Fall prevention in older adults is a major goal and concern for nurses. Currently, more than 33 million individuals in the United States are age 65 or older and will fall at least once a year. Between 5% and 15% of these falls will result in soft tissue injury or fractures. Falls are responsible for more than one third of the deaths from unintentional injury in persons age 65 and older. Secondary complications such as pneumonia, sepsis, and skin ulcers may lead to a subsequent decline in the health status of older adults following a fall induced hip fracture (Commodore, 1995). Post-fall syndrome (e.g., fear of falling, social withdrawal, depression) can occur in some older adults, resulting in restricted mobility and increased dependence (Vellas, Wayne, Carry, & Baumgartner, 1998).
Since the enactment of the Omnibus Budget Reconciliation Act (OBRA) of 1987, there has been a significant reduction in the use of physical restraints to prevent falls in institutionalized elderly adults because of the developing awareness of the physical and psychological problems associated with them. In October of 1990, OBRA mandated major health care policy changes, including new definitions, guidelines, and regulatory criteria for restraint use among older adults residing in nursing homes. The OBRA mandate emphasized the importance of reducing the prevalence of restraint use because of the increased risk of secondary physical complications associated with their use in older adults (Dawkins, 1998; Mahoney, 1995; Middleton, Keene, Johnson, Elkins, & Lee, 1999; Stilwell, 1991). These secondary complications include muscular rigidity and weakness from lack of movement, reduced or impaired circulation, constipation, fecal impaction, incontinence of urine and feces, ankylosed joints and contracted muscles, pressure sores, bone résorption due to demineralization, a reduction in metabolic rate, electrolyte losses, and death due to strangulation or impaired respiratory functioning (Brower, 1991).
Figure. Number of total falls that occurred in each month for Period 1 and Period 2.
Since the inception of the OBRA movement, the prevalence of physical restraint use in nursing homes has decreased from 25% to 84% (Evans, & Strump, 1989) to between 20% and 40% (Gold, 19%). The number of restraint-free facilities has increased from 1% in 1989 to 8% in 1995 (Castle & Fogel, 1998). Although these reductions are encouraging, a resistance to restraint reduction persists (Phillips, Hawes, & Fries, 1993).
Ethical and legal issues of prolonged physical restraint use may explain this resistance to reduce restraint use. According to Strumpf and Evans (1991), the use of physical restraints may threaten the three cardinal principles of ethics (i.e., beneficence, non-maleficence, autonomy). Health care providers are morally obligated (non-maleficence) to protect people from evil or harm (beneficence) while simultaneously maintaining a respect for their right to autonomy. An ethical dilemma may occur when a nurse has to decide whether to use a mechanical restraint as an intervention to prevent injury knowing the consequences of decreasing an older adult's mobility and freewill. This ethical dilemma between beneficence, nonmaleficence, and autonomy is cited most often in arguments for and against the use of mechanical restraints (Dawkins, 1998).
Fear of litigation is a legal issue that may also prevent restraint reduction in institutions (Dawkins, 1998). In spite of these fears, there have been no legally reponed cases against long-term care facilities on the sole basis of failure to restrain. However, legal action has been taken against institutions that ignore federal and state regulatory criteria preventing the use of unnecessary mechanical and chemical restraints for residents and the use of restraints for the convenience of staff members in nursing homes (Strumpf & Evans, 1991).
A synthesis of the research literature in the use of physical restraints on elderly clients in long-term care facilities identified the following four recurring themes:
* Reasons for restraining.
* Candidates for restraints.
* The efficacy of restraints.
* Restraint Education Programs (REPs).
The major reasons cited for restraining clients was to prevent falls, ensure client safety, adherence to policies permitting the use of restraints, maintenance of medical treatments, nurse's own sense of security and comfort, legal liability, and behavior control (Bock & Schilder, 1988; Dawkins, 1998; Lee, Chan, Tarn, Si Yeung, 1999; Quinn, 1993; Thomas, Redfern, & John, 1995).
Profiles of frequently restrained older adults included (Arbesman, & Wright, 1999; Bradley, Siddique, & Dufton, 1995; Burton, German, Rovner, Brant & Clark, 1992; Evans, Sc Strumpf, 1989; Mion et al., 1989; Rawsky, 1998; Sullivan-Marx, Strumpf, Evans, Baumgarten, & Maislin, 1999):
* Advanced age.
* Cognitively impairment with severe inability to perform activities of daily living (ADL).
* A history of falling, wandering, disruptive behavior, depression, social isolation, and visual impairment.
The efficacy of restraint use from earlier studies have indicated the number of reported falls has not been significantly reduced when physical restraints have been used with elderly clients (Lofgren, MacPherson, Crânien, Myllenbeck, & Sprafka, 1989; Miles & Irvine, 1992; Tinetti, Liu, & Ginter, 1992). Arbesman and Wright (1999) reported older adults have a two to five rimes greater risk for falling directly after restraint application. A study by Castle and Fogel (1998) investigated the differences between restraint-free and nonrestraint-free nursing homes and found residents in restraint-free facilities had fewer ADL limitations and less incontinence. In addition, they found restraint-free facilities were smaller, more likely to be in urban areas, and had more full-time RNs per resident on staff then full-time licensed practical nurses (LPNs) and nurse aides.
Bradley's et al (1995) pilot study instituted a REP in four long-term care facilities in Nova Scotia. After completion of the REP, Bradley et al (1995) reported staff perceptions of the importance of restraint use had declined and the importance of alternative approaches had increased. Use of restraints in two facilities had decreased, and the overall number of reported incidents involving falls, injuries, and resident aggression or violence had declined. A clinical trial conducted by Evans et al. (1997) found significant declines in restraint use (specifically vest restraints), a significant decrease in fall rates, and no reported cases of serious injuries after implementing a 6-month Restraint Education-with-Consultation program (REC). Neufeld et al (1999) reported a 90% reduction (41% to 4%) in physical restraint use and a significant decrease in the percentage of moderate to severe injuries after an educational intervention program was implemented in 16 diverse nursing homes.
Restraint reduction, increased caregiver knowledge, and lower fall rates and fall-induced injuries are the benefits of implementing REPs in nursing homes. But, would a simple change in policy prohibiting the use of physical restraints have the similar effect in relation to the number of reported falls and fall-related injuries? One southeastern long-term care facility provided a natural setting for an ex post facto descriptive study specifically investigating these two questions:
FREQUENCY AND TYPE OF INJURY SUSTAINED IN THE FALLS DURING PERIOD 1 AND PERIOD 2
FREQUENCY OF HOSPITALIZATIONS DUE TO FALLS DURING PERIOD 1 AND PERIOD 2
* Is there a difference in the number of falls among older adults residing in this long-term care facility during a time when restraints were in use and during a time when the facility was restraint-free?
* Is there a difference in the number of fall-related injuries among older adults residing in this long-term care facility during a time when restraints were in use and during a time when the facility was restraint-free?
The study sample consisted of all the elderly residents residing in a 98bed southeastern long-term care facility from January of 1995 to December of 1996. All residents residing in the study facility from January 1995 to December 1995 were considered Period 1; those residing in the same study facility from January 1996 to December 1996 were considered Period 2. All residents age 65 and older residing in the facility during the study interval were eligible for inclusion. Only one resident was excluded from the sample population because of age.
The variable of interest was the number of falls experienced by residents during two study intervals that included 1 year of restraint use and the year following the implementation of a restraint-free policy. According to the Health Care Financing Administration (HCFA) (1990) interpretive guidelines to OBRA 1987,
FREQUENCY OF WHERE, HOW, AND WHEN FALLS OCCURRED
a physical restraint is any manual method, physical, mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot easily remove which restricts free movement or normal access to one's body. Leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars, and geriatric chairs are physical restraints (p. 44).
A fall was defined as an unexpected involuntary loss of balance by which a person comes to rest lower or at ground level (Commodore, 1995).
Data were obtained from facility incident report records of falls. An instrument with face validity was developed to categorize the data found on these records into mutually exclusive groups for purposes of counting (Appendix). Categories included age; assessment of confusion; restraint use; fall-related injuries; and how, when, and where the incident occurred. Consistency of this data was tested through a comparison of different incident report forms in the southeastern area. Comparison of forms from other long-term care facilities, acute care facilities, and a government hospital were reviewed and compared. All incident report forms contained identical information pertaining to the documentation of an incident.
Permission to conduct the study was obtained from the director of nursing in the form of a written agreement. This written agreement authorized release of incident report records to be reviewed for data analysis with a statement ensuring individual confidentiality and anonymity in the handling and storage of data. Because incident reports were the data source for this study, no written consent from individuals was necessary (Krowchuk, Moore, & Richardson, 1 995). The researcher then reviewed all the incident reports procured from January 1 995 to December of 1996 when the longterm care facility could still use physical restraints followed by the year after the long-term care facility implemented a restraint-free policy and prohibited the use of restraints.
Statistical analysis using nominal and ordinal level data were computed by using frequencies, percentages and chi-square tests of significance. Data were tallied only on residents who fell during each month and then summated at the end of each period year. The levels of significance for these tests were 0.05.
Differences in the Number of Falls
Results from this investigation showed that 206 falls occurred in Period 1 (1995) and 249 falls occurred in Period 2 (1996). There was no statistically significant difference in the number of falls per month among residents between the two periods [?2 = 9.8, df=n,p = 0.55] (Figure).
Of the 206 older adults who fell during Period 1, 12 (5.8%) residents fell while restrained and the remaining 194 (94.2%) fell while unrestrained. Types of fall-related injuries while restrained were no apparent injury, 5 (42%); lacerations, 4 (33%); contusions, 1 (8%); hip fractures, 1 (8%); and possible fracture, 1 (8%).
Differences in the Types of Injuries
There was a statistically significant difference in the type of injuries sustained among residents who fell in Period 1 and residents who fell in Period 2 [?2 = 12.57, df= 5,p = 0.02]. In Period 1, a lower percent of residents sustained no apparent injury (121, or 59%) but there were higher rates of fractures (12, or 6%) and lacerations (41, or 20%). In Period 2, a higher percent of residents sustained no apparent injury (175, or 70%) and there were fewer fractures (5, or 2%) and lacerations (36, or 14%) (Table 1).
Other Key Findings
Further analysis of the data identified some other related findings. There were significantly more residents hospitalized (12, or 6%) while restraints were being used then when restraints were prohibited (5, or 2%) (?2 = 13.0, df- \,p = 0.03) (Table 2). Most of the falls occurred in the resident's rooms (71%), getting up from a chair (40%), and during the day shift (47%) (Table 3).
The results of this study indicated there was no significant difference in the number of recorded falls when physical restraints were being used and the number of recorded falls after a restraint-free policy was initiated in this long-term care facility. This suggests the risk of falling remains constant whether a policy allows or prohibits the use of physical restraints. Twelve residents who were physically restrained still managed to fall and sustain injuries. These injuries included lacerations, a contusion, and one fractured hip with subsequent hospitalization. This may provide support for Arbesman and Wright's (1999) work that suggested older adults are at a higher risk for falling after restraint application. These findings further support other research studies suggesting physical restraint application may not be an effective tool in the prevention of falls (Arbesman & Wright, 1999; Bradley et al., 1995; Evans et al., 1997; Lofgren et al., 1989; Miles & Irvine, 1992; Tinetti, Liu, & Ginter, 1992).
Additional findings suggested a significant decline in the number of reported injuries after the restraint-free policy was enacted. There were more falls with no apparent injury, fewer fractures and lacerations, and fewer hospitaiizations in the second period than in the first when restraints were being used. Thus, policies permitting residents to move freely without restraint may not decrease the number of falls, but may decrease the severity of injuries in the fall.
Results of intervention studies implementing REPs that promote multidisciplinary approaches present the prevalence, myths, and effects of physical restraints; discuss legal and ethical issues; identify specific alternatives to restraint use; and suggest similar reductions in die number of reported fall cases with serious injury (Bradley et al., 1 995; Evans et al., 1 997). The results of this study suggest a simple change in policy had a similar effect as education programs in the reduction of falls and fall-related injuries.
Other related findings identified the majority of falls had occurred in the resident's rooms, while getting up from a chair, and during the day shift give support to similar findings in Resnick's (1999) study of 220 community-dwelling older adults. Resnick found most falls occurred between noon and midnight, inside the resident's apartment, while performing ADLs (e.g-, bathing, dressing, toileting), and when walking or transferring.
The development of alternative strategies and creative interventions in the prevention of falls and fall-related injuries are essential in the nursing care of older adults. Interventions need to focus more on injury prevention rather than the act of falling itself. Injury prevention begins with assessment and recognition of older adults at a higher risk for falling. Older adults with a history of falling or cognitive and physical impairments are at a higher risk for falling than older adults with physical impairments from the aging process. In addition, assessment of the environment should be considered when identifying risk factors. Bezon, Echevarría, and Smith (1999) developed a Fall Prevention Program for community-dwelling elderly adults based on two approaches:
* Identification of persons at risk for falling based on a risk assessment tool.
* Amelioration of these risk factors through the implementation of specific interventions. Bezon et al. (1999) developed the assessment tool and interventions by combining intrinsic and extrinsic factors known to increase the risk of falls in older adults. According to Commodore (1995), extrinsic or environmental factors include the following:
* High beds.
* Inadequate lighting.
* Sliding carpets.
* Nonlocking bed wheels.
* High steps.
* Worn stair treads.
* Inappropriate chair heights.
* Lack of arm rests.
* High cabinets.
* Glare on floors.
* Ill-fitting walking aids or footwear.
* Objects on the floor.
Intrinsic factors are related to the health status of the older adult, and include the following:
* Altered mobility.
* Sensory impairment.
* Poor eyesight.
* Orthostatic hypotension.
* A history of falls.
* Increase in age.
* Use of alcohol.
Bezon et al. (1999) reported a reduction in the number of falls from 30% to 3% in a sample of 115 community-dwelling residents through interventions developed specifically from the identification of intrinsic and extrinsic risk factors. Thus, assessment of resident risk factors and environmental risk factors is essential in fall and fall-related injury prevention.
Several limitations of this study were identified. One limitation included the time periods chosen for data collection. It is possible the facility may have been decreasing the amount of restraint use in Period 1 because staff knew restraint reduction or elimination was imminent. The findings of no difference between the number of recorded falls for older adults between the two time periods may reflect these changes.
Another limitation was that the data collection tool did not identify what total percentage of residents in the facility had physical restraints in Period 1. Data were obtained only from incident report records of resident falls. Only 12 residents were identified as having a physical restraint in use while falling. However, the other residents who had a restraint and did not fall were not identified. According to the administrator of the facility, 11.8% of residents were restrained during Period 1. This information was obtained from the "Quality Assurance" documents completed each month (Administrator, personal communication, May 1, 1997). The last limitation identified in this study is the inability to generalize these findings to the entire population of older adults, as data only reflect residents of one longterm care facility.
With aging, the risk of falling and sustaining serious injury remains a serious problem. Older adults who frequently fall affect the health-care system by increasing health-care costs due to recurrent hospìtalìzations, nursing home placements, and decreasing health status. Recognizing older adults' increased risk for falling because of the aging process and those who are at a greater risk for falling, aids the nurse in developing a plan of care to ensures client safety from accidental injury from falling.
Findings from this research study indicate that the use of physical restraints on elderly residents in this one long-term care facility was not an effective intervention m the prevention of falls and serious injury. Implementing other alternative measures that include a thorough assessment of resident factors and environmental factors may be the intervention of choice to ensure client safety and human dignity.
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FREQUENCY AND TYPE OF INJURY SUSTAINED IN THE FALLS DURING PERIOD 1 AND PERIOD 2
FREQUENCY OF HOSPITALIZATIONS DUE TO FALLS DURING PERIOD 1 AND PERIOD 2
FREQUENCY OF WHERE, HOW, AND WHEN FALLS OCCURRED