Minimizing the use of restrictive devices in dementia patients at risk for falling

doi:10.1016/j.cnur.2004.02.015

Nursing Clinics of North America

Volume 39, Issue 3, September 2004, Pages 625-647

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Restrictive devices

Physical restraint is defined according to its functional application as any device, material, or equipment that inhibits mobility or change in position and cannot be removed by the person easily [18]. Examples include, but are not limited to, vest restraints, hand mitts, and belts. Side rails are adjustable metal or rigid plastic bars that attach to the bed and come in a variety of sizes (full, three-quarter, half, and quarter-length rail) and shapes [19]. Many nursing home beds include

Negative physical consequences of restrictive device use

Prolonged physical restraint has been correlated with numerous adverse physiological outcomes in animal [48], [49] and human research. Negative outcomes reported in the literature include hyperthermia [50], rhabdomyolysis [51], brachial plexus injury [52], axillary vein thrombosis [53], compressive neuropathy [54], and stress-induced cardiac rhythm disturbances [55]. Side rails also have been identified as a vector for nosocomial infections. Several different types of microbes have been

Negative psychological consequences of restrictive device use

Hospitalized elders express extreme distress when restrained and may suffer adverse psychological effects expressed as anger, demoralization, humiliation, feelings of low self worth, depression, and reduced social functioning [85], [86], [87], [88]. Interestingly, although restraints are used to treat agitation, these devices are correlated strongly with behavioral symptoms such as physical or verbal aggression, especially among those with dementia [88], [89], [90], [91]. Delirium also has been

Physical restraints

Negative consequences associated with restraint use served as a major impetus to change federal law regarding restraints [47]. The Omnibus Budget Reconciliation Act of 1987 [95] resulted in significant reductions in restraint use in US nursing homes, from an overall prevalence of 36% in 1988 [96], to approximately 13.1% in 1998 [97], to 8.86% in 2003. The legislation, in concert with emerging empirical evidence over the last decade, has had a tremendous impact on nursing home practice [3], [98]

Physical restraints

Reduction in hospital physical restraint use began in the early 1990s, spurred by the drastic practice shifts in nursing homes [11], [24]. Restraint standards developed by the Joint Commission on Accreditation of Health care Organizations [110] have led to reductions in overall physical restraint use and as changes in restraint use patterns [21], [40], [111]. Mion et al contend that current restraint use is employed more often to prevent treatment disruption than to avert falls and related

Lack of evidence to support restrictive device use

Restrictive device use is based on a general belief that restriction of a body part or prevention of voluntary transfer from a chair or bed will reduce falls. Numerous studies, however, report a significant incidence of falls and injury among restrained confused patients in both nursing home and hospital settings [5], [14], [35], [114], [115]. Table 1 summarizes studies reporting fall rates associated with restrictive device use.

A study examining the relationship between restraint use and falls

Outcomes associated with restrictive device reduction

Several clinical intervention studies examine both the degree of restrictive device reduction and the effect of the reduction efforts on patient and staff outcomes. Most studies compare interventions with historical control or baseline rates using a before–after study design [116]. Some also have designed their intervention to achieve concomitant reduction of chemical restraints or inappropriate usage of psychoactive medications. Several studies have demonstrated that this is possible in the

Alternatives to restrictive device usage

Although several individual alternatives to restraints and side rail have been proposed, the efficacy and safety of these interventions have not been evaluated prospectively for their individual contribution to fall reduction [129]. Hip protector pads are the best-studied single intervention strategy for fall-related injury prevention among high-risk elders. Several, large-scale, randomized and controlled clinical trials have demonstrated a strong association between reduced hip fracture rates

Approaches to minimizing/eliminating restrictive device usage

Restrictive devices are used to reduce fall and injury risk that often has multiple causative factors. Optimal resolution also requires multiple interventions that rely on coordination by means of interdisciplinary dialog and action [137]. Comprehensive assessment, coordinated care management, and individualized intervention plans targeting identified risk factors have been found to be the most successful strategies to reduce restrictive devices. Several approaches to implementing these

Summary

The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has

Acknowledgements

The author wishes to acknowledge the excellent assistance of Brenda Rodriguez in the preparation of this manuscript.

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Cited by (38)

Psychiatric Nurses’ Attitude and Practice toward Physical Restraint
2017, Archives of Psychiatric Nursing
This study was to assess psychiatric nurses' attitude and practice toward physical restraint among mentally ill patients.
A descriptive research design was used to achieve the study objective. The present study was carried out in three specialized governmental mental hospitals and two psychiatric wards in general hospital. A convenient purposive sample of 96 nurses who were working in the previously mentioned setting was included. The tool used for data collection was the Self-Administered Structured Questionnaire; it included three parts: The first comprised items concerned with demographic characteristics of the nurses, the second comprised 10 item measuring nurses' attitudes toward physical restraint, and the third was used to assess nurses' practices regarding use of physical restraint.
There were insignificant differences between attitudes and practices in relation to nurses' sex, level of education, years of experience and work place. Moreover, a positive significant correlation was found between nurses' total attitude scores, and practices regarding use of physical restraint.
Psychiatric nurses have positive attitude and adequate practice toward using physical restraints as an alternative management for psychiatric patients. It is important for psychiatric nurses to acknowledge that physical restraints should be implemented as the last resort. The study recommended that it is important for psychiatric nurses to acknowledge that physical restraints should be implemented as the last resort.
Use of physical restraints on the elderly: Attitudes, knowledge and practice among nursing staff
2013, Revista Espanola de Geriatria y Gerontologia
Explorar las actitudes, los conocimientos y la práctica relacionada con el uso de restricciones físicas en profesionales de enfermería que trabajan con ancianos, así como la relación entre estas variables.
Estudio transversal de tipo descriptivo y correlacional realizado en 8 residencias geriátricas, basado en 3 cuestionarios que examinaban las citadas variables.
Se incluyeron 378 encuestas (94 enfermeras y 284 auxiliares). Los profesionales tenían una actitud ligeramente en contra de las restricciones, si bien estaban dispuestos a usarlas para evitar caídas. Con relación a los conocimientos, obtuvieron un 66% de aciertos; solo un 32% creía que existen alternativas a la contención y el 69,1% ignoraba que pudiese causar la muerte de pacientes. Además, un 69,8% afirmó que su formación era escasa. La práctica podría considerarse aceptable, si bien un 61,9% opinaba que no sería necesario solicitar a la familia el consentimiento informado y solo el 47,1% de las enfermeras registraría siempre en la historia su uso. Existen diferencias en cuanto a actitudes, conocimientos y práctica entre los 2 grupos profesionales. Se observa que cuanto peores son los conocimientos y más favorable es la actitud hacia este procedimiento, peor es la práctica profesional vinculada a su aplicación.
La actitud del personal ante la restricción física es ambigua, y en sus conocimientos y práctica se han detectado creencias erróneas. Dada la influencia de los conocimientos sobre el resto de las variables es necesario mejorar la formación de los profesionales.
To investigate the attitudes, knowledge and practice on the use of physical restraints by nursing staff working with the elderly, as well as the relationship existing between these variables.
A cross-sectional descriptive and correlational study was conducted among professionals from eight nursing homes. Three questionnaires asking about the mentioned variables were used.
A total of 378 questionnaires were finally included (94 nurses and 284 auxiliary nurses). The professionals’ attitude was generally against the use of restraints, although they were in favour of using them to avoid falls. With regard to knowledge, they obtained 66% of the correct answers; only 32% believed that there were alternatives to restraints, and 69.1% were unaware that these procedures could cause the death of patients. A total of 69.8% said that their training regarding restraint was limited. The practice could be considered acceptable, although the 61.9% thought it was not necessary to get informed consent from the family, and only 47.1% of the nurses always recorded its use in the patient's history. Differences between attitudes, knowledge and practice were found among the two groups. A relationship between the variables was confirmed; less knowledge and more favourable attitude towards physical restraints correlate with a worst practice.
The attitude of the staff to physical restraints is ambiguous, and erroneous concepts have been detected in their knowledge and practice. Given the influence of knowledge on the rest of the variables, the training of the professionals needs to be improved.
Process evaluation of a multicomponent intervention program (exbelt) to reduce belt restraints in nursing homes
2013, Journal of the American Medical Directors Association
Citation Excerpt :
The relative, thus, acquired the nursing home staff view that restraints could prevent dangerous situations and adverse consequences such as falls. Since this is no longer considered true,16,17 this project helped nursing home staff inform the resident's relatives that there are more humane measures to provide safety and involve them in the decision making process. The high level (79%) of relatives involvement in the decision making process underscores the importance of engaging relatives in this process.
The current study describes the process evaluation of a multicomponent intervention program (Expelling Belts [EXBELT]) to reduce the use of belt restraints in psychogeriatric nursing homes. The aim was to assess the feasibility and ascertain suggestions for optimization of the EXBELT program.
A descriptive study comprising longitudinal elements.
Fifteen psychogeriatric nursing home wards in 6 Dutch nursing homes.
The study population consisted of 4 different groups of participants who took part in the intervention arm of the quasi-experimental study examining the effectiveness of EXBELT: nursing home staff who attended the final session of the educational program; 2 nurse specialists who delivered the educational program and did the consultations; 4 groups of delegates representing the nursing home associations where the EXBELT program was implemented; and the relatives of those residents in the intervention group who were restrained with a belt at the start of the study.
Both quantitative and qualitative data were collected from the study population. Data were assessed by means of self-administered questionnaires, recording forms, group interviews, telephone interviews, and monthly meetings.
The EXBELT study was largely performed according to protocol and very well received by nursing home staff as well as resident's relatives. Suggestions to improve the EXBELT program include the addition of examples of how to communicate about the policy change, improving the reach of the intended target population, adding more case-based learning strategies, and embedding the available consultants more proactively.
The implementation of EXBELT was highly successful in the current research population and is likely to be feasible in psychogeriatric nursing homes in general.
Preventing belt restraint use in newly admitted residents in nursing homes: A quasi-experimental study
2012, International Journal of Nursing Studies
Citation Excerpt :
Poor mobility, high dependency and impaired cognitive status are the strongest predictors of restraint usage (Burton et al., 1992; Capezuti, 2004; Gallinagh et al., 2002; Hamers et al., 2004; Sullivan-Marx et al., 1999). Several studies demonstrated that in almost all cases, physical restraints are used as safety measures (Capezuti, 2004; Hamers et al., 2004; Werner, 2002), mainly to prevent falls (more than 90%) (Capezuti, 2004; Hamers et al., 2004; Werner and Mendelsson, 2001). Other uses include the prevention of wandering, the control of restless and aggressive behaviour and maintenance of a resident's position while seated in a chair (Capezuti, 2004; Castle et al., 1997; Gallinagh et al., 2002; Hantikainen, 1998; Ryden et al., 1999).
Physical restraints are commonly used in psychogeriatric nursing home residents despite reports of negative consequences. Most research has focused on restraint reduction without addressing methods to prevent initiation of restraints in nursing homes. EXBELT has been found to decrease belt restraint use but should also be evaluated for its use in preventing restraints.
To investigate the effectiveness of the EXBELT intervention to prevent the use of belt restraints on psychogeriatric residents newly admitted to nursing homes.
Quasi-experimental study design.
Twenty-six nursing home wards from thirteen Dutch nursing homes.
Newly admitted residents (n = 104) during a four month period.
Fifteen wards (intervention group) implemented the EXBELT intervention, which consisted of four components: a policy change, education, consultation and the availability of alternative interventions.
Data on the use of belt restraints, other types of physical restraints, falls and fall-related injuries and psychoactive drug use were collected at T2 (4 months) and T3 (8 months) after baseline (T1) for those resident who were newly admitted after baseline and before T2 (4 months). Physical restraint use data were collected by a trained, blinded observer four times during a 24-h period.
A total of 104 residents were newly admitted after baseline (T1) and before T2. Of those, 82 were present on T2 and T3. Informed consent was obtained from legal representatives of 49 out of the 82 residents. In the control group (n = 20), 15% and 20% used belts at T2 (4 months) and T3 (8 months), respectively. In the intervention group (n = 29), these proportions were 3% and 0%, respectively (OR = 0.08; 95% CI (0.01–0.76); p = 0.03). There was no increase in the intervention group in the use of other physical restraints, falls and fall-related injuries or psychoactive drug use.
The EXBELT intervention effectively seems to prevent the use of belt restraints in newly admitted residents in psychogeriatric nursing homes.
Effect of Physical Restraint Reduction on Older Patients' Hospital Length of Stay
2012, Journal of the American Medical Directors Association
Citation Excerpt :
Unfortunately, we did not have longitudinal data on cognitive function, delirium, or mood to support the notion that restraint reduction can prevent or shorten the duration of delirium that is associated with poor clinical outcomes.34 Physical restraints may lead to physical de-conditioning.35 Unfortunately, interpretation of our data on mobility and ADLs was hampered by the significant number of missing data in the medical records.
Physical restraints are often used to prevent falls and to secure medical devices in older people in hospitals. Restraint reduction has been advocated on the grounds that physical restraints have negative psychological effects and are not effective in preventing falls. The potential effect of restraint reduction on length of hospital stay (LOS) has not been investigated. This study was undertaken to compare the average length of stay of older patients in a convalescent medical ward setting before and after a restraint reduction program.
This is a retrospective study.
A convalescent hospital in Hong Kong.
This study included 2000 patient episodes.
The use of physical restraint, LOS, and clinical outcomes of randomly selected patient episodes in the year before and after the implementation of a restraint reduction program were compared. The clinical outcomes included Modified Functional Ambulatory Categories and modified Barthel index. Subgroup analysis was performed on those with confusion as defined by dementia diagnosis, low abbreviated mental test score, or abnormal mental domain of Norton Score.
A total of 958 and 988 patient episodes admitted to 10 medical wards in a convalescent hospital in 2007 and 2009 were examined. There were no significant differences in the baseline characteristics of patients in the 2 years. With the implementation of the restraint reduction scheme, the rate of physical restraint use declined significantly from 13.3% in 2007 to 4.1% in 2009 for all patients. The average LOS of patients was significantly lower in the year after the implementation of restraint reduction (19.5 ± 20.7 versus 16.8 ± 13.4 days in 2007 and 2009 respectively, P < .001). On subgroup analysis, the reduction in LOS was significant in the cognitively impaired patients (23.0 ± 26.5 to 17.8 ± 15.0 days in 2007 and 2009 respectively, P < .001), but not in the cognitively normal patients. There were no significant differences between the 2 years in the incidence of fall, mobility, and activities of daily living on discharge.
Physical restraint reduction was associated with significant reduction in average length of stay in convalescent medical wards, especially in the cognitively impaired patients.
Quality of life of residents with dementia in traditional versus small-scale long-term care settings: A quasi-experimental study
2012, International Journal of Nursing Studies
The number of people living with dementia worldwide is increasing, resulting in a need for more residential care. In response to criticism of the traditional medical approach to residential dementia care, many large nursing homes are transforming their traditional care facilities into more home-like small-scale living facilities.
This study examined the assumed benefits of small-scale living for residents with dementia, compared to traditional long-term care in the Netherlands and Belgium. The primary outcome was quality of life, divided into nine different domains.
The study had a longitudinal design within a one-year time interval.
Five long-term care settings in the Netherlands and Belgium containing four traditional and twelve small-scale living units participated in the study.
Data were obtained from 179 residents with dementia (age > 65 years) (Dutch small-scale N = 51, traditional N = 51, Belgian small-scale N = 47, traditional N = 30).
Nurses and nursing assistants were trained to fill in the questionnaires.
In the Dutch sample, residents in small-scale settings had higher mean scores on ‘social relations’, ‘positive affect’, and ‘having something to do’ than residents in traditional settings. Moreover, mean scores on ‘caregiver relation’ and ‘negative affect’ remained stable over time among residents in small-scale settings, but decreased in traditional settings. These differences could not be explained by differences in behavioural characteristics, behavioural interventions, or social interaction. In the Belgian sample, fewer differences were found between traditional and small-scale settings. Nevertheless, residents in small-scale settings were reported to experience less ‘negative affect’ than those in traditional settings, which could be explained by differences in depression. Over time, however, residents ‘felt more at home’ in traditional settings, whereas no such increase was found for small-scale settings. Moreover, the mean quality of life scores on ‘restless behaviour’, ‘having something to do’ and ‘social relations’ decreased in small-scale settings, but remained stable in traditional settings.
Both small-scale and traditional settings appear to have beneficial effects on different domains of quality of life of residents with dementia. Future research should focus more on the quality and content of the care provided, than on the effects of the scale and design of the environment in long-term care settings.

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Review articleMinimizing the use of restrictive devices in dementia patients at risk for falling

Section snippets

Restrictive devices

Negative physical consequences of restrictive device use

Negative psychological consequences of restrictive device use

Physical restraints

Physical restraints

Lack of evidence to support restrictive device use

Outcomes associated with restrictive device reduction

Alternatives to restrictive device usage

Approaches to minimizing/eliminating restrictive device usage

Summary

Acknowledgements

First page preview

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Changes in bedrail prevalence during a bedrails reduction initiative

J Am Med Dir Assoc

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

J Adv Nurs

Hospital nurses' views about physical restraint use with older patients

J Gerontol Nurs

Restraint-free care for acutely ill patients in the hospital

AACN Clin Issues

Focus groups: nursing staff's experiences using restraints

Clin Nurs Res

Physical restraint use in the hospital setting: unresolved issues and directions for research

Milbank Q

Restraint reduction and legal risk management

J Am Geriatr Soc

Medicolegal aspects of hospital siderail use

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AACN Clin Issues

Dementia as a risk factor for falls and fall injuries among nursing home residents

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Review article
Minimizing the use of restrictive devices in dementia patients at risk for falling