Deprivation of Liberty not Mobility

mobility zimmersThere is a very helpful summary here from the Social Care Institute for Excellence on what the Deprivation of Liberty Safeguard (DoLS) process entails and examples of when it is appropriate.

 

As you may already know DoLS is an amendment to the Mental Capacity Act 2005 (Schedule A1) and is intended to provide legal support and guidance for external individuals/institutions maintaining the health and wellbeing of individuals who have been deemed unable to do so independently. In some instances this includes restrictions on patients mobilising independently, particularly with patients who are unable to assess their own ability to mobilise and/or are unable to recognise any dangers mobilisation poses to them.

 

My personal experience with DoLS usage was in a care home setting which catered to patients living with dementia. In particular, I saw the effects of DoLS on the institutional attitudes towards mobilising patients throughout the day. Staff were reticent to allow patients to walk about and would often guide them directly back to a chair and sit them down seconds after they had stood up. I also observed staff position small eating tables in front of patients to discourage them from standing.

 

The number of available staff often determined how much patients could mobilise and staffing numbers were based on the amount of funding individual patients had. For example, some patients qualified for one-to-one supervision for some or all of a 24 hour period and staff would be specifically allocated to a patient throughout that time. Difficulties came with patients who only qualified for funding during the day and were expected to sleep during the night. If an unfunded but still at risk patient woke up during the night it could leave night staff struggling to supervise that patient and keep the other residents safe simultaneously. Of course changes to the funding would be applied for if the patient began regularly mobilising throughout a 24 hour period, but the changes took time and often required staff to do more with less. Over time this had led to an ethos of minimal mobility for all as this allowed for immediate (though not necessarily long-term) patient safety.

 

Although patients with dementia may be unable to personally assess their own fear of falling and may judge dangerous situations poorly, relatives and carers may overestimate the risk of falling and enforce bed rest and immobility to keep patients with dementia safe (Cox & Vassallo, 2015). This restriction can then lead to loss of muscle strength and further agitation/confusion which increases risk of falls (Evans & Cotter, 2008).

 

Schedule A1 is clear that the actions taken under the umbrella of a DoLS must always be in the best interests of the patient. But who decides what is in the best interests of the patient from moment to moment? While one health care professional may see restricting mobility to maintain patient safety as an unnecessary precaution that impacts on patient dignity, another may feel that the physical consequences of a fall far outweigh the insult a patient may suffer from being repeatedly encouraged to sit down. Unfortunately, the final decision appears to be geared towards protecting the institution rather than the patient. I feel that a fear of injury from falls and the resulting label of poor quality care nudges institutions to take an overly protective approach which encourages staff to choose a reduction in mobility over an increased risk of falls.

 

Simple answers to resolving this concern do not exist. Maintaining patient safety does not necessarily mean restricting activities. However, we are all working with the resources that are available to us and as nurses we have to use what we are given to the best of our ability to provide the highest standard of care we can. Be aware that everything you do must always be in the best interests of the patient. Making alterations to how and when a patient can mobilise may be appropriate on an individual basis but be certain to review this regularly as well as any time the situation changes. Do not get in a habit of reducing patient mobility across the board as a shortcut to minimising their risk of falling.

 

I push myself to stay personally reflective on my own practice and regularly consider these questions from Christopher Johns’ (1994) model for reflection:

(1) What was I trying to achieve?

(2) What are the consequences of my actions – for the patient/family, myself and my colleagues?

(3) How did I feel about this experience when it was happening?

(4) How did the patient feel about it?

 

References

Cox C and Vassallo M (2015). Fear of falling assessments in older people with dementia. Reviews in Clinical Gerontology, 25(2):98-106.

Evans LK and Cotter VT (2008). Avoiding restraints in patients with dementia: understanding, prevention, and management are the keys. Am J Nurs, 108:40-49.

Johns, C. (1994). Nuances of reflection. Journal of Clinical Nursing, 3:71-75.

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