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Restraints

Restraint Use in the Geriatric Population

STATEMENT

The New Jersey State Nurses Association is committed to quality care and maintenance of quality of life for our older population in acute and long term care settings. Federal Regulations effected in 1990 under the Omnibus Reconciliation Act support quality of life issues and reduction of restraint usage. The New Jersey State Nurses Association opposes the use of unnecessary physical and/or chemical restraints. Restraints do not substitute for safe environments or adequate supervision and staffing, and should never be used for the purpose of discipline or convenience to control client behavior.1

EXPLANATION

Physical restraints are any devices used to restrict a client's free physical movement. Examples include: Geri-chairs with table tops, wrist restraints, hand mitts, waist belts, safety belts, jackets or vest type devices to restrict movement. Problems that have been associated with restraint use are- wheelchair positioning problems, wandering, behavior problems, falls and balance, and tampering with support devices. All of these problems can be corrected by proper use/ or modification of devices. This does not require a lot of expertise and is very cost effective. Patients are more likely to become agitated and climb over side-rails once restraint has been applied. Additionally, patient falls or potential for falls are often reasons for the use of physical restraining devices. There is some evidence to indicate that patient falls are more likely to occur after restraining device has been applied. Serious physical and psychological consequences are incurred as a result of restraint use. A decision to utilize restraints in these instances should be made only after a thorough evaluation by the nurse is conducted. Furthermore, nursing documentation should reflect realistic and appropriate alternatives to improve mobility and prevent falls.

Chemical restraints include non-therapeutic use of psychoactive drugs prescribed to control mood, mental status or behavior. Alternative therapeutic measures should be employed to manage problematic behavior, psychosocial difficulties and environmental changes.3

METHOD

Imminent injury to self or others is an emergency situation, which may warrant immediate restraint, however, prolonged use of restraints indefinitely should be avoided. This necessitates periodic re-evaluation of the client's condition. Falls, cognitive impairment, wandering and agitation are behaviors which require expert nursing assessment and intervention, however, restraints should only be used as a last resort and only after alternative measures have proven ineffective.4 Protocols with clear documentation for the management in acute care and long term care should be established. Protocols should include emergent condition management. Policies and procedures should be developed to use in daily practice and inservice programs should be provided for all staff members.

If restraints are used, appropriate assessment of client, release of restraint, exercise and ambulation must be provided at regularly scheduled intervals. Nurses, in collaboration with the physician and the appropriate Rehabilitative and Mental Health Care Professionals, should continuously re-evaluate clients' conditions and attempt to reduce or eliminate chemical and/or physical restraints. The therapeutic plan of care should include alternative humanistic and therapeutic interventions designed to improve and/or maintain the client's functional and cognitive abilities. Other factors that must be considered before a decision to utilize restraints is made should include, the client’s response to restraints; the use of alternatives; resident/family/staff philosophy regarding use, and attitudes about restraints. Observations and discussion should be documented. The client and family should be included in the development of the plan care, and must be consulted regarding the use of restraints if they are recommended and provide consent whenever possible.

Nursing management of restraint use requires thorough patient assessment including assessment for fall risk. This should also involve identifying and treating health functional, or psychosocial problems that maybe causing conditions for which restraints have been ordered. Minimizing the use of restraints involves looking at care management alternatives such as nursing interventions to improve balance, gait, mobility and safety. When restraint is deemed necessary, alternative measures should be attempted and less restrictive restraints used whenever possible. Periodic evaluation of the client should be made to eliminate or reduce the use of physical and/or chemical restraints; including responding to psychosocial needs, responsive healthcare, meaningful activities, and exercise.

The Gerontological Nurse is in a prime position to assess, and manage the need for prevention of the abuse of chemical and physical restraints. The Gerontological Division of NJSNA considers client safety along with supporting risk-taking measures that promote and maintain independence to an aging population. We recommend that alternatives to restraints be utilized after performing a risk assessment screen, in clients who present with treatment interference and documented disruptive behavior, that cannot be controlled by less restrictive measures. Nursing must continually integrate current research into practice standards. We believe that prevention of abuse and the reduction of the use of restraints is an integral part of the nursing process.

We, therefore, advocate that this position be implemented through evaluation of each client for the use of restraints, to include alternative methods, education of clients, families and staff, and the development of hazard free environments, and the continued development of appropriate risk assessment tools in both acute and long term care institutions.

REFERENCES

1 Rules and Regulations. (1989) Federal Register, 54:481.3.

2 The Long Term Survey. (2990) Interpretive Guidelines, AHCA, Rev. 232: p.51.

3 The Long Term Survey. (1990) Interpretive Guidelines, AHCA, Rev. 232: p.51.

4 Morrison, J., Crinklaw-Wiancko, D., et.al. (1987) Formulating a Restraint Use Policy, J. of Nursing Administration, 17:3, pp. 39-43.

5 Evans, L.K., Strumpf, N.E., and William, C.C (1991)

Redefining a Standard of Care for Frail Older People: Alternatives to Routine Physical Restraint. In Kane, R., Katz, P., and Mezey, M.Eds. Advances in Long Term Care Vol. I. New York: Springer.

Alternative Interventions to Restraints

Brower, H. T. (1991) The Alternatives to Restraints, J. of Gerontological Nursing, 17:2, pp.18-22.

HCFA. (1995) Resident Assessment Instrument ( RAI) Version 2.0 Manual Appendix C

McHuthion, E. and Morse, J.M. (1989) Releasing Restraints: A Nursing Dilemma, J. of Geronotological Nursing, 15:2, pp. 16-21.

Rader, J. (1991) Modifying the Environment to Decrease the Use of Restraints, J. of Gerontological Nursing, 17:2, pp 9-13.

Written by: Congress on Practice
New Jersey State Nurses Association

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