Restraint-free care: a look back.

It has been over six years since the 90-bed skilled free standing facility in which I was the Director of Nursing eliminated the use of physical restraints and reduced the use of chemical restraints or (psychotropic drugs) to less than 2%. It was a slow process and, in a few cases, almost painful. To put some perspective on this, I need to tell a couple of stories about the Administrator and the Director of Nursing.

One night six years ago, as I was working late in my office, I heard a page: "Nurse to the dining room stat." When I arrived I saw a resident in a wheelchair slumped down and turning blue; she had on a vest restraint, and her chest was not moving. The bottom of the restraint was wrapped tightly around her and the top of the restraint was pulled across her throat, constricting her breathing. I tried to reposition her, but was unable to do so because of the positioning of the restraint. I feared that any movement would crush her trachea. I yelled "someone find me a pair of scissors." By the time someone found a pair of scissors (no easy matter, especially when you really need them), the resident was limp and non-responsive. We were finally able to cut the restraint away from the resident and perform emergency procedures. And, fortunately, she eventually recovered to her prior level of functioning.

After the incident, I returned to my office and (when the shaking receded) thought about it and how it could have been prevented. After making a complete list of all the residents that were presently being restrained in out facility, I realized that about 35% of them were physically restrained and 45% were on behavior-altering drugs without supportive documentation. I decided to put down on paper the reason for each restraint and, strangely enough, I couldn't come up with a reason for at least half of them -- including the resident that almost strangled. Her documentation indicated that the restraint was for "safety," even though she hadn't walked for years and hadn't been known to try to get out of her chair. The best reason I could come up with for her vest restraint was that she had been admitted from an acute care hospital with the order for a restraint.

The next day the Administrator admitted an elderly female resident with the diagnosis of dementia. She came from home accompanied by her son and daughter-in-law. She was deerful, alert, and knew her name and her family's names, although she was disoriented as to time and place. She was ambulatory, continent, and very friendly. After going through the admission process she was shown to her room, and the Administrator (feeling pretty smug about admitting a walking, talking, continent resident) went about his business.

Later that evening, on his way out the door, he noticed a resident making odd noises, squirming and calling out, "Help me, I'm being held a prisoner!" Approaching her and noticing that she had on a vest restraint, he recognized the resident that he had admitted just a few hours previously. This crying, frowning, squirming woman (with eyes like those of a frightened animal) just couldn't be the same person -- could it? He immediately located the charge nurse, who was busy down the hall passing her evening medications, and asked why this new resident had been restrained. The charge nurse replied, "I knew I was going to be busy down the hall and I didn't want her escaping, so I put on a restraint." The administrator pondered this response for a long time.

These incidents motivated us to find another way to protect elderly residents from self-harm. The Administrator and I decided on a team approach, with input from OT, PT nursing, social service and administration; we though this would greatly increase our chances of success. In the summer of 1989, the team developed a philosophy of restraint-appropriate care.

There wasn't a great deal of literature in support of this -- quite the opposite was true. In 1989 restraint usage was the accepted practice for 50% of all nursing home residents. Once we had made our commitment, we knew we had to start with educational programs for all staff regarding the myths of restraint use, the side affects of use and the need for alternatives.

The team developed restraint alternative lists, with choices based on the behavior the resident was exhibiting. The problems were posed by wanderers, positioning difficulties, gait and balance disorders, communication problems, removal of life-sustaining treatments and participation in activities programs.

The positional problems seemed to be the easiest to address, so the team started there. The team released one resident at a time and didn't go to the next resident until we felt that the first resident was safe. When the team had to work with reluctant family members, the team enlisted their help by asking them to observe and record the resident's behavior during the release period. This was so successful that in a couple of months we had discontinued almost half of the restraints and had noted no increase in injuries to these residents.

During the next few months, the team developed activities programs for the residents (i.e., exercise programs, not just the traditional "three B's" -- bingo, Bible study and birthday parties). Our restorative assistant and activities director worked diligently on new and improved programs. Residents attended these programs unrestrained and the team observed their behavior. Still more restraints were removed without negative outcome. By the fall of 1989 only 5% of our residents were still in restraints.

This was the most difficult group for whom to come up with appropriate alternatives. The team again reviewed each of these residents one at a time and came up with some creative alternatives. By January, 1990, we were restraint-free.

Residents continued to be transferred into our facility with orders for both physical and chemical restraints. When this happened the team would inquire from either the resident or significant other why the restraint had been ordered. The next step was to call the facility that had transferred and ask the nurse, "Why the restraint?" Frequently the team found the reason had more to do with the residents' age than any other reason. The next step would be to evaluate whether an alternative needed to be developed before removing the restraint, or could it just be removed completely. The team would then notify the resident's physician and, if needed, get an order to discontinue the restraint. There were a few reluctant physicians and significant others, but for the most part we were able to come to an agreement.

A typical example from our first year: We had a resident on a major tranquilizer. Nursing had been unsuccessful in trying to get the physician to discontinue the medication, even though the resident had not demonstrated any aggressiveness or agitation in the past three months. In fact, she was lethargic and exhibited a poor appetite. I called the physician and this time informed him of the residents lethargy, lack of appetite and lack of aggressive behavior. He agreed to try tapering the medication over the next month. This physician had been the resident's family physician for over 20 years, but when he visited her again two months later he didn't recognize her. When she walked past him, he said, "I didn't know she could still walk."

Though most physicians were agreeable to trial time without the restraint, if I ran into a problem, I would involve our Medical Director and the family.

There have been many occasions when a family member had concerns over releasing restraints for fear that their loved one would get hurt. One such occasion comes to mind: A paraplegic, aphasic male resident had experienced numerous falls trying to escape his restraint. The team had worked on several alternatives for him, including lowering his bed, locking the bed, placing a non-skid mat on the floor, having him wear non-slick socks, and placing his wheelchair locked and next to his bed, with a light left on. The resident's multiple sisters (who visited daily) were very concerned about all this. Finally, with lots of counseling, they agreed to try the alternatives. The sisters were encouraged to come individually and stay with their brother at different times of the day to observe his behavior. It took less than a week for them to see how removing his restraint had changed his outlook on life. He developed a smile "from ear to ear," was never restrained again and lived another two years.

Over time I have come to the conclusion that finding the right alternative, the right activity, and the right restorative program is essential for each and every resident, if we are to seriously reduce and eliminate restraint usage. The most important aspect of restraint reduction is establishing a facility philosophy and then educating all the staff accordingly. Ultimately, you must believe that the use of restraints isn't the solution, it's the problem. That is the essential first step toward setting a new standard of care and enhancing the resident's quality of life.

Diana Johnson, RNC, BHN, is a consultant DPA Associates, Kansas City, KS, and has presented workshops nationally on restraint free/appropriate care, based on her experiences in a skilled nursing facility and as case manager for a hospital-based SNF unit.