The Hidden Restraint – Part 1 – Restraints
Imagine if we considered locked doors in memory care wards as restraints.
by Dr. Al
Power, ChangingAging Contributor
Having given
many seminars on restraint reduction 15-20 years ago, I am very familiar with
how CMS defines a restraint. It’s any device, attached to or adjacent to a
person’s body that prohibits freedom of movement.
So obviously
a Posey vest fits the definition. But also a low chair from which a person
cannot rise independently is also a restraint, even when not tied. The bottom
line is that if you could move freely by yourself otherwise, and now you cannot,
you are being restrained.
So by those
criteria, what is another device adjacent to a person that prevents freedom of
movement? How about…a locked door?
Now the Feds
don’t define it as a restraint; but it fits the criteria. Imagine if in your
quarterly QI reports you had to code every person behind a locked door as being
restrained. How would that affect your profile?
Before you
fill the comment box with questions about “How can we keep people safe without
a locked door?” let’s consider a few other parallels with restraints.
Restraints were
applied by well-meaning people (myself included 25 years ago) in order to
protect people against falls and injury. The problem is, they didn’t do that.
Subsequent studies showed that not only did restraints not prevent serious
injuries—they also created severe emotional distress, due to the person being
tied and feeling trapped. Furthermore, they took the focus away from
understanding why the person wanted to move in the first place, thereby ignoring
a host of unmet needs.
So it is
with locked doors. While physical safety is always an important consideration,
“security” comprises much more than physical safety—it also means emotional and
psychological security, which includes such attributes as familiarity, trust,
respect, dignity, privacy, and balance. The problem is that many things we do
to increase physical safety help us to feel better, but actually decrease the
sense of security felt by the person
.
So it is
with the locked door. As I wrote in
Dementia Beyond Disease:
Imagine that the person feels a need
to leave because of one of a variety of reasons—that her children may need
attention, that he has to go home from work, that she needs some exercise and
fresh air, or simply that this place just does not feel like a place where he
wants to stay all day. What will the reaction of each of these individuals be
when confronted by a locked door? “You cannot go to your children,” “You cannot
leave work,” “You cannot get any fresh air,” or “You must stay in this place
that you do not like.
So once again, we have a
staff-centered solution that actually decreases the person’s sense of security
and increases both the level of anxiety and the very desire to leave as well!
The person returns repeatedly to the locked door, bangs on the door, calls out
for help, or otherwise expresses her distress. It is another self-fulfilling prophecy, as the “special care unit” proves to be the
home of the “most agitated residents.”
Like other
restraints, the locked door also decreases staff members’ critical thinking
skills. Once they know the person cannot leave, they stop thinking about why
the person wanted to leave in the first place. I have a very simplistic way of
looking at someone who tries to leave an area: she is either trying to find
something that is not there, or else to get away from something that is there.
The locked door satisfies neither of these concerns.
Furthermore,
it is not always a sign of distress. It may be simply looking for exercise,
fresh air, or a change of scene, as we all do. Once again, the limiting view of
seeing such actions as “symptoms of dementia” pathologizes something we would
all feel in that situation. I often ask people to imagine that they were
spending several days to weeks in such a place and could not leave by themselves;
how long could you last before you started to climb the walls??
This also
explains why disguising the door as a bookshelf or other fixture is
counterproductive. If there is a need or desire that leads the person to try to
leave, this may hide the door, but does nothing to give them what they need.
They may stop banging on the locked door, but you have done nothing to help
their sense of well-being. You have focused on your tasks and ignored the
person. There is no other way you can spin this.
Is it easy
to operate without a locked door? No it’s not. It wasn’t easy to untie people
back in the 1990s either. It took a lot of investigation, education, and
operational shifts to meet people’s needs so that it could be done safely. But
as the recent Facebook post by Dr. Bill Thomas shows, it can be done very
successfully. And although this particular home had very few residents and
enriched staffing ratios, many larger nursing homes and assisted living
communities are succeeding without locked doors using the usual staffing
compliment.
How do we
get there? In Part 2, I’ll give you a road map…
About Dr. Al
Power, ChangingAging Contributor:
Al Power is
a geriatrician, author, musician, and an international educator on
transformational models of care for older adults, particularly those living
with changing cognitive abilities. You can follow his speaking schedule at http://www.alpower.net/gallenpower_schedule.htm
Reprinted from: http://changingaging.org/dementia/hidden-restraint-part-1/?utm_source=ChangingAging&utm_campaign=549c889a9e-hidden_restraint&utm_medium=email&utm_term=0_10c6c015a2-549c889a9e-57814809&mc_cid=549c889a9e&mc_eid=819b812096
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