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Introduction
Restraint-Free Care: A Paradigm Shift
1.
Why Use Restraint-Free Care?
The
Nursing Home Reform Act of OBRA
1987 mandates the rights of nursing home residents
to humane care, including freedom from restraint.
Systematic efforts toward reduction and elimination
of restraints require significant commitment from
administration and nursing staff who collaborate with
the interdisciplinary team on a day-to-day basis to
provide individualized care.
The nurse is in the critical position of coordinating
the development of a plan for practical methods of
managing mobility and behavioral issues that in the
past would have resulted in the use of restraints.
The following review of literature provides the clinician
with information necessary to approach this issue
affecting quality of life of nursing home residents.
A
physical restraint, as defined by the Centers
for Medicare & Medicaid Services (CMS)
Interpretive Guidelines (483.12 F tag 221),
is “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 include but are not limited to, leg
restraints, arm restraints, hand mitts, waist/
belt restraints, pelvic restraints, lap cushions
and lap trays that the resident cannot remove,
soft ties or vests, chest/pelvic combinations,
and vest/chest/jacket restraints. Certain facility
practices also meet the definition of restraint,
including: using bed rails to keep a resident
from getting out of bed as opposed to promoting
mobility while in bed; tucking in a sheet so
tightly that a bed-bound resident cannot move;
using chairs that prevent rising; and placing
a wheelchair-bound resident so close to a wall
that the wall prevents movement.
Seclusion, the involuntary confinement of a
resident alone in a room that the resident is
physically prevented from leaving, may also
be characterized as a form of restraint.
According to Federal Regulations (2001) “depending
on their purpose, siderails may or may not be
restraints.” When siderails prevent or
impede the resident’s desired movement,
such as getting out of bed when the resident
wants to get out of bed, the rails are considered
a restraint. If the resident uses siderails
to promote bed mobility, the rails are not considered
a restraint. The policy does make clear that
when siderails serve both purposes, to enhance
bed mobility and to keep the resident from getting
out of bed, the rails are considered a restraint.
3.
Trends in Restraint Use
Even with significant reductions in restraint use
since the passage of OBRA’87,
from an overall prevalence of 36% in 1988 (1)
to approximately 13.1 % in 1998 (2),
restraint use varies widely (3).
Some nursing homes reported almost 20 % usage and
others greater than 25% usage (4).
The majority of restrained residents were cognitively
impaired ambulatory residents whom staff identified
as being of high risk for falling (5).
No national figures for siderail utilization exist
due to the variation in how facilities describe siderails
as restraints. However, data from an ongoing study
of siderail use in three nursing homes revealed that
in 1999, bilateral siderails were used in approximately
40% to 70% of nursing home residents (6).
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