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Eliminate restraints

November 12, 2010
by Carmen Bowman, MHS, ACC
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Why do we use restraints? The usual response is that we use them so people will not fall. Do restraints, including alarms, prevent falls? Maybe sometimes, if we're lucky, but we really only prevent a fall if we

happen to get there in time. What this tells us is that the very use of alarms is built on happenstance. I wonder how much sense that makes, and suggest that we weigh this consideration against the adverse effects that alarms and other restraints bring about.

Joanne Rader, RN, MN, PMNNP, is a leader in the restraint-reduction movement that began in the 1980s. She is a pioneer in the culture change movement, particularly with Bathing Without a Battle, and a Pioneer Network founding member. She has turned her attention to reducing the use of alarms and asks, “What are we saving the hips for if we don't let people move or even walk?” Did you know that restraints are not used in some other countries? You can probably guess why. Those care providers feel it is undignified to tie people up or “alarm” them, and they simply don't do it.

So what are some pros and cons of restraints? On the pro side of the scale, we know (don't we?) that they prevent falls. It's time for us to count the costs and weigh what that pro is worth. Is it worth the following long list of cons?

  • Physical cons: cardiac overload, bone loss, edema, skin trauma, pressure ulcers, malnutrition, contractures, increased infection

  • Psychological cons: agitation, aggression, depression, increased confusion, social isolation, traumatic memories1

Oakview Terrace in Freeman, South Dakota, has been restraint-free, including alarms, since 2005. Co-Director of Nursing Theresa Laufmann teaches that the main outcome of restraints, of course, is lack of mobility, just as Rader alludes to above. Lack of mobility causes all sorts of problems, such as pain-which is now a big focus of the MDS 3.0; increased risk for deep vein thrombosis-especially following surgery; increased constipation, with increased use of meds with increased side effects (see a vicious cycle?), and with an increased risk for fecal impaction-a sentinel event; and pressure ulcers, which again lead to pain and another vicious cycle. Laufmann is proud to point out that with Oakview's focus on no restraints there has been a reduction in pressure ulcers, and, in fact, since April 2009, there have been none. Restraints also result in an increased risk for falls due to decreased range of motion, pulmonary function, balance, and strength, plus shortened tendons, contractures, etc. Oh my, what a vicious cycle. Do you ever feel caught up in it?

Laufmann also states, “Most of us could not achieve quality of life if we had to be dependent upon another person's availability for our mobility.” Just imagine for a moment if you could not drive. How would you get where you need to go? How would your quality of life be affected? Even your health? Do you you feel the stress, if nothing else?

So now let's ponder alarms. Why do we use chair and bed alarms? What are the pros and cons? Do they really prevent falls? Well, ask yourself: Is your fall rate any less because you use them? Has your fall rate gone down dramatically since you put alarms in place (something you probably did a long time ago)? What are the cons of alarms? Have you ever tried one? Experiential learning affects us at a deeper level, so try sitting on an alarm in a meeting, then try sitting on one all day. Do it and it will help change your paradigm. Then have others do it, too.

Here is the reality of what we are observing and hearing about alarms:

  • Alarms contribute to a lack of sleep; they wake up both the resident using one and the roommate.

  • Alarms cause physical harm by causing the individual to not move so the alarm won't go off. (Remember all those lack-of-mobility cons?)

  • Alarms cause psychological harm when the individual is told by other residents to be quiet.

  • Alarms make people feel as if they are in trouble all the time.1

Leaders in this arena are helping us to realize that our reaction when an alarm sounds is typically to the alarm, not to the person. Just observe what staff do when an alarm goes off. Typically, what do we tell the person? “Sit down.” In other words, we react to the restraining alarm, not to the needs of the person. Otherwise we would say, “What can I help you with, Mrs. Smith?”2

There is a terrific 2008 webinar on restraint reduction offered by Colorado Foundation for Medical Care, the Colorado QIO, which is still available (see references). In this webinar, Oakview Terrace leaders share that in 2006 they had 136 resident falls, but in 2007 falls decreased to 100. Fewer falls. Can you guess why? After staff removed all restraints, including alarms, falls decreased!

Do you want to achieve fewer resident falls? Consider getting educated, getting ready, and taking the plunge like so many are doing in their efforts to eliminate yet another very institutional practice of medical-model living.

Carmen Bowman, MHS, ACC, is the Owner of Edu-Catering: Education for Compliance and Culture Change in LTC, a consulting and training company in Firestone, Colorado. She can be reached at (303) 833-1492.

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