Reducing restraint on residents in Hong Kong care home settings

Individuals from the Jockey Club Centre for Positive Ageing discuss reducing using restraint on residents in Hong Kong care home settings

Restraint use among residents in care home settings could be significantly reduced by implementing a multi-component restraint reduction programme, a research study conducted by Jockey Club Centre for Positive Ageing (JCCPA) said. ⁽¹⁾

The study involved the implementation of a comprehensive programme over 12 months. The programme included staff training, examination of current care practices, environmental design modifications, monthly case conferences, and support from multidisciplinary experts.

Implemented in two care homes, the programme demonstrated a significant 30% reduction in restraints. One of the primary reasons for employing restraints, fall prevention from chairs, was also significantly reduced following the implementation of the restraint reduction programme.

Restraint on residents in Hong Kong care home settings

It is a common practice to employ physical devices, such as geriatric tables, safety vests, mitts, and lean-back chairs, to restrict the movement of individuals in various care settings. In Hong Kong, safety vests and seat belts are commonly used as restraints in local care homes, followed by mitts and limb holders. The global prevalence of physical restraint varies widely, ranges from 15% to 85% ^(1-3), depending on the definition used.

Hong Kong experiences the same phenomenon, and physical restraint is claimed to be the most common form of elderly abuse in local care settings. Unfortunately, the situation is deteriorating. A longitudinal study indicated that restraints in Hong Kong increased by 40% over ten years, from 52.7% in 2005 to 74.2% in 2015. ⁽⁴⁾

The authors attributed the increasing trend to several factors, including the growth of the elderly population, a rising number of individuals with impaired cognitive function, and an increase in individuals with limited self-care abilities and mobility being enrolled in care home settings.

Individuals with dementia have more chance of being restrained, and the severity of dementia correlates with the use of physical restraints. A study revealed that approximately 60% of residents with dementia living in nursing homes were found to be restrained, primarily during nighttime, often with up to five different types of restraints. ⁽⁵⁾ This vulnerable group requires particular attention when addressing the issue of physical restraint.

The main reason for employing restraints on residents in care home settings is to protect them from falls and related injuries. Residents with a history of previous falls or fractures are more likely to be subjected to restraint. A research study showed that four-fifths of the residents in nursing homes were restrained to prevent falls and related injuries. ⁽⁶⁾

Managing challenging behaviour is another common reason for the use of restraints. Both physical and verbal aggressive behaviours, such as throwing objects or shouting at staff, have been found to correlate with the use of physical restraints. ⁽⁷⁾

Restraints are often claimed to be used to protect the safety of residents, staff, and others involved. Other reasons for their use include compensating for the shortage of healthcare workers, facilitating treatment, and assisting with performing personal care. ^(2,8,9)

The impact of restraint

Both temporary and prolonged restraint can lead to negative physical and psychological outcomes. The use of restraints deprives residents of the ability to exercise, which can result in a loss of muscle strength and endurance, decreased mobility, and increased incontinence. ⁽¹⁰⁾

Restraints can impair blood circulation in the restrained body part, leading to blood stasis and affecting the nerves. ⁽¹⁾ Other common symptoms of prolonged immobility include contractures and pressure ulcers. ⁽⁵⁾

Contradicting the intended purpose of preventing falls and related injuries, restraints can exacerbate the risk of falls and expose individuals to injuries, such as suffocation when attempting to escape from safety vests, and, in severe cases, even death.

Restrained residents in care home settings often experience a low quality of life. Their rights are disregarded, and they feel humiliated and uncertain about the reasons for being restrained. ⁽⁶⁾ The loss of social interaction and disorientation further exacerbate cognitive decline, devastating for individuals with dementia.

Challenging behaviour may escalate when the movement of the residents is prohibited, despite it being one of the main reasons for using restraints. Research has demonstrated that restraints can lead to negative emotions such as agitation, frustration, anxiety, and depression. ⁽¹¹⁾ This creates a vicious cycle, perpetuating the detrimental impact on the individual’s well-being.

Interventions to reduce restraint

Various interventions have been developed over the past decades to reduce restraint use. Multi-component programmes incorporating staff training on knowledge and attitudes regarding restraint reduction and consultation have proven effective in lowering restraint use in different countries worldwide.

Since healthcare workers are typically involved in the decision-making and application of restraints, their education, attitudes, and opinions regarding restraint use greatly influence their willingness to reduce its use.

Comprehensive training programmes, encompassing theoretical and practical aspects, can equip healthcare workers with the necessary knowledge and confidence to reduce restraint use effectively. Previous applications of multi-component restraint reduction programmes in hospital wards in Hong Kong have yielded positive results ^(4,12), indicating the feasibility of implementing such programmes in the local setting.

The widespread use of physical restraints in care home settings, including Hong Kong, raises concerns about the well-being of residents and emphasises the urgent need for effective interventions. The detrimental effects of physical and psychological restraint use underscore the importance of finding alternative approaches to ensure the safety and dignity of individuals in care home settings.

Multi-component restraint reduction programmes

The research study conducted by JCCPA highlights the potential of multi-component restraint reduction programmes, which incorporate key elements such as staff training, environmental design modifications, and regular case conferences to reduce restraints among care home residents significantly.

References

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