Subacute Care/Hospital Forum

Restraints: Nursing Practices in Acute and Chronic Care

One decade after the passage of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), a new study indicates that nurses in long-term care settings do not believe they are very familiar with the restraint provisions of that law. Further, nurses in acute-care settings-who may work occasionally in subacute-care settings-are largely unfamiliar with the law and unmotivated to learn more about it.

These are some of the conclusions that can be drawn from a survey of nurses published in the March/April issue of Geriatric Nursing. Bryant and Fernald¹ report on nurses' attitudes and opinions and analyze reasons for the gap between acute and chronic care.

Marked Differences in Restraint Use

The authors interviewed 72 nurses, 32 from chronic-care and 40 from acute-care settings. Acute-care nurses used restraints more often than did long-term care nurses, for reasons such as to facilitate treatment due to altered mental status, to prevent wandering or prevent self-harming, for noncompliance, or for agitation.

The first three reasons listed above were cited by significantly more acute-care than chronic-care nurses as factors in restraint use. Nurses in chronic care used restraints more often to prevent patients from harming others and to prevent falls, but the difference was not significant.

The types of restraints used also differed significantly between practice settings. Acute-care nurses reported more use of jacket vests, wrist restraints, four-point leather restraints, and bedsheets. More than 90% of acute-care nurses reported use of restrictive restraint methods (jacket vests, wrist restraints, and bed alarms). More than 80% of long-term care nurses reported use of seat belts and harness restraints, but only 3% used bed alarms; none reported use of wrist restraints or four-point leather restraints.

Use of alternatives to restraints was markedly different between the practice settings. Table 1 lists techniques that were used more frequently in one practice setting.

Table 1. Frequency of Alternative Restraint Use in Acute and Chronic Care^a

More Common in Acute Care	More Common in Chronic Care
Pain relief	Music therapya
Reality orientationa	Therapeutic touch
Beds lower to floor	Reminiscencea
Increased lighting	Behavior modificationa
Accessible call light	Crafts
Clear pathways	Regular routine
Defusing agitated behaviora	Diversional activities

a Significantly different from the other practice setting.

Differences Come from Education, Knowledge, Need

While the types of patients, illnesses, and procedures present in the acute-care institution sometimes necessitate increased use of restrictive restraints, the survey shows that acute-care nurses are largely unaware of the immense concern over restraints in less acute settings.

While 100% of chronic-care nurses believed that a physician's order was needed to use restraints, only 47% of acute-care nurses agreed. Some 32% said no order was needed, and 20% did not know.

A total of 31% of chronic-care nurses and 75% of acute-care nurses said they were not familiar at all with OBRA '87. Only 19% of chronic-care nurses were very familiar with the landmark law, while 37% of chronic-care and 2% of acute-care workers were somewhat familiar with it.

The authors conclude their study with these words of advice to their nursing colleagues: "By finding more feasible alternatives that can be effectively used in the acute care setting, as well as expanding their knowledge base on the detrimental effects of restraints, nurses in acute care can use their creativity and resources to enhance the quality of life for their patients during an acute care stay."

L. Michael Posey, Academics Editor
The Consultant Pharmacist

Reference

1. Bryant H, Fernald L. Nursing knowledge and use of restraint alternatives: acute and chronic care. Geriatr Nurs 1997; 18(2): 57-60.