Chains That Bind: Racial Disparities in the Use of Physical Restraints in US Nursing Homes

Background.  A body of research has emerged shedding light on disparities within the US nursing home industry.  Disparities in the documentation of end of life wishes, the use of antipsychotic medications, and the presence of urinary incontinence, pressure ulcers, and immunizations have been noted with blacks having poorer outcomes than whites in each of these areas (references available at presentation).  This research adds to our understanding of disparities in nursing homes with an examination of the relationship between race and the use of physical restraints.  We hypothesize that blacks are more likely to be physically restrained than non-blacks.

 

Methods.  Data for this study came from the 2004 National Nursing Home Survey (NNHS).  The 2004 NNHS employed a stratified, multi-stage probability design to examine a nationally representative sample of 13,507 residents from 1,174 nursing homes.  The dependent variable was restraints (bed rails, side rails, trunk restraints, limb restraints and chair restraints).  The primary independent variable was race (black, non-black).  Individual level control variables included:  behavior problems; falls; activities of daily living; and cognitive impairments.  Logistic regression was used to test the study’s hypothesis.  Odds ratios are provided with 95% confidence intervals.

 

Results.  Cross-tabs indicated a statistically significant relationship between race and physical restraints (c² = 51.783, df = 1, p < .001).  Almost half of blacks were restrained with some type of device compared to only 38% of non-blacks. Logistic regression indicated that the odds of black residents being restrained by any type of device were 1.401 times higher than the odds for non-blacks (95% CI = 1.247,1.575). When compared to non-blacks, the odds for blacks were 1.625 times higher for bed rails (95% CI = 1.410, 1.872), 1.111 times higher for side rails (95% CI = .977, 1.263), 1.322 times higher for trunk restraints (95% CI = 1.000, 1.747), 1.664 times higher for limb restraints (95% CI = .732, 3.784) and 1.245 times higher for chair restraints (95% CI = .921, 1.684).

 

Implications.  Findings suggest blacks were more likely to be physically restrained than non-blacks.  This is especially concerning given the physical and psychological complications associated with restraints including, death, pressure ulcers, incontinence, depression, cognitive declines and more. To eliminate these disparities and to create a just society within US nursing homes, practitioners, policy makers and researchers must come together to develop and test interventions to ensure that race is not a conscious or unconscious factor in the use of restraints.  Nursing home social workers could take an active role in identifying disparities with a simple calculation of the percent of residents restrained in their facility by race and facilitating cultural diversity and cultural sensitivity training to help facility employees become more mindful of unconscious treatment differences based on race/ethnicity.  Policy makers could put in place additional regulations requiring facilities to address disparities with monetary penalties for noncompliance. Researchers should test the effectiveness of interventions with findings disseminated in peer-reviewed scholarly journals, academic conferences and in plain language summaries that can be easily understood and replicated by providers.