Nursing is a profession that involves a fusion of autonomy and collaboration in taking care of individuals of all ages who are not in a state of good health for promotion of a safe and healthy environment. However nursing is different from other health care professions in terms of training, scope of practise and advent of patient care. However every profession in the world is accompanied by challenges and obstacles. One of the biggest challenges in nursing is to decide between applying restraints or using alternate intervention on agitated dementia elderly patients. Understaffed nursing bodies and nursing homes usually do not allow nurses the time to intervene with these patients using therapeutic communication and this at times can cause the use of restraint measure on these patients to conflict with legal, ethical and professional nursing system. Especially among nursing experts, the appropriateness of using restraints on distressed dementia elderly patients has become a sensitive topic of discussion. Similarly, this paper aims to discuss the use of restraints related to the professional aspect of nursing exemplifies with a real life scenario where a dementia elderly patient is being physically and chemically restrained in the surgical unit 4 North-West (4NW) of Jewish General Hospital during the clinical internship of 180.AO 60N.

Summary of incident

On February 8th, 2013, Ms A.C., a 96 year old female patient hospitalized in 4NW, was brought to the attention of nurses when Ms. A.C. refused to take her medication and moved herself on the edge of bed while all four bedrails were still raised. Ms. A.C. was restricted to stay in her bed because she has recently undergone a left hip replacement surgery due to a recent fall injury. Moreover, she has a relevant medical history of right hip hemiarthroplasty, dementia and Alzheimer’s disease. The nursing clinical instructor prevented Ms. A.C. from falling by standing opposite to the patient with the left arm holding around patient’s back and left shoulder and with the leg blocking patient’s knee. Meanwhile, the nursing instructor calmly explained to Ms. A.C that it was unsafe for her to ambulate which could further deteriorate her left hip injury if she keeps it flexed at 90 degrees. After a lengthy session of therapeutic communication by the nursing instructor, Ms. A.C. still exhibited agitated behavior. Subsequently after initial assessment by the nursing instructor, the patient was determined that she had impaired cognition to understand the reason of her hospitalization, to recognize where she was and to be cooperative. After failing in calming the patient, the nurse in-charge then attempted to administer Haloperidol, as prescribed, orally to the Ms. A.C. which she resisted to take either. Ms. A.C. was brought back to supine position on bed with collaboration of the nursing staff. As the patient had an intravenous access, Dimenhydrinate, which could be found in patient’s PRN medication list, was administered intravenously by the nurse in-charge to Ms. A.C. After five minutes, the patient slept quietly on bed. The student nurse then closely monitored Ms. A.C.’s vital signs every hour after the administration of Dimenhydrinate.

In this real life situation, both physical and chemical restraints are being applied on patient. The four side rails of the bed and the physical presence of the nursing instructor around the patient both serve as the physical restraint. The chemical restraint used in this case is the administration of Dimenhydrinate. The professional nursing issue to be discussed in this paper is to determine whether the use of chemical restraint is necessary and appropriate in this particular situation.

Criteria indicating credibility of nursing resources

Before getting into discussion on the professional aspect of nursing in using restraints on dementia elderly patients, the credible nursing resources, such as nursing journals and articles, are necessary to be included as reference during this discussion. The purpose of the nursing articles is aimed to continuously improve nursing care and to provide credible evidence-based knowledge for the general public and for nurses. The credibility of a nursing article can be determined by the following criteria: written by recognized expert, peer reviewed, current and connected to recognized organization.

In the nursing academic article, “Use of physical restraint in institutional elderly care in Finland”, used as one of the references of this paper, can be found in the “Cumulative Index to Nursing and Allied Health Literature” (CINAHL) database. The overview snapshot of this article as shown in the CINAHL database indicates that the article was selected to publish in the “Research in Gerontological Nursing” journal, in 2009. Therefore, the content of this journal is considered to be current as it was published within these recent five years. Moreover, this article was reviewed by expert peer and especially by the editorial board. Thus, this academic article is a credible nursing resource.

Acknowledgement of using restraints on dementia elderly patient

The nurse in-charge administered Dimenhydrinate intravenously to Ms. A.C. to prevent the patient from further deteriorating the left hip and from falling. Physical restraints are seen to be used to increase the patient’s safety who are in a poor health state by preventing falls (Saarnio et al., 2007; Suen et al., 2006) but that seemed to fail in this case so the nurse had to use chemical restraint on Ms. A.C. With regard solely to the professional aspect of nursing, I am in favor with this nursing intervention in this particular circumstance, because we are all in consensus that the patient’s safety is the first priority. Moreover, since the patient demonstrates agitated behavior and impaired cognition, nurses are at risk of physical injury during the de-escalation of patient agitation. Furthermore, Ms. A.C. is at risk of further injured her left hip while sitting at the edge of the bed, who is also at risk of developing other complication, such as fracture and hip dislocation. Therefore, I believe that applying both physical and chemical restraints for the sake of the patient’s safety is the appropriate nursing intervention for this exceptional circumstance.

In A.C.’s case, I believe that dementia has affected the patient’s cognition and prevents her from being cooperative with the nursing staff. Zampieron, Galeazzo, Turra, and Buja (2010) points out that “aggressors often have impaired cognitive processing and data suggested that many patients may not have been fully aware of their situation and might have experienced some difficulty in comprehending the staff member’s actions, which triggered the episode of violence” (p. 2338). In my knowledge, A.C’s case was of a serious fall and the restraint was intended to protect her from falling again. Restraint should only be used to prevent harm to the person who is being retsrained according to the Mental Capacity Act 5005 (Rhidian Hughes, 2008). Falls frequently result in serious injuries and pain regardless of the older adult’s cognitive status or living situationand falling is a leading contributor to hospitalization, lowered quality of life, negative psychosocial consequences, loss of confidence, attenuated activities of daily living and death (J.Williams, 2010). Concerning resident characteristics, one prime contributor was the presence of dementia. Physical therapists and special aid cares described that residents who have cognitive impairment with limited sense of judgment, foresight, incapability to know their capabilities and to navigate their environment, tent to ambulate more and can result in a fall (Kaasalainen & Williams, 2010). “. . . and they seem to get to a point um in their abilities where they just have this urge to get up and don’t recognize they don’t have the skills to do that” an occupational therapist describes the problem that is majorly linked with falls (J. Williams et al, 2010). Older people are most likely to be restrained if they have physical and mental disability, are perceived to be difficult or threatening or cannot be persuaded by other means to do what staff wants them to do (Commission for social Care Inspection, 2007). All three of these conditions may apply to older people with learning disabilities who are, therefore, particularly likely to experience restraint to prevent from fall.

With the advent of Bill 90, nurses have greater decisional power and more latitude to use their own judgment. It also allows them the autonomy to make decisions as to the use of restraint measures. However there are a few limitations:

Restraint measures must be used only as a last resort

Nurse must use their clinical judgment and decision making power to make the best choice for the patient (restraint use must be justified)

Nurses are empowered to resort to restraints after examining the options, including alternative measures

Nurses will determine what kinds of measures are needed, how long they must be used, and the necessary monitoring

In A.C’s case, all these limitations were taken in consideration as evident from the scenario. The sole purpose was to protect her from further aggravating her condition. Moreover she is suffering from dementia and is unable to judge or understand her position and environment which she is not responding to. In this situation the nurse in charge first tried other options like calmly making her understand what she is going through but after failing in doing so she had to opt for the last resort. Nurse in charge however did consult her prescription first to confirm whether sedatives have been prescribed or not and after an assurance, she took the step of chemically restraining her and if I would have in her place, I would also have followed the same procedure in this particular case.

However, there are always two sides of the coin. We cannot neglect what other side of the issue has to say and the reasons behind that. A.C’s case was of a fall and fracture and the restraints used were not meant to be long term, however in the usual nursing practice, other cases have of dementia patients have been recorded where restraints were used without a valid justification and not as last resort. Thereafter, these cases are framed as A.C’s case when questioned by the authorities. Reported reasons for its use are preventing interference with treatment, controlling behavior such as aggression and wandering, and lack of nursing staff (Pellfolk & Karlsson, 2010). After dementia has been diagnosed in people with learning disabilities, there is a greater likelihood of nursing home care being sought (J. Ridley & S. Jones, 2011). However, care staff may have little training or experience in dealing with people with dementia (Department of Health (DH) 2009), learning disabilities or both.

Dementia is associated with a range of challenging behaviours, most of them difficult to manage, including agitation, anxiety, irritability and motor restlessness. It can lead to eating problems and mood disorders, and behaviours such as wandering, pacing, aggression, psychosis and sexual disinhibition. It is also associated with abnormal vocalizations, including shouting, screaming and demands for attention. People who have dementia and who exhibit such challenging behaviour are more likely to be restrained. It involves the intentional restriction of a person’s voluntary movements or behaviour, associated with a range of nursing interventions, from the use of sedatives to the application and use of plaster casts (Counsel and Care, 2002). Different types of restrictive practices are used as identified by Watson (2001): Physical restraint by staff by holding, moving or blocking people’s movements, mechanical, involving the use of equipment such as cot sides, heavy tables and baffle locks are some commonly used physical restraints. Reetta Saarnio (2009) advises that the need for such physical restraint can be reduced through the use of technical aids aimed at increasing the safety of elderly patients, such as pillows and bedside mats (p. 277). Chemical restraint involves the prescribing of medications or use of over-the-counter drugs. In some cases, this can involve the use of illegal drugs. Psychological, whereby staff makes verbal commands or conveys, verbally or visually, false information and technological, involves the use of equipment such as electronic tags and door alarms.

Ontario law sanctioned the use of restraints by the nurses with certain restrictions but at the same time makes it challengeable under the Charter of Rights and Freedom Canada, by providing insufficient procedural protection to residents in the nursing home. The charter gives the right of life, freedom, security and liberty to the person and the use of restraints violate this libertyand freedom (Canadian Charter of Rights and Freedom, section 7). Arbitrary detention and imprisonment is against the right of a person (Canadian Charter of Rights and Freedom, section 9) and restraining is a kind of detention. In my view, these legalities when come in contact with the everyday nursing practices create confusion for the nurses. The major reason of this is the lack of legal knowledge in nursing practice and the incomplete outline of the procedural rights in regard to the use of restraints in the law. Lack of proper legal knowledge and legal training of nurses has lead to some fatalities due to the use of restraints in the health care world.

An Ontario patient admitted at the Centre for Addiction and Mental Health in 2005 was physically restrained for five days which resulted in his death from acute pulmonary thromboembolism. After this incident, a new best practice guideline was developed by the Registered Nurses’ Association of Ontario that aimed limiting use of restraints in health-care facilities. Evidence-based knowledge on prevention, assessment, and alternative approaches, de-escalation interventions for limiting the use of chemical and physical restraints and stresses that restraints should only be opted after all other approaches have failed. There has been legislation that outlines that consent for use of a restraint must be in place and that the doctor must be notified to review the patient’s condition and follow up on orders for restraints (Patient Restraints Minimization Act, 2001). The focus should be on getting patients and their families engaged in an assessment to plan and identifying the alternative approaches (Brenda Dusec, 2001).

In case of dementia patients the use of restraints becomes even more sensitive issue whether it’s an application of a physical restraint or a chemical restraint. Non restrictive practices have been promoted when dealing with the dementia patients and when essential limited and appropriate restraint should be used but as the last resort (National Dementia Strategy, 2009). Use of chemical restraints such as sedatives and neuroleptics to manage behavior is discouraged and if under uncontrollable circumstances such as extreme violent and aggressive behavior which threatens the safety of the patient, otherpatients or the nursing staff, is used should be a part of the patient’s prescription and should be reviewed routinely. According to a study lead by Poole and Mott in 2003, nurses reported the use of chemical restraints on the patients during busy periods and to manage workloads. Some adverse effects of neuroleptic medicines on dementia patients have been found. These drugs can advance the cognitive decline. Since dementia patients are unable to show their consent regarding the administration of any drug, special procedures should be followed (Department for Constitutional Affairs, 2007) to protect the elderly patients from further deteriorating their cognitive skills.

Under the review of the literature that I have gone through, my stance on the use of restraints has shifted a little. Though it has not gone completely against its use but in my opinion should be used according to the Least Restraint Policy (J. Williams et al, 2010). These policies allow you to understand your position as nurse and your decision power more effectively. Understanding your patient that you are taking care of must be utmost priority. Only then you will be able to figure out the reasons for his/her behaviour and can act accordingly by taking into account the alternatives such as therapeutic communication or understanding that whether their needs and care requirements are fulfilled or not. Furthermore, I favour the least amount of restraint use under the legal procedures and policies, for the right reason and not on faulty grounds. The use of chemical restraints should be avoided as much as possible especially in the case of dementia patients and other alternatives should be used which include incorporating the help of patient’s relatives and family, and discussing the patient’s issue with other experienced fellow nurses in case use of restraint seems inevitable. I think this approach can help you take a better decision which satisfies the patient as well as your own self.

In the professional nursing practice, the use of restraints is common and that too without justified and valid reasons and can be used to as a result of lack of knowledge and proper training on the hands of the nursing staff. Therefore, staff education in small dwelling groups is very important to increase their knowledge with both the medical aspect as well as the legal aspect, changing their attitudes and can reduce the use of physical and chemical restraints. Nurses should be trained in making meticulous assessment including physical health, mental health and related psychosocial needs. It will help them to understand the service users’ needs and evaluates them to judge the use of minimum and controlled restrained.

This paper outlines the needs of patients as well as the nursing staff referred to the use and implications of physical and chemical restraints on the elderly patients with dementia. In my opinion, only a proper training and education of the nursing staff regarding the medical, ethical and legal procedures on the use of restraints and incorporating these in their everyday practice can help in reducing the unjustified use of restraints on elderly patients especially those suffering from dementia. Nurses need to put themselves in the position of these patients to understand what they need and why they behave in a way that forces the nurses to use restraints on them. Change in policy and awareness amongst the nurses to follow these policies can help make the environment of the nursing homes more healthy and benign for our elderly peers.