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Physical Restraints in the Elderly: To Use or Not to Use

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Physical restraints are commonly used with elderly patients in non-psychiatric care settings. Studies done in the U.S. of extended care facilities for older people have estimated that between 25 and 43 percent of that population ? that's at least one of every four ? have been restrained at least once.1

There are several reasons given for using restraints with the elderly population. Restraints may be seen as the only practical way to protect the safety of elderly patients and reduce the potential for legal liability if they injure themselves or others while being cared for. Specific reasons include fall prevention, limiting wondering behavior and preventing dislodging or interference of therapeutic devices, and controlling violent or agitated behavior.2


 Important Issue for Nurses
The use of restraints with the elderly population is a very important issue in nursing. Patient safety should be every nurse's top priority; therefore, nurses need to have a thorough knowledge base of the risks and benefits of using physical restraints. Their use also may be seen negatively by patients' family members if the nurse can not properly explain how the restraint use is helping the patient. In addition, restraint use can be a source of aggravation for the patient who is being restrained.

Pros and Cons
The case for using restraints is made on the basis of providing patient protection. Reasons related to patients' safety, such as preventing falls and interference with medical treatment, such as preventing pulling out a feeding tube or catheter, were consistently identified in one study as the most important reasons for the use of physical restraints in acute and long-term care settings.3 If an elderly patient is confused and at risk for hurting himself, the use of physical restraints may be one alternative for ensuring patient safety.

Negatives associated with using physical restraints with the elderly population include reports that suggest their use actually increases risk of patient injury instead of providing protection against injury. One study done in an acute care setting revealed that restraint use can result in numerous problems for the elderly, including death by strangulation, fall injuries, deconditioning, skin breakdown, incontinence, constipation and psychological effects such as agitation and emotional distress.2

Another study reported up to 47 percent of recorded falls are restrained patients and those who fall while restrained suffer more serious injuries. In addition to the ineffectiveness of restraints to prevent falls, the gerontology literature has shown that the use of restraints has several adverse effects including strangulation, increased agitation, increased incidence of complications from immobilization, entrapment and death with bedrail use, increased incidence of nosocomial infections and pressure sores, incontinence, increased length of hospital stay, and greater mortality. It also was reported that almost 70 percent of restrained patients successfully self-extubate, indicating that restraints are ineffective at preventing dislodging of therapeutic devices.4

The results of these studies show that although the intentions of the nurse are to prevent patient injury, research actually indicates that the use of restraints with the elderly population increases risk of injury.

The use of physical restraints by the nurse can cause negative feelings for patients' family members as well as for nurses. Strong emotional responses to the use of restraints by family members have been documented. Seeing a loved one restrained has the power to destroy trust and the nurse-family relationship.4 The thought of a family member being tied down can be very disturbing for many people.

Nurses themselves also may have negative feelings about the use of restraints. Feelings of frustration, guilt and ambivalence have been reported by nursing staff related to their use.1

Physical Restraints Affect Nursing Care
The overall effect of physical restraint use on nursing care of the elderly is negative. Studies have shown that instead of protecting them ? the primary reason for using restraints ? they actually place them at higher risk for injury. If the patient is not being protected and is also suffering emotionally, the decision to use physical restraints needs to be reconsidered. The intention of nursing care is to help patients, not to put them at increased risk of harm. Physical restraints may be beneficial to the care of elderly patients in certain situations, but should be used as a last resort.

The decision to use physical restraints needs to be made by an informed and educated provider. The potential benefits and risks need to be fully understood before automatically using restraints with confused elders.       

What Can Nurses Do?
The most important thing nurses can do to ensure the best decision regarding physical restraint use is being made is to be properly educated. Nurses need to ensure that the decision to use physical restraints is made because there are no other safe options available - in other words, restraints should be used as a last resort.5 If there is any possibility that the restraints are being used to try to make someone's job a little easier or to save time, they should not be used. Preserving patient dignity is a nurse's duty, not an option. Being tied down is not dignified and this needs to be considered as well as safety issues when faced with the decision of whether or not to restrain a patient.

In a study on restraint use for patients with dementia in two health care settings it was stated that nursing staff must provide patients with the means to preserve their health, physical safety, dignity and quality of life. The study found that nurses with a higher level of knowledge of restraint guidelines were less likely to use restraints than their counterparts with less knowledge about the guidelines. Nurses have considerable power and influence on the decisions to use restraints. Therefore, it is their responsibility to be properly educated on the subject.5

There are studies being done to find alternatives to restraint use. One explored the relationship between listening to a patient's preferred music and his behavioral responses. Thirty patients aged 65 to 93 participated in the study, which indicated there may be some benefits to patients who are out of restraints and listening to music. There did not seem to be any significant effect otherwise.6

Impact of Use & Education
The impact of using physical restraints within the elderly population without proper education will result in increased injuries related to this use. Nursing care will suffer if the issue is not addressed and improved. Elderly patients who are restrained are at risk for loss of dignity and functional ability.2 The impact of increasing nurses' education about the risks and benefits of using physical restraints may decrease overall restraint use. Nurses need to be educated about alternatives to restraint use and that restraints only should be used when all other options are exhausted.

Nursing Implications
Nursing implications regarding the use of physical restraints in the elderly need to be taken seriously. If restraints are planned, nurses need to ensure that they are thoroughly educated about their benefits and risks. Nurses also need to be aware of legal and ethical implications regarding the use of restraints.

Restraints should not be used without proper knowledge of the guidelines and regulations governing their use. Patients' dignity should be preserved and not compromised. Patients always should always be treated as human beings and never as a job or task that has to be done. Nurses also need to understand that family members may find seeing their loved one in restraints very disturbing. It also should be understood that sometimes putting an elderly patient in restraints increases the risk of the exact harm that the nurse is trying to prevent.

The most important thing for the nurse to remember is that safe patient care is his or her utmost responsibility and the use of physical restraints should be as infrequent as possible.

References
1. Karlsson, S., Bucht, G., Eriksson, S., & Sandman, P. (2001, December). Factors relating to the use of physical restraints in geriatric care settings. Journal of the American Geriatric Society, 49(12), 1722-1728.

2. Myers, H., Nikoletti, S., & Hill, A. (2001, March). Nurses' use of restraints and their attitudes toward restraint use and the elderly in an acute care setting. Nursing and Health Sciences, 3(1), 29-34.

3. Werner, P. & Mendelsson, C., (2001, September). Nursing staff members' intentions to use physical restraints with older people: testing the theory of reasoned action. Journal of Advanced Nursing, 35(5), 784-791.

4. Kielb, C., Hurlock-Chorostecki, C., & Sipprell, D., (2005, March). Can minimal patient restraint be safely implemented in the intensive care unit? Dynamics, 16(1), 16-19.

5. Weiner, C., Tabak, N., & Bergman, R., (2003, September). The use of physical restraints for patients suffering from dementia. Nursing Ethics, 10(5), 512-525.

6. Janelli, L., Kanski, G., & Wu, Y., (2004/2005, Fall/Winter). The influence of individualized music on patients in physical restraints: a pilot study. Journal of the New York State Nurses Association, 22-27.

Samantha Ziglar received her BSN from the University of North Carolina at Greensboro in May 2006. She hopes to begin work on her MSN at UNCG in August.


 

I am a former geriatric nurse from almost 30 years ago. At that time, restraints use was very common to protect safety if necessary. Today.....my stepfather has no balance, dementia, and is only supposed to walk with a walker with supervision. Because of the dementia, he forgets this. Tries to get up, get the walker, or just reach for something and then falls. He's had numerous fractures, head traumas, sutures, concussions, CT Scans, etc. He just can't "remember" that he can't get up alone. The nursing home he's in doesn't support restraints. But just three weeks ago he was in the ER 2X in one day for falls, head injury, fracture and suture. (And once just last week while an inpatient in a hospital.) A geriatric chair with the tray folded down would allow him mobility that he doesn't have now, but also help to protect his safety. This is a very sad situation. Nursing staff can't monitor all patients 24/7 and most families can't afford private care 24/7. I don't believe in restraint as a means of convenience...but patient safety.......absolutely!

Connie March 25, 2014
VA



Personally I will try every alternative to restraints possible before placing a patient in them. I've been involved in placing many patients in restraints. At times they are necessary to protect the patient and the staff, but I find myself more resistant to that intervention than many staff with whom I've worked. It would be nice to have alternative interventions that actually worked. Until they are found, some nurses, especially those in acute psychiatric units like me, will have to continue using them when.

Rodney Butterfield,  RNNovember 18, 2013
Vacaville, CA



I agree that restraints should only be used as a last resort. When restraints must be used the patient should be monitored closely for risk of injury. Restraints are not intended to be a free card for staff not wanting to provide time and attention to a patient.

Lorena Racey,  RN,  HospitalNovember 14, 2013
Chicago, IL



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