Nursing Homes Remove Restraints

THOUSANDS of Americans who live in nursing homes are finding new freedom. In a growing number of states the restraints that formerly tied them, usually unhappily, into their chairs are being removed, in part under the pressure of the federal nursing-home reform law that took effect last October. By all accounts this is one law that really works.

The results ``have definitely improved the quality of life of our residents,'' says Francine Foley, assistant executive director of the Miami Jewish Home & Hospital for the Aged. When freed from restraints most residents become calmer, are more active, fall less frequently, and even eat better, says Brenda McKenzie, the home's director of nursing. Staff morale soars as well.

Nursing homes began to discover that the tying of residents in their chairs, or beds, actually produced more physical and mental problems than it solved.

Some institutions use a second method of restraining residents - drugs that render them docile. Reform advocates are seeking reduction in their use as well, but to date most of the efforts have been to remove physical restraints, says Elma Holder, executive director of the National Citizens' Coalition for Nursing Home Reform.

Reformers say, however, that so far as is known institutions are not substituting drugs for physical ties: Rather, there is a genuine loosening of the restraints.

The original purpose of most restraints was to keep often frail or confused residents from harming themselves or others by falling, wandering away, or assaulting other residents. Critics charge that restraints were generally unnecessary, dehumanizing, and are too often used to make it easier for the staff.

Health experts estimate that two in every five nursing-home patients across America are restrained at least part of each day. Some experts say the figure may be much higher.

No one yet knows how many formerly restrained nursing home residents are now untied across America. But reports from individual states and nursing homes that have taken the lead show that in some places the difference has been dramatic.

For instance, a year and a half ago approximately one in every five residents of the Miami Jewish Home was restrained at least part of the day. But by February of this year less than 1 percent were.

Similarly, two New Hampshire nursing homes were restraint free within two months after the New Hampshire Health Care Association began a campaign in 1988 to have restraints removed. At the time 45 to 50 percent of the site's nursing-home residents were being restrained by various devices, says Vivienne Wisdom, the association's director whom reform advocates credit with being a national leader in the movement.

Three months ago at least 15 New Hampshire nursing homes said they had become restraint free, Ms. Wisdom says.

`ONCE we had really good providers [nursing homes] that showed this could be done ... and wasn't as difficult as everybody had thought, then a lot of others'' began to follow, says Holder.

Three developments in the mid to late 1980s coincided to produce the climate in which a roll back of restraint use could occur, says Sarah Greene Burger, a registered nurse who is a consultant to the Coalition:

* Individual nursing homes and state organizations took the lead. Facilities in Florida, New Hampshire, Vermont, and Massachusetts are in the lead, Holder says.

* Several researchers pointed out that European nations were giving care to similar populations without use of physical or chemical [drug] restraints.

* In 1987 Congress passed a nursing-home reform law, which took effect last October. One section required the use of restraints to be justified. ``It forced all of us to take a much closer look'' at the reasons for restraining each patient, says Paul Willging, executive vice president of the American Health Care Association, an organization of nursing homes.

Freeing residents from physical bonds requires more activities for persons now able to move about, more supervision, a redirection of nursing staff's time and energies, and increased attention to residents' individual needs. The result: Better care, and an improved quality of life.

For all the progress, one cloud looms: the ramifications of this spring's agreement between the state of California and the federal government's Health Care Financing Administration, which administers most national law that affects nursing homes.

Under pressure from Republican Gov. Pete Wilson of California, the federal agency agreed to review with state officials the guidelines on how the nursing-home reform law should be carried out. Among other things these guidelines had specified when nursing homes could use physical restraints or drugs.

Holder says by nursing-home industry acknowledgment, two-thirds of California residents are now restrained; she fears that any relaxation of the guidelines ``unravels the whole situation [nationally], turns back the clock again.''

Willging says that's a misperception: that the agreement will have no effect on the national movement to remove restraints. California is unique, he says, because its regulatory system separates liability and culpability - for instance, state law permits a nursing home to be fined if a patient wanders away. Faced with that prospect many California institutions may seek to continue tying residents in their chairs, to avoid possible suits.