The Use of Restraint for Older Adults in Nursing Homes

The practice of restraining elderly patients who are cognitively unsound is still rife in many countries, despite the fact that it is ethically and morally wrong from all angles (Ye et al., 2018). These are usually elderly patients with multiple comorbid conditions but also having a neurodegenerative condition. These neurocognitive disorders such as dementia render these elderly patients cognitively deficient such that they tend to forget easily (amnesia) and have trouble speaking and expressing themselves. They thus face many risks to their wellbeing such as wandering off onto the road where a vehicle may knock them down. They are also at risk of falling accidentally and getting hurt. These patients therefore require all-round care from nurses and other caretakers like nurse assistants for them not to suffer harm caused by their cognitive incompetence. But this requires a huge workforce if it is to be a reality. So nurses have been resorting for many years to the next easy option of physically restraining the patient in bed (Kor et al., 2018). This is common practice (not evidence-based practice) done to ostensibly protect them from injury and accidents. The purpose of this paper is therefore to look at the current available literature and what it says about the common practice of physically restraining elderly patients with cognitive decline.

Nursing Practice Problem and PICOT Question

That using physical restraints on cognitively impaired residents in nursing homes is a nursing practice problem posing an ethical dilemma is not in question. The reason is that the practice paradoxically causes more harm than the good it is supposed to bring. A cognitively impaired elderly resident may suffer amnesia, spatial disorientation, and language problems; but their clarity of mind and consciousness of what goes on around them is intact. This means that they know and can see what is being done to them only that they cannot complain directly. As such, the practice will cause them long-lasting psychological trauma that may complicate their recovery and quality of life. Since they cannot turn on their own when restrained in a supine position, there is also the risk of developing pressure sores in the sacral region. These are just a few examples demonstrating that physical restraints violate the bioethical principle of non-maleficence (to do no harm) or primum non nocere (Haswell, 2019). The principles of autonomy (including informed consent) and justice are also violated.

In order to get the latest peer-reviewed scholarly literature, a PICOT question was formulated to inform the search. This question was “In elderly patients with dementia and other neurodegenerative disorders in nursing homes (P), does the use of physical restraints (I), compared to purposeful hourly nursing rounds (C) lead to better overall outcomes like faster recovery (O) in a period of six months (T)?” Key words were formulated from this PICOT question and then entered in the search engines of four research databases namely PubMed, ProQuest, CINAHL, and Cochrane. It is two of the recovered articles addressing the PICOT question that are summarized in this paper in terms of objective, methodology, results and other parameters. The Use of Restraint for Older Adults in Nursing Homes Essay Discussion Paper

Background of Studies

A good number of elderly patients suffering from dementia and other neurocognitive disorders are cared for at home. Because there is no family member who will be there with them watching over them 24 hours a day seven days a week; caretakers resort to the use of physical restraints to keep the cognitively impaired patient in place as they tend to other duties (Moermans et al., 2018). To make matters worse, the study by Moermans et al. (2018) also shows that there are actually some providers who themselves prescribe to caretakers physical restraint as a way to keep the patient from harming themselves. The researchers acknowledge that this is unethical and barbaric and should stop and be replaced by evidence-based patient-centered approaches.

The other issue is that to do with the knowledge, attitudes, practices, and skills of nurses and other caretakers for these cognitively challenged patients (Kong et al., 2017). There is a dearth of knowledge on the effects of this practice on the part of a good number of nurses working in these care homes. What emerges from the study by Jacobsen et al. (2017) is that there is complacency in most of these nursing homes such that common practice prevails over evidence-based practice. People are not motivated to change and therefore take the easiest way out of physically restraining the patients.

Study Summary

Two of the studies retrieved from the database search will be summarized and analyzed in this paper. They are the quantitative studies by Jacobsen et al. (2017) and Moermans et al. (2018). As stated, the nursing practice problem is the continued use of physical restraint on cognitively impaired elderly patients in nursing homes and at home despite being unethical and not evidence-based. The purpose of the Jacobsen et al. (2017) study was to see if an education intervention to enlighten and educate nurses on the dangers of restraint would change attitudes (Wang et al., 2022). The end goal was to stop the practice by providing information. As a research question, the researchers sought to find if other patient-centered strategies like performing hourly rounds would be better than the barbaric act of tying the patient to the bed. The importance of the above to nursing practice is that the nurses in the long-term care homes would embrace evidence-based interventions in place of unproven common practice.

It is the same practice problem that also inspired the study by Moermans et al. (2018). They purposed to determine who orders such interventions such as restraints and also how rampant the practice is in reality. To them, too; the objective was to find alternative ways of preventing such patients from harming themselves without subjecting them to suffering. The guiding research question was also whether other patient-centered approaches exist to replace the unethical one of restraint. The significance to nursing practice is that nurses will be encouraged to be compassionate and caring as illustrated in Jean Watson’s Theory of Human Caring (Alharbi & Baker, 2020). This would be the way the nurses would accomplish their professional mission of being advocates of hope. Restraining the already frail and confused patients physically does not conform to this role.

Relationship of the Studies to the PICOT Question

The PICOT question addressed itself to the efficacy of the practice of restraint vis-à-vis other tried and tested patient-centered interventions such as hourly rounds. Looking at the studies, they specifically address the same practice issue of the suitability or otherwise of restraints. This means that the studies actually provide answers to the PICOT question. The dependent and independent variables, the study and control groups, as well as the interventions mirror those n the PICOT question.

Methodology of the Studies

Moermans et al. (2018) used a quantitative cross-sectional study method to do their study. Their sample was made up of elderly nursing home patients who had cognitive deficiencies (n=1,194). The benefit of this method is that it will provide a clear and unambiguous picture of the problem as it is at the time without the confusion brought by confounding variables. The limitation on the other hand would be on the effect of the sample size on the results and their generalizability. For Jacobsen et al. (2017), the methods used was a mixed method with the sample comprising of nurses in a total of 24 nursing homes across the country of study. The limitation with this method is that the mixed method may bring confusion during data analysis. The advantage is that it draws from both quantitative and qualitative methodologies and hence is more representative.

Results of the Studies

A majority in the sample population in Moermans et al. (2018) turned out to have been subjected to physical restraining during the study. To be noted was that these were patients being taken care of at home but with the direction of professional providers who did not expressly prohibit the use of restraints. The implication of this is that the practice is indeed rife and ways need to be found to change the state of affairs. The answer lies in alternative evidence-based patient-centered interventions that would not harm the patient psychologically and physically.

The culture of the organization as well as the type of leadership was found to be largely responsible for the practice of using restraints. The authors found glaring differences in procedures and practices across the institutions studied. Where there was no culture of change, the practice of restraining patients was extensive. Likewise, in organizations that did not have transformational leadership there was a problem with sticking to procedures and protocols.

Comparison of Outcomes and Evidence-Based Practice Recommendations

The PICOT question predicted outcomes that were patient-centric and patent-centered. Indeed, the outcomes of the studies also pointed to the need for adoption of more patient-centered interventions that did not harm the patients. In all, the evidence-based practice recommendations such as purposeful hourly rounding, nurse training and education, and the use of bedside alarms would be preferred (Guirguis-Blake et al., 2018). These would bring about more favorable patient outcomes.

Ethical Considerations

The use of physical restraints on any patient is unethical. It violates the ethical principle of autonomy as the patient does not give informed consent for the intervention (Haswell, 2019). It also violates the ethical principles of justice and nonmaleficence. Being treated differently is not just; and being restrained causes both psychological and physical harm to the patient. All these violations must be replaced by beneficence and this would only be possible by applying the evidence-based recommendations.

Conclusion

The practice of physically restraining cognitively impaired patients in nursing homes is still rampant. It is however unethical and belongs to the realm of common practice. Studies show that the practice has no basis in scholarly literature and empirical trials. The recommendation by authors of various studies is that more patient-centered interventions to protect the safety of the elderly frail patients who are confused are needed.

References

Alharbi, K.N., & Baker, O.G., (2020). Jean Watson’s middle range Theory of Human Caring: A critique. International Journal of Advanced Multidisciplinary Scientific Research, 3(1), 1-14. https://doi.org/10.31426/ijamsr.2020.3.1.3011

Guirguis-Blake, J., Michael, Y., Perdue, L., Coppola, E., & Beil, T. (2018). Interventions to prevent falls in older adults. JAMA, 319(16), 1705. https://doi.org/10.1001/jama.2017.21962

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. The Use of Restraint for Older Adults in Nursing Homes Essay Discussion Paper https://doi.org/10.12968/joan.2019.8.4.177

Jacobsen, F.F., Mekki, T.E., Førland, O., Folkestad, B., Kirkevold, Ø., Skår, R., Tveit, E.M., & Øye, C. (2017). A mixed method study of an education intervention to reduce use of restraint and implement person-centered dementia care in nursing homes. BMC Nursing, 16(1), 1–11. https://doi.org/10.1186/s12912-017-0244-0

Kong, E.-H., Song, E., & Evans, L.K. (2017). Effects of a multicomponent restraint reduction program for Korean nursing home staff. Journal of Nursing Scholarship, 49(3), 325–335. https://doi.org/10.1111/jnu.12296

Kor, P.P., Kwan, R.Y.C., Liu, J.Y.-W., & Lai, C. (2018). Knowledge, practice, and attitude of nursing home staff toward the use of physical restraint: Have they changed over time? Journal of Nursing Scholarship, 0(0), 1-11. https://doi.org/10.1111/jnu.12415

Moermans, V.R.A., Bleijlevens, M.H.C., Verbeek, H., Tan, F.E.S., Milisen, K., & Hamers, J.P.H. (2018). The use of involuntary treatment among older adults with cognitive impairment receiving nursing care at home. A cross-sectional study. International Journal of Nursing Studies, 88, 135-142. https://doi.org/10.1016/j.ijnurstu.2018.09.004

Wang, J., Liu, W., Wang, H., Zhao, Q., & Xiao, M. (2022). Difference of physical restraint knowledge, attitudes and practice between nurses and nursing assistants in long-term care facilities: A cross-sectional study. Risk Management and Healthcare Policy, 15(0), 243-255. https://doi.org/10.2147/RMHP.S349545

Ye, J., Xiao, A., Yu, L., Wei, H., Wang, C., & Luo, T. (2018). Physical restraints: An ethical dilemma in mental health services in China. International Journal of Nursing Sciences, 5(1), 68–71. https://doi.org/10.1016/j.ijnss.2017.12.001

Evidence of Revision –  10%

Evidence of incorporation of research critique feedback and revision is comprehensive and thoroughly developed.

This section is looking to see if you made changes based upon the feedback that you have received in previous assignments.

Nursing Practice Problem and PICOT Question – 5%

PICOT question clearly articulates a nursing practice problem using substantial supporting information from numerous reliable sources.

This is asking for your PICOT statement but also how it relates to the practice problem you identified.  You should have several sources in this section.

Background of Studies – 5%

Background of studies, including problem, significance to nursing, purpose, objective, and research questions, is thorough with substantial relevant details and extensive explanation.

This is exactly the same as in previous assignments.  You can combine this information when you can.  For example if two papers have the same general purpose you can combine that.  Just be sure that I can tell that you have addressed all four articles.

Method of Studies – 5%

Discussion of method of studies, including discussion of conceptual/theoretical framework, is thorough with substantial relevant details and extensive explanation.

This is exactly the same as in previous assignments.  If you can include the conceptual / theoretical framework, that is great.  It is sometimes hard to find in research articles if at all.  You want to describe the method used for each of the articles.

Results of Studies – 5%

Discussion of studies results, including findings and implications for nursing practice, is thorough with substantial relevant details and extensive explanation.

Again, the same as in previous articles.  You will want to provide themes from the qualitative articles and the numbers based upon the quantitative articles.

PICOT Question, Research Articles, and Nursing Practice Problem Relationship – 10%

Discussion of the relationship between the PICOT question, research articles, and nursing practice problem is extremely thorough with substantial relevant details and extensive supporting explanation.

Simply tie things together.  Explain how the articles support your PICOT statement and practice problem.  You should support this through substantial details and supporting explanation.

Proposed Evidence-Based Practice Change  – 10%

The proposed evidence-based practice change is extremely thorough and includes substantial supporting explanation and numerous relevant details.

This is a new section and you will describe what the change is that you are working toward.  This is theoretical at this point, but speak to this as if you are working to implement this change in your facility

Ethical Considerations – 5%

Discussion of ethical considerations associated with the conduct of nursing research is thorough with substantial relevant details and extensive explanation.

Same as previous assignments.  General overview of the ethical considerations.  You can combine this for all articles.  Just provide a detail of how participants are protected in the research.

Conclusion – 5%

Conclusion summarizes utility of the research from the critical appraisal, knowledge learned, and the importance of the findings to nursing practice.

This is where you will really summarize everything you have discussed at this point.

The Use of Restraint for Older Adults in Nursing Homes Essay Discussion Paper