Physical restraint: Potentially excessive use in Ontario nursing homes (2024)

Table of contents

• What are restraints?
• Why are physical restraints used in nursing homes?
• How is "potentially excessive use of physical restraints" defined?
• Why does inappropriate use of antipsychotics matter?
• What Ontario nursing homes have the highest use of antipsychotics?
• How was data collected?

What is restraint use?

Restraint encompasses any method or intervention that curtails or manages an individual's movement or behavior. There are three primary categories of restraints:

• Physical Restraints: These involve mechanisms or devices that directly restrict a person's physical movement or behavior. They can include items physically attached to a person's body, such as straps or bedrails, as well as physical barriers that impede mobility within an environment.
• Chemical Restraints: Chemical restraints involve the use of medications to modify or restrict an individual's behavior. Common examples include tranquilizers and sedatives, which are administered to control or manage disruptive conduct.
• Environmental Restraints: Environmental restraints pertain to alterations made in a person's surroundings to limit or regulate their movement. For instance, a locked door can serve as an environmental restraint, preventing access to certain areas.

The Canadian Institute for Health Information only publishes public data on physical restraints.

Why are physical restraints used in nursing homes?

Physical restraints are used in nursing homes for several reasons, although their use is increasingly subject to strict regulation and ethical scrutiny. Historically, physical restraints were used to prevent residents from injuring themselves or others, to manage behaviors that were seen as disruptive, or to facilitate the provision of medical care. The primary rationale has been the safety of the residents and the staff, particularly in situations where a resident may be at risk of falling, pulling out essential medical devices like IV lines or catheters, or when they exhibit aggressive behaviors.

The overarching objective when considering the use of restraints is to employ them as an option of last resort. When absolutely necessary, the following principles guide their application:

• Least Restrictive: Efforts should be made to choose the least restrictive form of restraint, such as administering the smallest effective dose of medication or opting for the mildest physical restraint method.
• Shortest Duration: Restraints should be employed for the shortest feasible period. They should be removed as soon as the safety and well-being of the senior can be adequately ensured without their use.
• Exploration of Alternatives: Prior to resorting to restraints, caregivers and healthcare providers should exhaust multiple alternatives. Person-centered care and behavior management strategies should be explored and prioritized, addressing the root causes of challenging behaviors in seniors.
• Informed Consent: A critical ethical consideration is the involvement of the senior and/or their designated decision-maker in an informed consent discussion. This discussion should encompass the risks, benefits, and available alternatives to restraint use, ensuring that all parties fully understand and concur with the decision.

Why does excessive use of physical restraints matter?

Research indicates that the inappropriate use of restraints can have detrimental effects, especially for individuals with dementia. Several concerns arise from this practice.

• Restriction of Freedom: Restraints, whether physical or chemical, can curtail a senior's freedom and independence. For example, chemical restraints may leave them sedated and immobile, while physical restraints, like those used on geriatric chairs, can impede natural movement, leading to frustration. Such restrictions can result in a loss of confidence and self-esteem.

• Physical Harm: Seniors may suffer physical injuries due to restraint use, including skin abrasions, bruises, and even fractures. Attempting to free themselves from restraints can lead to additional harm.

• Psychological Distress: The emotional well-being of seniors can be significantly affected by the use of physical restraints. This can manifest as anxiety, fear, loss of dignity, agitation, depression, isolation, post-traumatic stress, and a decline in social interaction. Cognitive function, particularly in seniors with dementia, may also deteriorate due to psychological distress.

• Cognitive and Physical Decline: Extended periods of restraint use can exacerbate cognitive and physical decline in seniors. Muscle atrophy, reduced mobility, and overall health deterioration can result from prolonged immobilization.

How was data collected?

The Canadian Institute for Health Information (CIHI) divides the number of residents who have been subjected to daily physical restraints, divided by the total number of residents in the facility.

Daily physical restraint is defined as the use of restraints for a period exceeding 92 days after a resident's admission into a nursing home.

The calculation excludes comatose residents and those who are quadriplegic.

Restraints encompasses those used for the trunk, limbs, and devices such as chairs that prevent residents from rising or moving freely.

The data for this measure is collected from long-term care facilities through the Continuing Care Reporting System, or the Integrated interRAI Reporting System.

This indicator rely on data from four consecutive quarters for calculation. As residents undergo quarterly assessments, a single resident's data can contribute to the indicator up to four times within a year.