The effects of research on clinical practice: the use of restraints

Clinical and organizational factors related to the reduction of mechanical restraint application in an acute ward: an 8-year retrospective analysis

Background:

The purpose of this study was to describe the frequency of mechanical restraint use in an acute psychiatric ward and to analyze which variables may have significantly influenced the use of this procedure. Methods: This retrospective study was conducted in the Servizio Psichiatrico di Diagnosi e Cura (SPDC) of Modena Centro. The following variables of our sample, represented by all restrained patients admitted from 1-1-2005 to 31-12-2012, were analyzed: age, gender, nationality, psychiatric diagnoses, organic comorbidity, state and duration of admission, motivation and duration of restraints, nursing shift and hospitalization day of restraint, number of patients admitted at the time of restraint and institutional changes during the observation period. The above variables were statistically compared with those of all other non-restrained patients admitted to our ward in the same period. Results: Mechanical restraints were primarily used as a safety procedure to manage aggressive behavior of male patients, during the first days of hospitalization and night shifts. Neurocognitive disorders, organic comorbidity, compulsory state and long duration of admission were statistically significantly related to the increase of restraint use (p<.001, multivariate logistic regression). Institutional changes, especially more restricted guidelines concerning restraint application, were statistically significantly related to restraint use reduction (p<.001, chi2 test, multivariate logistic regression). Conclusion: The data obtained highlight that mechanical restraint use was influenced not only by clinical factors, but mainly by staff and policy factors, which have permitted a gradual but significant reduction in the use of this procedure through a multidimensional approach.

Physical restraints in an Italian psychiatric ward: clinical reasons and staff organization problems

PURPOSE

To analyze physical restraint use in an Italian acute psychiatric ward, where mechanical restraint by belt is highly discouraged but allowed.

DESIGN AND METHODS

Data were retrospectively collected from medical and nursing charts, from January 1, 2005, to December 31, 2008. Physical restraint rate and relationships between restraints and selected variables were statistically analyzed.

FINDINGS

Restraints were statistically significantly more frequent in compulsory or voluntary admissions of patients with an altered state of consciousness, at night, to control aggressive behavior, and in patients with "Schizophrenia and other Psychotic Disorders" during the first 72 hr of hospitalization.

PRACTICAL IMPLICATIONS

Analysis of clinical and organizational factors conditioning restraints may limit its use.

Programme d'intervention visant à réduire l'utilisation des contentions physiques dans des unités de soins de longue durée — mise en oeuvre et effets sur le personnel soignant

This study aimed at (a) developing a restraint reduction program, (b) describing its implementation in long-term care units, and (c) examining its effects on care staff's perceptions of and knowledge about the use of restraints. The program was composed of three parts: consciousness-raising meetings, staff education, and clinical follow-up. The study was a randomized, controlled clinical trial with eight intervention care units (five nursing homes) and 11 controls (five additional nursing homes). Care staff was surveyed at two time intervals over a 7-month period (pre- and post-test intervention; intervention care units: N = 171 [T0] and N = 158 [T1]; controls: N = 181 [T0] and N = 166 [T1]). The implementation of the program was successful and results showed significant changes in care staff perceptions of and knowledge about the use of restraints.

Nurses' feelings and thoughts about using physical restraints on hospitalized older patients

AIM

To explore nurses' feelings and thoughts about physically restraining older hospitalized patients.

BACKGROUND

The use of physical restraints is still highly prevalent in hospitals; furthermore, older patients are most likely to be so restrained. Studies in acute care settings have focused mainly on nurses' knowledge, attitudes, or practice concerning physical restraints, on physical restraint reduction programmes, on nurses' perceptions about the use of physical restraints, or on elderly patients' experiences with physical restraints. To the best of our knowledge no studies have been conducted on hospital nurses' feelings and thoughts about the use of physical restraints in Taiwan.

DESIGN AND METHODS

A qualitative approach was used to understand this phenomenon. Semi-structured interviews were carried out, from August 2002 to March 2003, with 12 nurses working in three hospitals. The interviews were audiotaped and transcribed verbatim; content analysis was used to analyse the data.

RESULTS

Nurses reported a variety of emotional responses regarding the use of physical restraints, including sadness, guilt, conflicts, retribution, absence of feelings, security, and pity for the restrained older people. Rationalization, sharing with colleagues, and compensating behaviours were ways that nurses used to manage their negative feelings.

CONCLUSIONS

Most nurses had negative feelings towards the use of physical restraints. Among these nurses there was a struggle between patients' autonomy and the practice of care. However, other nurses said they had 'no feelings' or 'feeling of security' while using physical restraints.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study may contribute to filling the gaps in nursing knowledge, to improving protocols for physical restraint use in hospitals, and may also assist nurse managers to create a supportive practice environment. It is recommended that in-service training programmes should cover misconceptions regarding physical restraint use, ethical issues and how to cope with feelings while using physical restraints.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

A review of physical restraint minimization in the acute and residential care settings

OBJECTIVES

The objective of this review was to investigate physical restraint minimization in acute and residential care settings. The first aim was to determine the effectiveness of attempts to minimize the use of physical restraint, and the second was to generate a description of the characteristics of restraint minimization programmes.

METHOD

A comprehensive search was undertaken involving all major databases and the reference lists of all relevant papers. To be included in the review studies had to be an evaluation of restraint minimization in an acute or residential care setting. As only a single randomized controlled trial (RCT) was identified, it was not possible statistically to pool the findings of different studies on the effectiveness of restraint minimization. To generate a description of the characteristics of restraint minimization programmes, the reported components of these programmes were identified and categorized.

RESULTS

A total of 16 studies evaluating restraint minimization were identified: three in acute care and 13 in residential care. Of these, only one was an RCT, with the most common approach being the before and after study design. Based on the findings of the single RCT, education supported by expert consultation effectively reduced the use of restraint in residential care. There has been little evaluation of restraint minimization in acute care settings. The common approach to restraint minimization has involved a programme of multiple activities, with restraint education being the characteristic common to most programmes.

DISCUSSION

Evidence suggests that physical restraint can be safely reduced in residential care settings through a combination of education and expert clinical consultation. There is little information on restraint minimization in acute care settings. The major finding of this review is the need for further investigation into all aspects of restraint minimization.

The use of physical restraints as a safety measure in the care of older people in four rehabilitation wards: findings from an exploratory study

We investigated the prevalence and type of physical restraint used with older persons on four rehabilitation wards in Northern Ireland. A longitudinal observational approach was used. One hundred and two patients were observed on four occasions over a three-day period. Most of the patients (68%) were subjected to some form of physical restraint, side-rails being the most commonly observed method. Those who were restrained were dependent on nursing care to meet their needs and received more drugs than those whose mobility was not restricted. No association was found between restraint use and nursing staffing levels, nor was there any association with the incidence of falls. Nurses rationalised their use of restraint as being linked to wandering and patient protection in cases of confusional type behaviours. An association was found between stroke and the maintenance of positional support through the use of restraints (side-rails and screw-on tabletops). Approximately, one-third of those restrained had this noted in their care plans, with concomitant evidence of patient/family involvement in the restraining decision.

Side rail use and bed-related fall outcomes among nursing home residents

OBJECTIVES

To analyze the effect of physical restraint reduction on nighttime side rail use and to examine the relationship between bilateral side rail use and bed-related falls/injuries among nursing home residents.

DESIGN

Secondary analysis of data collected in a longitudinal, prospective clinical trial designed to reduce restraint use.

SETTING

Three nonprofit nursing homes.

PARTICIPANTS

To examine the first question regarding the effect of physical restraint reduction on side rail usage, we included all nursing home residents who survived a 1-year data collection period (n = 463). To answer the second research question concerning the relationship between side rail status and bed-related falls, subjects' side rail status for each of the four data collection periods was compared. The sample for this analysis includes only those with consistent side rail status (n = 319) for the four observations periods: either 0/1 side rail (n = 188) or 2 (bilateral) side rails (n = 131).

MEASUREMENTS

Side rail and restraint status was directly observed by two research assistants, twice each night shift (10 p.m.-6 a.m.) for three nights at each of four data collection points. Nighttime fall-related outcome data were obtained from a review of nursing home incident reports during the entire 1-year data collection period (T1 through T4). Cognitive status was measured using the Folstein Mini-Mental State Examination. Functional and behavioral status was obtained using subscales of the Psychogeriatric Dependency Rating Scale.

RESULTS

Over a 1-year period, there was an increase in the proportion of bilateral side rail use for all three nursing homes. Based on the multiple logistic regression analysis, there was no indication of a decreased risk of falls or recurrent falls with bilateral side rail use, controlling for cognition and functional and behavioral status (adjusted odds ratio (AOR) = 1.13, 95% confidence interval (CI) = 0.45,2.03). Similarly, bilateral side rail use did not reduce the risk of recurrent falls, controlling for cognition and functional status (AOR = 1.25, 95% CI = 0.33,4.67).

CONCLUSION

Despite high usage of bilateral side rails, they do not appear to significantly reduce the likelihood of falls, recurrent falls, or serious injuries. Bed-related falls remain clinically challenging. The data from this study, coupled with increasing reports of side rail-related injuries and deaths, compel us to seek and empirically test alternative interventions to prevent bed-related falls.

Using restraint with nursing home residents: a qualitative study of nursing staff perceptions and decision-making

The study reported in this paper applied a qualitative and interpretative approach to nursing staff perceptions of the use of restraint with elderly nursing home residents, and into nurses' decision-making on restraint use. The data were collected using unstructured interviews with a purposive sample of 20 trained and untrained nursing staff from two Swiss nursing homes. Data analysis was based on Colaizzi's phenomenological method. Three main themes were extracted from the data: (1) understanding the term restraint, (2) situations in which the decision to apply restraint is considered justified and (3) situations in which nursing staff are uncertain about the use of restraint. The underlying bases with respect to decision-making were: understanding restraint, the rights and responsibilities of both residents and staff, and the duties of staff. Staff members were ambiguous in their understanding of restraint and they showed positive as well as confused attitudes towards its use. Their behaviour was defensive and protective rather than challenging. Further research is required on what is meant by safety in care of the elderly nursing today. In nursing practice, as far as issues of restraint are concerned, greater attention should be devoted to the relationship between elderly residents' self-determination and responsibility for their actions.

Physical restraint management of hospitalized adults and follow-up study

During the winter of 1998 the management of 118 (N = 118) physically restrained adult patients in a 238-bed urban acute care hospital were assessed by 26 registered nurse (RN) data collectors. In the spring of 1999, following a comprehensive hospital-wide staff development program and revised physical restraint protocol, 10 RN data collectors conducted a follow-up study of 53 (N = 53) restrained adults in the same institution. In both studies, data regarding restraints management were gathered using a Restraint Management Improvement Indicator. Following a program of restraint management education, substantial improvements were found for virtually all of the physical restraint indices studied. The findings suggest that future educational efforts should be undertaken to further improve the documentation in hospital medical records regarding medical orders and ongoing observation, assessment, and interventions for physically restrained patients. Future research should further document and study interventions to reduce or eliminate the use of physical restraints.

Nurses' perceptions of chemical restraint use in long-term care

The purpose of this pilot study is to validate the use of the Perceptions of Restraint Use Questionnaire (PRUQ) in assessing chemical restraint perceptions among nurses working in long-term care. The convenience sample includes 60 licensed nurses working in six long-term care facilities in Illinois. The reliability analysis for a modified version of the PRUQ, based on the research sample chosen, was found to have a Cronbach's coefficient alpha of .9450. Study findings reflect a moderately positive attitude toward chemical restraint use by nurses in long-term care.

Using research to establish protocols for practice: a statewide study of acute care agencies

The purpose of the study was to examine research utilization practices relative to developing and revising practice protocols in acute care agencies in Delaware. Nurse leaders in 13 acute care agencies identified resource nurses most familiar with the development and revision of agency protocols. Thirty-two resource nurses from 11 agencies, representing critical care, emergency, general medical, general surgical, obstetric, and psychiatric nursing, were interviewed. Interviews were tape-recorded and transcribed. Examples of research-based protocols, defined as those supported by research citations, were obtained. The authors found that the majority of protocols submitted, although referenced, were not research-based. Most institutions used textbooks and standards to support nursing practice protocols. The authors concluded that nurses who are responsible for developing and revising agency protocols were not familiar with the use of research findings to guide the development or revision of protocols and were unsure what constituted the "use of research."

Restraint reduction: a new philosophy for a new millennium

With the use of restraints to manage difficult patients becoming routine, one hospital initiated strategies to reduce restraint use. The authors describe the development and implementation of a restraint reduction program, educational strategies, and the evaluation program. The program is successfully reducing the prevalence of restraint use.