Replies to a “Call for help”

IEPLIF~ TO A 'CALL FOR HELP" Ietween J a n u a r y and July 1, I re~ived 55 replies from readers to my 'Call For H e l p " ( J a n . / F e b . , p. 9) in i~hich I asked readers to send helpful ~licies or programs used by their intitutions to decrease the overuse of nechanical restraints, nursing altertatives to restraint that had been tseful, and references to published ,r unpublished literature that had telped them. T h e replies came from nurses, ihysicians, social workers, and instiutional administrators in 28 states n d four foreign countries. T h e leters contained reactions, ideas, opin3ns, reports on small experiments, ,ublished and unpublished sthdies, :uidelines for staff, and an astonishag 243 suggested references, most f which I had not found in a litera- r e search. O f these references, 50 were dupliates and 67 related to other than eriatric patients (infants, children ndergoing medical or surgical proedures, clients with skin diseases, risoners resisting custody, even Red ;ross instructions to control a franic drowning person during rescue fforts). A total of 126 references eemed clearly or possibly relevant the restraint of the confused elder¢; a list will be prepared for the repondents and other interested read-

" W h e n I ' m with him, visiting, I can modify his behavior so that the restraint can be taken off but as soon as I go (e.g. absence of the familiar figure and 1"1 attention) they say they have to use restraints again. I feel helpless tO control it and guilty to be at work instead of giving fulltime care." A few reported their employer's unwillingness to have any written policy on restraints or to permit any entry in the record when restraints were applied. Letters in this category gave little indication that the writer was changing or challenging the care although it was deplored and specific examples of "deplorable c a r e " were given. T h e Cheerers a n d Handwringers, however, enclosed the most references (169), indicating that the writers were geniunely interested and looking for help. The Monitors" replies were much more encouraging. These letters documented that restraint use, like accidents, was a m a t t e r of record. Some letters showed examples of entries made by one nurse (the writer). Some dealt with records kept on a small or large nursing unit. S o m e included illustrations from an entire patient population over a given period of time.

Within these examples it was clear that some monitoring was done carefully but not used further (to the best of the respondent's knowledge) while in other settings the records were reviewed thoughtfully by the head nurse or a committee to help keep staff alert to preventable "overuse." Some data were well organized and translated into rates. T h e references sent by writers in this category ineluded institutional guidelines or "rules" and some had marginal com,ments or questions by nurses about their usefulness. T h e 12 Users o f Alternatives to R e s t r a i n t were e x t r e m e l y stimulating. As in the previous category, the alternatives ranged from ideas tested by a single nurse on assigned patients to published and unpublished studies on a large p a t i e n t population over a considerable period. Master's and doctoral studies in process were included. T h e projects ranged from innovations tried by nurses especially prepared in geriatric or geropsychiatric nursing to approaches used by all the caregivers, RNs, L P N s , aides, and volunteers. "'Alternatives to R e s t r a i n t " letters were a joy to read, even when the alternative was effective with only a segment o f the population. Most o f Continued on page 254

Responses to Schwartz Letter about Restraints

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[inds of Response T h e table categorizes the reponses. Cheerers and Handwringers aclude 26 respondents who ex;ressed gratitude that the letter had ¢.en published, and said in effect, :there must be a better way but I ion't know what it is. I f you can find h alternative, tell us and we'll be :lad to give it a try. T h e y spoke of tlieir concern with estraint as they saw it in the instituions where they worked or their disaay with the experience of their parnts or other older relatives who lere institutionalized. One said,

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*includes 50 duplicates and 67 that seemed irrelevant to the trigger-letter.

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LETTERS Continued f r o m page 250

these reports have been published or are awaiting publication; some are not yet complete. Discussion It was disappointing t h a t no respondent reported the a t t e m p t to record systematically all circumstances surrounding the decision to restrain an individual patient or all patients in a given g e o g r a p h i c area within a specified time frame. All documentation concerned the patient's behavior, not the staff's. W h e t h e r videotaped or recorded in a notebook, no c o m m e n t was offered on what m a d e a caregiver apply restraints at a given m o m e n t and what reaction the patient had. A n y watcher of public television in recent years has seen costly studies of animal behavior in the animal's own environment, including the reaction to m a n ' s invasion of that habitat. Incredibly difficult, largescale investigations of lions, polar bears, insects, and birds a r e carried out in African jungles, above the Artic Circle, and at the b o t t o m of the sea. Y e t no c o m m e n t in the responses of writers a b o u t restraint overuse referred to a n y observation of the c i r c u m s t a n c e s - - t h e behavior of the restrained and the res t r a i n e r - - i n a ho'spital or nursing h o m e just before and i m m e d i a t e l y after the application of restraints. T w o references were received that illustrated this type of study with p a - . tient populations of different age ranges and very different sets of circumstances: a book-length American report on'-a ward of young male patients with diseases t h a t m a d e death a likely outcome and a British study of " u n p o p u l a r patients" and the characteristics that caused t h e m to be so labeled (and given less than optimal care). Participant-observer studies are not easy to conduct but m i g h t give us better understanding o f cause and effect and assist in reducing the use of restraints. M y h e a r t y thanks to all who took the time to send graphic evidence of their personal concern for a problem that they saw as growing rather than moving toward solution. DORIS SCHWARTZ, RN,FAAN

Senior Fellow, School of Nursing University of Pennsylvania