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OPINION

Nursin' USA - Why do UK nurses consider restraints unacceptable?

  • 34 Comments

Our resident American nurse Sara Morgan wonders why the UK, with such a focus on patient safety, considers even minimal restraint unacceptable?

Physically restraining fellow human beings is a practice generally frowned upon. Restraints are reserved for criminals, those suspected of being criminals and particularly adventurous fancy-dress costumes. In healthcare, we are (thankfully) long past the days when psychiatric or unruly medical patients were tied to their beds, the wall or each other as a way of maintaining order.  Many activities that we nurses effortlessly navigate on a daily basis such as patients complaining, declining medication or questioning a doctor’s decision, were previously grounds for the application of restraints.  Isn’t it fantastic that we have evolved beyond such crude methods of interacting with patients?

But…

We have an enormous problem with patient falls. We’ve all seen the statistics: thousands of falls per year, resulting in hundreds of injuries, fractures and even deaths. According to the literature, about ¾ of falls are caused by ‘patient factors’ such as confusion or poor balance. Ideally, a nurse or healthcare assistant will always be available to help a patient to mobilise if they need assistance, or if a confused patient tries to get out of bed, to gently redirect them.  But realistically, we realise that there will inevitably be times when a nurse cannot be in two or three or even five place at once, and that confused patients will get out of bed without someone nearby and they will fall.

In the US, nurses and doctors were pragmatic about this and we happily used whatever tools we could get our hands on to stop confused patients from getting out of bed without help. Yes, this included restraints. But before anyone begins imagining scenes of patients languishing in chains, let me describe the ‘posey vest’. It is simple:  a vest that fits over the patient’s gown, zips up the back and has a set of cloth ties on either side of the waist.  These vests are remarkably similar to the red tabards that some nurses wear when on medication rounds, only more fitted and slightly shorter in length. Equally as unattractive, however.

Once the patient has the vest on, the ties are secured to the rails on either side of the bed.  The patient can move both his arms and his legs freely, he can sit up, lean forward, move any which way he wants, but his waist and therefore hips are securely centered on the bed.  If he tries to get out of bed, he feels the resistance from the ties at his waist, which is usually enough of a deterrent for the confused patient that his attention moves on to the next distraction and he stops trying to get out of bed. To ensure that they were used appropriately, posey vests required an order from a consultant, as well as the co-signature of the nurse, and the order had to be reviewed and rewritten every 24 hours.

I loved posey vests. They were a gentle way to stop patients from accidentally harming themselves with a fall. So I’ve always been confused that the UK, which is so good at focusing on patient safety, considers even such a minimal restraint unacceptable. If we are happy to strap toddlers into high chairs during meals and babies into car seats, why are we not willing to extend the same protection to vulnerable adults?   

I understand that patient dignity is a high priority and that things like posey vests are inherently undignified. But so is a bicycle helmet and I will not get on a bike in London without one firmly attached to my head, as silly as it may look. In that same spirit of promoting safety, I would rather have a conversation with a patient or their family about why a posey vest is a good idea, than have to explain afterwards why a hip fracture occurred in the middle of the night.

About the author

Sara Morgan trained and practiced as a nurse in the United States before coming to work in the UK.  She has worked as both a nurse practitioner and as a lead nurse on the Productive Ward initiative.

 

  • 34 Comments

Readers' comments (34)

  • Restraint is ulitmately a compromise. Its saying you can't do what you should be doing - being there for your patient to ensure safety. However there are numerous examples of covert restraint- wedging a bed table under the legs of a chair so the patient can't stand and then then is the old chectnut of cotsides. Peghaps we need to have a debate about this issue and well done Sara for raising it.

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  • I was a patient on a ward recently and a elderly patient ,who was somewhat confused removed her venflon which caused her to bleed profusely all over her bed. the nurse did not arrive at her bedside for some minutes. and i do not need to say more. I asked the nurse why the drip site was not more securely fixed ,i was told she could do more damage if we did that. what more damage could be done that the ability for the patient to bleed to death. surley in this day and age we have some way of securing such devises safely to protect the patient.

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  • Martin Gray

    Yes sara I would agree with you that some forms of restraint could be justified in ensuring patient safety. Falls are on the increaser, as is the number of elderly, confused patients; I would not consider it an unreasonable measure to have permission from the family to be able to apply something like the posie vest - I'm sure some fashion conscious nurse or student could design something a little more dignified in appearance than the red vest described.

    Good topic for debate.

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  • The posey vest that you have described have been linked with deaths. As have other forms of restraint.

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  • Well then, what is needed is some research to compare deaths as a result of falls in the elderly and confused in hospitals and deaths as a result of the vests.
    Then a rational and researched 'best practice' protocol could be developed,( in the absence of nurses having eyes in the back of their heads and two pairs of hands).
    It's not a perfect world is it?
    By the way Sara, we do use restraints here but they tend to be either makeshift (see above) or pharmacological, with all the sequelae that entails.

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  • The Johanna Briggs Institute has done quite a bit of work on this if I remember rightly.
    The way it was put to me by a German doctor was that to ensure deaths were avoided with restraints patients had to be under constant supervision. And if you are constantly watching the patients then the restraints should not be needed unless the person is being violent.
    It is true in this country we are more likely to reach for the drug keys before trying anything else.

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  • I am of the opinion that the confused elderly patient should not be nursed on an acute ward. the nurses are far to busy performing very intricate necessary tasks for her other patients. If indeed a confused elderly patient is admitted to such a ward there should be a nurse available to specialise her. this of course is not cost effective and will not be approved. we need to train general nurses more in the care of the elderly confused patient. or for that matter re=open elderly care facilities. to give these patients their rights to health care. and not health abuse.

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  • I am fully supportive of some form of restraint, whether it be in an acute or elderly care setting. Wherever they are they need constant supervision and that is just not practical unless of course someone is paid to be there constantly. But it is not going to happen so do the best you can with what you've got, fill out the incident forms and let those who have to account to the Patient Safety people deal with it. In the trust I work in, the policy is that if someone is a wanderer and at risk of falls, to accompany them and keep them out of danger and if they look as if they are about to fall, let them fall and pick up the patient afterwards, of course using appropriate handling equipment. It is the safest course of action to take as it minimises risk of injury to both parties. So just follow your trust policies and fill in the paperwork and keep yourself safe.

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  • The main problem is the lack of staff to watch over at risk patients, It is very well for people to talk about specialing wandering patients or accompanying them on their travels, but the other patients, some of whome may also be at risk, are also entitled to care, and with the budget widley expected to contain cuts to public services we are going to find ourselves even more thinly spread arround the wards

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  • I trained in England but now work in Canada, and yes I was astounded to see patients restrained when I first started practising here. But I have come to understand that it is in the patients best interest. There are many ways of restraining besides the posey vest. I used to work on a trauma unit where we would get a lot of head injured patients who could be very restless and confused we used a piece of equipment called the vail bed, this was a frame that surrounded the patients own bed had 4 mesh sides that were zipped up so the patient was enclosed, this enabled the patient to be safe but not restrained to the bed, bed rails were able to be used.
    For the short term we use 4 point restraints, they are usually sheepskin or thick foam that is put around patients wrists and ankles and tied to the bed, not always pleasant but if used always a necessity,usually used to prevent a patient from harming themselves, as you do not want your confused patient with an external fixator attached to their pelvis to try and get up or to take apart the fixator, and believe me post trauma confused patients will try.

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