Physical Restraints: Overview

Awareness regarding physical restraint use in nursing homes has increased since Congress passed the Omnibus Budget Reconciliation Act (OBRA) of 1987. The Centers for Medicare & Medicaid Services (CMS) defines a physical restraint as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body (42 CFR 483.13(a)). When determining whether a device meets the definition of a physical restraint, the assessor should not focus on the intent or reason behind the use of the device but the effect the device has on the resident. Research and standards of practice show that the belief that physical restraints ensure safety is often unfounded. In practice, restraints have many negative side effects and risks that, in some cases, far outweigh any possible benefit that can be derived from their use. Restraints not only may not prevent falls, but can cause greater harm including strangulation, loss of muscle tone, decreased bone density (with greater susceptibility for fractures), pressure sores, decreased mobility, depression, agitation, loss of dignity, incontinence, constipation, and in some cases, resident death. Benefits of refraining from the use physical restraints have been welldocumented in long-term care literature; they include improvement in residents quality of life, greater autonomy, use of fewer anti-psychotic medications, less skin breakdown, and fewer serious injuries due to falls (RAI Users Manual p. C-99). Research has clearly demonstrated that physical restraints can be damaging both physically and mentally for residents, cost more in terms of resources, and can increase the incidence of serious injuries, the percent of residents who were physically restrained in the U.S., according to the Chronic Care Physical Restraint Quality Measure, was a national mean of 8% for the third quarter of 2003. This figure demonstrates a decline in restraint use from the national mean of 9.72% when quality measure data was initially collected in the second quarter of 2002, however, the need for continued quality improvement in this area is apparent (Nursing Home Quality Initiative, National Quality Measures Summary Report).

Negative Consequences of Physical Restraint Use

Liability concerns, fall prevention, disruptive behaviors, and resident resistance to treatment are commonly perceived reasons for physical restraint use, when in fact; physical restraints can cause serious harm or functional decline (Castle & Mor, 1998). There are many adverse physiological and psychological consequences associated with the use of physical restraints on nursing home residents including urinary incontinence, increased agitation, circulation impairment, skin breakdown, decreased mobility (Williams & Finch, 1997), physiologic stressors, social isolation, and reduced sensory and perceptual input (Sullivan-Marx, 2001). Additional negative outcomes to residents can include: abnormal changes in body chemistry, basal metabolic rate, and blood volume; orthostatic hypotension; contractures; lower extremity edema; decreased muscle mass, tone, and strength; nosocomial infection; cardiac stress; problems with elimination; loss of self-image; increased confusion and combativeness; and even death (Evans & Strumpf, 1990).
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Legal issues and fear of a lawsuit may impede the efforts to reduce physical restraints in a nursing home setting. Caregivers often feel they will be liable for not protecting a resident from serious injury or necessary treatment if a physical restraint is removed or reduced; however, research indicates restraints increase the risk for serious injury (Evans & Strumpf, 1990). It is estimated that as many as 200 deaths occur every year as a result of strangulation or suffocation from physical restraints, even when they are applied according to manufacturers instructions (Guttman et al., 1999). Manufacturers of physical restraints often attribute the deaths to poor clinical decision-making or inadequate monitoring (Miles, 2002). A study by Sullivan-Marx et al. (1999b) found it was the staffs perception of fall risk, not actual falls, that influence their decision to restrain a resident. Studies by Capezuti et al. (1998a) and Castle and Mor (1998) provided evidence that physical restraint removal did not lead to an increase in falls or fall-related injury among nursing home residents. Also, physical restraint application did not lower the risk of falls or injuries for residents likely to be restrained (Capezuti et al., 1996) and in a similar study there was a correlation of physical restraints and continued or even increased incidence of fall-related injuries (Tinetti et al., 1992). In reference to bedrails, Capezuti and colleagues (2002) found that bilateral bedrails did not decrease falls or serious injuries. Parker and Miles (1997) point out that bedrails are up in most falls from bed, and most injuries occur when residents fall out of bed while attempting to climb over the rails. The immobilizing effects of physical restraints directly affect an individuals ability to ambulate safely by decreasing muscle mass, strength, and flexibility, and therefore contribute to falls and serious injury (Capezuti et al., 1996). In the past, physical restraints were viewed as preventive measures; however, multiple research studies are supporting the reality that they are in fact risk factors (Capezuti et al., 1996). The utilization of physical restraints in the nursing home often involves an attempt to control behavior, lack of alternate interventions, limited behavior assessment skills, belief that physical restraints provide a safe environment, and lack of education regarding the hazards of physical restraint use (Sullivan-Marx et al., 1999a). Often the rationale for the use of physical restraints is not acceptable. Initiation of physical restraints occurs more frequently with individuals with cognitive impairment (Sullivan-Marx et al., 1999a). In a study by Capezuti et al. (1996) nonconfused ambulatory residents were almost never restrained while confused ambulatory residents were restrained 37% of the time. Attempts to manage agitated behavior with physical restraints can exacerbate the agitation, increasing the risk of harm to the resident (Castle & Mor, 1998). According to Castle and Mor (1998) "there is little evidence to suggest that restraints ever were useful in the nursing home setting. This has led many authors to conclude that the efficacy of restraint lies in the fact that they are a convenience for staff because they control undesirable behavior".

Are Restraints Prohibited?

The Long-Term Care RAI Users Manual (2002) clarifies the CMS position on the use of
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physical restraints: The regulations and CMS guidelines do not prohibit the use of restraints in nursing facilities, except when they are imposed for discipline or convenience and not required to treat the residents medical symptoms. The regulation states, The resident has the right to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the residents medical symptoms (42 CFR 483.13(a)). Research and standards of practice show that the belief that restraints ensure safety is often unfounded. In practice, restraints have many negative side effects and risks that, in some cases, far outweigh any possible benefit that can be derived from their use. Prior to using any restraint, the facility must assess the resident to properly identify the residents needs and the medical symptom that the restraint is being employed to address. If a restraint is needed to treat the residents medical symptom, the facility is responsible to assess the appropriateness of that restraint. When the decision is made to use a restraint, CMS encourages, to the extent possible, gradual restraint reduction because there are many negative outcomes associated with restraint use. While a restraint-free environment is not a Federal requirement, the use of restraints should be the exception, not the rule (p.3-201). In the State Operations Manual (SOM, Rev 20, 09-00) the guidance to surveyors states that physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions and lap trays the resident cannot remove. Also included as physical restraints are facility practices that meet the definition of a restraint, such as: Using bed rails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed; Tucking in a sheet so tightly that a bed bound resident cannot move; Using wheelchair safety bars to prevent a resident from rising out of a chair; Placing a resident in a chair that prevents rising; and Placing a resident who uses a wheelchair so close to a wall that the wall prevents the resident from rising (SOM Appendix PP, PP45). Bed rails may be used to restrain residents or to assist in mobility and transfer or residents. The use of bed rails as restraints is prohibited unless they are necessary to treat a residents medical symptoms. Bed rails used as restraints add risk to the resident. They potentially increase the risk of more significant injury from a fall from a bed with raised bed rails than from a fall from a bed without bed rails. They also potentially increase the likelihood that the resident will spend more time in bed and fall when attempting to transfer from bed (SOM Appendix PP, p.45).

Further clarification of the CMS position on the classification of bed rails as physical restraints can be found in the Long-Term Care Resident Assessment Instrument (RAI) Users Manual (2002): In classifying any device as a restraint, the assessor must consider the effect the device
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has on the individual, not the purpose or intent of its use. It is possible for a device to improve the residents mobility and also have the effect of restraining the individual. If the side rail has the effect of restraining the resident and meets the definition of a physical restraint for that individual, the facility is responsible to assess the appropriateness of that restraint. Prior to employing any restraint, the facility must assess the resident to properly identify the residents needs and the medical symptom the restraint is being employed to address. When the facility decides that a restraint is needed to treat the residents medical symptom, CMS encourages, to the extent possible, gradual restraint reduction because of the many negative outcomes associated with restraint use. For residents who have no voluntary movement or involuntary movement, the staff needs to determine if there is any appropriate use of bed rails. Bed rails may create a visual barrier and deter physical contact from others. Some residents have no ability to carry out voluntary movements, yet they exhibit involuntary movements. Involuntary movements, residents weight, and gravitys effects may lead to the residents body shifting towards the edge of the bed. For this type of resident, clinical evaluation of alternatives (e.g., a concave mattress to keep the resident from going over the edge of the bed), coupled with frequent monitoring of the residents position, should be considered. While the bed rails may not constitute a restraint, they may affect the residents quality of life and create an accident hazard (p.3-201, 202).

Essential Systems For Quality Care

The following information suggests areas to focus on while evaluating facility processes for reducing physical restraint use. Organizational Commitment The success of a physical restraint reduction program is dependent upon the support of the administrator, director of nursing, family, and health team members (Sullivan-Marx, 2001). According to Williams and Finch (1997), this may be the single most important element of a successful restraint reduction program. Dunbar et al. (1997) observed that one of the most important factors in reducing the use of restraints was the administrators attitude and commitment, knowledge regarding restraint-free care, willingness to advocate for its implementation, and ability to guide and lead their facility through the process.

Many facilities find the best way to approach physical restraint reduction is with a multidisciplinary quality improvement team. Individuals considered for restraint reduction often have complex issues requiring the collaborative knowledge and perspective of various disciplines in order to decipher the meaning of behavior. By addressing the needs of individuals through a quality improvement framework, clinical practices and interventions for physical restraint reduction would become the standard rather than the alternative. Ideally a restraint reduction team should consist of a clinical coordinator, the administrator, charge nurse, physician, rehabilitation therapist, restorative personnel, social worker, activities director, nursing assistants, the resident, and the resident's family/representative if the resident wants them to be involved. Responsibilities of a restraint
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reduction team should include: resident assessment, individualized care plans, documented interventions and outcomes, maintenance of a restraint reduced environment, staff education, and communication. The physical restraint reduction team should develop a policy and procedure for physical restraints within their organization. Staff education based on the policy is imperative for consistent interventions, clear expectations, and quality decision-making regarding physical restraints. Components of the program should state beliefs and goals, reflect compliance with regulations, and define standards of practice. Strumpf et al. (1998) defines standards of practice for physical restraints, including: a) Behavior should trigger assessment and intervention aimed at individualized approaches to care without restraint; b) In the rare circumstance where a restraint is applied, this should only occur as a result of collaborative decision making among nurse, physician and other health team members. Such a decision should be the result of comprehensive assessment, case review, and sufficient evidence of attempted interventions. This decision must also incorporate informed participation and consent by patients/residents and families; c) Restraints are never used as a substitute for observation; and d) If for any reason restraints are to be used, then use is as a short-term measure only and as a last resort. Any application of a physical restraint is to be done by properly trained staff who are keenly aware of the potential hazards. When short-term use is unavoidable, attention to comfort, safety, and needs for food, hydration, elimination, exercise, and social interaction are required. The client should be debriefed following the experience of restraint to prevent negative emotional consequences. Staffing and Education Many long-term care providers feel physical restraint reduction efforts are too costly or unavailable, however, many nursing homes have reduced physical restraints without increasing staff or costs (Castle & Mor, 1998). Evans and Strumpf (1990) and Strumpf et al. (1998) identify four categories of interventions, most of which are readily available at a low cost. They include: physiologic care (e.g. comfort, pain relief, positioning and changes in medication or treatment); psychosocial care (e.g. remotivation, companionship and supervision); activities (e.g. distraction and recreation); and lastly, environmental manipulation (e.g. adequate lighting, home-like features and removal of restraint devices). Administrative support and staff training are also identified as cost effective readily available measures to support restraint reduction. In regard to successfully reducing physical restraints, many studies have found that it was not necessary to increase the number of full-time staff (Neufeld et al., 1999). In some cases staff were able to change their job duties from focusing on periodically releasing restraints, completing exercises, repositioning, reapplication of restraints, and documentation; to reallocating time for other activities such as resident socialization and increased monitoring of residents (Dunbar et al., 1997). According to Schnelle et al. (1992), monitoring a restraint reduction program and ensuring staff accountability for adhering to the program may actually
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result in less time due to the high time demands of restraint management. With the shortage of nursing time and assistance, staff may be motivated to find more appropriate ways to meet residents needs. It has been suggested that residents who are restrained consume more staff resources than do unrestrained residents (Evans & Strumpf, 1990). Staff or family attitudes and fears can prevent success with physical restraint reduction measures. The physical restraint reduction team should be proactive and provide education and resources, permit individuals to express their fears and doubts, and encourage active involvement in designing the plan of care. Approaching physical restraint reduction with an incremental plan allows caregivers to overcome their fears and resistance. Beginning with one unit at a time or starting with the easiest residents and working toward the more difficult may make the task of restraint reduction more feasible (Castle & Mor, 1998; Schnelle et al., 1992). The successful interventions will allow staff and family members to become more comfortable and confident with the reduction of physical restraints. Individualized Resident Care Individualized care has emerged as a primary key in restraint reduction. The goals of individualized care include promoting comfort and safe mobility, optimizing function and independence, and achieving the greatest possible quality of life. Such care requires clinicians to make sense of behavior rather than to control responses of clients (Strumpf et al., 1998). Individualized care entails knowing the patient, acknowledging the patients right to make choices, establishing relationships with providers, and allowing for participation and direction of care by the patient (Sullivan-Marx, 2001). An individualized approach will identify and address the specific needs of a resident, understand situations from a residents perspective, and implement approaches as varied as the needs of each individual resident (Walker et al., 1999).

Resident and family involvement, education, and support are critical to achieving restraint reduction and to the provision of individualized resident care. In order for a resident to be fully informed, the facility must explain, in the context of the residents condition and circumstances, the potential risks and benefits of all options under consideration, including using a restraint, not using a restraint, and alternatives to restraint use (RAI Users Manual p. C-103). The Long-Term Care Resident Assessment Instrument (RAI) Users Manual (2002) provides clarification on resident or family requests for physical restraints: While a resident, family member, legal representative or surrogate may request that a restraint be used, the facility has the responsibility to evaluate the appropriateness of that request, as they would a request for any type of medical treatment. As with other medical treatments, such as the use of prescription drugs, a resident, family member, legal representative or surrogate has the right to refuse treatment, but not to demand its use when it is not deemed medically necessary. According to the Code of Federal Regulation (CFR) at 42 CFR 483.13(a), The resident has the right to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and
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not required to treat the residents medical symptoms. CMS expects that no resident will be restrained for discipline or convenience. Prior to employing any restraint, the nursing facility must perform a prescribed resident assessment to properly identify the residents needs and the medical symptom the restraint is being employed to address. The guidelines in the State Operations Manual (SOM) state, the legal surrogate or representative cannot give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the residents medical symptoms. That is, the facility may not use restraints in violation of regulation solely based on a legal surrogate or representatives request or approval. The SOM goes on to state, While Federal regulations affirm the residents right to participate in care planning and to refuse treatment, the regulations do not create the right for a resident, legal surrogate or representative to demand that the facility use specific medical intervention or treatment that the facility deems inappropriate. Statutory requirements hold the facility ultimately accountable for the residents care and safety, including clinical decisions (p.3-200, 201). Resident Assessment Restraint reduction efforts must focus on the individual and the underlying issue initiating the application of a physical restraint. According to Capezuti (2000), removing physical restraints without addressing these issues may cause an increase in falls and injuries. Common problems precipitating physical restraint usage may include impaired mobility, injury risk, sleep disturbance, nocturia/incontinence (Capezuti et al., 1999), cognitive impairments (SullivanMarx, 2001), behaviors, and interference with medical treatments (Strumpf et al., 1998). Capezuti et al. (1998b) recommends a comprehensive individualized assessment prior to employing a physical restraint or when evaluating a resident for restraint reduction. The assessment should include data collection in the following four areas: 1) review of resident history, staff rationale for using physical restraints, and incident reports; 2) physical examination; 3) assessment of bedroom and bathroom environmental characteristics; and 4) identification of resident specific problems. Acute illness can cause a change in resident behavior and functional status and should always be ruled out through assessment and physical examination prior to implementing a physical restraint. It may be possible to identify and resolve the physical or psychological condition that caused restraints to be used. By addressing the underlying condition(s) and cause(s), the facility may eliminate the medical symptom that warrants the use of the restraint(s). In addition, a review of underlying needs, risks, or problems may help to identify other potential kinds of treatments. The first step in determining whether use of a restraint can be reduced or eliminated is to identify the reasons a restraint was applied (RAI Users Manual p.C-100). The Resident Assessment Protocol: Physical Restraints in the Long-Term Care Resident Assessment Instrument (RAI) Users Manual (2002) provides CMS guidance on medical symptom: Medical Symptom is defined as an indication or characteristic of a physical or psychological condition. The residents medical symptoms should not be viewed in
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isolation; rather the symptoms should be viewed in the context of the residents condition, circumstances, and environment. Objective findings derived from clinical evaluation and the residents subjective symptoms should be considered to determine the presence of the medical symptom. The residents subjective symptoms may not be used as the sole basis for using the restraint. Before a resident is restrained, the facility must determine the presence of a specific medical symptom that would require the use of the restraint, and how the use of the restraint would treat the medical symptom, protect the residents safety, and assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. Medical symptoms that warrant the use of restraints must be documented in the residents medical record, ongoing assessments, and care plans. (p.C-100). The experience of many health care providers suggests that facility goals can often be met without the use of physical restraints. In part, this involves identifying and treating health, functional, or psychosocial problems. This may be accomplished through resident care management alternatives, such as modifying the environment to make it safer; maintaining an individuals customary routine; using less intrusive methods of administering medications and nourishment; and recognizing and responding to residents needs for psychosocial support, responsive health care, meaningful activities and regular exercises. (p. C-99)

The Resident Assessment Protocol offers guidance for the review of conditions commonly associated with restraint use: Problem Behavioral Symptoms Risk of Falls Conditions and Treatments (Resistance to Tubes or Mechanical Devices) ADL Self-Performance Confounding Problems Associated With Behavioral Symptoms (Delirium; Impaired Cognition; Impaired Communication; Unmet Psychosocial Needs; Sad or Anxious Mood; Resistance to Treatment, Medication, Nourishment; Psychotropic Drug Side Effects; Behavior Management Program) A review of these conditions and/or other underlying needs, risks, or problems may reveal alternative methods of treatment that result in the reduction or elimination of physical restraints. To be effective interventions must address the underlying problem. (p. C-100-102) Care Planning The care plan establishes a course of action that moves a resident toward a specific goal utilizing individual resident strengths and interdisciplinary expertise; it crafts the how to of resident care (RAI Users Manual p. 1-2). The care planning process should be based on good clinical practice as specified in the federal requirements and additional guidance provided in the interpretive guidelines at 42 CFR 483.20 (k) (1) and (2). It is important for all facility staff to be aware of and utilize current standards of professional practice. This can be accomplished through a routine, up-to-date in-house training program or through the use of qualified external
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resources. New and more effective treatment modalities, resident activities, etc. are continually being identified which will benefit residents if built into their care plans. Alternative methods of treating falls, behavioral symptoms and other common problems associated with restraint use can be tailored to meet the individual needs of the resident. Strumpf et al. (1998) categorizes four types of interventions to address these problems: physiologic, psychosocial, activities, and environmental. Physiologic Physiological interventions involve identification of reasons for falling, comprehensive assessment, medication review and adjustment, rehabilitation involvement by PT/OT, provision of comfort, and pain relief (Strumpf et al., 1998). Capezuti et al. (1999) recommends interventions for impaired mobility including range of motion programs, and increasing staff awareness. According to Sullivan-Marx (2001) physiologic approaches to care of acutely confused older adults include such measures as diagnosing the cause of the delirium and taking steps to correct the cause. Relief of pain and maintenance of hydration and oxygenation should be a priority. Necessity of treatments should be reconsidered and discussed by team members (if the resident is being restrained to manage resistance to a tube or mechanical device). Interventions for individuals prone to injury include mattress bumpers, body pillows, and hip protectors (Capezuti et al., 1999). Individuals suffering from sleep disturbance may benefit from avoiding daytime naps, pharmacological evaluation, and pressure relieving interventions to promote comfort while in bed (Capezuti et al., 1999). Also, provide assistance with elimination before bedtime to reduce the chance of getting out of bed unassisted during the night. Interventions for incontinence involve thorough evaluation, elimination rounds, urinals, bedpans, absorbent pads, bedside commodes, and non-slip footwear (Capezuti et al., 1999). The guidance in the State Operations Manual (Rev 20, 09-00) identifies other interventions that the facility might incorporate in care planning for residents who have problems with bed mobility and/or transfers: Providing restorative care to enhance abilities to stand safely and to walk A trapeze to increase bed mobility; Placing the bed lower to the floor and surrounding the bed with a soft mat; Equipping the resident with a device that monitors attempts to arise; Providing frequent staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom; and/or Furnishing visual and verbal reminders to use the call bell for residents who are able to comprehend this information (SOM Appendix PP, PP 45-46) Psychosocial Psychosocial interventions include anticipating the residents needs, companionship, supervision, a calm approach, and active listening (Strumpf et al., 1998). For individuals with memory impairments, removing barriers such as full-length bedrails, and encouraging the use of assistive devices such as walkers and bedside commodes may prevent bed-related falls and injuries (Capezuti et al., 1999). Psychosocial approaches entail such interventions as enabling frequent family contact and supportive interaction with staff (Sullivan-Marx, 2001).
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The Resident Assessment Protocol: Cognitive Loss/Dementia in the Long-Term Care Resident Assessment Instrument (RAI) Users Manual (2002) provides CMS guidance on the evaluation of mood/behavior problems in cognitively impaired residents: Specific treatments for behavioral distress, as well as treatments for delirium, can lessen and even cure the behavioral problem. At the same time, however, some behavior problems will not be reversible, and staff should be prepared (and encouraged) to learn to live with their manifestations. In some situations where problem/distressed behavior continues, staff may feel that the behavior continues, staff may feel that the behavior poses not threat to the residents safety, health, or activity pattern and is not disruptive to other residents. For the resident with declining cognitive functions and a behavioral problem, you may wish to consider the following: Have cognitive skills declined subsequent to initiation of a behavior control program (e.g., psychotropic drugs or physical restraints)? Is decline due to the treatment program (e.g., drug toxicity or negative reactions to physical restraints)? Have cognitive skills improved subsequent to initiation of a behavior control program? Has staff assistance enhanced resident self-performance patterns? (p. C-12) Activity Activity interventions can include ambulation/weight bearing programs, restorative involvement, fall-prevention programs, transfer assistance, provision of meaningful activities, distraction, television, exercise, social activity, and structured routines (Strumpf et al., 1998). Sullivan-Marx (2001) also advocates activity and exercise programs to ensure mobility, maintain self-care activities, and prevent functional decline. The Resident Assessment Protocol: Activities in the Long-Term Care Resident Assessment Instrument (RAI) Users Manual (2002) provides CMS guidance on activity planning: For the nursing facility, activity planning is universal need. For this RAP, the focus is on cases where the system may have failed the resident, or where the resident has distressing conditions that warrant review of the activity plan. The types of cases that will be triggered are: (1) residents who have indicated a desire for additional activity choices; (2) cognitively intact, distressed residents who may benefit from an enriched activity program; (3) cognitively deficient, distressed residents whose activity levels should be evaluated; and (4) highly involved residents whose health may be in jeopardy because of their failure to slow down.(p. C-54) Among the issues to consider as the activity plan is developed are health related factors that may affect participation in activities; decline in resident status cognition, communication, function, mood, or behavior; environmental factors; and, changes in availability of family/friends/staff support (RAI Users Manual p. C 55-57). Environmental Environmental modifications include adjusting bed and toilet seat to appropriate heights,
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applying nonskid surfaces, installing overhead trapeze or transfer pole at the bedside, decreasing furniture clutter, providing adequate lighting, and motion alarms to decrease risk of bed-related injuries (Capezuti et al., 1999). Interventions also recommended for individuals with cognitive impairment include calendars, clocks, and photographs of loved ones (Sullivan-Marx, 2001). Strumpf et al. (1998) also recommends customized seating, accessible call lights, placing the mattress on the floor, varied sitting locations, placement of the resident near a nursing station, and adaptive clothing.

Conclusion
Residents who are not restrained tend to be less agitated, less fatigued, and more social. They are able to attend activities and social gatherings with friends and families, which increases communication and appropriate physical and sensory stimulation. Unrestrained residents exhibit greater independence with toileting, mobility, feeding, dressing, and strength, which decreases the burden of care, and saves time and supplies (Dunbar et al., 1997). The resident's autonomy and dignity improves without the confinement of physical restraints. Achieving restraint reduction also results in a sense of pride for caregivers. They gain a reputation for providing high quality of care to their residents, serious injuries significantly decline, staff turnover decreases, and staff morale and family support increases (Dunbar et al., 1997). Physical restraints can be significantly reduced without increases in serious injuries, staffing, or substitution of psychoactive drugs (Evans et al., 1997; Siegler et al., 1997; Neufeld et al., 1999).

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References Capezuti E. Preventing Falls and Injuries While Reducing Siderail Use. Annals of Long-Term Care. 2000; 8: 57-63. Capezuti E, Evans L, Strumpf NE, Maislin G. Physical Restraint Use and Falls in Nursing Home Residents. Journal of the American Geriatrics Society. 1996; 44: 627-633. Capezuti E, Maislin G, Strumpf N, Evans LE. Side Rail Use and Bed-Related Fall Outcomes Among Nursing Home Residents. Journal of the American Geriatrics Society. 2002; 50(1): 9096. Capezuti E, Strumpf NE, Evans LK, Grisso JA, Maislin G. The Relationship Between Physical Restraint Removal and Falls and Injuries Among Nursing Home Residents. Journal of Gerontology: Medical Sciences. 1998a; 53A(1): M47-M52. Capezuti E, Talerico KA, Cochran E, Becker H, Strumpf N, Evans L. Individualized Interventions to Prevent Bed-Related Falls and Reduce Siderail Use. Journal of Gerontological Nursing. 1999; 25(11): 26-34. Capezuti E, Talerico KA, Strumpf N, Evans L. Individualized Assessment and Intervention in Bilateral Siderail Use. Geriatric Nursing. 1998b; 19(6): 322-330. Castle NG, Mor V. Physical Restraints in Nursing Homes: A Review of the Literature Since the Nursing Home Reform Act of 1987. Medical Care Research and Review. 1998; 55(2): 139-170. Centers for Medicare & Medicaid Services. Revised Long-Term Care Resident Assessment Instrument Users Manual, Version 2.0, December 2002 with August 2003 and all other subsequent posted updates incorporated. Centers for Medicare & Medicaid Services. State Operations Manual, Provider Certification; Guidance to Surveyors Long Term Care Facilities, Appendix PP, PP44 PP-52.2. Cohen C, Neufeld R, Dunbar J, Pflug L, Breuer B. Old Problem, Different Approach: Alternatives to Physical Restraints. Journal of Gerontological Nursing. 1996; 22(2): 23-9. Colorado Foundation for Medical Care, funded by the Nursing Home QIOSC, Quality Partners of Rhode Island, CMS Contract #500-02-RI02, Nursing Home Quality Initiative National Quality Measures Quarterly Summary Report, March 2004. Dunbar JM, Neufeld RR, Libow LS, Cohen CE, Foley WJ. Taking Charge. The Role of Nursing Administrators in Removing Restraints. The Journal of Nursing Administration. 1997; 27(3): 428. Evans, LK. Knowing the Patient: The Route to Individualized Care. Journal of Gerontological Nursing. 1996; 22(3): 15-9.
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Evans, LK, Strumpf, NE. Myths about Elder Restraint. IMAGE: Scholarship. 1990; 22(2): 124-128.

Journal of Nursing

Evans LK, Strumpf NE, Allen-Taylor SL, Capezuti E, Maislin G Jacobsen B. A Clinical Trial to Reduce Restraints in Nursing Homes. Journal of the American Geriatrics Society. 1997; 45(6): 675-81. Guttman R, Altman RD, Karlan MS. Report of the Council on Scientific Affairs. Use of Restraints for Patients in Nursing Homes. Council on Scientific Affairs, American Medical Association. Archives of Family Medicine. 1999; 8(2): 101-5. Miles SH. Deaths Between Bedrails and Air Pressure Mattresses. Journal of the American Geriatrics Society. 2002; 50(6): 1124-5. Neufeld RR, Libow LS, Foley WJ, Dunbar JM, Cohen C, Breuer B. Restraint Reduction Reduces Serious Injuries Among Nursing Home Residents. Journal of the American Geriatrics Society. 1999; 47(10): 1202-1207. Public Law No. 100-203 Nursing Home Reform Act, Omnibus Budget Reconciliation Act, 1987 Parker K, Miles SH. Deaths Caused by Bedrails. Journal of the American Geriatrics Society. 1997; 45(7): 797-802. Patterson JE, Strumpf NE, Evans LK. Nursing Consultation to Reduce Restraints in a Nursing Home. Clinical Nurse Specialist. 1995; 9(4): 231-235. Schnelle JF, Newman DR, White M, Volner TR, Burnett J, Cronquist A, Ory M. Reducing and Managing Restraints in Long-Term Care Facilities. Journal of the American Geriatrics Society. 1992; 40: 381-385. Strumpf NE, Patterson JE, Wagner J, Evans LK. 1998. Restraint-Free Care: Individualized Approaches for Frail Elders. New York: Springer. Sullivan-Marx EM. Achieving Restraint-Free Care of Acutely Confused Older Adults. Journal of Gerontological Nursing. 2001; 27(4): 56-61. Sullivan-Marx EM, Strumpf NE, Evans LK, Baumgarten M, Maislin G. Initiation of Physical Restraint in Nursing Home Residents Following Restraint Reduction Efforts. Research in Nursing & Health. 1999a; 22: 369-379. Sullivan-Marx EM, Strumpf NE, Evans LK, Baumgarten M, Maislin G. Predictors of Continued Physical Restraint Use in Nursing Home Residents Following Restraint Reduction Efforts. Journal of the American Geriatrics Society. 1999b; 47: 342-348. Tinetti ME, Liu WL, Ginter SF. Mechanical Restraint Use and Fall-Related Injuries Among
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Residents of Skilled Nursing Facilities. Annals of Internal Medicine 1992; 116: 369-374. U.S. Department of Health and Human Services. (2001, October) 42 Code of Federal Regulations, Part 483 Subpart B, Requirements for Long Term Care Facilities, U.S. Government Printing Office and National Archives and Records Administration Office. Walker L, Porter M, Gruman C, Michalski M. Developing Individualized Care in Nursing Homes: Integrating the Views of Nurses and Certified Nurse Aides. Journal of Gerontological Nursing. 1999; 25(3): 30-5; quiz 54-5. Williams CC, Finch CE. Physical Restraints: Not Fit for Woman, Man, or Beast. Journal of the American Geriatrics Society. 1997; 45: 773-775.

This material was developed by the QIO program for CMS NHQI and is intended as general information. Any individual using the material must consider the possibility of human error, changes in medical sciences, and the need to use clinical judgment in each specific case. 14 of 14