Author Insights: Reducing Restraint Use Takes a Multifaceted Approach

German researchers Sascha Köpke, PhD, of the University of Lübeck, and Gabriele Meyer, PhD, of Witten/Herdecke University, demonstrated that reducing use of physical restraints in nursing homes is possible with an intervention that targets staff, resident, and family member attitudes about such restraints. Image: Anne Junghans (left) Witten/Herdecke University (right)

Changing the attitudes of nurses, family members, and leaders at nursing homes can reduce the use of physical restraints on nursing home residents, according to research findings published today in JAMA.

The use of physical restraints is a common practice in nursing homes in the United States and around the world, despite evidence suggesting that they may have a detrimental effect on the health and well-being of nursing home residents. In Germany, it remains common despite laws that have been passed discouraging the practice. So a team of German researchers tested whether a multicomponent intervention targeting the attitudes of nursing home staff, residents, and family members could help reduce the use of physical restraints in this setting.

In a cluster randomized trial in Germany, the researchers compared the use of restraints in 18 nursing home clusters with more than 2000 residents that had received the intervention and 18 control nursing home clusters with about 2000 residents. The intervention emphasized not using restraints and provided education to nursing home staff and other stakeholders. At baseline, about 30% of patients in both the intervention and control group nursing homes had physical restraints. Six months after the intervention, restraint use in the intervention nursing homes decreased to 22.6% compared with 29.1% in the control nursing homes.

Study authors Sascha Köpke, PhD, and Gabriele Meyer, PhD, discussed the findings with news@JAMA.

news@JAMA: Why are restraints used so often in nursing facilities?

Dr Köpke: We are used to viewing restraints as appropriate measures for fall prevention and dealing with challenging behavior. This does not only apply to nurses, but to everyone involved in residential care, including physicians, nursing home directors, judges, family members, and of course residents themselves. On the other hand, everyone is aware that restraining residents’ freedom is not an ordinary nursing intervention, but a serious interference with residents’ basic human rights. Nevertheless, for many persons involved, there does not seem to be an adequate alternative to restraining residents.
Dr Meyer: The easy availability of restraints is also part of the equation. In Germany, nursing home beds always have bed rails attached and also belts and fixed tables are easily accessible.

news@JAMA: What are the alternatives?

Dr Meyer: Even if it sounds odd, the main alternative to using restraints is not to use restraints. If we weigh benefit and harm of restraints, the scales definitely tend to tip to the harm side. It may seem paradoxical, but from all we know it seems highly likely that restraining nursing home residents does not reduce falls and fractures but may even lead to more fall-related injuries due to the detrimental effects of immobilizing frail elderly persons. If we accept the inappropriateness of restraining nursing home residents, we wouldn’t be looking for “alternatives” but would seek more appropriate measures to deal with the challenges of caring for frail and often cognitively impaired older persons. The main goal here is to ensure safe mobility and to avoid fall-related injuries.

news@JAMA: What distinguishes nursing homes that have successfully reduced restraint use?

Dr Köpke: Nursing homes have to build a culture of restraint avoidance. We have asked managers and head nurses of nursing homes who use very few restraints, and all reported that a change in their attitude towards restraint use was an important step towards avoidance of restraints.

news@JAMA: Do you think such an intervention would work as well in the United States or other countries?

Dr Meyer: The conclusion that restraints must and can be avoided seems generalizable to other countries and health care systems. We also point out in the article that the intervention could not completely abolish restraints and that there were still considerable differences in restraint rates between nursing homes—suggesting that for Germany at least, stricter application of legal regulations is warranted to further reduce restraints in nursing homes. This definitely holds for the United States and probably also for other countries.

Categories: Human Rights, Patient Safety/Medical Error, Quality of Life