Another study surrounding the use of restraints in non-psychiatric patients (Strumpf and Evans, 1998) reported that the nurses had difficulty reconciling the administration of restraints with concerns regarding patient dignity and autonomy. So it appears that the use of restraints is difficult on staff and patients alike. Interestingly enough, in a literature review for this paper, the writer could find no significant supporting data to recommend restraint devices as effective in the management of the confused or persistently agitated patient. In this case, it appears that many times patients are being placed into restraints more "because we have always done so with this kind of patient" rather than on the basis of any science that the use of restraint is beneficial to the patient.
Restraints and the Law
Any time a patient is to be considered for the application of restraint devices, it is important that all members of the care team be well versed in the federal regulations and facility policies surrounding restraints and the monitoring of the same. The same can be said for the knowledge of Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards surrounding restraints. These regulations and guidelines have in fact been based on a melding of medical research surrounding the use of restraints and a trend in the healthcare community towards improving the quality of life and healthcare in long-term care facilities. The Federal Nursing Home Reform Act of 1987 defined physical restraints as "any manual method or physical or manual device, material or equipment attached or adjacent to the resident's body which cannot be removed easily and can restrict the freedom of the resident's movement or normal access to one's body." This regulation also goes on to state "resident has the right to be free from any physical or chemical restraint imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms." This ensures that on a very busy day when the nurses are short staffed, Mrs. Johnson is not placed in a Posey vest simply because she has the tendency to wander and there is no one to keep a good eye on her. It is important to note that before the implementation of the Reform Act, it is estimated that approximately 40% of nursing home residents were physically restrained. Data now shows these numbers to be closer to 12%, a decrease that is hopeful but still sad in comparison with similar patient populations in European communities in which the restraint rate is less than 5%.
Of course, these federal regulations do not prohibit the use of restraints entirely but do help to ensure that strict limits are set and that parameters must be met before the use of restraints can be considered. Ultimately, the physical restraint is meant to be used to treat a medical symptom, and then only the least restrictive method will be used to allow the patient to continue at his or her highest level of function, as is safe and appropriate to the situation. In addition to these parameters, when restraints are felt to be the most appropriate measure to use in management of the patient, the use of restraints must be monitored in a systematic and objective manner to prevent the occurrence of adverse effects. In every case, the patient must be continually reassessed for the appropriateness of less restrictive devices. In addition, care must be paid to other possible complications of long-term restraint to include personal strengthening and rehabilitation programs.
The use of restraints in both medical and psychiatric patients is an issue fraught with emotional and clinical concerns. It appears clear that decision-making surrounding the use of restraints must be clear, and that attention must be paid to staff attitudes and reactions surrounding the use of restraints. Debriefings surrounding restraining and managing patients in restraint should be routinely used to reduce the anxiety surrounding the care of these patients and will probably improve job satisfaction of staff in long-term and psychiatric facilities. More research should be done on the needs and care of patients who absolutely require restraints and it is a given that any practitioner who is in the position to order restraints be familiar with the ethical and legal issues surrounding their prescription. Of course, every patient who is considered for restraint should always be approached with the least restrictive method possible and hopefully the restraints will never have to be used. But when they are used they should be used thoughtfully and with full consideration to the long-term and short-term effects on staff and patients alike.
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