September 20, 1996 Number 178

Restraint Reduction: Alternative Approaches to Care

Restraint reduction is currently the hot topic for nursing home providers in Illinois, with new licensure rules regarding restraints and psychotropic medications being published by the Illinois Department of Public Health. In addition, the Health Care Financing Administration has targeted Illinois for an intensive campaign called Partnership Without Restraints, involving training programs on restraint reduction techniques.

For the next three weeks, the Council Close-Up will be examining the operational issues surrounding restraint reduction, with practical suggestions for promoting resident safety, autonomy, and well-being. This first issue of the Close-Up, outlining the legal and theoretical basis for reducing restraints, features information distilled from the booklet Avoiding Physical Restraint Use: New Standards of Care, published by the National Citizens' Coalition for Nursing Home Reform.

Restraint Reduction: A Significant Federal Mandate

Since October of 1990, nursing facilities have had to comply with a significant federal mandate: that nursing home residents have "the right to be free" from physical restraints not required to treat their medical symptoms. Restraints may only be imposed:

(I) to ensure the physical safety of the resident or other residents, and

(II) only upon the written order of a physician that specifies the duration and circumstances under which restraints are to be used (except in emergency circumstances) until such an order could reasonably be obtained.

This mandate is part of a series of reforms intended to improve the quality of care in nursing homes that were enacted by Congress in the Omnibus Reconciliation Act of 1987 (OBRA-87).

Congress imposed this requirement because of concerns about widespread use of physical restraints in nursing homes, which restrict a person's ability to move about freely. The April 1, 1992 Surveyor Guidelines define physical restraints as: "any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body." Examples of physical restraints include hand mitts, vests that tie residents to their chairs or beds, and restrictive chairs, such as Gerichairs with lap trays and small wheels that limit mobility.

In carrying out the federal requirements on reducing restraints, nursing facilities have faced many operational challenges. Some of these have involved confusion about how restraints are defined. Others have involved the dynamics of changing long established practices--of introducing new routines and ways of thinking about the care of nursing home residents. While restraint reduction is a challenging process, nursing facilities have found that these programs have had profound effects on improving residents' feelings of security, comfort, and well-being.

Facts and Myths about Using Restraints

One of the major reasons for using restraints is protecting the safety of frail and confused elders. However, research shows that physical restraints do not make people safer. In fact, restraints are often harmful. When a person stops using a body part, that part no longer works very well. The old saying "use it or you'll lose it" is true -- people who are restrained become much weaker physically. These residents often try to get out of their restraints, sometimes resulting in serious injuries such as broken bones and concussions. At worst, restraints can lead to strangulation and death.

Some people will fall if they are not restrained. But research shows that these residents, when they do fall, have less serious injuries than those who are restrained. If restraints are removed and residents are helped to regain strength, they may fall less frequently and the falls will not hurt them as much. In addition to weakness, restraints can lead to many other negative physical and psychosocial effects. Possible physical outcomes include dehydration, urinary tract infection, incontinence, pressure sores, and pneumonia. Psychologically, restraint use can lead to depression, withdrawal, agitation, confusion, and frustration.

Nursing home staff sometimes fear that if they do not restrain residents, injured residents and families will sue the facility. Legal experts who have studied this issue point out that claims due to the misuse or inappropriate use of physical restraints have been far more numerous, successful, and serious than claims against a facility because a resident was not restrained.

Some facilities may be using restraints because they believe that it is less expensive and requires fewer nursing hours than not using restraints. However, a recent study shows that this belief is simply a myth. The study examined the staffing costs associated with the use of physical restraints among 11,932 residents at 276 nursing homes in seven states between 1983 and 1990. The 40% of nursing home residents who were physically restrained required much more care from nursing home staff than those who were not physically restrained. Residents with physical restraints required 67% to 75% more nursing assistant time than those without restraints. In addition, restrained residents also required more assistance with daily living activities than unrestrained residents.

Short term, emergency use of restraints may have some benefits for residents. For instance, restraint use may prevent a severely dehydrated and confused person from pulling out a lifesaving IV. A restraint may also allow a doctor or a nurse to examine a delirious person to find the cause of symptoms. However, even short-term, emergency use of restraints may have serious physical and psychological effects. When restraints are used, staff must try to prevent injury by using the least restrictive restraints, moving the restrained part every two hours, providing activities and socialization, toileting the resident, and removing the restraint as soon as the emergency is over.

Making a Decision about Restraints

The decision to use or not use a restraint belongs to the resident or the representative with the legal authority for health care decisions. Physicians and staff must present the risks, benefits, and other alternative treatments so residents can make a wise decision. Residents have the right to ask questions about care and should receive respectful and complete answers. A resident who makes a decision knowing all of the legal facts is exercising a legal right called "informed consent."

Residents and families often turn to physicians for help in deciding on treatment. Physicians are aware of the negative effects of restraints, but some need to learn of alternative ways to address the underlying symptoms which seem to warrant restraint usage. Physicians and nursing home staff should follow a systematic process in evaluating the appropriateness of restraints. According to Nursing Home Reform Law: The Basics by the National Citizens Coalition for Nursing Home Reform, this systematic process should answer the following crucial questions:

• What are the symptoms that led to the consideration of restraint use?
• Are the symptoms caused by the failure to: Meet individual needs and adjust to the resident's lifelong routines? Use aggressive rehabilitative and restorative care? Provide meaningful activities? Adjust to the resident's environment, including seating requirements?
• Can the cause of the symptom be removed? (e.g. an infection might cause an older person to become agitated.)
• If the cause cannot be removed, then has the facility attempted to use alternative care approaches (e.g. distraction of a person who wants to leave the facility with an activity.)
• If these alternatives have been tried and found wanting, does the facility use the least restrictive restraint for the least amount of time? Does the facility monitor and adjust care to reduce negative outcomes while continually trying to find and use less restrictive alternatives?
• Did the resident make an informed choice about the use of restraints? Were risks, benefits, and alternatives explained?
• Does the facility use the Physical Restraint Resident Assessment Protocol to evaluate the appropriateness of restraint use?

Nursing facilities have developed many successful alternatives to using restraints. Restorative nursing and physical therapy programs are being utilized to increase strength, flexibility, and balance. Activity approaches are helping to keep residents involved and to reduce restlessness and agitation. Supportive devices, such as wedge cushions for chairs, are being used to maintain or improve a resident's ability to function. And staff training about restraint reduction has proven to be a key element in fostering resident safety and autonomy.

Any alternative nursing home interventions to restraints will involve some degree of risk. However, residents and families must remember that risk is a part of life. A nursing home is not like a safety deposit box where a resident will be risk-free. Many residents have diseases which may incur a risk of falls. The nursing home must provide care to make residents as strong as possible, so the risk of falls is reduced. Most residents and families agree that the risk of falls is minimal compared to the harmful physical and psychological consequences of being restrained.