Restraint alternatives: Balancing act

Share this content:

Providers are cautiously finding ways to treat residents who have been untethered by nursing home reform, bringing new challenges.

One of the great stories in Neville Strumpf's considerable arsenal is the tale of the former circus acrobat who was admitted to a nursing home. The man was demented but still quite mobile. It was a cocktail for disaster, and facility staff knew it.
"He would do fairly incredible things, like climbing over banisters," recalled Strumpf, one of the nation's top researchers on the use of restraints in nursing homes and hospitals.
The acrobat's caregivers resisted trying to suppress all of his inner urges. Instead of trying to bind him in someplace, they became creative and went in the other direction. In other words, no physical restraints.
"The nurses got him a bicycle helmet, fitted him with better walking shoes and trained him more or less with a walker," Strumpf recalled with a smile. "After that, the staff didn't worry too much about his behavior. And they were thrilled. To see him contained in a chair wasn't good at all. He was very agitated and upset. He had all this diffuse energy."
Best of all, the staff had family members on their side with the customized approach.
"They saw him being fairly mobile, with the assumption that there would be some risk here, but the family was willing to take that risk," says Strumpf, director of the Center for Gerontologic Nursing Science at the University of Pennsylvania School of Nursing. "The shoes, walker and helmet helped, and there was an alarm system. They guy was moving around and that was great."
Nationwide, the situation was not so great less than two decades ago. As recently as 1986, nearly 40% of all nursing home residents were physically restrained, according to experts.
That figure has dropped steadily since then, however, and now is at just above 8%. The reduction of restraints has been one of the undisputed success stories for nursing homes over the past 15 years.
Yet more needs to be done, advocates stress. Turnover of residents – and staff – make the question of restraint-use a knot that can never be fully tied off.
Today, caregivers are trying to hone in on a proper amount of customized, or "patient-centered," care. More scrutiny of resident behavior, modified caregiving strategies, and innovative equipment and furnishings are powering the transformation.

Counter trend ahead?
The extreme success of restraint reduction may actually create analytical snafus in the near future.
"Restraints as we've known them over the years have gone down. But now that we see bed systems, and siderails in some cases, identified as restraints for some people, we might see numbers coming up in some states when they're looking at that in their restraint numbers," explained Beryl Goldman, widely regarded as the best known U.S. provider to teach and speak on restraint alternative programs.
Traditionally, restraints have been considered things such as lapboards, waist straps, vest restraints, geriatric chairs and other restrictive items.
But regulators recently have broadened their scope and give more examples of what they now see as restraints, Goldman explains. "That's made it more difficult to look at the numbers carefully."
Goldman has worked on restraint research and reduction projects for about 15 years for the Kendal Corporation. The Quaker faith-based operator headquartered in Kennett Square, PA, leads the Untie the Elderly® initiative known worldwide in provider circles. For the last eight years, Kendal has used a state grant to help other facilities reduce the use of restraints.
"What we've seen is facilities believe they're reporting all their restraints, but when a team goes in to look at them, they recognize some facilities are calling restraints something different, like 'enablers' or 'positioners,'" Goldman said.
The key is getting to know residents better, and then deploying never-growing workforces better than before, she explained.
"If before we had a person in a chair and staff were worried he would get up and fall, they would restrain him. Now, we look for the underlying reason for his need to get up," Goldman