Physical restraint of older adults is a common practice in institutional care in many countries (Evans et al., 2003), including Finland (Saarnio, Isola, & Backman, 2007). A study of Finnish elderly care institutions found that various forms of physical restraint had been used in 88% of the work units during the week preceding the study. The most common forms of physical restraint included raising the sides of the bed, using geriatric chairs with trays preventing the person from moving, and using wheelchairs and ordinary chairs with restraint belts (Saarnio et al., 2007). The use of physical restraint has been part of elderly care in Finland for decades (Paasivaara, 2002); however, it has been studied relatively little. Unlike in the care of patients with intellectual or developmental disabilities or mental health problems, the use of physical restraint in elderly care is not regulated by legislation in Finland.
On one hand, physical restraint is used to increase the safety of patients who are in poor condition by preventing falls (Saarnio et al., 2007; Suen et al., 2006). However, it is also used to prevent elderly patients from disturbing other patients (Chien, 2000; Saarnio et al., 2007). Patients’ tendency to wander (Gallinagh et al., 2002), as well as the facility’s need to enable care procedures (Chien, 2000; Werner, 2002), also make patients susceptible to physical restraint. In their study, Hamers et al. (2004) found that the use of physical restraint in elderly care was long term in nature. Prolonged use of physical restraint is harmful to older adults, as it causes incontinence (Cotter & Evans, 2006; Landi et al., 2003), immobility, and pressure ulcers (Cotter & Evans, 2006), and predisposes patients to infections (Mott, Poole, & Kenrick, 2005), serious injuries, institutionalization, and even untimely death (Evans et al., 2003).
The need for physical restraint can be reduced through the use of technical aids aimed at increasing the safety of elderly patients, such as pillows and bedside mats (Hoffman, Powell-Cope, MacClellan, & Bero, 2003), nurses’ creative (Janelli & Kanski, 2000) and systematic action (Freeman, 2004), as well as training (Capezuti et al., 2007; Janelli, Stamps, & Delles, 2006; Wagner et al., 2007). Restraint use can be reduced by enhancing working conditions, giving nursing staff the opportunity to use their skills and make decisions (Pekkarinen, Elovainio, Sinervo, Finne-Soveri, & Noro, 2006). According to Isola, Backman, Saarnio, and Paasivaara (2005), nurses’ personality and intuitive behavior can be used to decrease routine-based operation and the use of physical restraint in the care of individuals with dementia who exhibit challenging behavior. However, according to previous study results, nurses are seldom aware of alternatives to physical restraint (Chien, 2000; Suen et al., 2006).
Both quantitative (Kirkevold & Engedal, 2004; Suen et al., 2006) and qualitative approaches (Chuang & Huang, 2007; Gallinagh, Nevin, Campbell, Mitchell, & Ludwick, 2001; Gallinagh, Nevin, McAleese, & Campbell, 2001) have been used to study the use of physical restraint in older adults. Previous studies’ areas of focus have been the frequency of use of physical restraint (Hamers et al., 2004; Kirkevold & Engedal, 2004), the reasons for (Murphy, Williams, & Gill, 2002; Pekkarinen et al., 2006) and consequences of its use (Mott et al., 2005; Shorr et al., 2002), and nurses’ experiences with it (Chuang & Huang, 2007; Suen et al., 2006). The experiences of elderly patients (Gallinagh, Nevin, McAleese, et al., 2001; Huang, Chuang, Chen, Lee, & Lin, 2005; Strumpf & Evans, 1988) and their family members (Gallinagh, Nevin, Campbell, et al., 2001) with the use of physical restraint have been described to some extent, but a recent, research-based point of view of older adults and their family members is lacking.
The aim of this study is to describe the use of physical restraint and the perspectives of elderly patients and their family members on the use of physical restraint in long-term institutional care in Finland. The goal is to produce information that can be applied to the development of long-term institutional care for older adults.
Participants and Data Collection
This study used a qualitative, explorative, and descriptive design. The data in this study consist of observational data supplemented with theme interviews with the elderly patients and their family members. The data for the study were collected in four phases (Figure 1), beginning with planning the observation phase, which included choosing the study units, obtaining the permits required for the study, and informing the staff of the units taking part in the study.
Figure 1. Study Design.Note. D = Daughter; F = Female; H = Husband; M = Male; W = Wife.
Phase One. In Finland, long-term institutional elderly care is provided by both the municipal and private sector. Institutional care provided by the municipal sector is located in either health centers or nursing homes, while private sector care is located mainly in nursing homes. As the aim of the study was to gather a comprehensive body of data about the use of physical restraint in institutional elderly care, the three units taking part in the study were selected from both the municipal and private sectors. The units taking part in the study consisted of a municipal nursing home, a municipal hospice ward, and a private nursing home. After obtaining the permits to conduct the study, an information session was organized for the staff working on the units; after the session they could decide whether to take part in the study. The decision about taking part in the study was collective, and the head nurse of each unit passed on the information about the unit’s participation to the researcher (R.S.).
Phase Two. In the second phase of data gathering, observational data were collected. Units that took part in the observation study were long-term elderly care institutions in which some of the patients had illnesses leading to dementia. However, none of the units was designated as a dementia unit. The units varied in size, and the total number of beds ranged between 19 and 30. The observational data were compiled by one researcher over a period of 4 months. The observations were carried out in all of the units during all shifts: morning, evening, and night. Each unit was observed one to two times per week, amounting to approximately 6 to 16 hours per week.
The gathering of the observational data began by getting acquainted with the operation of each unit and by first observing all elderly care both in the common areas and in the patients’ rooms. As the field study progressed, the focus of observation shifted to situations featuring physical restraint of the elderly patients, and toward the end of the observation period, the researcher concentrated solely on observing situations where physical restraint methods were already known to be used (Spradley, 1980).
The researcher deemed her level of participation in the study as that of a moderate participant, ranking between active and passive participation on Spradley’s (1980) scale. She was open about her role as a researcher to the elderly patients, family members, and nursing staff but was not involved in the operation of the units. The researcher only intervened in situations where the patient was clearly in danger and no nurses were present. The researcher wore her own clothes in the observation units to prevent the older adults and their family members from getting a false idea of her role. She took field notes at regular intervals and kept a personal journal about the feelings and emotions evoked during the observation period, during which she also wrote short notes, which were elaborated into field notes after leaving the observation unit (Polit & Hungler, 1999; Spradley, 1980).
Phase Three. The third phase in the data gathering process, planning the interviews with the older adults and their family members, took place in the final phases of the fieldwork. During the observation period, the researcher got to know the older adults and their family members who visited the care units almost daily, making it possible for the researcher to distinguish potential informants for the study. The aim was to collect the interview data by following the principle of expediency; that is, individuals with experience of the phenomenon under inspection were chosen for the study (Sullivan-Bolyai, Bova, & Harper, 2005).
All of the elderly patients had personal experience with being subjected to physical restraint. All family members interviewed had also experienced their loved one being subjected to physical restraint. Seven elderly patients and 7 family members were interviewed during the study. The family members taking part in the study were between ages 55 and 78. Because only a few family members visited the units regularly, it was not possible to select patients and family members who were related to each other. The patients taking part in the study were all older than age 75. Their physical functional ability was relatively good, as they were all able to move around either independently or aided by a nurse. The researcher also evaluated with the nurses each elderly patient serving as an informant to ensure he or she possessed adequate verbal communication skills and had no serious memory problem that might make it difficult to understand and answer questions.
Phase Four. In the fourth phase of data gathering, elderly patients and family members were interviewed. The theme interviews took place toward the end of the observation period. As the aim was to get the elderly patients and their family members to bring up their own perceptions of the use of physical restraint in institutional care, loosely defined themes were used in the interviews. Using these interview themes, the researcher posed questions of the informants, asking for more detailed information.
The interviews took place in locations suitable for the informants. Locations were selected on the basis of privacy as well as practicality. Many of the family members wanted the interviews to take place at home or in their workplace. The interviews with the patients took place in locations chosen by the patients themselves, usually their own room, and in one case, in the day room at the institution. All interviews were audio recorded with informant consent. Transcribed, the total amount of observational data was 106 pages; interview data filled 160 single-spaced typed pages.
The observational and interview data were analyzed separately using the inductive content analysis method (Sandelowski, 2000). In the first phase, the observational data were transcribed and read through several times. An entity consisting of one or several sentences was chosen as the unit of analysis. The analysis process progressed by searching the data for statements referring to the physical restraint of older adults. The statements found were organized into categories on the basis of similarities and differences. The aim was to retain the terminology of the original data when forming the categories. At this stage, the researcher used her judgment to decide which matters were placed in the same category (Cutcliffe & McKenna, 2004). To control the consistency of the interpretation, the subcategories were compared once more with the original text. Each subcategory was given a name describing its contents. This was followed by similar analysis of the interview data, after which the subcategories were pooled based on the data. Finally, using continuous comparison, categories were produced from the subcategories, and main themes from these. A condensed example of the content analysis is presented in Table 1. In the text, six main themes with categories were identified and formulated.
Table 1: Condensed Example of Data Abstraction and Organization
The permits required for observation and conducting the study were acquired according to normal Finnish policy, so that permission was first obtained from the administration of each unit and then from the nursing staff working on the units. During the observation period, the researcher informed the patients and the family members in the study of her role as an observer. The patients and family members serving as informants were given a written account of the study and its purpose, and they were asked to give their consent to take part in the study. During the interviews with the older adults, the researcher actively monitored the physical and mental energy level of the informants. In the case of one person, the interview was cut slightly short because the informant (a patient) seemed tired and asked for the interview to be discontinued. The interview was not resumed at a later stage, as the informant no longer wished to continue.
The ethical dilemma with observational studies is related to the collective nature of observing: Individual nurses, elderly patients, or family members cannot exclude themselves from the observation. However, none of the individuals in the units taking part in the observation indicated to the researcher either directly or indirectly that the observations bothered him or her (Polit & Hungler, 1999).
Six main themes describing the physical restraint of elderly patients were found in the study. The themes describe stages in the use of physical restraint (Table 2):
- Factors predisposing patients to physical restraint.
- Ways in which the mobility of patients is restricted.
- Feelings and emotions evoked by physical restraint.
- Ways of coping with the physical restraint.
- Consequences of physical restraint.
- Alternatives to the use of physical restraint.
Table 2: Main Themes and Their Categories Describing the Physical Restraint of Elderly Patients
Factors Predisposing Patients to Physical Restraint
Factors predisposing patients to physical restraint were related to the patient’s safety, the patient’s gender, whether the patient disturbs environment, successful care procedures, the need for supervision, faulty grounds for the use of restraint, nursing culture, and an unsafe physical environment (Figure 2). An example of using physical restraint for the safety of the patient is when patients felt unsafe because they were afraid of restless patients. The patients wanted to lock their own door or asked a nurse to do it for them, because they were worried about restless patients entering the room. Another example of using physical restraint for the safety of the patient is when nurses limited a patient’s mobility due to apprehension about the patient’s safety (e.g., the patient could fall or get cramps and fall). If a patient had fallen previously and had been hurt, nurses were concerned the patient might fall again. Regarding patient gender, nurses restricted male patients more often than female patients.
Figure 2. Factors Predisposing Elderly Patients to Physical Restraint.
Nurses restricted patients when they disturbed the environment, which included being aggressive or going into other patients’ rooms. In addition, if a patient had a contagious infection, nurses forced the patient to stay in his or her own room because they wanted to prevent the spread of infection. In relation to successful care practices, restraint better enabled patient feeding, as the use of physical restraint was often the only way to calm down restless patients so they could eat.
Using physical restraint because of a need for supervision meant there were not enough nurses on the ward and there was little time to keep an eye on the patients. Restraint was sometimes used on faulty grounds, which meant nurses were unaware of the reasons for restraint use. This was exemplified when a nurse walked by a patient and wondered why the patient was restricted and who did it. There was also a faulty notation in a patient journal: A patient had moved from another ward to the present ward, and permission to use physical restraint was mistakenly noted in the patient journal.
Nursing culture made the patients susceptible to physical restraint because nurses and family members believed some measures were common in elderly care, such as raising the sides of the bed. An unsafe physical environment meant many safety risks and obstacles were present, and restraint was used to deter patients from moving on the ward.
Ways in Which the Mobility of Patients Is Restricted
This theme was composed of the following categories: patient’s voluntary restraint, direct and indirect restraint used by family members, direct and indirect restraint used by nurses, and restriction as a permanent state. Voluntary restraint occurred when patients did not feel safe on the unit; they locked their own door or asked a nurse to do it for them, worried about other patients entering the room and exhibiting demanding behavior.
The forms of physical restraint used by family members were either direct or indirect. When using direct restraint, the family member restricted the patient’s mobility by raising the sides of the bed or tying the patient to the bed with a duvet cover. Indirect restraint included giving nurses permission to physically restrict the patient or demanding that physical restraint be used.
The forms of physical restraint used by nurses were also either direct or indirect. Direct restraint refers to restraint in which some kind of equipment is used. This included both restricting the patient with something they were already in contact with (e.g., a belt) or using an indirect instrument (e.g., sides of bed). Nurses sometimes used two instruments simultaneously (e.g., a duvet cover and the sides of the bed). Direct methods used by nurses also included preventing the patient from moving by using physical force and strictly telling the patient to “stay put.”
Indirect forms of physical restraint used by the nurses included a mode of operation that promoted passivity, such as restricting the patient’s walking only to locations related to care procedures and taking away the patient’s mobility aid, such as a walker. Situations in which the nurse prevented the patient from calling for help with mobility (e.g., by removing the alarm bell) and those in which the patient intentionally did not receive help when calling for it were also considered to be indirect physical restraint. Keeping patients inadequately dressed was another form of indirect restraint, as described in the researcher’s field notes:
The elderly patient is sitting in a wheelchair in his underpants and tells me right away that he hasn’t been given trousers by the nurses although he has asked for them. He says that he’s too embarrassed to walk around in the corridor without his trousers on.
The use of physical restraint was seen as prolonged, and forms of physical restraint were also used during care procedures, such as feeding. In these cases, the patient was not released from the restraint during meals but was instead fed over the sides of the bed. The use of physical restraint was a recurring phenomenon.
Feelings and Emotions Evoked by Physical Restraint
The use of physical restraint caused divided feelings among the patients, family members, and the nurses. The patients and family members thought that physical restraint made the patient feel safer, yet they also had negative feelings about its use. Patients’ negative feelings had to do with frustration, fear, feelings of loneliness and being a prisoner, mistrusting the nursing staff, and experiencing the loss of human dignity. The use of restraint made the family members feel unease, fear, and anger. The restrained patient was considered a prisoner. Also contributing to the negativity was uncertainty about the reason for the use of restraint. Nurses considered the use of physical restraints to be unfortunate but necessary.
Ways of Coping with the Physical Restraint
Elderly patients used their right of self-determination as an important way of coping. This meant they were able to refuse the use of restricting equipment if they wished. For example, one patient said, “Well, they don’t use it if you tell them ‘no’.”
The patient might continuously try to free himself or herself from the restricting equipment. This was thought to reflect patient self-determination. An example was described in the researcher’s field notes: “The nurse talks about an elderly male patient who has learned to open the lock from the inside. He had also stuffed paper towel inside the lock to prevent the nurses from locking the door.”
Both patients and family members believed that accepting the situation helped them cope. Family members considered physical restriction a better option than the use of sedative drugs, and patients believed the use of humor helped in a restraint situation. The interviews also described patients’ resignation to the situation, which manifested itself as patients getting used to the use of physical restraint, as exemplified with the following patient comment: “Well, it’s not always fun, of course. Especially at first…but you do get used to it, in the end.”
Family members were considered to be supportive in situations that involved the use of physical restraint. Support manifested itself as concern for the patient’s well-being. For example, family members would make sure the belt used as a restraint aid was not too tight. Family members helped the patients cope in a concrete manner by lowering the sides of the bed or removing the tray placed in front of them. Family members also provided support to patients by explaining to them the reasons for the use of physical restraint. Family members believed it was important for the patients to know why their mobility was being restricted.
Nurses’ professional conduct was considered to be helpful to the patients in situations where physical restraint was used. The informants thought it was important for the nurse to tell the patient about the use of physical restraint and the reasons for it. The attention given to the patient by the nurse was considered to be part of professional conduct. One nurse placed cushions on the sides of the bed to make the patient more comfortable. Hugging or stroking were also observed as ways in which the nurses considered the patients’ well-being.
Consequences of Physical Restraint
Although the aim of the restraint was to prevent patients from moving, it was also seen as having positive consequences, enabling the patients to take part in stimulating activities. For example, a tray placed in front of the patient enabled him or her to read newspapers or magazines or look at photographs.
Restricting mobility also had various negative effects on the patients. The mildest consequence was depriving the patients of exercise, which they considered vitally important. The use of restraint caused hazardous situations, such as the patient sliding between the mattress and the side of the bed and a situation in which a patient strapped to a wheelchair and left unsupervised was wheeled away by another patient. The use of restraint also made patients susceptible to mental and physical maltreatment, such as when a patient was moved in a corner and left there; the nursing staff spoke as though the patient was not present, and the patient became the target of yelling and even physical violence from other patients. The most serious consequence was institutionalization, associated with fatigue, lack of initiative, and complete loss of mobility.
Alternatives to the Use of Physical Restraint
The nurses’ mode of operation was considered as a way to avoid the use of physical restraint. Nurses’ presence was seen as having a calming effect on the patients, which family members considered a form of positive restraint. Changing patients’ positions, offering a drink of brandy, and exhibiting a calm manner were also considered alternative modes of operation by the nurses. Nurses’ ability to assess the patients’ level of functional ability was seen as another way to avoid the use of physical restraint.
The use of technical aids was also considered a possible alternative to physical restraint. With proper shoes, head guards, or bedside mattresses, the use of physical restraint would not be necessary. In addition, family members believed an increase in the number of staff would decrease the use of physical restraint.
Reliability of the Study
The aim of research is to take the whole study process into account when assessing the reliability of the study, including observation of all phases, the study results, and their significance (Higginbottom, 2004). Reliability is assessed using the criteria proposed by Lincoln and Guba (1985): credibility, confirmability, transferability, and dependability. Credibility was confirmed using data triangulation (Lincoln & Guba, 1985). Before the onset of the actual observation, a 2-week trial period took place during which no field notes were taken. The researcher had never worked as a nurse in an elderly care institution, so she had no prior knowledge about the ways in which the mobility of patients can be restricted in this setting. This may be seen as increasing the reliability of the observational data.
A sufficiently long observation period also confirmed the reliability of the study. The researcher kept a personal journal in which she wrote down the feelings and emotions evoked by the observation period. The contents of the journal were not analyzed, but its existence ensured that the field notes contained only factual descriptions of the units’ operation. Collecting the observational data from three different kinds of organizations during 4 months and at different times of the day also increased the internal validity of the study. The triangulation of data (i.e., the interviews with the patients and their family members and the observational data gathered) gave a versatile and reliable picture of the use of physical restraint in institutional elderly care.
The quality of the data, secured by careful selection of informants, greatly affects the credibility of the study. Elderly patients who had personal experience in the use of physical restraint and their family members were chosen as informants. Patient informants were required to be able to communicate verbally and not to have serious memory problems, which would have made it more difficult for them to understand or answer questions. Only one of the patient informants was male, so the data do not represent both genders equally in this aspect. However, the researcher used the aforementioned criteria of evaluation in selecting the patient informants, and only one male patient fulfilled these criteria.
Some family members considered the field of study a delicate one and were afraid the information they provided might complicate their relative’s care. Because of this, informants were allowed to choose the location of the interviews. It was also emphasized that the study report would include no background information on which the informants could be identified.
During the lengthy observation period, the researcher became familiar to both the patients and the family members, which made the interviews smoother and increased the reliability of the study results. Informants were told that they were free to refuse or stop an interview without it affecting the patient’s care. In addition, the interview data were collected and analyzed by a researcher with experience interviewing older adults.
Study confirmability was accounted for by describing in as much detail as possible the purpose and implementation of the study. Examples of the data analysis have been provided, and the themes have been supported with authentic quotes.
Transferability refers to the applicability of the study to other situations (Lincoln & Guba, 1985). In this study, the study process and the formation of results were described as accurately as possible to allow evaluation of the transferability of the results. When assessing transferability, it is important to take into account that physical restraint is also a cultural phenomenon, and this study describes the perspectives of elderly Finnish patients and their family members.
The dependability of a qualitative study is linked to the confirmability of the results (Lincoln & Guba, 1985). The data were collected from three different kinds of units. The interviews with the informants were kept as similar as possible by using loosely defined themes as an aid. This improved reliability, as the same content areas were discussed during all interviews, although in different order. The dependability of the study was improved by re-analyzing the data after 3 months. Using two or more independent analyzers improves the confirmability and dependability of a study (Mays & Pope, 2000). In this study, it was not possible to use another categorizer along with the researcher, and thus the data were analyzed independently by the researcher. However, the dependability of the study was partly confirmed by analyzing the data twice. To improve dependability, the study supervisor monitored the analysis period and commented on it.
This study revealed that in addition to restraint methods revealed by earlier studies, such as restraint belts (Hamers et al., 2004), bed linens (Evans et al., 2003), sides of the bed (Gallinagh, Nevin, Campbell, et al., 2001), and locking the room door, the nursing staff also used physical force to prevent patients from moving and issued strict verbal commands forbidding patients from moving. In addition, the results of this study revealed that the nursing staff used indirect methods of restraint that have not been discussed in previous studies. These included actions that promoted passivity, such as limiting the patients’ mobility to care procedure locations and placing the patients’ mobility aids out of their reach. Another indirect restraint method used by the nursing staff was not answering the patients’ calls for help and moving or removing the patient’s alarm bell. The patients’ mobility was also indirectly restricted by keeping them inadequately dressed. These results challenge the current definition of physical restraint.
Molassiotis’ (1995) and Retsas’ (1998) definition of restraint—a restriction of mobility by use of an appliance or equipment—was the basis for this study. However, because the results also revealed other methods of physical restraint, the definition should be broadened to include these as well. This mainly concerns what nursing staff refrains from doing, such as leaving the patient without adequate clothing, alarm bell, or mobility aid and intentionally not assisting the patient with moving. Because most elderly patients see the nursing staff as experts, they believe that as “patients” they are obliged to do as the staff tells them (Penney & Wellard, 2007), which puts patients in a subordinate position when it comes to using restraint.
In addition, the results revealed a new form of restraint, voluntary restraint, in which patients felt unsafe in the care unit and willingly locked themselves in their own room. The patients were afraid of being disturbed by other patients exhibiting demanding behavior. If patients feel unsafe to the point of isolating themselves behind locked doors on a daily basis, it should be reconsidered whether the current care unit is the most suitable for them. As Slettebø (2008) noted, it is very important for elderly patients to feel safe in the nursing home. It is also possible that the patients showing demanding behavior and causing disturbances are not in the environment best suited to their needs. Because the study results revealed that an unsafe nursing environment made the patients more susceptible to the use of physical restraint, it is important to pay more attention to patients’ needs when selecting a care facility. Municipal health center care units are not necessarily the right place for long-term institutional elderly care, because—in terms of general security—they have not been designed with the needs of individuals with dementia in mind.
The active role of family members in situations involving physical restraint was an interesting and novel finding. Family members tied patients to the bed using bed linens. Family members also demanded the nursing staff use physical methods of restraint. The active role family members took in situations of physical restraint indicates that the nursing environment was not considered safe. The study by Gallinagh, Nevin, Campbell, et al. (2001) also revealed that family members of elderly patients accepted the restrictive use of the sides of the bed for the sake of the patients’ own safety.
This study revealed the use of restraint to be prolonged and permanent in nature, recurring daily. Prolonged use of restraint was also found in the study by Hamers et al. (2004). For the nursing staff in the current study, restraining patients seemed to become a routine feature of care, as the staff carried out daily care procedures, such as feeding, on a patient who was restrained, without freeing the patient for the time they were present. However, nursing staff should take note of situations where the patient in physical restraint can be allowed to experience freedom: The sides of the bed can be lowered or restraint belts removed while nurses are present and the patient’s safety can be guaranteed. By letting patients experience freedom in this manner, the staff can also prevent patients’ compulsive attempts to free themselves from the restraints.
The use of physical restraints was considered to have both positive and negative consequences for patients. The negative effects, such as depriving the patient of exercise, susceptibility to hazardous and abusive situations, and institutionalization, are in line with earlier studies (Cotter & Evans, 2006; Evans et al., 2003; Gallinagh et al., 2002). However, positive consequences of physical restraints have not been previously reported.