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A last resort: Alternatives to restraint use improve safety and quality of life

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Laura Wagner first used a restraint in the mid-90s, when she was a nursing student. She admits being unaware of the potential for injury – or even death – that could be linked to the device. At the time, Wagner was working as a nursing assistant at a long-term care home in the U.S. She was caring for an elderly woman who was being restrained daily in a recliner with a tray strapped across her midsection (a Geri-Chair). The woman had Alzheimer’s, and a tendency to become anxious and restless. Nobody really knew that she could walk, Wagner recalls. Back then, Wagner says she felt impartial about restraints, and accepted them as a part of this woman’s routine care. She looks back and realizes she was too inexperienced to know otherwise.

After a failed attempt to fit the woman’s large Geri-Chair into a small washroom, Wagner discovered the resident could walk, if given the opportunity. She began taking her on routine strolls to the dining hall and back, and up and down the hallway. Wagner noticed the woman became less agitated.

“She didn’t need to be restrained as much as a result of (regular walking),” she says. In fact, Wagner was able to help her become more mobile and free from restraints for longer periods of time. This experience made the young nurse realize just how detrimental restraints can be to a patient’s safety and quality of life, and just how easy it can be for a nurse to make a difference.

Wagner’s decision to walk with her patient was a small act with significant consequences. Without even realizing it, Wagner discovered a viable alternative to restraints. She says all nurses should look for alternatives to restraints whenever possible, and the Registered Nurses’ Association of Ontario (RNAO) agrees. In fact, this is the central focus of one of the association’s newest best practice guidelines (BPG), Promoting Safety: Alternative Approaches to the Use of Restraints.

Today, Wagner is a geriatric nurse practitioner who has dedicated part of her career to research on restraint use and improving safety in nursing homes. She co-led a panel of experts that created the BPG shortly after a coroner’s inquest into the death of Jeffrey James, a patient at the Centre for Addiction and Mental Health (CAMH) in Toronto. After five days of being physically restrained in July 2005, James collapsed, and later died in hospital after a blood clot formed in his leg.

Wendy Fucile, former president of RNAO, provided testimony and a nursing perspective at the inquest into James’ death. When it wrapped up, recommendations were set out by the province’s coroner, including one that RNAO develop a BPG to address restraints, accompanied by an educational program. The BPG was released in March 2012, and is now a reference guide for nurses, other health professionals, and health-care organizations. It recommends the use of restraints only when all other options have been exhausted. It’s meant to “challenge health care providers to think about how we can provide care that’s safer,” says Wagner. “We’re not thinking enough about some of the alternatives that could be used.”

Methods of restraint use are not limited to physical means. There are also chemical restraints, such as antipsychotic medications, and environmental restraints, like seclusion. All are commonly used in long-term care homes, acute care, and mental health settings. According to a 2011 report from the Canadian Institute for Health Information, almost 25 per cent of people admitted to mental health beds in Ontario are restrained physically or with medication, predominantly to maintain safety of clients and staff.

Wagner says most nurses can likely recall an experience with restraints. These experiences are tough to forget, especially given restraints can contribute to physical and mental decline. They are physically demeaning, and can cause pressure ulcers, strangulation, and death, she says. In fact, studies cited in another RNAO BPG, Prevention of Falls and Fall Injuries in the Older Adult, suggest that restraints can actually increase the severity of falls.

Some nurses rely on restraints because they’re the easiest option during a busy work day, Wagner says. Families can also factor into the decision. Relatives don’t want their loved one to fall, for example, and don’t understand that people can be harmed from restraint use: “We need to think creatively about how we can maintain a person’s safety without having to restrain them.”

Athina Perivolaris, an advanced practice nurse at CAMH, co-led that organization’s three-year prevention of restraints and seclusion initiative following James’ death. She also co-led the BPG panel with Wagner. She acknowledges that it’s not always easy to find alternative options to restraint use. Practitioners may focus too much on the point at which troubling behaviour has already escalated. When care providers are “only looking at that end point, then you really have a limited opportunity to consider or even implement alternatives,” she says. The BPG focuses on the earlier stages of intervening, and collaboration with clients and families to come up with alternatives that are supportive.

If a restraint is used, learning from each and every instance is also key, she adds. A debriefing with staff to address what could be put in place to prevent future use of a restraint, or a meeting with the client, will help health professionals to better understand the patient perspective.

Perivolaris says guidance from all levels of management, in addition to clear policies, is essential when health care organizations begin steering the focus away from regular restraint use as an intervention for safety. “You can have a really good policy, but it’s just a policy unless you also have (strong leadership) to support the expectations in the policy,” she says.

There isn’t any definitive statistical information on exactly how many patients in Ontario have died as a result of being restrained. In addition to the story of Jeffrey James, there is the story of Toronto senior Florence Rose Coxon, who died in 2008 while struggling to free herself from a belt that was fixed around her waist in a wheelchair. It was reported she died of asphyxiation.
These stories are powerful reminders of what can go wrong, and why restraints should be a last resort. In each case, the facilities where these individuals lived were responsible for revising their restraint policies.

Wagner hopes the BPG will bring more attention to the issue, and encourage nurses to share their success stories and innovative alternatives. This, she says, will “help evolve the movement and (persuade practitioners) to consider how we can think differently about this topic.”

This is a shortened version of a feature that appeared in the July/August 2012 issue of Registered Nurse Journal, the flagship publication of the Registered Nurses’ Association of Ontario (RNAO).


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