Restraints in Dementia Care: A Nurse’s Guide to Minimizing Their Use

By Atul Sunny Luthra, Yarima Gonzalez and Heather Millman

Your best tool to optimize patient care by minimizing restraint use

Frontline nurses face fraught decisions every day about whether and how to use restraints in dementia care. They need to consider many complicated issues: legislation governing the use of restraints, the policies of health-care facilities, the expectations of families, and—most importantly—the well-being, dignity, and safety of patients and care providers.

Frontline nurses need the right support to navigate decisions about restraint use.

Dr. Atul Sunny Luthra and his colleagues have developed an algorithm to provide that support. Their work comes from focus-group consultations with frontline staff, a review of current literature on restraint use, and a clear summary of key legislation. The algorithm’s systematic approach ensures restraints are a last-resort measure, and puts the right steps in place when restraints are necessary.

This short guide includes:

• A review of nurses’ perspectives on restraint use.
• Alternatives to restraints in patient management and assessment of clinical indicators for restraint use.
• Procedures to ensure informed consent when restraints are necessary.
• A reference on appropriate and inappropriate restraint use in everyday clinical situations.

• Language: English
• Publisher: Brush Education
• Release date: Jul 17, 2019
• ISBN: 9781550598025

Atul Sunny Luthra

Atul Sunny Luthra, MD, MSc, FRCPC, is the medical coordinator for the Program for Older Adults at Homewood Health Centre in Guelph, Ontario, Canada. He is the medical lead in the Behavioural Health Unit at St. Peter’s Hospital, Hamilton Health Sciences, and is an associate clinical professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University in Hamilton, Ontario, Canada. He is also a research scientist with Schlegel’s Research Institute in Aging at the University of Waterloo in Kitchener-Waterloo, Ontario, Canada.

Book preview

Cover: “Restraints in Dementia Care: A Nurse’s Guide to Minimizing Their Use” by Atul Sunny Luthra's, Yarima Gonzalez and Heather Millman.

Restraints in Dementia Care

Restraints in Dementia Care

A NURSE’S GUIDE TO MINIMIZING THEIR USE

Atul Sunny Luthra, MD, MSC (PHARMACOLOGY), FRCPC

with

Yarima Gonzalez, BSC, MSC, OT REG. (ONT.)

Heather Millman, MA

A logo shows a stylized book beside the text, Brush Education Inc.

Contents

Acknowledgements

Introduction

1 Five clinical scenarios: perspectives on restraint use from frontline staff at Homewood Health Centre

2 Nurses’ perceptions of restraint use: a literature review

3 Clinical indicators for restraint use: a literature review

4 The law and restraint use

5 Obtaining informed consent for restraint use

6 A decision-making algorithm for restraint use in dementia care

7 A reference on appropriate restraint use

References

About the authors

Acknowledgements

This book is dedicated to Kenneth Murray, founder of the Murray Alzheimer Research and Educational Program (MAREP), University of Waterloo. MAREP has recently found a home with Schlegel-UW Research Institute for Aging, University of Waterloo, Ontario, Canada. I would like to thank the research students sponsored by MAREP (A. Capabianco and S. Houlberg) who have assisted me in researching this book.

Above all, I would like to thank my wife and the kids for their unwavering support for my scholastic and clinical work.

—A.S.L.

Introduction

This guide comes from recognizing a gap in the everyday clinical practice of using restraints in dementia care. The gap occurs at the point of deciding whether to use restraints based on identifying specific risks associated with specific clinical situations. This gap poses a key obstacle in reducing the use of restraints in dementia care.

We aim to close this gap by offering a practical cognitive-rational algorithm for decisions about using restraints, and a reference on appropriate and inappropriate contexts for restraint use.

We conducted a series of unstructured focus groups with nursing staff at Homewood Health Centre in Guelph, Ontario, Canada to explore the challenges of common clinical situations in dementia care—situations where decisions about the use of restraints typically come into play. This process established perspectives about restraint use from frontline nursing staff.

We then researched the literature for more information on staff perspectives, and for indicators on restraint use. We reviewed the laws governing restraint use in Ontario, and worked through the process of obtaining informed consent, which is a key frontline legal issue in the use of restraints.

With this information in hand, we created the decision-making algorithm in this guide, and the reference on using restraints in clinical practice.

We hope this guide enhances the skill set of nursing staff, and other health-care professionals, in minimizing the use of restraints in dementia care, and helps educate families involved in dementia care about the use of restraints.

Disclaimer

The publisher, authors, contributors, and editors bring substantial expertise to this reference and have made their best efforts to ensure that it is useful, accurate, safe, and reliable.

Nonetheless, practitioners must always rely on their own experience, knowledge, and judgement when consulting any of the information contained in this reference or employing it in patient care. When using any of this information, they should remain conscious of their responsibility for their own safety and the safety of others, and for the best interests of those in their care.

To the fullest extent of the law, neither the publishers, the authors, the contributors nor the editors assume any liability for injury or damage to persons or property from any use of information or ideas contained in this reference.

1

Five Clinical Scenarios

Perspectives on Restraint use from Frontline Staff at Homewood Health Centre

The use of restraints in dementia care remains a controversial issue, regardless of the reasons for using restraints. Over the last two decades, initiatives to minimize restraint use have focused on multistep approaches, including educational programs for frontline staff, expanded roles for interdisciplinary teams (IDTs), and legislation. Educational programs have included print and digital brochures, interactive websites, and workshops and symposiums. IDTs have expanded to include occupational and recreational therapists with expertise in creating and implementing alternative care plans to the use of restraints. Finally, provincial governments have enacted legislation to regulate the use of restraints in dementia care.

The knowledge gained from legislation, combined with evidence-informed clinical research, has resulted in the generation of best-practice guidelines that govern the clinical use of restraints for all regulated health-care professionals. These best-practice guidelines often inform policy-and-procedure documents in regulated health-care institutions. Policy-and-procedure documents govern the use of restraints by regulated health-care staff in the care of persons with dementia, and ensure rigorous adherence to best practices. These documents are meant to provide regulated health-care staff with parameters to operate within, once the clinical decision to apply restraints has been made. They include specific clinical indicators for the use of restraints in the care of persons with dementia within legislated health-care facilities, but they do not guide staff in considering risks posed by specific clinical indicators in the context of specific clinical situations. Hence, these documents do not generally guide health-care staff on the appropriateness of using restraints in specific clinical situations.

The five clinical scenarios presented in this chapter, which involve agitated behaviours, make this point clear.

Agitation covers a wide range of issues in persons with dementia who exhibit behavioural symptoms. It is one of the most all-encompassing terms in the dementia literature. It is often used interchangeably with terms describing physical aggression, verbal aggression, disinhibited behaviours, disruptive behaviours, and many other behaviours.

The literature is slowly moving away from the term agitation and toward terms such as behavioural expressions and responsive behaviours—terms that acknowledge and capture the behavioural and psychological symptoms of dementia (BPSD) that most persons with dementia experience. Behavioural expressions tends to be