied

Nurses' attitudes toward older persons on their use of physical restraints.

This descriptive study explores the relationship between acute care nurses' attitudes toward older persons, their attitudes toward the use of physical restraints, and their actual use of physical restraints. Restraint use by 52 nurses employed in a hospital setting was assessed for a 1-week period. Three weeks later, two attitude questionnaires were administered to the same group of nurses. Although the incidence of restraint use was low (< 5%), results indicated that nurses with negative attitudes toward older persons were likely to favor the use of restraints with older persons (p = .006). Negative attitudes, however, were not related to the actual use of physical restraints. Factors such as the number of older persons (p = .02) and confused patients (p = .01) in the nurse's assignment, the unit census (p = .00), patient age (p = .00), mental status (p = .00), and the presence of incontinence (p = .00) were significantly related to restraint use. These findings suggest that strategies other than changing nurses' attitudes may be more effective in reducing restraint use.

Adolescent↗

PubMed1993

Nursing staff attitudes on the use of physical restraints in a teaching nursing home.

This study supports the importance of assessing the intrinsic and extrinsic attitudes and perceptions of staff on physical restraints. Any program developed to remove physical restraints in nursing homes should focus on safety issues and behavioral interventions that prevent injury to staff and resident. Environmental adaptations that would enhance residents' safety, such as alarms and wedge cushions, would be useful in a restraint reduction program. Educating staff about the risks of physical restraints and about safe alternative interventions might change their attitudes. By developing an educational program that focuses on a few residents at a time and by involving a multidisciplinary team, a truly individualized approach to restraint-free care for residents might be developed.

Aged↗