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?
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.