Recently, I agreed to serve as an expert witness for a case involving nurses' use of physical restraints (restraints) on older adults. As a result of this case, I became very interested in research related to the topic. After an extensive review of the literature, the following definition for physical restraints was developed.
Physical restraints are devices, material and equipment which: 1| are attached to or are adjacent to the patient's body; 2J prevent free bodily movement to a position of choice (standing, walking, lying, turning, sitting); and 3) cannot be controlled or easily removed by the patient. Temporary immobilization of a part of the body for the purpose of treatment, such as casts, splints and arm boards is not included in this definition. In response to the unpleasant connotation attributed to the word, the legal implications of restraining a person and the ambiguity of the word, a number of euphemisms have emerged for "restraints." Examples are: protective devices, soft restraints, geriatric safety chairs and patient safety devices. Regardless of the term which is used, nurses seem very aware of nursing care which may fit the above description Qf "restraints."
Interviews and questionnaires reveal that nurses are very concerned about the use of restraints. Many feel that the use of restraining devices is increasing due to the nursing shortage and the emphasis on the nurse's potential liability for patients who injure themselves or others. These concerns were in reference to hospital and nursing home patients, however, there were comments that restraints were often sent home with the patient at the time of discharge. Several nurses state there is an increase in the number of restraints used on each patient and that it is not unusual, especially in acute care hospitals, to see patients with restraints on all four limbs plus a jacket or body belt restraint.
Nurses' education about the use of restraints, when included, appears to be limited to an hour or less during their orientation to the institution. Nurses frequently speak of the stress related to their decisions about restraints. To quote one nurse "I remember always being in a dilemma about putting a patient in restraints. Some of the patients became violent after the restraints were applied, which made me wonder if the behavior was caused by the restraints, we would have five to six confused patients on a 30-bed unit at one time. Some had Alzheimer's disease, others had confusion related to treatments or other causes. I always wondered if there was a better way to deal with the problem."
These responses to interviews and questionnaires were preliminary studies including about 50 nurses. More rigorous and comprehensive studies are needed to determine the current nursing practice related to use of physical restraints on older adults.
Nurses and other health-care professionals are beginning to address this problem. Nursing leaders such as Doris Schwartz have encouraged nurses to be involved in finding solutions. During the last few years, there have been several clinical articles published. Two videotapes1 2 have been produced plus several research studies have been reported. As noted in the prevous review, these offer valuable information and guidelines for future studies.
Frengley and Mion3 reported that patients 70 years of age and older were restrained more frequently than younger patients and that patients who were restrained, including each age group, had a length of stay more than twice as long as their unrestrained counterpart. DiMaio et al4 found that "during the past two years the medical examiner's office has encountered four deaths caused by these vests in nursing homes in our community " Katz, Weber and Dodge5 reported that six patients had died of strangulation by a physical restraint garment. Cape6 stated that hospitals which used fewer restraints had about half the accident rates compared to the other hospitals.
Yarmesch and Sheafer7 reported the lack of concensus among nurses related to the use of restraints and the use of alternative measures. Innovative alternatives to the use of restraints are reported by Hussian and Brown8 who studied the use of grid patterns on the floor to control wandering behavior. Widder9 described an electronic device which alerts the nurse when the patient swings a leg over the edge of the bed. Fulmer et al10 published standards for the use of restraints. Young, Muir-Nash and Niños" explored the use of "white noise" as a method of decreasing nocturnal wandering. Evans and Strumpf12 studied the use of restraints in the United States compared to Scotland.
Robbins et al13 recommend that the early identification of patients at risk for restraint may reduce the use of restraints by concentrating surveillance which would permit early intervention in such areas as increased staffing and reality orientation. Rader, Doan and Schwab14 suggested new approaches which require that the facility's administration be willing to take some legal risks in order to promote more freedom and a better quality of life for residents.
In summary, nurses in clinical practice, education and research are working together to solve problems related to the use of physical restraints on older adults. However, there are still many unanswered questions. Nursing research studies should be developed from the problems and potential solutions which are identified in clinical practice in addition to the studies which have already been reported. Readers are encouraged to share their thoughts, experiences, projects and other activities related to the use of physical restraints on older adults.
- 1. Sawyer J, Achtenberg B, Mitchell C: Code Gray: Ethical Dilemmas in Nursing. Boston, Fanlight Productions, 1985.
- 2. Diehl P: Restraints, The Difficult Decision. Philadelphia, JB Lippincott, 1986.
- 3. Frengley JD, Mion LC: Incidence of physical restraints on acute general medical wards. J Am Geriatr Soc 1986; 34:565-568.
- 4. DiMaio VTM, Dana SE, Bux RC: Deaths caused by restraints vests. JAMA 1986; 255(7).
- 5. Katz L, Weber F, Dodge P: Patients restraint and safety vests: Minimizing the hazards. Dimens Health Serv 1981; 58:10.
- 6. Cape R: Freedom from restraint. Gerontologist 1983; 23:217.
- 7. Yarmesch M, Sheafor M: The decision to restrain. Geriatric Nursing July-August, 1984.
- 8. Hussian RA, Brown DC: Use of two dimensional grid patterns to limit hazardous ambulation in demented patients. J Geranio! 1987; 5:558-560.
- 9. Widder B: A new device to decrease falls. Geriatric Nursing, SeptOctober, Ì985.
- 10. Fulmer T, et al: Nursing guidelines for the use of restraints in nonpsychiatric settings. / Gerontol NUTS 1987; 9(3).
- 1 1 . Young SH, Muir-Nash J, Niños M: An innovative approach io the management of nocturnal wandering behavior. J Gerontol Nurs 1988; (14)5.
- 12. Evans L, Strumpf N: Patterns of restraints: A cross-cultural view. The Gerontologist, vol. 27, October, 1987, 272A.
- 13. Robbins LJ, Boyko E, Lane J, et al: Binding the elderly: A prospective study of the use of mechanical restraints in an acute care hospital. J Am Geriatr Soc 1987; 35:290-296.
- 14. Rader J, Doan J, Schwab M: How to decrease wandering: A message of agenda behavior. Geriatric Nursing, July-August, 1985, 196-199.