A blog by Tamara Backhouse
Media reports have highlighted the plight of care homes as COVID-19 becomes more prevalent within them. Problems sourcing adequate personal protective equipment; having access to testing; needing to take COVID-19 positive patients back from hospital, and staff shortages due to shielding, social isolation and illness have compounded their difficulties.
Older or vulnerable adults are more at risk of serious consequences from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), particularly those in care homes who often have multiple complex needs and comorbidities. It is not surprising that care home staff are feeling under pressure and strained at this time.
A group of researchers from across the NIHR ARCs, led by Professor Claire Goodman (ARC EoE), have developed ‘Top Tips for Tricky Times’ for care home staff to help them manage difficulties during the pandemic.
One issue care home staff identified was that social distancing was difficult to apply in communal care settings, especially with people with dementia who may not understand and comply. Was it even possible to manage social distancing without resorting to using restraint?
The guidance is clear (1,2,3) that restraint should not be used. If it is used, restraint should abide by these principles. That it is:
- used for an individual person’s support
- a last resort and only when other options have been excluded; and its use must always be minimised
- in the person’s best interests
- the least restrictive option
- not depriving a person of their liberty unless absolutely necessary to prevent serious harm to the person
- proportionate to the harm the caregiver is seeking to prevent
Guidance was clear on what staff could not do, but less helpful on the alternatives. We carried out a small literature search via PubMed to find out about alternatives to restraint in care homes. There is a literature on alternatives to using pharmacological interventions to reducing behaviours that staff find challenging. Our search found little research providing clear practical information about what to do instead of restraint when urgent action is required and no research stating which methods of restraint, if having to resort to it, would be the most effective, least restrictive or more ethically acceptable.
Research evidence did offer some principles and suggestions:
- Identify and address resident’s unmet needs to reduce the need to resort to restraint (5).
- Use an individualised, person centred approach to support the person’s human rights and needs (5,10).
- Use individualised safety plans and/or risk assessments (6).
- Consider alternative approaches to restraint such as modifying the environment (8) or exercise or walking (10).
- Enable access to an enclosed garden or other secluded area if possible (6) or promote a dementia enabling environment (5).
- Support team members of all levels – senior/manager leadership and appreciation and co-worker support can reduce the use of restraints (6,11).
- Consider the use of a champion to support staff to find alternatives to restraint (6); optimise communication about identified issues between team members perhaps at handovers, and involve external professionals if needed (5).
- Review identified issues with the person’s GP and contacting and eliciting support from community mental health and dementia teams where necessary (3).
- Involve the person as much as possible in decisions about new care practices (6), trying to gain informed consent from them and/or an appropriate appointed person (5). Documenting decisions (5).
- Educate staff about the principles, ethical considerations and the negative consequences, of restraint (4,5,7,8,9) and how to communicate well and manage behaviours (6).
- Use trained staff to review and monitor any ongoing restraint (5,6).
This is an incredibly difficult area of practice. Staff are likely to feel conflicted whether they restrain or not. The lack of practical and specific information to help care home staff manage difficult situations and no evidence means care home staff are left on their own to manage in this time of crisis. For example, are chemical restraints more acceptable for short periods than physical restraints or restrictions such as locking doors? What are the least restrictive options?
Guidance and evidence was most likely to focus on what care home staff ought not do rather than how they should navigate the need to restrain. One recent resource sets out how care homes can adapt the home environment to prevent infection and control the spread of COVID-19. Having a clear demarcation of risk zones throughout the home may help care home staff who are struggling with the issue of social distancing (12).
There are no simple solutions to resolving the tensions between a person’s human rights and ensuring their safety and well-being. However, guidance and research evidence stops short of addressing how to implement least restrictive, proportionate restraints or restrictions. This is understandable; no researcher would recommend restraint of older people in long-term care. However, it ignores the fact that care home staff have no research informed resources to help them work through issues of restraint during the pandemic.
The coronavirus pandemic seems to have led to a heightened awareness of the work of care homes. We should build on this to work to sustain engagement from policy makers and funders after the pandemic. Restraint is an under-reported, hidden area of practice. There is a need for open conversations about restraint use and evidence based alternatives to take place with different audiences.
The pandemic has brought to the fore the very specific care and information needs of care homes. The case of restraint has exposed the need for researchers to work with care home staff to address the questions they need answering.
- ‘The Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) During the Coronavirus (COVID-19) Pandemic (April 9th 2020)’ guidance: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878910/Emergency_MCA_DoLS_Guidance_COVID19.pdf
- The Mental Capacity (amendment) Act 2019 Deprivation of Liberty Safeguards (DoLS) http://www.legislation.gov.uk/ukpga/2019/18/enacted https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/437661/Final_DoLS_Guidance_2015.pdf
- BGS guidelines for managing the COVID-19 pandemic in care homes (2020) https://www.bgs.org.uk/resources/covid-19-managing-the-covid-19-pandemic-in-care-homes
- Anderson, K., Bird, M., MacPherson, S., & Blair, A. (2016). How do staff influence the quality of long-term dementia care and the lives of residents? A systematic review of the evidence. International Psychogeriatrics, 28(8), 1263-1281. doi:10.1017/S1041610216000570 https://www.cambridge.org/core/journals/international-psychogeriatrics/article/how-do-staff-influence-the-quality-of-longterm-dementia-care-and-the-lives-of-residents-a-systematic-review-of-the-evidence/0CC8A1DA42CE1A6A16C721D0B42920AB
- Bellenger E. Ibrahim JE. Bugeja L. Kennedy B. (2017) Physical restraint deaths in a 13-year national cohort of nursing home residents. Age Ageing. 46(4):688-693. doi: 10.1093/ageing/afw246.
- Goulet M-H. Larue C. Dumais A. (2017) Evaluation of seclusion and restraint reduction programs in mental health: A systematic review, Aggression and Violent Behavior, 34, 139-146, https://doi.org/10.1016/j.avb.2017.01.019. https://www.sciencedirect.com/science/article/pii/S1359178917300320?casa_token=8PtBZSMIw44AAAAA:vij70zs5MMv0_EAuv11QU-f-JKF-t3ljtf66k3emEUycIJNY09Ia2wfdS1Cs2SHP1vWAPYni
- Kong E-H. Song E. & Evans LK. (2017) Effects of a Multicomponent Restraint Reduction Program for Korean Nursing Home Staff, Journal of Nursing Scholarship, 49:3,325–335
- Kor PP. Kwan RYC. Liu JY. Lai C. (2018) Knowledge, Practice, and Attitude of Nursing Home Staff Toward the Use of Physical Restraint: Have They Changed Over Time? Journal of Nursing Scholarship, 50(5):502-512. doi: 10.1111/jnu.12415
- Lan SH. Lu LC. Lan SJ. Chen JC. Wu WJ. Chang SP. Lin LY. (2017) Educational intervention on physical restraint use in long-term care facilities - Systematic review and meta-analysis. J Med Sci. 33(8):411-421. doi: 10.1016/j.kjms.2017.05.012.
- L. Robinson D. Hutchings HO. Dickinson L. Corner F. Beyer T. Finch J. Hughes A. Vanoli C. Ballard J. Bond. (2006) Effectiveness and acceptability of non‐pharmacological interventions to reduce wandering in dementia: a systematic review, International Journal of Geriatric Psychiatry, 22(1) 9-22. https://doi.org/10.1002/gps.1643
- Willemse B. De Jonge J. Smit D. Dasselaar W. Depla M. & Pot A. (2016) Is an unhealthy work environment in nursing home care for people with dementia associated with the prescription of psychotropic drugs and physical restraints? International Psychogeriatrics, 28(6), 983-994. doi:10.1017/S1041610216000028
- Fewster E. (2020) Care Homes Strategy for Infection Prevention & Control of Covid-19 Based on Clear Delineation of Risk Zones. https://ltccovid.org/2020/05/01/resource-care-homes-strategy-for-infection-prevention-control-of-covid-19-based-on-clear-delineation-of-risk-zones-update/