The Hidden Restraint – Part 1 – Retraints

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…