Restraint-Free Care in Nursing Homes

The use of physical restraints is based on the belief that restricting a body part will prevent movement that could lead to falls and injuries. Numerous studies describe both the lack of therapeutic benefits and also the negative effects of restraints. Physical restraints are viewed as an environmental hazard and are included in the risk analysis for falls and injuries.

Research To Support Restraint-Free Care

Restrained residents still fall. A study exploring the relationship between falls and restraint use among confused, elderly residents concluded that restraints are not associated with a significantly lower risk of falls or fall-related injuries. Restraints significantly increase the number of falls and injury among older persons.

Restrained residents fall more frequently and are more likely to experience serious injury from falls. Preventing falls and injuries is the most commonly stated reason for using restraints in the nursing home. The incidence of falls and fall-related serious injuries actually increases when residents are restrained.

Restraint removal does not increase the incidence of falls or fall-related injuries. Removing restraints does not increase fall rate and fall-related injuries . In fact, the incidence in the number of falls and fall-related serious injuries decreases when restraints are removed.

Individualised, comprehensive interventions reduce the incidence of falls. One fall intervention study demonstrates the effectiveness of a multifactorial fall prevention program consisting of an assessment of risk factors and targeted interventions to reduce falls-injuries . Fall prevention programs generally address side effects of medication; need for observation; pain-comfort needs; promotion of safe mobility and other rehabilitative/restorative needs; and seating, bed, and other equipment needs . Research supports interventions that promote activity to prevent immobilization, a complication of restraint use. Exercise programs and consistent support of residents to perform self-care in activities of daily living are effective in improving strength and balance, thus, reducing risk for falls .

Siderails do not prevent falls and injury and can cause serious injury. As early as 1983, researchers questioned the rationale for using siderails to prevent falls and injuries and described a significant incidence in falls and injuries associated with siderails. Bilateral full siderails do not significantly reduce the likelihood for falls, serious injuries, or recurrent falls . Siderail efficacy to prevent falls and fall-related injuries has never been demonstrated  and siderails pose the same adverse effects as do other restraints including increased immobility, infections, negative psychological effects, and urinary incontinence and infections .

Perceived fall risk and behavior changes related to cognitive loss are the most frequently stated reasons for using restraints. Staff attitude studies suggest falling, combative behavior, interfering with treatment, injury to self and others, confusion, wandering, poor positioning, and poor judgment as the most frequent rationales for restraining residents. Moreover, these studies demonstrate that the perceived risk of falling is the most commonly stated reason for using restraints. A request by the resident’s family to use a restraint to prevent falling is another common reason. This may result in facility fears of litigation and reluctance to seek alternatives to restraints . However, family members tend to accept restraint removal when staff educate them to alternative plans to prevent falls-injuries .

Source:  Hartford Center of Geriatric Nursing Excellence