Lois K. Evans

Tying down the elderly. A review of the literature on physical restraint.

The apparently widespread practice of physical restraint of the elderly has received little systematic research, despite reported clinical awareness of its iatrogenic effects on frail elders. Prevalence rates in various settings range between 6% and 86%, with cognitive impairment an important risk factor for restraint. Despite strongly held beliefs, efficacy of restraints for safeguarding patients from injury has not been demonstrated clinically. This paper reviews the current status of knowledge regarding physical restraint use with the elderly and suggests a research agenda and implications for ethical practice.The apparently widespread practice of physical restraint of the elderly has received little systematic research, despite reported clinical awareness of its iatrogenic effects on frail elders. Prevalence rates in various settings range between 6% and 86%, with cognitive impairment an important risk factor for restraint. Despite strongly held beliefs, efficacy of restraints for safeguarding patients from injury has not been demonstrated clinically. This paper reviews the current status of knowledge regarding physical restraint use with the elderly and suggests a research agenda and implications for ethical practice.

The ethical problems of prolonged physical restraint.

The rising prevalence of physical restraint warrants careful examination of the moral, ethical, and legal dimensions of the practice. For the frail elderly, quality of life, decision making, and informed consent are significant issues. The ethical dilemmas created by the use of physical restraints, and the need to consider restraint as an issue fundamental to the nursing home milieu and beliefs about quality of life, require understanding of and commitment to care that is individualized and person-centered. The elements identified in care settings where restraints are rarely, if ever, used evolve from an awareness of the needs of the individual resident, continuous monitoring of health status, and appropriate adjustments in the care plan.

KNOWING THE PATIENT: The Route to Individualized Care

Provision of individualized care is dependent on knowing the patient as a person. Three factors contributed to individualized care: congruent societal and health care values; commonalities of patient needs in all settings; and primacy of caring through knowing the patient. Role modeling by mature nurses appears to have been of prime importance in the transmission of this way of nursing.

REDUCING PHYSICAL RESTRAINTS: Developing an Educational Program

1. Philosophical premises for an educational program aimed at restraint reduction include beliefs about quality of care, commitment to understanding the meaning of behavior, and desire to shift practice from control of behavior to individualized approaches to care. 2. If change is to occur, an educational program aimed at restraint reduction must recognize the potential contributions of all staff members, use an interactive teaching style, and promote discussion and problem solving. 3. Results of testing a Restraint Education Program suggested that altering staff beliefs and increasing knowledge produced a change in restraint practices, at least in the short term.

Responding to safety issues in frontotemporal dementias

As frontotemporal dementia progresses in individuals, safety issues related to behaviors and injury become a paramount concern. In addition to self-care deficits, frontotemporal dementias are often characterized by behavioral manifestations that include aggression and disinhibition. These behaviors may place the patient and caregivers at risk of injury, stress, and social embarrassment, and frequently lead to institutionalization. Additionally, motor disturbances associated with frontotemporal dementias may contribute to risk of injury from falls. The authors present an integrated biopsychosocial model to guide assessment of needs that may be expressed through behavior. Environmental, behavioral, and psychosocial strategies to assist caregivers in preventing and responding to behaviors and risks are discussed, with the goal of promoting maximum function and quality of life and minimizing caregiver strain. The authors discuss the dangers of physical restraints, which are commonly suggested as a response to fall risk and behavioral symptoms without an awareness of research-based data regarding their lack of efficacy. Benefits and risks of a variety of need-based interventions are presented in a practical, clinically relevant manner. The discussion of diverse safety-enhancing interventions is intended to enable clinicians and caregivers to identify individualized care strategies for patients with frontotemporal dementia.

Individualized interventions to prevent bed-related falls and reduce siderail use.

Five categories of problems that often result in siderail use: memory disorder, impaired mobility, injury risk, nocturia/incontinence, and sleep disturbance. As nursing homes work toward meeting the Health Care Financing Administrations mandate to examine siderail use, administrators and staff need to implement interventions that support safety and individualize care for residents. While no one intervention represents a singular solution to siderail use, a range of interventions, tailored to individual needs, exist. This article describes the process of selecting individualized interventions to reduce bed-related falls.

Outcomes of nighttime physical restraint removal for severely impaired nursing home residents

There is ample evidence that physical restraint reduction does not lead to increased falls or injuries. This study tests the effect of removing nighttime restraints by comparing two groups: Restrained in bed at pre- but not postintervention (n = 51), or restrained in bed at both pre- and post-intervention (n = 11). No differences in nighttime fall rates between the two groups were detected. Nighttime physical restraint removal does not lead to increases in falls from bed in older nursing home residents. Although markedly reduced in nursing homes, restraint use remains a common practice among hospitalized older adults. We should continue to focus efforts on developing new, individualized approaches to reduce risk of falling from bed among frail elders.

Nursing consultation to reduce restraints in a nursing home.

Consultation is an important function of advanced practice nurses. Within nursing practice, the process of providing consultation has been studied primarily in acute care settings. A CNS in a 180-bed, nonprofit nursing home implemented the intervention for a controlled clinical trial of nursing interventions to reduce physical restraint use. The consulting process undertaken by the CNS is described, and conclusions are offered regarding the most effective approaches to consultation by advanced practice nurses in nursing homes.

MODELS OF GERIATRICS PRACTICE

BACKGROUND AND OBJECTIVES: Frail older adults are especially vulnerable in a health system that is fragmented and fails to focus on preservation or restoration of function. The School of Nursing at the University of Pennsylvania, together with the School of Medicine and the Hospital of the University of Pennsylvania, established the Collaborative Assessment and Rehabilitation for Elders (CARE) Program to meet the needs of this population. We used the British Day Hospital as a model because it provides a comprehensive approach to care and a bridge between acute, home‐based, and institutional long‐term care. We have designed our program to provide innovative, interdisciplinary care as well as to be reimbursable under current and future payment structures. This nurse‐managed, collaborative practice seeks to maximize independent functioning, promote health, and enhance quality of life for chronically ill, frail older adults living in the community whose needs are left unmet by existing services. The program was certified as a Comprehensive Outpatient Rehabilitation Facility (CORF) in December 1993 to maximize reimbursement of services through Medicare and other third party payers. With a Gerontological Nurse Practitioner as care manager, clients receive an intensive, individualized, time‐limited program of nursing, rehabilitation, mental health, social, and medical services in one setting several days each week. Additional geriatric services, such as primary care, are available in the same location when needed.

Trends in aging care in Scotland and Scandinavia.

The proportion of older adults in Western European countries, as in the United States, continues to increase rapidly. Faced with geriatric care dilemmas decades earlier, however, these countries have had more experience on which to base the development of community-based, integrated care systems for the elderly. This article provides observations from a 1993 World Health Organization Fellowship study of long-term care facilities in four European countries: Scotland, Sweden, Norway and Denmark. Several emerging trends in geriatric care documented in the literature were confirmed. These included: moratoria on institutional long-term care, emphasis on informal care and support, provision of 24-hour assistance in the home, care management to individualize care, and an expanded set of providers within integrated delivery systems.