Journal of Gerontological Nursing

Physical and Pharmacologic Restraints in Long-Term Care Facilities

Helene Middleton, MSW; Richard G Keene, PhD; Christine Johnson, RN, MS; Allan D Elkins, MSW; Ann E Lee, MSW

Abstract

ABSTRACT

This study examined the effects of education on the attitudes and practices of long-term care staff toward use of restraints. The intervention, a 1-day educational seminar, used a collaborative team of speakers from the Utah Survey Agency and medical professions. Seminar goals were threefold: first, to provide information about best practices for managing behaviors of individuals with dementia in long-term care settings; second, to provide an explanation of the Omnibus Budget Reconciliation Act regulations pertaining to restraint use; and third, to present alternative strategies to link best practice guidelines to the provision of care. Results showed significant changes in participants' attitudes toward use of restraints. Participants reported replicating the seminar for nursing home staff, revisiting facility policies on restraints, and modifying resident care plans.

Abstract

ABSTRACT

This study examined the effects of education on the attitudes and practices of long-term care staff toward use of restraints. The intervention, a 1-day educational seminar, used a collaborative team of speakers from the Utah Survey Agency and medical professions. Seminar goals were threefold: first, to provide information about best practices for managing behaviors of individuals with dementia in long-term care settings; second, to provide an explanation of the Omnibus Budget Reconciliation Act regulations pertaining to restraint use; and third, to present alternative strategies to link best practice guidelines to the provision of care. Results showed significant changes in participants' attitudes toward use of restraints. Participants reported replicating the seminar for nursing home staff, revisiting facility policies on restraints, and modifying resident care plans.

In the past 2 decades, there has been growing attention and concern regarding the use of restraints with long-term care residents. In 1986, the Institute of Medicine Committee on Nursing Home Regulation study concluded that, in the poorest-performing facilities, residents had high rates of pressure sores, had high rates of preventable infections, and received inadequate medical attention, and that the use of physical and chemical restraints was common.

Studies from 1975 to 1989 on the prevalence of restraint use in longterm care settings indicated rates between 25% and 85% for physical restraints (Evans & Strumpf, 1989; Folmar & Wilson, 1 989) and between 58% and 72% for pharmacologie restraints (Beardsley, Larson, Burns, Thompson, & Kamerow, 1989; Beers, Avorn, Soumerai, & Everitt, 1988; Covert, Rodrigues, & Solomon, 1977). In terms of adverse effects, numerous studies have demonstrated that both physical and pharmacologie restraints are associated with physical disability, more frequent falls, cognitive impairment, functional decline, confusion, behavioral symptoms, and loss of dignity and liberty (Marks, 1992; McShane et al, 1997; Strumpf & Evans, 1991; Werner, Cohen-Mansfield, Braun, & Marx, 1989).

Table

TABLE 1GENERAL BELIEFS ABOUT PHYSICAL RESTRAINTS

TABLE 1

GENERAL BELIEFS ABOUT PHYSICAL RESTRAINTS

Table

TABLE 2PHYSICAL RESTRAINT USE

TABLE 2

PHYSICAL RESTRAINT USE

Table

TABLE 3RATIONALES FOR USE OF PHYSICAL AND PHARAAACOLOGIC RESTRAINTS

TABLE 3

RATIONALES FOR USE OF PHYSICAL AND PHARAAACOLOGIC RESTRAINTS

As a result of the concerns regarding the misuse of restraints in long-term care settings, the Omnibus Budget Reconciliation Act (OBRA) (1987) mandated that residents have "the right to be free from. ..any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms." Although the number of restrained long-term care residents dropped after the implementation of the OBRA (1987) regulations, recent studies suggest that between 20% and 40% of longterm care residents have remained in physical restraints (Gold, 1996) and that the prevalence of antipsychotic drug use has only decreased between 25% and 36% (Shorr, Fought, & Ray, 1994; Vladeck, 1996). The main reasons cited by long-term care staff for using physical restraints are prevention of falls, wandering, disruptive behaviors, severe cognitive impairment, and safety of residents (Burton, German, Rovner, Brant, & Clark, 1992; Janelli, Kanski, & Neary, 1994; Tinetti, Liu, Marottoli, & Ginter, 1991). Agitation and severe cognitive impairment are the most consistent predictors of pharmacologie restraint use (Sloane et al., 1991).

Results of recent studies suggest that leading barriers to reducing restraints is the belief that restraints decrease falls and prevent injuries (Brower, 1991; Capezuti, Evans, Strumpf, & Maislin, 1996; Monane & Avorn, 1996) and that restraints make caregiving more efficient for staff (Blakeslee, Goldman, Papougenis, & Torell, 1991; Evans & Strumpf, 1990). Additional studies cite fear of litigation (Francis, 1989), resistance from residents' family members, lack of caregivers' knowledge of alternative strategies to restraints, and problems interpreting the federal regulations (Kane, Williams, Williams, & Kane, 1993).

The increasing prevalence of dementia in long-term care settings may account for the continuing practice of restraining older people. Epidemiologie studies conducted during the past 10 years have demonstrated rates of psychiatric illness in long-term care settings between 80% and 94%, with approximately one half to three quarters of residents having dementia (Chandler & Chandler, 1988; Roper, Shapira, & Chang, 1991; Rovner Sc Katz, 1993), Of residents with dementia, investigators have found that approximately 25% to 50% exhibit psychiatric and behavioral symptoms including delusions, depression, wandering, disruptive vocalizations, verbal abusiveness, physical aggression, and resistance to necessary care (Rovner et al., 1991; Rovner, Steele, German, Clark, & Folstein, 1992; Wagner, Ten, & OrrRainey, 1995).

The present study was undertaken to determine the effects of an educational seminar on participants' attitudes and practices toward use of restraints. Three of the authors (H.M., C.J., A.E.L.) participated in the seminar because a key underpinning of the intervention was the use of a collaborative team of speakers with representation from the Utah State Survey Agency and medical professions. The seminar addressed the following subjects:

* Discussion of the federal regulation requirements for resident assessment, resident rights, quality of life, and quality of care.

* Discussion of how these regulations impact the lives of residents with dementia and support decreased restraint use.

* Best practice guidelines for managing behavior problems exhibited by individuals with dementia.

* Care alternatives to restraints.

The study examined changes in restraint use, as reported by seminar participants, as well as changes in participants' attitudes toward the use of restraints.

METHOD

An 8-hour seminar was presented to 83 participants currently employed in long-term care settings. The seminar consisted of:

* Lectures by two physicians on the adverse effects of physical and pharmacologie restraints with elderly residents.

* A discussion of Medicare/ Medicaid certification laws and survey procedures related to restraint use.

Table

TABLE 4GENERAL BELIEFS ABOUT PHARMACOLOGIC RESTRAINTS

TABLE 4

GENERAL BELIEFS ABOUT PHARMACOLOGIC RESTRAINTS

* Best practice guidelines, including content taken from the Health Care Financing Administration's (1994) Surveyor Guidebook on Dementia.: Evaluating Cornpliance With Regulatory Requirements.

* Alternative care strategies to restraints.

Instrument

The Restraint Questionnaire for Staff (Hardin et al., 1994) was modified to assess participant attitudes and perceptions regarding use of restraints. The questionnaire was administered 1 week before the seminar and was followed by a second administration 3 weeks after the seminar.

The questionnaire was a 34-item, self-administered instrument with 16 items measuring attitudes toward restraints. Additional items assessed perceptions regarding restraint procedures and the number of residents who may have restraints removed without negative consequences. Participants were asked to rank common types of restraints and list interventions which may be employed as alternatives to restraints. Following the seminar, participants were asked if their own or the facilities' use of restraints had changed and to specify the type of change that had been implemented. Demographic items on the questionnaire included staff position, type of facility, level of education, and years of clinical experience.

Table

TABLE 5ALTERNATIVE TREATAAENTS

TABLE 5

ALTERNATIVE TREATAAENTS

Sample

A letter, describing the intent of the study, and the questionnaire was mailed to preregistered participants 1 week before the seminar. Respondents were assured of anonymity and provided $5.00 for returning the completed questionnaire. Of the 83 participants who completed the pretest questionnaire, 33 (40%) were RNs, 12 (14%) were long-term care administrators, 9 (11%) were social workers, 8 (10%) were therapeutic recreation specialists, 6 (7%) were social service aides, 5 (6%) were licensed practical nurses, 3 (4%) were certified nursing assistants, 3 (4%) were Adult Protective Service investigators, 2 (2%) were care coordinators, and 2 (2%) were state or local long-term care ombudsmen. Years of clinical experience ranged from 1 to 35 years, with a mean of 11.23 years.

Posttest questionnaires were mailed to the same participants 3 weeks subsequent to the seminar with a remittance of $10 if returned. Fiftyfour participants returned the questionnaire for a 65% response rate.

Data Analysis

Questionnaire responses were analyzed to determine the percentage of respondents endorsing each statement. Tests of significance between pre-administrations and post-administrations were performed using Wilcoxon Signed Rank Test for two-by-two tables and exact probabilities test for two-by-two tables (Hollander & Wolfe, 1973; McNemar, 1969).

RESULTS

The results of the study are presented in two sections: Findings Regarding Physical Restraints and Findings Regarding Pharmacologie Restraints. The seminar was well received, with all but one of the participants recommending the seminar be offered to colleagues.

Findings Regarding Physical Restraints

The most salient finding from the questionnaire was the belief that fewer residents needed to be physically restrained (Table 1). Item 1 indicated the seminar significantly decreased the perceived desirability of physical restraints (p < .001). Item 2 indicated the seminar significantly increased the belief that physical restraints cause resident confusion p < .05). Item 3 indicated the seminar significantly increased the belief that physical restraints contribute to injuries from resident falls (p < .05). Item 4 indicated the seminar significantly changed the belief that physical restraints increase nursing time (p < .02).

Seminar participants were asked to rank the use of physical restraints in their facilities. The ranked means for physical restraints are reported in Table 2. It was found that the restraints used, from most to least common, were: side rails, waist restraints, geri-chairs, vests, pelvic restraints, mittens, and wrist restraints. The most common rationales of the use of physical restraints were: falls, confusion, violence, poor judgment, and interference with treatment (Table 3).

The seminar participants reported changes in both personal and facility practices in the use of physical restraints after the seminar. Fifty-one percent of participants reported changes in personal practices. In order of decreasing frequency, they were:

* Reviewing the facility policy on use of restraints (41%).

* Using less-restrictive interventions (34%).

* Replicating the seminar for nursing home staff (32%).

* Modifying resident care plans (23%).

* Creating a policy on the use of physical restraints (9%).

Thirty-six percent of participants reported that their facility implemented changes in the use of restraints as a result of the seminar. Participants reported the following changes:

* Offering more recreational programs (25%).

* Creating a restraint committee (21%).

* Incorporating new policies into quality assurance programs (16%).

Findings Regarding Pharmacologie Restraints

The most noteworthy finding from the questionnaire was the belief that fewer residents needed to receive pharmacologie restraints (Table 4). Item 1 indicated the seminar significantly decreased the perceived desirability of pharmacologie restraints (p < .005). Seminar participants also believed pharmacologie restraints were more likely to increase undesirable side effects. Item 2 indicated the seminar significantly increased the belief that pharmacologie restraints cause resident confusion (p < .02). Item 3 indicated the seminar significantly increased the belief that pharmacologie restraints contribute to resident falls (p < .005). Item 4 indicated the seminar significantly changed the belief that pharmacologie restraints increase nursing time (p < .02). Item 5 indicated the seminar significantly reduced the perceived need for pharmacologie restraints (p < .001).

In listing alternatives to restraint use, the seminar significantly altered opinions regarding alternatives to pharmacologie restraints (Table 5). The four alternatives seen as more viable interventions were an increase in recreational activities (33% to 59%, p < .003), consideration of a differential diagnosis (20% to 50%, p < .001), reassessment of residents* need for pharmacologie restraint (6% to 19%, p < .03) and increased staff training (5% to 22%, £ < .002). Fewer participants listed the need for increased supervision (46% to 20%, p < .003) and psychosocial interventions (93% to 76%, p < .01). In listing alternatives to physical restraints, the seminar significantly reduced the recommendation for increased supervision (70% to 33%, p < .001).

The most common rationales for the use of pharmacologie restraints were: violence, confusion, poor judgment, interference with treatment, and falls (Table 3).

Seminar participants reported changes in both personal and facility practices in the use of pharmacologie restraints after the seminar. Fiftyseven percent of participants reported changes in personal practices. In order of decreasing frequency they were:

* Reading the facility policy on use of pharmacologie restraints (36%).

* Replicating the training for facility staff (29%).

* Using less restrictive interventions (29%).

* Modifying resident care plans (23%).

* Creating a policy on the use of pharmacologie restraints (7%).

Thirty-one percent of participants reported that their facility implemented changes in the use of pharmacologie restraints as a result of the seminar. Participants reported the following changes:

* Reviewing recreational programs (23%).

* Creating a psychotropic medication committee (20%).

* Incorporating new policies into quality assurance programs (16%).

CONCLUSIONS

The goal of reducing or eliminating restraint use has become central to both nursing practice and federal law. The findings from this study suggest that an educational program based on best practice guidelines complemented by an explanation of OBRA (1987) requirements is an effective method for altering staff attitudes toward use of restraints in nursing homes. Following the seminar, participants were able to identify potential negative outcomes of restraint use such as increased resident confusion and falls, and increased nursing time. In listing care alternatives to both physical and pharmacologie restraints, fewer participants identified the need for increased supervision. In addition, viable alternatives to pharmacologie restraints were identified as an increase in resident activities, consideration of a differential diagnosis of residents' behaviors, reassessment of the need for medication, and increased staff training.

Participants also reported changes in both facility and personal practices. Changes in facility practices included review of the facility activity program, creation of a restraint committee, and incorporation of new policies into quality assurance programs. Changes reported in personal practices included reviewing the facility policy on restraint use, implementing less restrictive interventions, and modifying resident care plans.

Although OBRA (1987) has provided an incentive for nursing home providers to examine use of restraints, the literature suggests education is an essential element in changing beliefs regarding restraint efficacy, reducing restraint use, and empowering nursing and other professional staff with a repertoire of care alternatives (Evans et al., 1997; Rovner, Steeîe, Shmuely, & Folstein, 1996). Although the degree to which OBRA (1987) or education alone can effect change is unknown, these findings suggest an effective method is the synergy between regulation and education.

REFERENCES

  • Beardsley, R.S., Larson, D.B., Burns, B.J., Thompson, J.W., & Kamerow, D.B. (1989). Prescribing of psychotropics in elderly nursing home patients. Journal of the American Geriatrics Society, 37, 327330.
  • Beers, M., Avorn, J., Soumerai, S.B., & Everitt, D.E. (1988). Psychoactive medication use in intermediate-care faculty residents. Journal of the American Medical Association, 260, 3016-3020.
  • BIakeslee, J.A., Goldman, B.D., Papougenis, D., SC Toreil, C.A. (1991). Making the transition to restraint-free cure. Journal of Gerontological Nursing, 17(2), 4-8.
  • Brower, H.T. (1991). The alternatives to restraints. Journal of Gerontological Nursing, 17(2\ 18-22.
  • Burton, L-C-, German, P.S., Rovner, B.W., Brant, LJ-, & Clark, R.D. (1992). Mental illness and the use of restraints in nursing homes. The Gerontologist, 32, 164-170.
  • Capezuti, E., Evans, L-, Strumpf, N., & Maisltn, G. (1996). Physical restraint use and falls in nursing home residents. Journal of the American Geriatria Society, 44, 637-633.
  • Chandler, J.D., 8t Chandler, J.E. (1988). The prevalence of neuropsychiatrie disorders in a nursing home population. Journal of Geriatric Psychiatry and Neurology, 1(2) 71-76.
  • Covert, A.B., Rodrigues, T., & Solomon, K. (1977). The use of mechanical and chemical restraints in nursing homes. Journal of the American Geriatrics Society, 25, 85-89.
  • Evans, L.K., & Strumpf, N.E. (1989). Tying down the elderly: A review of the literature on physical restraint. Journal of the American Geriatrics Society, 37, 65-74.
  • Evans, L.K., SL Strumpf, N.E. (1990). Myths about elder restraint. Image, 22(2), 124128.
  • Evans, L.K., Strumpf, N.B., Allen-Taylor, S.L., Capezuti, E., Maislin, G., & Jacobsen, B. (1997). A clinical trial to reduce restraints in nursing homes. Journal of the American Geriatrics Society, 45, 675-681.
  • Folmar, S., & Wilson, H. (1989). Social behavior and physical restraints. The Gerontologist, 29, 650-653.
  • Francis, J. (1989). Using restraints m the elderly because of fear of litigation [Letter to the editor]. New England Journal of Medicine, 320, 870.
  • Gold, M. (1996). Ethics: Blending resident rights with safety. Provider, 22(6), 37-45.
  • Hardin, S.B., Magee, R., Stratmann, D., Vinson, M.H., Owen, M., & Hyatt, E.G. (1994). Extended care and nursing home staff attitudes toward restraints. Journal of Gerontological Nursing, 20(3), 23-31.
  • Health Care Finance Administration. (1994). Surveyor guidebook on dementia: Evaluating compliance with regulatory requirements. Baltimore, MD. Author.
  • Hollander, M., & Wolfe, D.A. (1973). Nonparametric statistical methods. New York: Wiley SC Sons.
  • Institute of Medicine Committee on Nursing Home Regulation. (1986). Improving the quality of care in nursing homes. Washington DC: National Academy Press.
  • Janelli, L.M., Kanski, G.W., & Neary, M.A. (1994). Physical restraints: Has OBRA made a difference? Journal of Gerontological Nursing, 20(6), 17-21.
  • Kane, R.L., Williams, C.C., Williams, T.F., & Rane, R.A. (1993). Restraining restraints: Changes in a standard of care. Annual Review of Public Health, 14, 545-584.
  • Marks, W. (1992). Physical restraints in the practice of medicine: Current concepts. Archives of Internal Medicine, 152, 2203-2206.
  • McNemar, Q. (1969). Psychological statistics (4? ed.). New York: Wiley & Sons.
  • McShane, R., Keene, J., Gedling, K., Faîrburn, C., Jacoby, R., & Hope, T. (1997). Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with necropsy follow up. British Medical Journal, 314(7076), 266-270.
  • Monane, M., & Avorn, J. (1996). Medications and falls: Causation, correlation, and prevention. Clinics in Geriatric Medicine, 12, 847-856.
  • Omnibus Budget Reconciliation Act, Subtitle C. Nursing Home Reform Act. (1987). (Public Law No. 100-203) [On-line]. Available http://www.ssa.gov/OP_Home/ ssact/titlel9/l 91 9.htm
  • Roper, J.M., Shapira, J., & Chang, B.L. (1991). Agitation in the demented patient: A framework for management. Journal of Gerontological Nursing, Í7(3), 17-21.
  • Rovner, B.W., German, P.S., Brant, L.J., Clark, R., Burton, L., & Folstein, M.F. (1991). Depression and mortality in nursing homes. Journal of the American Medical Association, 265, 993-996.
  • Rovner, B.W., & Katz, LR. (1993). Psychiatric disorders in the nursing home: A selective review of studies created to clinical care. International Journal of Geriatric Psychiatry, 8(\), 75-87.
  • Rovner, B.W., Steele, C.D., German, P., Clark, R., & Folstein, M.F. (1992). Psychiatric diagnosis and uncooperative behavior in nursing homes. Journal of Geriatric Psychiatry and Neurology, J(2) 102-105.
  • Rovner, B.W., Steele, C.D., Shmuely, Y1 & Folstein. M.F. (1996). A randomized trial of dementia care in nursing homes. Journal of the American Geriatrics Society, 44, 7-13.
  • Shorr, RJ, Fought, R.L., & Ray, W.A. (1994). Changes in antipsychottc drug use in nursing homes during implementation of the OBRA-87 regulations. Journal of the American Medical Association, 271, 358-362.
  • Sloane, P.D., Mathew, L.J., Scarborough, M., Desai, J.R., Koch, G.G., & Tangen, C. (1991). Physical and pharmacologie restraint of nursing home patients with dementia. Journal of the American Medical Association, 26Í, 1278-1282.
  • Strumpf, N.E., & Evans, L.K. (1991). The ethical problems of prolonged physical restraint. Journal of Gerontological Nursing, 17(2), 27-30.
  • Tinetti, M.E., Liu, W., Marottoli, R.A., & Ginter, S.F. (1991). Mechanical restraint use among residents of skilled nursing facilities. Journal of the American Medical Association, 265, 468-471.
  • Vladeck, B. (1996). The past, present and future of nursing home quality. Journal of the American Medical Association, 275, 425.
  • Wagner, A.W., Teri, L., & Orr-Rainey, N. (1995). Behavior problems of residents with dementia in special care units. Alzheimer Disease and Associated Disorders, 9(3), 121-127.
  • Werner, P., Cohen-Mansfield, J., Braun, J., & Marx, M.S. (1989). Physical restraints and agitation in nursing home residents. Journal of the American Geriatrics Society, 27, 1122-1126.

TABLE 1

GENERAL BELIEFS ABOUT PHYSICAL RESTRAINTS

TABLE 2

PHYSICAL RESTRAINT USE

TABLE 3

RATIONALES FOR USE OF PHYSICAL AND PHARAAACOLOGIC RESTRAINTS

TABLE 4

GENERAL BELIEFS ABOUT PHARMACOLOGIC RESTRAINTS

TABLE 5

ALTERNATIVE TREATAAENTS

10.3928/0098-9134-19990701-12

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