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Restraints in Elderly Patients: Types, Dangers, and Regulations

Some factors cause anxiety and apprehension for a nurse at work, including the patient’s violent behavior. Imposing a restraint on the patient may relieve the nurse’s anxiety yet limit the patient’s freedom. However, there are certain situations where restraining a patient would be the best possible option to ensure the safety of the patient and his/her surroundings. Nurses are ethically obligated to ensure that the personal rights of a patient are not infringed and that the patient is not subjected to inappropriate restraints such as punishment, coercion, staff convenience or discipline. Restraints have been used for centuries to control violent behavior, especially in the case of severe mental illnesses. Additionally, improper use of restraints in nursing can result in sanctions imposed by the Department of State Health and the Joint Commission (TJC). This paper synthesizes the types of restraints, hospital policies and associated procedures, and the legal and ethics of restraints in Florida.

Restraints in Nursing

Elderly patients have been physically restrained for a long time due to the changes that occur in health care. The number of hospitalized elders has grown significantly due to concerns regarding protecting them from falls and injuries and reducing their interference with medical devices. The growing scarcity of nurses also contributes to such restraining measures. However, restraints should only be used as the last resort for keeping the staff, patients, and visitors safe. Environmental, physical, or chemical restrictions are controversial measures used to control the behavior or restrict a patient’s movement. They are mainly used in nursing to protect the client from injury, ensure that he/she follows treatment and control disruptive behavior. Moreover, Potter, Stockert, Perry, and Hall argue that restraints can increase confusion, amplify the severity of falls, and lead to the loss of bone mass, muscle atrophy, decubitus ulcers and incontinence. Nursing restraints, including chemical, physical, and environmental forms, are associated with significant dangers to an individual; thus, the State of Florida has imposed some tough measures against them, allowing their use only as a last resort.

Types of Restraints

Restraints exist in the chemical, physical, and environmental forms. A restraint intentionally restricts a person’s behavior or voluntary movement. Restraints vary with the practice setting. For instance, a nurse in a correctional facility attends to clients under environmental restraints. In the case of pediatric wards, the clients are typically restrained in cribs. Therefore, the nurses must determine the best and most appropriate restraints depending on the specific practice settings.

Chemical Restraints

Drug use to restrict a client’s movement results in a chemical restraint. It may be used purposely for sedating an individual. Therefore, chemical restraint is mostly referred to as the use of psychopharmacological drugs such as anti-anxiety medications and sedatives. However, it is prohibited to use chemical restraints on resident clients unless the drugs and medications are necessary to treat an existing medical condition or prevent the patients from physically harming themselves or others. Additionally, it is strictly prohibited to use chemical restraints for non-medical purposes, such as staff convenience and discipline. Their use is only allowed in instances where a client’s behavior jeopardizes his/her safety or the safety of others. Nevertheless, even in these scenarios, the nature and duration of the restraint must be outlined in the client’s medical file.

Chemical restraints are also divided into subtypes depending on the drugs used. Thus, psychopharmacological drugs are primarily psychopharmacological, which affect an individual’s behavior, sensation, mood and thinking. These drugs are known to rapidly relax a person but are associated with severe side effects. Antipsychotics such as olanzapine, haloperidol, droperidol and risperidone are also employed as chemical restraints. These drugs are extremely dangerous and, thus, should be used with tremendous caution. Benzodiazepines are another group of drugs that can alleviate seizure disorders, panic attack symptoms, muscle tension, insomnia and seizure disorders. Finally, dissociative anesthetics form a part of chemical restraints since they are a kind of hallucinogen that distort a client’s perception of sight and sound and dissociate a person from himself/herself and the environment.

Chemical restraints are also subjected to laws that prevent nurses from employing them unnecessarily. The regulations give nursing home residents confidence that they will not be chemically restrained purposely for discipline or convenience. Chemical restraints are only allowed in case of possible hazard to the patient’s safety and require gaining consent from the client or his/her representative. Chemical restraints can be imposed only when ordered by a licensed physician who outlines the circumstances and duration of the restraints.

Chemical restraints are the most dangerous kind of restraints. Psychotropic drugs risk adverse effects on the patient’s mental and physical health. Therefore, they should be used only when there is an absolute necessity since if taken unnecessarily; they can cause serious health problems, such as damage to the cardiovascular system and the heart of a person with dementia. Chemical restraints’ other risks and harmful effects include memory loss, agitation, depression, orthostatic hypotension, functional decline and increased dependence. They are also likely to contribute to muscle disorders, low blood pressure, increased risk of falls and accidents, and other adverse effects.

Physical Restraints

Physical restraints are the methods of physically restricting the freedom of movement by using material objects which cannot be removed easily by the patient. These restraints include physical or manual devices such as wrist and ankle restraints, hand mitts, vests that tie clients to beds or chairs, and restrictive chairs. Physical restraints attached to the body can be very dangerous and deadly due to the increased likelihood of a client falling and being trapped by the restraint, which can result in injuries, suffocation, strangulation and even death. They have the potential to cause harm in residence, pain and discomfort. Unnecessary physical restraints can contribute to muscle atrophy, which is the weakening of muscles that can result in the inability to walk after a long period.

Additionally, the patient can suffer psychological and emotional distress due to the decrease of an individual’s sense of dignity and inability to perform normal daily activities. Using physical restraints is an ethical issue since most facilities impose them for convenience rather than necessity. However, they can be substituted with more frequent supervision, individualized rest periods and toileting schedules. Nurses can also use appropriate seats and lowered beds, occupational therapy, and increased social and physical activities.

Environmental Restraints

Environmental restraints are environmental measures used to control a person’s mobility in a secluded place, such as a time-out room, a garden or a secure unit. Holding a patient in seclusion involuntarily is typical in many emergency departments, and all psychiatric units have a room for seclusion. However, such rooms are usually unavailable in medical-surgical units since seclusion is used only with aggressive clients. Hence, physical and environmental restraints can be imposed on clients who behave in a violent and self-destructive manner, whereby the patients should be continuously monitored to avoid accidents or intentional self-harm.

Hospital Policy and Procedure

The hospital policy outlines a wide –range of principles that should be put into practice with clients, including their legal position where suitable. It is usually hard to decide whether to use a restraint or not and when to use it. According to Potter et al., decisions regarding restraints in emergency and urgent situations can be made without consultation with others. However, the staff must account for their actions since unlawful restraints can result in civil liability. Nursing organizations will always support employees who work in a reasonable and measured way and by their training and professional standards. The policy aligns with nursing values, which include adhering to professional standards and using continuous improvement as its focal point.

The hospital policy does not support the use of force or threat to make a patient do something against his/ her will or restrict an individual’s freedom of movement with or without their permission. The hospital policy suggests that action can fit the restraint definition, but it does not make it automatically wrong or unacceptable. Restraints sometimes amount to the deprivation of liberty and form a part of the framework for the Mental Capacity Act, which states that patients should not be denied their liberty to receive care or treatment. A patient must also consider the Independent Mental Capacity Advocate (IMCA) without friends or relatives hospitalized for more than 28 days.

A restraint should be imposed on a patient after a proper assessment of his/ her condition by the individual taking the action. Restraining a client without the capacity should involve a reasonable action that does not harm the patient. The Mental Capacity Act allows the incorporation of restraining actions under certain conditions but proscribes actions that can deprive an individual’s liberty. The common law also has a duty imposed on all social and health care workers, which means that the hospital staff under the common law can take appropriate and necessary measures to prevent a person from harming himself/ herself and any other person due to challenging behavior caused by an illness.

Potter et al. assert that the Mental Health Act allows the use of restraints in treating a physical disorder if it is linked with a mental disorder. In such cases, hospital admission is found to be necessary since it serves the interests of the client’s health and safety or is meant to protect others from harm. Additionally, the Deprivation of Liberty provisions and the Mental Capacity Act (MCA) should be applied in case of treatment of a physical condition against the patient’s will. The MCA applies to individuals subjected to the MHA except for a few cases. An individual under the care of a guardian empowers him or her to make certain decisions that concern the health and well-being of the person. Moreover, suppose it is impossible to treat a patient detained under the MHA due to a mental disorder without his/ her consent. In that case, the healthcare staff can treat the disorder even if the patient refuses treatment.

However, before using a restraint, a variety of considerations should be made by the clinical team. They include the underlying condition and treatment of the patient, his/her behavior, and the mental capacity of the patient, which enables her or him to make decisions regarding behavior, learning difficulties, and religious and cultural issues. Understanding clients’ behavior and responding to their needs is the main purpose of patient care. The healthcare staff must comprehensively assess all their patients to establish therapeutic management that would benefit the clients. This assessment involves identifying the underlying cause of the agitated behavior and deciding whether there is a need for its prevention. After identifying the reason for a certain behavior, the clinical team decides on the best strategy for handling the situation, which should be documented in the patient care notes.

Assessing the client’s mental capacity is paramount when introducing restraining measures. Obtaining informed consent is necessary before imposing any restraint on a patient unless the individual’s mental capacity to make decisions is limited. Assessment of an individual’s capacity has to be done by the MCA Act, which includes completing the MCA forms and documenting the decisions made. All in all, informed consent is vital in healthcare as patients know about their care.

The care environment is another factor that should be considered, as the environment can affect a patient. Environmental factors such as extreme staffing shortage, high noise levels and the poor communication skills of the staff can affect the quality of care that the patients receive. The staff should also be conscious of their duty of care, which differs from that of patients. Using a restraint on a person who incurs a serious risk of harm can sometimes be a part of the medical practitioner’s ability to execute his/her duty of care. It is, therefore, the commitment of the healthcare staff to make decisions on the necessary level of the duty of care by measuring the practice and standard skills. Therefore, a balance must be achieved between maintaining the patient’s freedom and dignity and minimizing the risk of injury or harm.

Hence, restraints in nursing should be used only as a last resort and involve the consent of the patient, his/her guardians or relatives. Discussing the use of restraint with the patient’s parents and guardians before implementing it is appropriate. However, the final decision is usually made by the consultant, who is supposed to act in the client’s best interest. Hence, restraints should be considered when other therapeutic behavioral management methods have failed or are inadequate. If a restraint is considered the best option, the porters and security staff should be contacted to assist in maintaining the safety and health of the patient.

Legal and Ethics of Restraints in the State of Florida

In Florida, the legal and ethics of restraints are controlled very seriously. State laws vary between states, and Florida law requires that restraints in nursing be used only after authorization in writing by a licensed practitioner with the state’s permission. The authorization has to specify the explicit amount of time that the restraints will be used. When the need for a restraint is considered an emergency, a licensed and qualified nurse can act on behalf of a physician and apply the restraints, which should be noted in writing in the patient’s records. However, restraints are the last option, which should be imposed after all other measures have been taken. Before initiating the procedure, the individual and the environment should be properly inspected to ensure the patient’s safety.

Conclusion

Restraints in nursing occur in chemical, physical, and environmental forms. All these restraints can harm the patient since they are associated with adverse effects on the human body. That is the reason why hospitals have set policies and procedures to prevent the inappropriate use of restraints, making them the last resort, which can be applied only after all other proper measures are put in place to avoid further problems. Hence, restraints in nursing can be beneficial to the patient to ensure an individual’s safety and the safety of others; however, at the same time, they are associated with numerous problems, such as the lack of freedom and the increased risk of accidents and falls.

📎 References:

1. Cassie, K. M., & Cassie, W. (2013). Racial disparities in the use of physical restraints in U.S. nursing homes. Health & Social Work, 38(4), 207-213.
2. Muñiz, R., Gómez, S., Curto, D., Hernández, R., Marco, B., García, P., …Olazarán, J. (2016). Reducing physical restraints in nursing homes: A report from Maria Wolff and Sanitas. Journal of the American Medical Directors Association, 17(7), 633-639.
3. O’Keeffe, S. T. (2017). Physical restraints and nursing home residents: Dying to be safe? Age & Ageing, 46(4), 536-537.
4. Potter, P., Stockert, A., Perry, A., & Hall, A. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier.