Health Care and Use of Physical Restraints
Physical Restraints,Prevalence of Physical Restrains,Believes About Restrains and nursing Home,When and Where Restrains Needed,Alternative of Restrains ,Nurse Specializing In Restrains,Physical and Psychological Impact of Restrains,Reduce Restrains Use or Make Free from Restrains,Impact of Reduction/Elimination of Restrains,Current Approaches to Retrains,Objection on the Use of Restrains,Monitoring During Restrains,Physiological Variables.
Physical Restraints
A physical restraint is any device or object attached to or
adjacent person’s body to a that cannot be removed easily and restricts freedom
of movement. Bilateral full-length siderails and some types of furniture are
also considered restraints when used to limit movement.
Although this entry
focuses mainly on physical restraints, it is important to keep in mind that
these devices are often used in conjunction with psychopharmacologic drugs.
When such drugs are given for the purposes of discipline or convenience and are
not required to treat specific medical or psychiatric conditions, they are
considered chemical restraints.
Prevalence of Physical Restrains
The prevalence of physical restraints in non-psychiatric settings,
estimated in 1989 to affect 500,000 elderly persons daily in hospitals and
nursing homes, led many to conclude that a restraint crisis existed.
High
prevalence in the United States was sharply contrasted with what at the time
appeared to be lesser use in several countries in Western Europe.
The
historical antecedents for these differences appeared related to American
beliefs that were embedded by the end of the 19th century: restraint use was
therapeutically sound, necessary to control troublesome behavior, and prevented
tragic accidents and injuries.
Believes About Restrains and nursing Home
For nearly 100 years those beliefs were largely unchallenged;
debate concerning the efficacy of physical restraint was limited, and
alternative interventions were rarely considered.
The efforts of advocacy
groups and committed clinicians, change in nursing home regulation and standards
for accreditation of hospitals, warnings from the Food and Drug Administration
(FDA), and research demonstrating successful restraint reduction have forced a
complete reexamination of their use.
Although prevalence has declined in the
US. nursing homes to approximately 8.86%, restraint use and the problems
associated with it remain a global concern.
When and Where Restrains Needed
Physical restraints are applied in hospitals and nursing homes
primarily for three area sons: fall risk, treatment interference, and
behavioral symptoms.
To date, no scientific basis of support demonstrates the
efficacy of restraints in safeguarding patients from injury, protecting
treatment devices, or alleviating such behavioral symptoms as wandering or
agitation.
Several recent studies, in fact, suggest relationships between
physical restraints and falls, serious injuries, or worsened cognitive function
( Capezuti , Strumpf , Evans, Grisso , &Maislin , 1998).
Alternative of Restrains
However, health care professionals and other caregivers see few
alternatives to restraint use in some situations. Misplaced fears about legal
liability, lack of interdisciplinary discussions about decisions to restrain,
and staff perceptions about individual behaviors also influence restraint
practices.
Insufficient staffing levels and the costs of hiring additional
employees have long been regarded as obstacles to minimal use of physical
restraints.
Hospital studies offer indirect links between staffing levels and
restraint use by demonstrating that weekend days and night shifts are the most
frequent times when restraints are used ( Bourbonniere , Strumpf , Evans,
&Maislin , 2001; Whitman, Davidson, Sereika , & Rudy , 2001).
Several
reports of restraint reduction in nursing homes and one clinical trial show
that prevalence of physical restraints can be significantly reduced without
increasing serious injuries or hiring more staff (Evans, LK, et al., 1997).
Data show that caring for nursing home residents without restraints is less
costly than caring for residents who are restrained (Phillips, CD, Hawes, &
Fries, 1993).
Nurse Specializing In Restrains
Hospitals and nursing homes often do not have personnel with
expertise in aging or with the requisite skills for assessing and treating
clinical problems specific to older adults.
Studies provide promising evidence
that a model of care using advanced practice nurses specializing in geriatrics
can reduce restraint use in nursing homes and hospitals through staff education
and consultation (Evans, LK, et al., 1997; Sullivan Marx, Strumpf , Evans ,
Capezuti , &Maislin , under review).
Physical and Psychological Impact of Restrains
Continued use of physical restraints is paradoxical in view of
mounting knowledge about their considerable ability to do harm.
Physical
restraints are known to reduce functional capacity and exert physical and
psychological effects (Castle &Mor , 1998; Ev – ans , LK, &Strumpf ,
1989). Furthermore, restraint use can lead to accidental death by asphyxiation
(Miles, SH, & Irvine, 1992).
Persons who are likely to be restrained are
usually those of advanced age who are physically and mentally frail, prone to
injury and confusion, and experiencing, invasive treatments. The evidence is
compelling that prolonged physical restraint further contributes to frailty and
dysfunction.
Reduce Restrains Use or Make Free from Restrains
Restraint-free care can be accomplished through implementation of a
range of alternative approaches to assessment, prevention, and response to the
behaviors routinely leading to restraint. For such practices, however, changes
in fundamental philosophy and attitudes among institutions and caregivers must
occur.
In settings where restraints have been reduced, there is strong emphasis
on individualized, person-centered care; normal risk taking; rehabilitation and
choice; interdisciplinary team practice; environmental features that support
independent, safe functioning: involvement of family and community; and
administrative and caregiver sanction and support for change.
The presence of
professional expertise, particularly expert nurses and physicians with
education and skill in geriatrics, is crucial for sustained cultural change.
Although legislation and other forms of external regulation or
control do not in and of themselves change beliefs or entirely alter entrenched
practice, the Nursing Home Reform Act, part of the Omnibus Budget
Reconciliation Act (OBRA) of 1987 (enacted in 1990), helped to raise standards
in nursing homes.
The FDA, in response to the known risks of physical
restraints and reports of restraint related deaths, mandates that all devices
carry a warning label concerning potential hazards.
Impact of Reduction/Elimination of Restrains
Following a decade of emphasis on restraint reduction/elimination
in nursing homes, clinicians, researchers, and regulators have recently focused
attention on these practices in acute care settings.
As with nursing homes, the
Joint Commission on Accreditation of Healthcare Organizations and the Centers
for Medicare and Medicaid Services define restraint use as both physical and
chemical. Standards mandate that restraints be used only to improve wellbeing
in cases where less restrictive measures have failed to protect the patient or
others from harm.
In addition, continual individualized assessment and
reevaluation of the patient by clinicians and consultation with the patient’s
own provider must occur with restraint use. Direct care staff must also be
trained in proper and safe use of restraining devices.
Current Approaches to Retrains
Current approaches to restraint reduction vary along a continuum
from promotion of restraint free care to an attitude of tolerance for restraint
use under certain circumstances.
To some extent, successful reduction of
physical and chemical restraints in nursing homes underscores the need to
achieve the same changes in hospitals, where a disproportionately high
incidence of iatrogenesis occurs, much of it exacerbated by the use of physical
restraints and adverse reactions to psychoactive drugs .
The resulting
complications especially delirium, pressure ulcers, infections, and fall related
serious injuries can add dramatically to the cost of care by contributing to
further loss of function.
Objection on the Use of Restrains
Although professional organizations in nursing and medicine have endorsed
non use of physical restraints and appropriate use of psychoactive drugs as the
standard of care in all health care settings, the intensity of debate
surrounding physical restraint use in hospitals has escalated ( Maccioli et
al., 2003 ).
Clinicians caring for specialty populations, such as those
found in critical care, trauma, neurology and neurosurgery, and
hematology/oncology, are confronted with the need to identify, test, and
implement interventions that reduce reliance on physical restraints.
A standard
of least restrictive care will challenge professional caregivers to use
comprehensive assessment to make sense of individual behaviors and to employ a
range of interventions that enhance physical, psychological, and social
function, as well as to acknowledge and affirm the uniqueness and dignity of
the old person.
Monitoring During Restrains
Physiological monitoring is used by nurse scientists to measure
biological functioning in living organisms. Generally, it refers to data
collected through an interface of technological instrumentation with a living
organism.
Technological instrumentation can be relatively simple, such as a
thermometer, or as complex as combined hemodynamic and clinical laboratory
instrumentation used to measure oxygen utilization in the critically ill patient.
Physiological monitoring is used to examine both normative functions (eg,
homeostasis) and disordered responses (eg, illness and related manifestations).
Physiological monitoring occurs in vivo and in vitro, among animal models, in
laboratory settings, and in clinical practice areas. Information about
physiological parameters promotes understanding about the phenomenon with which
nurses are concerned: health supporting and health restoring human responses.
Physiological Variables
A variety of physiological variables are measured by nurses:
(a)
electrical potentials of the brain, heart, laboring uterus, and muscle
(b)
pressures in arteries, veins, lungs, mouth, esophagus, bladder, vagina, uterus,
and brain
(c) sound (mechanical) waves in the ear and heart
(d) temperature and
the concentration of gases in the lungs and blood
(e) physical symptoms such
as size and color of bruising, stool, and wounds
(f) serum levels of
hormones, coagulation factors, and molecular proteins that influence local and
systemic responses to injury, illness, and infection.
The most common
physiological measures reported in nursing research are blood pressure, heart
rate, weight, and temperature. Monitoring of physiological measures can be
either direct or indirect, can be used continuously or at a particular point in
time, and can include physical, electronic, and biochemical devices.
Physiological monitoring devices are found in the acute care setting, home
health care settings, and outpatient and surgical environments and offer a rich
data source for clinical research. Research by nurses using physiological
monitoring has increased steadily since the 1980s ( Sechrist &Pravikoff ,
2002).
Increased numbers of nursing scientists are pre-wall with a strong
theoretical and experiential base for designing physiological studies. One
aspect of their work has been to evaluate the accuracy, selectivity, precision,
sensitivity, and error of physiological measures so that reliability and
validity are supported.
Another important focus of physiological monitoring has
been to link physiological responses to patient/client outcomes studies. A
third and relatively new area of research is the examination of biomarkers,
linking physiological monitoring with cellular and molecular responses to
illness and interventions.
Examination of changes that occur as a consequence
of nursing practice has produced a broad range of research, as evidenced by the
variety of physiological studies listed by CINAHL and PubMed in the past 10
years.