Nurse practitioners with aged care expertise and specialist mental health nurses may help reduce the systemic use of restraints in residential aged care.

Systemic issues within residential aged care are enabling the use of restraints, despite the practice being illegal in any other age group, highlights CQUniversity research.

“Older people appear to have less rights than other age groups: in any other age group, restraint is illegal. However, legislation allows restraints to be applied to older people who reside in RACFs,” said CQU researcher and registered nurse Jennifer Mulvogue.

Ethical and moral challenges associated with using physical and chemical restraints in Residential Aged Care Facilities (RACFs) were examined in the CQUniversity study. Several issues contributed to restraint use in RACF which is a human rights issue often hidden in RACFs, said Dr Mulvogue, who has a background in mental health nursing.

“When I refer to physical restraint, I mean objects placed against the body or around the body to prevent a person’s movement or preventing them from moving.”

Examples of physical restraints include table-top restraints, which are chairs designed to restrict movement and prevent older people from getting out of a chair; or ties, straps, or furniture positioned so the person can’t leave a space; or bed rails in place to keep a person from getting out of the bed. Physical restraints can also be locked doors.

“There is also chemical restraint, which is the intentional medicinal sedation of an older person to control their behaviour,” said Dr Mulvogue.

Inadequate staffing increases restraint use

Restraint, including chemical restraint, was often used instead of providing adequate staff numbers or adequately training staff on how to work effectively with older people who may have diverse cognitive abilities or health needs, the research found.

“RACF staff are often placed in positions where they feel they have ‘no choice’ but to restrain older people because they do not have the human resources to manage a situation otherwise. Staff often feel pressured to maintain the status quo (and use restraints) and can lack the confidence to question why a restraint is used. 

RACF staff are constantly placed in compromising unethical and morally conflicting situations,” said Dr Mulvogue.

“If they complain, they are moved on or replaced. A research participant who is also a registered nurse described being the only RN on a shift, having responsibility for 200 residents, and not having the time to assess residents adequately and that chemical restraint occurred because there weren’t enough RNs to work with people who had additional needs.”

Research participants expressed concerns about ‘profit over care’ and not having enough ‘hands on deck’ to provide the care needed. Providers were often not held accountable for poor standards of care, including overusing restraint.

Legislation and policy should work toward prohibiting restraint and should incentivise facilities that demonstrate competent, restraint-free models of care, the research recommended.

“Policy and funding changes are absolutely necessary. More expertise is needed in the sector to improve clinical care. Nurse practitioners with aged care expertise, expertise in working with people who live with dementia, or mental health nursing specialism are needed,” said Dr Mulvogue.

“Very often, institutional care is not the best care for older people, and other sectors (such as the mental health and disability sectors) have moved away from this type of care.

“Different models of care, providing opportunities for people to have alternatives, such as smaller homes or ensuring funding is adequate to enable people to stay at home.”

Dr Mulvogue is a Registered Nurse with a background in mental health nursing. She holds a PhD, a Master of Education, and postgraduate qualifications in mental health, educational leadership, and management. She is an undergraduate nursing and postgraduate mental health nursing lecturer at CQUniversity.

The PhD study The machinations of restraint use in residential aged care: A critical discourse analysis is open access and available here