Restraints or alternatives: safety work in care of older persons

To examine the factors and complexity that account for physical restraints use and their alternatives as nurses' protect the safety of older adults.

Research on physical restraints has repeatedly shown the human, financial and work costs associated with their use, but their use continues to be a major quality issue across hospitals and across countries for older persons.

Interviews with medical surgical nurses in a Midwestern hospital in the United States were recorded and interpreted using grounded theory.

Using data that described the complexity of initiating, maintaining, or discontinuing restraints, we captured the density of these processes and showed how nurses made decisions about restraint use. The tasks carried out to protect the older person's safety often involved using restraints or their alternatives and these tasks then set in motion a cascade of other types of tasks or work, e.g., diagnostic, comfort, articulation.

The study extended the work on chronic illness trajectories and formulated a framework for understanding the complexity of the use of restraints and their alternatives. Using a tracing approach we were able to predict the types of situations that would most likely result in the initiation, maintenance and discontinuation of restraints or the use of alternative procedures.

The study has identified a process of 'safety work' that identified the risk associated with the problem, the work to cope with the problem and risk, the conditions that influenced the process and the consequences or outcomes of the work strategies to maintain the older person's safety.