A patient’s safety is one of a nurse’s primary concerns. It has become a big issue focused on by the general public and policy-makers after medical errors have been increasingly publicized and more hospital-related injuries are reported (Stanford University, 2001). The International Council of Nurses define a nurse’s role as someone who can work on his own and/or in a team to care for people of all age groups, their families, social groups, and communities, whether well or unwell, and in different settings. Nurses promote health, prevent illness, and look after the sick, disabled and the dying. Furthermore, they advocate for a safe environment, participate in research and moulding new policies to better the health care system. (International Council of Nurses, 2010).
But what happens if a nurse has to decide between a patient’s safety and upholding that patient’s right to freedom, dignity, and respect? For this assignment, the researcher wishes to take a closer look on physical restraint use in the elderly, specifically on dementia patients and why nurses find the need to use restraints important despite the drive of facilities and hospitals to eradicate or lessen their use. With the decrease in cognitive capability in some of the elderly patients, how comfortable are nurses in putting them on restraints? Do they find these patients are ripped off of their independence? If restraints are not to be used, then what alternatives are nurses left with? These are some of the questions the researcher aims to answer through a review of current literature on the topic.
Old age brings about numerous problems including physical, emotional, and functional disorders. (Butler & Lewis, 2003). Storrs (2008) describes old age as a biological change which causes diminishing powers of adjustment. This is evident when we see patients unable to cope with their surroundings. Some common physical changes in old age include decrease in cardiac output, increase in blood pressure, impairment of gas exchange, elevation of blood glucose, decline in lean body mass, and loss of muscle mass which makes an elderly person’s locomotion difficult (Boss & Seegmiller, 2001). Not only do changes occur physically, but the elderly also experience various mental alterations. Mental changes may occur following normal aging, medication side effects, and natural functional loss. (Woodward, 2004). Common mental impairments associated with old age include decline in memory retention, depression, and increased anxiety. (Woodward, 2004). Physical and mental changes in older adults make them vulnerable to accidents, often ending with them hurting themselves.
This is more so if the patients suffer from Dementia. Although not a normal part of ageing, Dementia is a common disease in people over 65 years of age. (Ministry of Health, 2013). Dementia is a term used to describe decrease of brain function resulting in memory loss, poor communication skills, absence of reasoning, and inability to perform activities of daily living. (Bupa, 2010). It causes patients to be forgetful and confused, with little or no regard to hazards around them. Confusion, lack of insight, and impulsiveness can result to a display of behavioural problems, thereby making patients with Dementia prone to accidents and injuries (Ministry of Health, 2013). A study by Cunningham (2006) investigates why institutionalised Dementia patients tend to be more “disruptive”. He states that an unfamiliar setting combined with memory problems can be a scary situation for Dementia patients and they react to how they see fit. Adding to this, hospital routines may be misinterpreted which can lead to behaviours that are challenging. (Cunningham, 2006) However, there is a strong suggestion that nurses must try to understand the meaning behind challenging behaviours, and seek ways to inculcate familiarity and lessen distress amongst Dementia patients. (Cunningham, 2006).
The numerous mental, physical, and emotional problems of patients with Dementia leave nursing staff to assist and supervise these patients in most of their activities (Weiner, Tabak, & Bergman, 2003). It is therefore vital that nurses take extra precautions when looking after patients with Dementia to prevent them from doing things that may hurt them or the people around them. Because of the continuous demands to keep patients safe while allowing time to perform daily tasks, some nurses are forced to involve coercion in the form of physical restraints. (Weiner, Tabak, & Bergman, 2003). A physical restraint is any mechanical or physical means or equipment attached to a person, which restricts movement, mobility, or access to a one’s body. (Health Care Financing Administration, 2000).
It may include, but is not limited to, anklets, vest, straight jacket, and lap belts. A device may be considered as a restraint depending on its effect on a person. For example, a sheet may not be a restraint when used as a blanket; however, tucking the sides under the mattress and restricting the person from getting out of bed makes it a restraint. A geri-chair or a tray table are ordinarily not restraints but if they are used to stop a person from getting up, then it becomes one. (Health Care Financing Administration, 2000) Physical restraints are not medical interventions, and its application can be based upon a caregiver’s decision. The Nursing Interventions Classification define physically restraining a patient as putting on, taking off, or causing a device to limit his mobility (Sullivan-Marx, 1996). Account of current practice
Dementia is the progressive decline in cognitive function which is more than what is expected to occur as a person advances in age. It is a non-specific disease which affects brain function, memory, communication skills, problem solving, and attention. (Nordqvist, 2009). In New Zealand, it is estimated that 60% of residents in care homes are diagnosed with moderate to severe Dementia, and every year an additional 250 beds are allocated for new admissions with the same diagnosis. (Bupa, 2010). An article in The New Zealand Herald reveals that 50,000 people in New Zealand are now living with Dementia, and the number could triple by 2050 (The New Zealand Herald, 2013).
However, with the increase in dependency in aged care, there is an alarming decrease in the number of qualified staff willing and able to care for these patients (New Zealand Labour, 2010). Because Dementia patients are unable to reason and decide for themselves, their welfare is almost always left in the hands of the nurses looking after them. But with the complex patients that are handled by nurses daily, it is common for staff to use physical restraints on patients to get them to do what the nurses expect them to do, within the time frame they are expected to be done. (Weiner, Tabak, & Bergman, 2003).
But nurses are not just to restrain patients. As professionals governed by a specific body, nurses’ use of restraints is to be limited. In 18 July 2005, a policy was released by the Canterbury District Health Board (CDHB) Restraint Approval and Monitoring Group stating that all care facilities and acute hospitals in the region are to limit restraint use on patients. (Restraint Approval & Monitoring Group) In the United States, 7%-10% of Dementia patients are at one point restrained during hospitalisation, with 8% actually being tied down (McHutchion & Morse, 1998). These numbers were gathered 11 years after strengthening of the Residents’ Bill of Rights in the USA which included the patients’ Right to freedom from physical restraints.
(Klauber & Wright, 2001) In New Zealand, 3.4%-21% of acutely ill patients were restrained during hospitalisation, with the restraint duration of 2.7 -4.5 days. It is quite different from the number of cases of restraint use in residential care. It was reported that 12%- 47% of patients were restrained in care facilities, with 32% of them restrained no less than 20 days a month. There is a wide range of duration of restraint use from a day to 350 days in a year. (JBI, 2002) These numbers paved way for more researchers to look into the finding ways to effectively lessen restraint use. However, most studies still show that nurses are resistant to the idea of totally removing restraints as an option. Review Aim
The rate of prevalence of Dementia cases, the decline in the number of qualified staff to look after them, and the rampant use of physical restraints on these patients are all very alarming. Even with policies in place to limit restraint use, nurses seem to still use physical restraints on patients. Basically, this review will circle around how much knowledge nurses have about physically restraining dementia patients. This review aims to discover nurses’ understanding of restraint use and unmask the reasons behind their choice to use physical restraint on Dementia patients. It aims to discover any restraint policy on restraint use in Dementia patients.
It will compare data amongst available literature on nurses’ perception of physical restraints and their take on the drive for minimisation of its use. The effects of physical restraint on patients will also be uncovered as articles are subjected to analysis. Literature will also be analysed for any suggestions on how to totally eradicate or avoid restraint use. A study by the Centre for Medicare and Medicaid Services reveal that within the last decade, there has been a constant decrease in the number of physical restraint use in care homes. From 1999, 21.1% of care facilities would physically restrain elderly patients. However, in 2007, the report states that less than 5% support restraints use. (Center for Medicaid and State Operations/Survey and Certification Group, 2008) The researcher aims to draw out a conclusion on the reason behind this change and discover why despite the constant drive of administrative bodies to minimise restraint use, nurses still apply physical restraints on the elderly patients. Search Strategy
Search engines like the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, and Medline were utilised to find significant articles in relation to the review aim. Key words ‘physical restraint’, ‘dementia’, ‘long term care’, ‘nurse’ ‘attitude’ and ‘behaviour’ were used. Google and Yahoo search engines, and the New Zealand Nursing magazine Kai Tiaki, were also used to find related studies. After reading the found articles, the researcher finalised the most relative articles based on search criteria set out.
The search criteria included full reports, quantitative or qualitative studies, and literature reviews. The articles have to be in English, published from 2000 to present, can be accessed fully, participated on by nurses, and limited on physical restraints used on Dementia patients. Because of the limitation in results, the researcher broadened the search and included studies done in acute settings, as long as the patient in restraint has a diagnosis of dementia. After further deliberation, 7 journal articles were chosen for the review. Critical analysis of the literature
Three themes were drawn from the literatures chosen. These themes are a) factors that affect a nurse’s decision to use restraints b) why restraints are used and c) effects of restraints on dementia patients. a. Nurse Education influences decision-making
The studies revealed that the nurse’s level of knowledge about restraints dictates their decision on whether to use restraints or not. According to the study by Yamamoto et al (2009), a nurse must have either a positive cognition or a negative cognition about restraints to consider its use or choose not to act on a situation. Nurses also have to analyse the situation and decide on how to cope. Their coping dictates their decision-making. (Yamamoto & Aso, 2009) For this study, the authors surveyed 272 nurses in general wards in Japan using a questionnaire involving the ethical dilemma of using restraints. This study wanted to elaborate on how nurses make up a decision of restraining a patient based on how well they cope with difficult or challenging patients.
Another study by Weiner et al (2003), states that a nurse has to have knowledge on patient’s rights, code of ethics, and restraint guidelines for them to decide on restraint use. The study further shows that restraint application can be viewed beneficial either to the patient, the nurse, or the institution. Comparing nurses in acute settings to those in care homes, it was found that the latter are less likely to agree to the use of restraints. This may be because most nurses working in care facilities have more knowledge about their facilities’ restraint guidelines. (Weiner, Tabak, & Bergman, 2003) Unlike other researchers, this study involves the institution and gives light to how big a role it plays in how a nurse decides about restraints. Testad et al (2005) performed a randomised single-blind controlled trial in four nursing homes in Norway. In their study, they conducted seminars and guidance sessions over six months for nurses working in care facilities. There was a documented decline of 54% inrestraint use after the educational programmes were concluded. (Testad, Aarsland,, & Aarsland, 2005)
b. Reasons for Restraint Use
Though nurses are trying to keep patients safe by applying physical restraints, these restraints are more harmful. Scherder et al (2010) view restraint use as detrimental to a dementia patient’s cognition and physical activity. They emphasize that using physical restraints on dementia patients causes more harm than good. Keeping dementia patients on restraints reduce physical mobility, increase patient’s stress, and even accelerate incontinence. (Scherder, Bogen, Eggermont, Hamers, & Swaab, 2010) A study in Israel by Natan et al (2010) 120 nurses were used as samples. 67.2% of these nurses admitted to having had restrained a patient over the past year. Some decision-making factors that nurses point at are subjective norms, the resident’s physical state, and the nurse’s own stress level.
Nurses turn to restraints when a patient becomes increasingly difficult to manage and starts to prevent treatments such as intravenous infusions, catheter or tube insertions. (Natan, Akrish, Zaltkina, & Noy, 2010) Cotter states there is a greater likelihood for restraints to be put on dementia patients because they pose the most threat to fall, hurt themselves or hurt others. (Cotter, 2005) “In moderate to severe dementia, the risk for falls is greater because of gait apraxia and unsteadiness. Agitation, disorientation, and pacing behaviours from delirium and dementia can precipitate staff to use restraints.” (Cotter, 2005) c. Effects of Restraints on Patients
One common denominator amongst the literatures in the review is the concern for the dementia patients on restraints. Some of the listed effects of physical restraints mentioned in these articles include function decline, pressure sores, incontinence, and increased agitation. Cotter referred to dementia patients as most prone for restraint application because of their increased confusion, wandering, poor memory, poor judgement and distraught perception. (Cotter, 2005) Wang (2005) states that there is no scientific evidence that states physical restraints protect patients. Though nurses believe that restraints can keep patients safe, it may be contrary to the fact. (Wang & Moyle, 2005).
Accidents like asphyxiation when patients are caught between their restraints, and falls from when they try to climb out of bed rails have been documented. Another reason that restraints are not so good to use is because patients get fatigued from struggling when in restraints and then become unsteady once they get off the restraint. (Cotter, 2005) Restraints also leave a very negative experience on the patient. Dementia patients respond with anger, resistance, fear, and humiliation. The following is statement made by a patient after being restrained: (Strumpf & Evans, 1998) “I felt like a dog and cried all night. It hurt me to have to be tied up…the hospital is worse than a jail” Discussion
Recently not a lot of studies have been made on the use of restraint on dementia patients. Most articles are outdated and not applicable anymore. With the mushrooming of nursing care homes and the booming industry of nursing facilities, researches should be made on how nurses feel about eradicating or lessening restraint use. The locale of these studies is also not very diverse. More studies should be conducted in various settings and environments. A patient in acute care may have a different set of concerns compared to patients in long term care facilities. A thorough analysis of why patients would need restraints in respect with the different settings they are in would have been beneficial. Like knowledge, cultural beliefs may impact on a person’s decision. A study by Hamers et al (2009) used cross-sectional method to find out about reasons, consequences, and appropriateness of restraint use as seen by nurses from different parts of the world. They discovered that some degree of cultural differences determine these nurses’ ideas towards restraint use. (Hamers, Meyer, Kopke, Lindenmann, & Groven, 2009).
Conducting studies in a more global approach can draw out an idea of why some nurses prefer physically restraining patients while others don’t. The studies show a decline in restraint use after education sessions were presented to nurses. They occur at short term, all within a 6-month period which may influence the outcome of the study. The lectures may have influenced the participants’ attitude towards restraint use because they were recent, and not because they were meaningful to their practice. The studies in the review indicate that nursing education plays a very important role in influencing nurses’ decision on using restraints. A nurse has to be presented the rationale, risks, and alternatives to restraint use for them to be able to make a decision.
The Hawthorne Effect may play a part in the studies conducted. The term Hawthorne Effect was coined Henry Landsberger in 1953 to refer to participants altering their answers because of the knowledge that they are being observed. (Sonnenfeld, 1985). The nurse-participants may have opted not to restrain patients at the time the research was being conducted because of fear of being judged for their decisions. Another grey area not thoroughly discussed in the literatures reviewed is the influence of policies set out by governing bodies or administration on nurses’ decision making. It was briefly mentioned in the study by Weiner (2003) but never really elaborated on.
The study stated that the institution is taken into consideration when nurses decide on restraint use. Nurses view the institution as one that benefits if restraints are used. (Weiner, Tabak, & Bergman, 2003) A comparison of institution policies should have been made. These institution policies on restraint use differ in most care facilities and comparisons of how well nurses are in following them can draw a different angle on the situation of physically restraining patients. Also, the effectiveness of these policies should be evaluated to allow for their improvement. The studies also focused on reasons why patients are put on restraint. Not very well discussed was what happens with the nurse before he/she decides to use the restraint. The studies in the review failed to look at the situation from a nurse’s perspective. The clear message of the literatures reviewed is that restraints can and must be avoided in patients with Dementia. No scientific evidence shows that restraints promote safety for these patients. On the contrary, more studies show detrimental effects of restraint application. Personal review and implications for nursing practice
The results of the studies reviewed all indicate that there is a need to highlight lack of education amongst nurses regarding restraint use. Because knowledge and sense of accountability play major roles in restraint application, keeping nurses updated with trends and new policies should be prioritised. Even with reports of decrease in restraint use, a number of incidents involving misuse of restraints are still rising. One in particular is the incident last September 2010 involving a known nursing care facility wherein it was proven that an 85-year old patient has been wrongly restrained on numerous occasions. The patient’s wife has been repeatedly objecting restraint use but the hospital did not oblige.
The staff reasoned that the patient had a high falls risk, and high levels of agitation, aggressiveness and restlessness. The cause of the breach was said to be due to systemic failure (Otago Daily Times, 2013). This shows that though policies may be put in place, it is not an assurance that they are being followed. A closer look at the effectiveness of these policies and their appropriateness to the setting has to be taken into consideration. Currently the Canterbury District Health Board (CDHB) has a restraint minimisation and safe practice guideline in place. This supports their aim to reduce restraint use and treat restraints as a last resort to protect patients from harm. Nurses can be directed with the guidelines to ensure safe practice. (Canterbury District Health Board, 2012) As mentioned earlier, a nurse’s perspective is often looked past. A study by Lai (2007) indicate that at times nurses feel that when it comes to issues on restraints, their “inadequacy and inaccurate knowledge” have always been magnified but rarely is the pressure to “do what is right” in difficult situations brought up.
According to the study, nurses still use restraints despite ambivalence because of fear of responsibility. A patient may fall and break his hip because he was not restrained despite poor mobility. Another reason nurses tend to use restraints is because of lack of support from management. As the nurses reported, even if they do their best, issues on short-staffing can still push them to use restraints as an aide to keep patients safe. (Lai, 2007) Another reason mentioned by Lai (2007) in her study is the constant pressure that nurses feel from management. Often it is the culture of the unit that dictates a nurse’s willingness to restrain a patient. A ward that strives to keep fall incidents at a low would be happy to apply physical restraints on patients to achieve that goal. Conclusion
The researcher observes a strong connection between how a nurse views a situation and the options he has on how to act upon that situation. These nurses must be given the opportunity to learn and relearn restraints to help them make valid and safe decisions for their patients. Without available options in place of restraint use, nurses will continue to utilise physical restraints because of the pressures they have to face with regards to the patients’ needs. A discussion of available options in place of restraint application is needed to allow for a more acceptable choice. Accountability of outcomes because of failed actions, like not applying a restraint, appears to be greater than putting a restraint on a patient. A dementia patient is still a human being entitled to his rights of freedom and dignity, and nurses have to weigh this with the notion that these patients may also be challenging.
It is therefore necessary to refer to available guidelines to assist nurses in making a decision with regards to patients care. Also, keeping updated with trends in patient care may help nurses make informed decisions. Restraint use can easily become a norm when nurses feel it has been a common occurrence in a unit. All decisions have to be weighed in and thought of properly, exerting all other possible interventions before restraints are utilised. A restraint-free environment is far from being realised when nurses, families and administration still regard it as a solution and not a problem. With that said, nurses should not be viewed as the culprits in restraint application. Instead, nurses should be part of the solution.
Courtney from Study Moose
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