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OPINION

UK nurses do care deeply about patient safety – which is why they don’t use restraining vests

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Frances Healey on the use of restraint vests and why the UK is lucky to have avoided introducing them.

This article is in response to Nursin’ USA - Why do UK nurses consider restraints unacceptable?

The consequences of a fall in hospital can be severe, and the risk of falls and injury are a great cause of anxiety to nurses who want to keep their patients safe. But advocating that nurses in the UK should copy their American counterparts by tying patients to their beds or chairs with restraining vests is not the way forward. The Royal College of Nursing in their guidance on restraint (RCN, 2008) state that “Vest, belt or cuff devices specifically designed to stop people getting out of beds or chairs are in relatively common use in hospital and care home settings in many countries outside the UK, including in Europe, the USA and Australia. These devices are not acceptable in the UK.”

Undoubtedly there are situations where nurses have a duty to intervene to keep patients without capacity safe, even if this involves restraining them - we would and should try to stop a delirious patient walking out of hospital – and the RCN guidance gives good advice on difficult situations where restraint as a last resort may or may not be appropriate. But there are very sound reasons why their guidance outlaws vest, belt and cuff devices. Firstly, these devices have been associated with a series of deaths from asphyxiation – a patient struggling to escape the vest may tighten it around their chest or neck (Capezuti, 2004). Patients tied to their beds or chairs with these devices have much greater likelihood of developing pressure ulcers and thromboses, and are more likely to die in hospital (Evans et al, 2003). Incontinence becomes almost inevitable, and patients already disorientated by a hospital admission will only become more distraught if they find themselves tied to their bed; the recollections of patients restrained in this way make harrowing reading (Mion et al, 1996).

And in addition to the direct harm they can cause, they do not reduce the risk of falls. In the short term, an agitated patient may still fall, but with their chair or wheelchair landing on top of them. In the longer term, even one or two days tied to their bed or chair will affect the strength and balance of a frail older person, so unless you plan to tie them down for the rest of their life, their time in the restraining vest will have left them weakened and even more vulnerable to falls (Mahoney, 1998). This may be why countries where their use is permitted have falls rates greater than (Schwendimann et al, 2006)or equal to (Krauss et al. 2007)rates from England and Wales (National Patient Safety Agency, 2010), and why organisations that stop using these devices find that fewer falls occur (Evans, 2002).

And we have a legal system that rightly protects vulnerable adults from unjustified deprivation of liberty (Mental Capacity Act, 2005). The responses to Sara’s opinion piece shows just how much we need this, as some suggest these vests should be used not only for falls prevention but to ensure patients with dementia can’t annoy other patients. And whilst Sara’s comparison of older patients with toddlers is one that makes me uncomfortable, it is worth reflecting that strapping toddlers into their highchairs for days at a time is also unacceptable, however ‘safe’ that might make them.

Far from being accepted as good practice in the rest of the world, most other countries are making dedicated efforts to eliminate or drastically curtail the use of these devices (Australian Commission for Safety and Quality in Healthcare, 2009). They would see the UK as lucky for having avoided introducing them. This is not to say we should be complacent; the use of medication to control behaviour – chemical restraint – also causes serious harm. But substituting restraining vests for chemical restraint is not the answer either; there are a range of far more positive steps that Sara and all other nurses who care about preventing falls can take, and many resources that are available to help them (Patient Safety First, 2009) including at patientsafetyfirst.nhs.uk, profane.eu.org,www.scie.org.uk/socialcaretv/ and institute.nhs.uk.

 

About the author

Frances Healey is head of patient safety at the National Patient Safety Agency

  • 13 Comments

Readers' comments (13)

  • I do agree with this article on the whole, and restraint should never be used wholesale. However I still think there should be some sort of provision allowing Nurses and Doctors to initiate a care plan for restraint in extreme circumstances, both for patient and staff safety.

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  • Mike
    I thought that was the point of the mental health act

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  • Well said Frances. Its frightening to think that nurses would even consider restraint that tied someone down to a bed. THis is where care and risk management meet and we have to put care first. Caring involves thinking around the problem not just jumping at the quickest solution. Dignity has to be our guideing principle when an individual is unable to protect themself from harm "Do unto others...."

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  • Anonymous | 13-Jul-2010 1:22 pm, that is what I meant, although I may not have explained myself very well. As long as measures such as the MHA are there to give us that option when it is necessary in extreme circumstances, then the wholesale use of restraint is not necessary. A blanket system (either yes or no to restraint) is not the best way either way.

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  • Martin Gray

    I don't recall anyone suggesting that such restraints should be used on a permanent basis, and the impression I got was that such physical restraint would only be used in certain circumstances. Chemical restraint, as you put it, is still used under the terms of the MHA in certain cases is it not?

    No restraint, physical or otherwise, should cause any harm to the patient. That goes against our code of practice; however, is it not also the case, under that same code, that we have a duty to protect our patients from harm? It is a dilemma that has no solution I fear.

    From the article I can only assume that any patient put under physical restraint is then 'forgotten about' when it comes down to toileting, etc. hence the incontinence, and lack of movement combined with bodily waste is bound to increase the probability of pressure sores and thrombosis significantly. That is not only pure bad nursing practice but shows a lack of common sense and laziness in not putting knowledge into practice.

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  • Are restraints cheaper than specialing a human being?

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  • Well i have had to use restraints on a general ward because of a confused and extremely aggressive patient; female in her late 70's she clearly had been the same person but with insight her whole life as her own children lamented she was violent to them when they were younger. so it wasn't ideal but it sure stopped us from getting hurt by her.

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  • Martin Gray

    'Dignity has to be our guiding principle' please explain to me what is dignified about a confused or aggresive patient creating mayhem on a ward or in a nursing home, upsetting all the other confused patients and putting staff on edge whilst they try to 'think round the problem'.

    Of course care is important, as is dignity, but unfortunately in providing the former there is some loss of the latter. What is important is preventing a patient hurting themselves and/or others. How long have GPs prescribed sedating drugs for elderly confused patients at the request of the nursing staff I wonder. It is the way in which the drugs are used that is also an issue.

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  • I think the balance we have, as described by Frances is the right one. Not only does our system protect the patient, it also protects the nurse in that the use of restraint was a considered action.

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  • I have worked abroad, in Europe, where on one occasion an agitated and distressed patient was tied by her wrists to the cot sides. I was horrified which shocked the other nurses as they couldn't understand why I had a problem with this. I pointed out that other than it being inhumane it didn't resolve the problem as the patient was still agitated and distressed, if not more so because she was restrained. To which the nurses quickly dismissed saying that at least she was safe and their backs were covered. She was never offered a comode until her family requested it.

    Once when I was working night shift in the UK we had an elderly alcoholic chap who was wandering and climbing into bed with the patient next to him who was recovering from an acute MI, or should I say on his way to another one as he was terrified by the older alcoholic guy. It was too busy a night to stay with the wandering alcoholic so unfortunately my colleague and I decided to bind him carefully to a reclining chair and recline him. We made every point though to check on him, chat to him as we were running by with comodes, drip stands, the usual....
    We really had no choice as another patient had a respiratory arrest and another an acute GI bleed. In these exceptional circumstances, we had no choice.

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