Organization-wide strategies will help staff to embrace reduced restraint use. Several projects aimed at achieving restraint-free care have been conducted in long-term care and acute care settings, with varying degrees of success.1-5 Common elements among them include administrative support and commitment; staff education on dementia, assessment and behavioral management, ethical and legal issues surrounding the use of restraints, and individualized care; and an interdisciplinary team that helps design an individualized care plan for at-risk and restrained patients. Consultants may also be helpful in developing behavioral management plans.

Beliefs and values within an organization regarding approaches to pain management or the use of surveillance can cause resistance to change and lead to fundamental problems in the care of patients with dementia.6, 7 Clinicians and other staff members may not understand that agitation or irregular behavior in patients with dementia may signal a change in health or an unmet need. Staff education might not in itself bring about lasting change.1 A nurse who champions change is important, as is providing staff access to experts in the field, such as geriatric advanced practice nurses or an interdisciplinary restraint-reduction team.6

Ongoing data collection and monitoring, as part of a quality-assessment and quality-improvement system, are very important to achieving and maintaining a reduction in restraint use. The quality-improvement team should routinely review the use of restraints in the facility, identify particular challenges, and develop strategies to address them. Staff must be oriented to a culture in which dialogue regarding challenging cases is ongoing and not having all the answers is acceptable. Consistent staff assignments, access to supportive equipment such as bedside commodes and over-bed trapezes, and technology that supports reliable admission data and communication of care strategies should be institutionalized. Staff should be recognized and rewarded for reducing or eliminating the use of restraints; one effective approach is to post unit results in public locations.8 It's also crucial to develop a plan for maintaining restraint reduction during times of staffing shortages.

Lois K. Evans, PhD, RN, FAAN

Valerie T. Cotter, MSN, CRNP, FAANP

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