Journal of Gerontological Nursing

EDITORIAL 

Restraint-Free Care: Is It Possible?

Hilke Faber, MN, RN, FAAN

Abstract

For the first time in the history of nursing home public policy, there is a Congressional mandate that says: "Every nursing home in this country must care for its residents in such a manner and in such an environment as will promote the maintenance or enhancement of the quality of life for each resident, and provide the services needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident." The Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act (OBRA) of 1 987 becomes effective October 1,1990.

More than one third of this law is devoted to the protection of residents' rights with a new emphasis on the quality of their lives. Incorporated into this new focus on rights and quality of life is an especially revolutionary provision that states: "The resident has a right to be free from any physical restraints imposed or psychoactive drug administered for purposes of discipline or convenience, and not required to treat the resident's medical symptoms." This means, effective October 1 , 1 990, physical/chemical restraints shall only be used after less restrictive alternatives have been attempted and documented as ineffective. If restraints are ultimately determined necessary, then use will first have to be explained to the resident or legal representative and a signed consent obtained. The restraint, however, may only be used for the specific periods for which it has been determined to be an enabler and demonstrated that it will promote greater functional independence than less restrictive measures.

No longer will physical/chemical restraints be allowed as the first alternative for managing wandering or physically abusive residents, or those at risk of falling without convincing evidence that less restrictive measures prove to be ineffective. No longer will the immediate work environment or staffing shortages be acceptable excuses for the use of physical/chemical restraints. Nor will liability be an acceptable rationale, as the new standard of practice will be to only use restraints as a last resort.

Clearly, this provision is revolutionary and evoking considerable anxiety and frustration for many nurses responsible for the safety and well-being of nursing home residents. Many are questioning the feasibility and practicality of this provision, particularly when they work in physical settings not conducive for adequate resident supervision and are assigned heavy workloads and plagued with chronic understating and high turnover.

Restraint-free care can become a reality and has been the standard of practice in a number of European countries. The Kendal Crosslands Corporation, Philadelphia, has insti] tuted a restraint-free policy in their facilities for the past 1 7 years. They have also demonstrated that it does not require more staff. In fact, they . have shown that it takes more staff U tie and untie residents on the 2-houi schedule currently required by law. It should be pointed out, too, thatth kinds of resident care needs in their facilities are comparable to those found in most skilled nursing facili-1 ties. There are numerous other, yet still too few, facilities scattered around the country involved in the movement to untie the elderly.

As professional nurses, we can probably, in all honesty, agree that restraints have been over-used, misused, and have too often resulted in serious injuries and even death. When asked, some staff have even admitted not being able to recall why a particular restraint was applied, sheepishly realizing that the lack of ongoing assessment and doc umentation may have contributed tc unnecessary use of restraints over ar avoidable extended period. Restraints have admittedly become toe much of a ritualistic or habitual response, rather than part of a well thought-out plan as…

For the first time in the history of nursing home public policy, there is a Congressional mandate that says: "Every nursing home in this country must care for its residents in such a manner and in such an environment as will promote the maintenance or enhancement of the quality of life for each resident, and provide the services needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident." The Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act (OBRA) of 1 987 becomes effective October 1,1990.

More than one third of this law is devoted to the protection of residents' rights with a new emphasis on the quality of their lives. Incorporated into this new focus on rights and quality of life is an especially revolutionary provision that states: "The resident has a right to be free from any physical restraints imposed or psychoactive drug administered for purposes of discipline or convenience, and not required to treat the resident's medical symptoms." This means, effective October 1 , 1 990, physical/chemical restraints shall only be used after less restrictive alternatives have been attempted and documented as ineffective. If restraints are ultimately determined necessary, then use will first have to be explained to the resident or legal representative and a signed consent obtained. The restraint, however, may only be used for the specific periods for which it has been determined to be an enabler and demonstrated that it will promote greater functional independence than less restrictive measures.

No longer will physical/chemical restraints be allowed as the first alternative for managing wandering or physically abusive residents, or those at risk of falling without convincing evidence that less restrictive measures prove to be ineffective. No longer will the immediate work environment or staffing shortages be acceptable excuses for the use of physical/chemical restraints. Nor will liability be an acceptable rationale, as the new standard of practice will be to only use restraints as a last resort.

Clearly, this provision is revolutionary and evoking considerable anxiety and frustration for many nurses responsible for the safety and well-being of nursing home residents. Many are questioning the feasibility and practicality of this provision, particularly when they work in physical settings not conducive for adequate resident supervision and are assigned heavy workloads and plagued with chronic understating and high turnover.

Restraint-free care can become a reality and has been the standard of practice in a number of European countries. The Kendal Crosslands Corporation, Philadelphia, has insti] tuted a restraint-free policy in their facilities for the past 1 7 years. They have also demonstrated that it does not require more staff. In fact, they . have shown that it takes more staff U tie and untie residents on the 2-houi schedule currently required by law. It should be pointed out, too, thatth kinds of resident care needs in their facilities are comparable to those found in most skilled nursing facili-1 ties. There are numerous other, yet still too few, facilities scattered around the country involved in the movement to untie the elderly.

As professional nurses, we can probably, in all honesty, agree that restraints have been over-used, misused, and have too often resulted in serious injuries and even death. When asked, some staff have even admitted not being able to recall why a particular restraint was applied, sheepishly realizing that the lack of ongoing assessment and doc umentation may have contributed tc unnecessary use of restraints over ar avoidable extended period. Restraints have admittedly become toe much of a ritualistic or habitual response, rather than part of a well thought-out plan as to how they will contribute to the well-being of the resident.

Joanne Rader, clinical nurse Specialist, at the Benedictine Nursing Center, Mt. Angel, Oregon, claims that 50% to 60% of all residents currently restrained in nursing homes can easily become restraint-free by simply introducing the concept of non-restraint to the resident, family, and staff; by relieving them of any eas of blame for falls and injuries; and by focusing on the ethical di lemmas of safety and freedom.

If, indeed, this finding is true, it seems that the challenge before us need not be so overwhelming, especially as there is convincing evidence that residents freed from restraints have dramatically improved in their cognition, physical strength, balance, and conti nency. They have been able to reclaim their dignify and freedom. Most importantly, their psychosocial well-being has been restored with their ability to move about at will. Furthermore, staff morale has significantly improved in restraint-free settings, contributing to a decline in turnover. This can be attributed to greater job satisfaction from being able to interact with residents in a more meaningful way. The time formerly used to tie and untie restraints. or cope with overmedicated residents, can now be directed towards more beneficial interventions and interactions for both resident and caregiver.

Eliminating the use of restraints is not only required, but also has proven to be possible. As nurses, we have an opportunity to provide the leadership it will take to make this public policy a reality and to instill an attitude that values the unique qualities of each resident requiring our caring services.

10.3928/0098-9134-19901001-03

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