Patient injury and physical restraint devices: a systematic review

Adverse events related to physical restraint use in intensive care units: A review of the literature

Physical restraints are widely used and accepted as protective measures during treatment in intensive care unit (ICU). This review of the literature summarizes the adverse events and outcomes associated with physical restraint use, and the risk factors associated with their use during treatment in the ICU. The PubMed, Scopus, and Google Scholar databases were screened using predefined search terms to identify studies pertaining to adverse events and/or outcomes associated with physical restraint use, and the factors associated with their use in adult patients admitted to the ICU. A total of 24 articles (including 6126 patients) that were published between 2006 and 2022 were identified. The described adverse events associated with physical restraint use included skin injuries, subsequent delirium, neurofunctional impairment, and a higher rate of post-traumatic stress disorder. Subsequent delirium was the most frequent adverse event to be reported. No alternative measures to physical restraints were discussed, and only one study reported a standardized protocol for their use. Although physical restraint use has been reported to be associated with adverse events (including neurofunctional impairment) in the literature, the available evidence is limited. Although causality cannot be confirmed, a definite association appears to exist. Our findings suggest that it is essential to improve awareness regarding their adverse impact and optimize approaches for their detection, management, and prevention using protocols or checklists.

Neurological diagnostic tests for patients with and without delirium: a prospective observational study

Since most of the precipitating factors of delirium are not due to neurological disorders, neurological diagnostic tests (NDTs) may be of limited value. We hypothesized that delirium has a high burden of NDTs with a low diagnostic yield. All patients admitted to the internal medicine wards of a single secondary teaching hospital between November 2019 and January 2020 were eligible. Within the first 48 h of their admission, they had a formal evaluation by a neuropsychologist to screen for presence of delirium. NDTs (brain MRI, brain CT, electroencephalography (EEG), and lumbar puncture) performed during the hospital stay were compared between patients with and without delirium using a logistic regression model stratified by a propensity score. The proportions of diagnostic yield (acute anomalies that changed the treatment management) provided by each type of examination were compared. Of 217 patients included, 19/32 patients (61%) with delirium had one or more NDTs, compared to 48/185 (26%) without delirium (adjusted OR 2.7; 95%CI 1.1-6.7; p = 0.027). The proportions of NDT results affecting management for patients with and without delirium were 13 and 20% for brain CT scans (p = 0.71), 29 and 38% for brain MRI (p = 0.99), and 20 and 10% for EEGs (p = 0.99), respectively. The higher proportion of NDTs performed on patients with delirium was associated with a low diagnostic yield, although not statistically different from those performed among inpatients without delirium. There is a need for restrictive, evidence-based guidelines to help with the work-up for patients with delirium.

Guideline Recommendations on Behavioral and Psychological Symptoms of Dementia: A Systematic Review

OBJECTIVE

To synthesize recommendations on assessing and managing behavioral and psychological symptoms of dementia (BPSDs) in existing clinical practice guidelines on dementia care to learn from and adapt recommendations to a Canadian context and language for describing BPSDs.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Moderate to high-quality clinical practice guidelines on dementia care that made 1 or more recommendations on BPSD assessment or management.

METHODS

We searched MEDLINE, Embase, JBI EBM, PsycINFO, AgeLine, and gray literature for clinical practice guidelines on dementia care making recommendations on BPSD, published between January 1, 2011, and October 13, 2022. Two independent reviewers conducted study screening and data abstraction. Four independent reviewers completed quality appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool; included guidelines had a mean overall AGREE II score ≥4.

RESULTS

Our systematic review identified 23 moderate to high-quality clinical practice guidelines (264 recommendations). The mean overall quality score on the AGREE II tool ranged from 4 to 6.5. Recommendations were clearly presented (mean clarity of presentation score 73.5%), but guideline applicability was not consistently addressed (mean applicability score 39.3%). BPSD was the most prevalent term describing neuropsychiatric symptoms (number of guidelines [n] = 14). People with lived experience contributed to 6 guidelines (26.1%). Ten guidelines (43.5%) described 1 or more health equity considerations. Guidelines made recommendations for assessing and managing agitation (n = 12), aggression (n = 10), psychosis (n = 11), depression (n = 9), anxiety (n = 5), apathy (n = 6), inappropriate sexual behavior (n = 3), nighttime behavior (n = 5), and eating disturbances (n = 3). There was substantial variability in recommendation statements, evidence quality assigned to each statement, and strength of recommendations.

CONCLUSIONS AND IMPLICATIONS

There are several moderate to high-quality clinical practice guidelines making recommendations on BPSD assessment and management, but variability in recommendation statements across guidelines and insufficient consideration of guideline applicability may hamper guideline dissemination and implementation in clinical practice.

Restraint in somatic healthcare: how should it be regulated?

Restraint is regularly used in somatic healthcare settings, and countries have chosen different paths to regulate restraint in somatic healthcare. One overarching problem when regulating restraint is to ensure that patients with reduced decision-making capacity receive the care they need and at the same time ensure that patients with a sufficient degree of decision-making capacity are not forced into care that they do not want. Here, arguments of justice, trust in the healthcare system, minimising harm and respecting autonomy are contrasted with different national regulations. We conclude that a regulation that incorporates an assessment of patients' decision-making capacity and considers the patient's best interests is preferable, in contrast to regulations based on psychiatric diagnoses or regulations where there are no legal possibilities to exercise restraint at all in somatic care.

Physical Restraint Usage in Hospitals Across the United States: 2011-2019

Objective

To determine the change in rates of physical restraint (PR) use and associated outcomes among hospitalized adults.

Patients and Methods

Using national inpatient sample databases, we analyzed years 2011-2014 and 2016-2019 to determine trends of PR usage. We also compared the years 2011-2012 and 2018-2019 to investigate rates of PR use, in-hospital mortality, length of stay, and total hospital charges.

Results

There were 242,994,110 hospitalizations during the study period. 1,538,791 (0.63%) had coding to signify PRs, compared with 241,455,319 (99.3%), which did not. From 2011 to 2014, there was a significant increase in PR use (p-trend<.01) and a nonsignificant increase in PR rates from 2016-2019 (p-trend=.07). Over time, PR use increased (2011-2012: 0.52% vs 2018-2019: 0.73%; p<.01). Patients with PRs reported a higher adjusted odds for in-hospital mortality in 2011-2012 (adjusted odds ratio [aOR], 3.9; 95% CI, 3.7-4.2; p<.01) and 2018-2019 (aOR, 3.5; 95% CI, 3.4-3.7; p<.01). Length of stay was prolonged for patients with PRs in 2011-2012 (adjusted mean difference [aMD], 4.3 days; 95% CI, 4.1-4.5; p<.01) and even longer in 2018-2019 (aMD, 5.8 days; 95% CI, 5.6-6.0; p<.01). Total hospital charges were higher for patients with PRs in 2011-2012 (aMD, +$55,003; 95% CI, $49,309-$60,679; p<.01). Following adjustment for inflation, total charges remained higher for patients with PRs compared with those without PRs in 2018-2019 (aMD, +$70,018; 95% CI, $65,355-$74,680; p<.01).

Conclusion

Overall, PR rates did not decrease across the study period, suggesting that messaging and promulgating best practice guidelines have yet to translate into a substantive change in practice patterns.

Factors affecting nursing practice of patient physical restraint among nurses

BACKGROUND

This study was aimed to identify perception, knowledge, attitude and nursing practice toward use of physical restraints among clinical nurses.

METHODS

The research participants were 180 nurses from general hospitals located in Korea. Data were collected using self-report questionnaires regarding perception, attitude, knowledge, and nursing practice on application of physical restraints and analyzed using t-test, ANOVA, Pearson correlation coefficients, and multiple regression.

RESULTS

There were significant negative relationships attitudes towards the use of physical restraints with knowledge (r = -.32, p < .001). Knowledge showed a positive correlation with nursing practice (r = .28, p < .001). Factors affecting nursing practice of clinical nurses were identified as knowledge (β = .23), education experiences on physical restraints (Yes) (β = .18), and work unit (ICU) (β = .43). The explanation power of this regression model was 22% and it was statistically significant (F = 7.45, p < .001).

CONCLUSION

This study suggests that knowledge, education experiences on physical restraints, and work unit were the strongest predictor on nursing practice toward use of patient physical restraints. Therefore, developing and applying evidence-based educational intervention programs by work unit to reduce the inappropriate use of physical restraints in hospitals are required.

[Psychological impact of restraint during care]

Restraints in the healthcare context is a controversial and complex topic. Used for providing care, the latter could lead to psychological implication for both patients and caregivers. A thorough understanding of those psychological consequences can support the decision-making as well as considering the safety and emotional needs of the patient.

A multicomponent intervention program to Prevent and Reduce AgItation and phySical rEstraint use in the ICU (PRAISE): study protocol for a multicenter, stepped-wedge, cluster randomized controlled trial

BACKGROUND

Physical restraints remain to be commonly used in agitated intensive care unit (ICU) patients worldwide, despite a lack of evidence on efficacy and safety and reports of detrimental short and long-term consequences, such as prolonged delirium and a longer ICU length of stay. Physical restraint minimization approaches have focused mainly on educational strategies and other non-pharmacological interventions. Combining these interventions with goal-directed light sedation therapy if needed may play an important contributory role in further reducing the use of physical restraints. The aim of the study is to determine the effectiveness of a multicomponent intervention (MCI) program, combining person-centered non-pharmacological interventions with goal-directed light sedation, compared to physical restraints.

METHODS

A multicenter stepped-wedge cluster randomized controlled trial will be conducted in six Dutch ICUs. A power calculation based total of 480 (expected to become) agitated adult patients will be included in 26 months with a subsequent 2-year follow-up. Patients included in the control period will receive standard care with the current agitation management protocol including physical restraints. Patients included in the intervention period will be treated with the MCI program, consisting of four components, without physical restraints: education of ICU professionals, identification of patients at risk for agitation, formulation of a multidisciplinary person-centered care plan including non-pharmacological and medical interventions, and protocolized goal-directed light sedation using dexmedetomidine. Primary outcome is the number of days alive and outside of the ICU within 28 days after ICU admission. Secondary outcomes include length of hospital stay; 3-, 12-, and 24-month post-ICU quality of life; physical (fatigue, frailty, new physical problems), mental (anxiety, depression, and post-traumatic stress disorder), and cognitive health; and 1-year cost-effectiveness. A process evaluation will be conducted.

DISCUSSION

This will be the first multicenter randomized controlled trial determining the effect of a combination of non-pharmacological interventions and light sedation using dexmedetomidine compared to physical restraints in agitated ICU patients. The results of this study, including long-term patient-centered outcomes, will provide relevant insights to aid ICU professionals in the management of agitated patients.

TRIAL REGISTRATION

NCT05783505, registration date 23 March 2023.

Clinical Features of Delirium among Patients in the Intensive Care Unit According to Motor Subtype Classification: A Retrospective Longitudinal Study

PURPOSE

Delirium in the intensive care unit (ICU) poses a significant safety and socioeconomic burden to patients and caregivers. However, invasive interventions for managing delirium have severe drawbacks. To reduce unnecessary interventions during ICU hospitalization, we aimed to investigate the features of delirium among ICU patients according to the occurrence of hypoactive symptoms, which are not expected to require invasive intervention.

MATERIALS AND METHODS

Psychiatrists assessed all patients with delirium in the ICU during hospitalization. Patients were grouped into two groups: a "non-hypoactive" group that experienced the non-hypoactive motor subtype once or more or a "hypoactive only" group that only experienced the hypoactive motor subtype. Clinical variables routinely gathered for clinical management were collected from electronic medical records. Group comparisons and logistic regression analyses were conducted.

RESULTS

The non-hypoactive group had longer and more severe delirium episodes than the hypoactive only group. Although the non-hypoactive group was prescribed more antipsychotics and required restraints longer, the hypoactive only group also received both interventions. In multivariable logistic regression analysis, BUN [odds ratio (OR): 0.993, pH OR: 0.202], sodium (OR: 1.022), RASS score (OR: 1.308) and whether restraints were applied [OR: 1.579 (95% confidence interval 1.194-2.089), p<0.001] were significant predictors of hypoactive only group classification.

CONCLUSION

Managing and predicting delirium patients based on whether patients experienced non-hypoactive delirium may be clinically important. Variables obtained during the initial 48 hours can be used to determine which patients are likely to require invasive interventions.

Physical restraint in older people: a statement from the Early Career Network of the International Psychogeriatric Association

The International Psychogeriatric Association (IPA) has expressed significant concerns over the use of physical restraints in older people across diverse aged care settings. Following an extensive analysis of the available literature, the IPA's Early Career Network (ECN) has formulated a collection of evidence-based recommendations aimed at guiding the use of physical restraints within various care contexts and demographic groups. Physical restraints not only infringe upon human rights but also raise significant safety concerns that adversely impact the physical, psychological, social, and functional well-being of older adults. Furthermore, their effectiveness in geriatric settings remains inadequate. Given these considerations, the IPA and its ECN firmly assert that the use of physical restraints should only be considered as a final recourse in the care of older people.

Association of physical restraint duration and undesirable outcomes amongst inpatients comorbid with dementia and pneumonia in acute care settings

AIMS AND OBJECTIVES

This study aimed to examine the association between physical restraint duration and undesirable outcomes amongst inpatients comorbid with dementia and pneumonia in acute care hospitals.

BACKGROUND

Physical restraints are frequently used in the management of patients, especially amongst patients with dementia. No previous study investigated the potential undesirable effects of physical restraints in patients with dementia.

METHODS

This was a cohort study using a nationwide discharge abstract database in Japan. Patients aged ≥65 years with dementia hospitalised for pneumonia or aspiration pneumonia between April 1, 2016 and March 31, 2019 were identified. The exposure was physical restraint. The primary outcome was hospital discharge to the community. Secondary outcomes included hospitalisation costs, functional decline, in-hospital mortality, and institutionalisation for long-term care.

RESULTS

A total of 18,255 inpatients with pneumonia and dementia in 307 hospitals were included in this study. Of them, 21.5% and 23.7% had physical restraint during full and partial days of hospital stays, respectively. Discharge to the community incidence rates was lower in the full-restraint vs. the no-restraint group (27 vs. 29 per 1000 person-days; HR, 1.05 [95% CI, 1.01-1.10]) and the partial-restraint vs. the no-restraint group (17 vs. 29 per 1000 person-days; HR, 1.79 [95% CI, 1.71-1.87]). The risks of functional decline were higher in the full-restraint vs. the no-restraint group (27.8% vs. 20.8%; RR, 1.33 [95% CI, 1.22, 1.46]) and the partial-restraint vs. the no-restraint group (29.2% vs. 20.8%; RR, 1.40 [95% CI, 1.29, 1.53]).

CONCLUSIONS

The use of physical restraints was associated with a lower incidence rate of discharge to the community and an increased risk of functional decline at discharge. Further research is needed to judge the benefit-risk balance of physical restraints in acute care settings.

RELEVANCE TO CLINICAL PRACTICE

Understanding the risk of physical restraints allows medical staff to improve the process of decision making in everyday practice. No Patient or Public Contribution.

REPORTING METHODS

The reporting of this article conforms to the STROBE statement.

Physical Restraint Use in Nursing Homes-Regional Variances and Ethical Considerations: A Scoping Review of Empirical Studies

BACKGROUND

Physical restraints are known to violate human rights, yet their use persists in long-term care facilities. This study aimed to explore the prevalence, methods, and interventions related to physical restraint use among the elderly in nursing homes.

METHODS

The method described by Joanna Briggs was followed to conduct a scoping review without a quality assessment of the selected studies. An electronic search was conducted to find eligible empirical articles using MEDLINE, PsycINFO, EMBASE, Web of Science, Scopus, Google Scholar, CINAHL, and grey literature. The database search was performed using EndNote software (version X9, Clarivate Analytics), and the data were imported into Excel for analysis.

RESULTS

The prevalence of physical restraint use was found to be highest in Spain (84.9%) and lowest in the USA (1.9%). The most common device reported was bed rails, with the highest prevalence in Singapore (98%) and the lowest (4.7%) in Germany, followed by chair restraint (57%). The largest number of studies reported the prevention and/or risk of falls to be the main reason for using physical restraints, followed by behavioral problems such as wandering, verbal or physical agitation, and cognitive impairment. Most studies reported guideline- and/or theory-based multicomponent interventions consisting of the training and education of nursing home staff.

CONCLUSIONS

This review provides valuable insights into the use of physical restraints among elderly residents in nursing homes. Despite efforts to minimize their use, physical restraints continue to be employed, particularly with elderly individuals who have cognitive impairments. Patient-related factors such as wandering, agitation, and cognitive impairment were identified as the second most common reasons for using physical restraints in this population. To address this issue, it is crucial to enhance the skills of nursing home staff, especially nurses, in providing safe and ethical care for elderly residents with cognitive and functional impairments, aggressive behaviors, and fall risks.

The use of patient sitters at a Swiss hospital: A retrospective observational study

OBJECTIVE

Patient sitters are frequently used in acute care hospitals to provide one-to-one care for agitated or disorientated patients to assure the safety and well-being of patients. However, there is still a lack of evidence on the use of patient sitters, especially in Switzerland. Therefore, the aim of this study was to describe and explore the use of patient sitters in a Swiss acute care hospital.

METHODS

In this retrospective, observational study we included all inpatients who were hospitalized between January and December 2018 in a Swiss acute care hospital and required a paid or volunteer patient sitter. Descriptive statistics were used to describe the extent of patient sitter use, patient characteristics, and organizational factors. For the subgroup analysis between internal medicine and surgical patients Mann-Whitney U tests and chi-square tests were used.

RESULTS

Of the total of 27'855 included inpatients, 631 (2.3%) needed a patient sitter. Of these, 37.5% had a volunteer patient sitter. The median patient sitter duration per patient per stay was 18.0 hours (IQR = 8.4-41.0h). The median age was 78 years (IQR = 65.0-86.0); 76.2% of patients were over the age of 64. Delirium was diagnosed in 41% of patients, and 15% had dementia. Most of the patients showed signs of disorientation (87.3%), inappropriate behavior (84.6%), and risk of falling (86.6%). Patient sitter uses varied during the year and between surgical and internal medicine units.

CONCLUSIONS

These results add to the limited body of evidence concerning patient sitter use in hospitals, supporting previous findings related to patient sitter use for delirious or geriatric patients. New findings include the subgroup analysis of internal medicine and surgical patients, as well as analysis of patient sitter use distribution throughout the year. These findings may contribute to the development of guidelines and policies regarding patient sitter use.

[Physical restraints in acute hospitals: A quantitative observational study as a starting point for the further development of quality management]

Physical restraints in acute hospitals: A quantitative observational study as a starting point for the further development of quality management Abstract: Background: Despite the known associated risks and adverse events, physical restraints are mostly observed in daily care practice of long-term care. Comparatively few studies are available for normal wards. Research question/aim: The explorative cross-sectional study investigated prevalences, types and reasons of physical restraints in nine selected normal wards of a maximum care hospital. Methods: The prevalences and types of physical restraints were collected in the early and late shift in summer 2020 via direct observation using standardised observation forms. The reasons for the use were recorded via a standardised survey of the nursing staff. Results: In the early shift, 15 out of 167 patients had physical restraints (9%), in the late shift 23 out of 191 (12%). People over 80 years were most affected (n = 8; 23.5% and n = 14, 25.9%). The highest prevalence was found in the clinic for neurogeriatrics with 21.4% (n = 3) and 37.5% (n = 6). Bedside restraints were used particularly frequently (n = 14; 93.3% and n = 22, 95.7%, resp.). The physical restraints were predominantly justified with the protection against fall injuries (n = 8, 53.3% and n = 15, 65.2%). Conclusions: Raising awareness among nursing staff through training and other accompanying measures are starting points for reducing physical restraints. In order to achieve sustainable changes, the management level should initiate appropriate measures and consistently accompany their implementation.

The Importance of Person-Centered Approaches to Managing Behavioral and Psychological Symptoms of Dementia: A Case Report

Behavioral and psychological symptoms of dementia (BPSD) are common and associated with increased morbidity and mortality in dementia. In this report, we describe a patient with severe BPSD who was effectively managed with a variety of non-pharmacologic strategies. A 70-year-old Navy veteran and retired commercial flooring business owner with a history of dementia was admitted to the hospital with aggressive behavior. He was no longer manageable by his family. He required intermittent use of restraints and multiple antipsychotics during hospitalization. He spent much of his time crawling on the floor, "working" on floor tiles, which was often difficult for staff to safely accommodate. However, with time, interprofessional staff identified signs of distress and developed strategies to safely engage the patient's current perception of his situation. This case highlights how BPSD may be driven by a person's identities and roles from earlier stages of life. Approaching and managing these symptoms flexibly can enhance dementia care.

Health Effects of Policing in Hospitals: a Narrative Review

IMPORTANCE

Law enforcement activity, in the form of outside agencies or hospital security forces, is increasingly common in American healthcare. Little is known about the potential effects of this prevalent, modifiable exposure on hospital staff and patient health. This narrative review characterizes existing evidence on the direct and indirect health effects of law enforcement activity in hospitals.

OBSERVATIONS

Law enforcement activity in hospitals can affect health outcomes through four mechanisms: (1) physical health effects related to workplace violence, restraint use, excessive force, and weapon use; (2) mental health effects involving perceptions of safety and psychological distress; (3) social effects related to the patient-provider relationship, mistrust, and bias and discrimination; and (4) legal and ethical considerations affecting overall well-being.

CONCLUSIONS AND RELEVANCE

Unchecked law enforcement activity in hospitals may risk patient physical and mental health, reduce patient trust, result in bias and discrimination, and contribute to legal and ethical rights violations. Importantly, law enforcement activity in hospitals may also contribute to staff perceptions of safety. To fill knowledge gaps on the measurable impact of law enforcement activity in the hospital on staff and patients, hospitals should collect and publicly share robust data on law enforcement activity in their facilities, create and adopt patient-centered policies to ensure safety and protect patient health and privacy, and implement evidence-based interventions that safely reduce law enforcement involvement with patients.

Physical Restraint Experiences of Family Caregivers of Patients With Stroke in Turkey: A Qualitative Study

The purpose of this study was to explore the experiences and needs of family caregivers of stroke patients who require physical restraints. The themes and sub-themes that emerged included "the reason for the use of PR" (disruptive behaviors of the patient and personal reasons of caregivers), "the turmoil of having to use PR" (inevitableness, comparing benefits and harms, the emotional effect of PR, and physical effects), and "unmet needs and suggestions" (unmeet needs and suggestions). Nurses should take the experiences of patient relatives into account in the process of PR application, organize training programs, and determine application standards for PR.

Understanding nurses' justification of restraint in a neurosurgical setting: A qualitative interview study

BACKGROUND

Despite its negative impact on patients and nurses, the use of restraint in somatic health care continues in many settings. Understanding the reasons and justifications for the use of restraint among nurses is crucial in order to manage this challenge.

AIM

To understand nurses' justifications for restraint use in neurosurgical care.

RESEARCH DESIGN

A qualitative, descriptive design was used. Data were analysed with inductive qualitative content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden.

ETHICAL CONSIDERATIONS

Approved by The Regional Ethics Committee, Stockholm, Sweden.

FINDINGS

The analysis resulted in three categories. The category Patient factors influencing restraint use describes patient factors that trigger restraint, such as a diminished decision-making competence, restlessness, and need for invasive devices. The category Specific reasons for justifying restraint describes reasons for restraining patients, such as restraint being used for the sake of the patient or for the sake of others. The category General reasoning in justifying restraint describes how nurses reason when using restraint, and the decision to use restraint was often based on a consequentialist approach where the nurses' weighed the pros and cons of different alternatives.

DISCUSSION

Nurses with experience of restraint use were engaged in a constant process of justifying and balancing different options and actions. Restraint was considered legitimate if the benefit exceeded the suffering, but decisions on which restraint measures to use and when to use them depended on the values of the individual nurse.

CONCLUSION

How nurses reason when justifying restraint, why they use restraint, and who they use restraint on must be considered when creating programs and guidelines to reduce the use of restraint and to ensure that when it is used it is used carefully, appropriately, and with respect.

Coming to Grips-How Nurses Deal With Restlessness, Confusion, and Physical Restraints on a Neurological/Neurosurgical Ward

Physical restraints are viewed as potentially dangerous objects for patient safety. Contemporary efforts mainly focus on preventing bad outcomes in restraint use, while little attention is paid under what circumstances physical restraints are applied harmlessly. The aim of this research was to understand how physical restraints are used by neurology/neurosurgery ward nurses in relation to the protocol. In ethnographic action research, the Functional Resonance Analysis Method (FRAM) was used to map and compare physical restraints as part of daily ward care against the protocol of physical restraints. Comparison between protocol and actual practice revealed that dealing with restlessness and confusion is a collective nursing skill vital in dealing with physical restraints, while the protocol failed to account for these aspects. Supporting and maintaining this skillset throughout this and similar nursing teams can prevent future misguided application physical restraints, offering valuable starting point in managing patient safety for these potentially dangerous objects.

Prevention of physical restraints in the acute care setting (PROTECT): study protocol for a cluster-randomised controlled pilot study

INTRODUCTION

Physical restraints (PR) are regularly used in acute care settings, although evidence for their effectiveness and safety (eg, for prevention of falls) is lacking. Their use is associated with adverse events, such as decreased mobility and injuries for patients. We developed a complex intervention to prevent PR in acute care settings according to the UK Medical Research Council Framework, and investigated the feasibility. The intervention comprised the qualification of key nurses as multipliers and a short interprofessional information session. The intervention has proven to be feasible. It also became apparent that further development of the intervention and the study procedures is necessary. Therefore, this study aims to refine and pilot the complex intervention. Furthermore, the objective of this pilot study is to improve study procedures.

METHODS AND ANALYSIS

In a preparatory phase, we will conduct focus groups and individual interviews with the target groups to explore the possibilities for adaption of the intervention and implementation strategies. Subsequently, a cluster-randomised controlled trial with a 6-month follow-up period will be conducted. It is planned to recruit eight general hospitals in Germany (area of Halle (Saale) and Leipzig) with 28 wards and 924 patients per observation period (2772 overall). Primary outcome is the proportion of patients with at least one PR after 6 months. Data will be collected by direct observation over a period of seven consecutive days and three times a day. Secondary outcomes are falls, interruptions in therapy and prescription of psychotropic medication. A comprehensive process evaluation will accompany the study.

ETHICS AND DISSEMINATION

The Ethics committee of the Medical Faculty of the University of Halle (Saale) approved the study protocol. Results will be published in a peer-reviewed journal and presented at conferences. Study information and additional material will be freely available on an already existing website.

TRIAL REGISTRATION NUMBER

DRKS00027989.

A Nomogram for Predicting Physical Restraint of Patients in Intensive Care Unit

Background

Despite its ethical implications, physical restraint (PR) is widely used in the intensive care unit (ICU) to guarantee the safety of patients. This study investigated the frequency and risk factors of PR use for patients in the ICU to establish a predictive nomogram.

Methods

Clinical parameters of patients admitted to the ICU of Jiangsu Province Hospital from January 2021 to July 2021 were retrospectively collected. Independent risk factors of PR were analyzed by univariate and multivariate logistic regression analyses. The R software was used to establish the nomogram. Model performance was validated using the concordance-index (C-index) and calibration curves.

Results

The rate of PR use was 46.32% (233/503 patients). Age (B = 0.036, odds ratio [OR]: 1.037, 95% confidence interval [CI]: 1.022-1.052, P < 0.001), consciousness disorder (B = 0.770, OR: 2.159, 95% CI: 1.216-3.832, P=0.009), coma (B = -1.666, OR: 0.189, 95% CI: 0.101-0.353, P < 0.001), passive activity (B = 1.014, OR: 2.756, 95% CI: 1.644-4.618, P < 0.001), delirium (B = 0.993, OR: 2.699, 95% CI: 1.097-6.642, P=0.031), -3 < Richmond Agitation Sedation Scale (RASS) score <2 (B = 0.698, OR: 2.009, 95% CI: 1.026-3.935, P=0.042), RASS score ≥2 (B = 1.253, OR: 3.499, 95% CI: 1.126-10.875, P=0.030), and mechanical ventilation (B = 1.696, OR: 5.455, 95% CI: 2.804-10.611, P < 0.001) were identified as independent risk factors for PR in the ICU (P < 0.05) and included in the nomogram. The C-index was 0.830, and the calibration curve indicated good discriminatory ability and accuracy (mean absolute error: 0.026).

Conclusion

The prediction nomogram model of PR in ICU was established based on age, mobility, delirium, consciousness, RASS score, and mechanical ventilation. It showed good discrimination and accuracy. This nomogram may predict the probability of PR use in the ICU and guide nurses in developing precise interventions to reduce the rate of PR.

Race and Ethnicity and the Utilization of Security Responses in a Hospital Setting

BACKGROUND

Security emergency responses (SERs) are utilized by hospitals to ensure the safety of patients and staff but can cause unintended morbidity. The presence of racial and ethnic inequities in SER utilization has not been clearly elucidated.

OBJECTIVE

To determine whether Black and Hispanic patients experience higher rates of SER and physical restraints in a non-psychiatric inpatient setting.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All patients discharged from September 2018 through December 2019.

EXPOSURE

Race and ethnicity, as reported by patients at time of registration.

MAIN OUTCOMES

The primary outcome was whether a SER was called on a patient. The secondary outcome was the incidence of physical restraints among patients who experienced a SER.

KEY RESULTS

Among 24,212 patients, 18,755 (77.5%) patients identified as white, 2,346 (9.7%) as Black, and 2,425 (10.0%) identified with another race. Among all patients, 1,827 (7.6%) identified as Hispanic and 21,554 (89.0%) as non-Hispanic. Sixty-six (2.8%) Black patients had a SER activated during their first admission, compared to 295 (1.6%) white patients. In a Firth logit multivariable model, Black patients had higher adjusted odds of a SER than white patients (adjusted odds ratio (aOR) 1.37 [95% confidence interval: 1.02, 1.81], p = 0.037). Hispanic patients did not have higher odds of having a SER called than non-Hispanic patients. In a Poisson multivariable model among patients who had a SER called, race and ethnicity were not found to be significant predictors of restraint.

CONCLUSION

Black patients had higher odds of a SER compared to white patients. No significant differences were found between Hispanic and non-Hispanic patients. Future efforts should focus on assessing the generalizability of these findings, the underlying mechanisms driving these inequities, and effective interventions to address them.

A Quasi-experimental study on prevention and reduction of involuntary treatment at home (PRITAH) in people with dementia

AIM AND OBJECTIVES

To examine the implementation (reach, dose, fidelity, adaptations, satisfaction), mechanisms of impact (attitude, subjective norm, perceived behavioural control and intention) and context of the PRITAH intervention.

BACKGROUND

Involuntary treatment, defined as care provided against one's will, is highly prevalent in home care. The PRITAH intervention comprises policy, workshops, coaching and alternative measures for professional caregivers to prevent and reduce involuntary treatment in home care.

DESIGN

Quasi-experimental study.

METHODS

Eight home care teams from two care organisations participated in this study. Guided by the Theory of Planned Behavior, the mechanisms of impact were evaluated with questionnaires. Implementation and context were assessed using attendance lists, evaluation questionnaires, focus groups and logbooks. The study adhered to the TREND checklist.

RESULTS

124 of 133 eligible professional caregivers participated (93%). All four components were delivered with minor deviations from protocol. Participants' subjective norms and perceived behavioural control changed over time in favour of the intervention group. No effects were seen for attitude and intention. Barriers included an unclear policy and lack of communication between stakeholders. The multidisciplinary approach and possibility to discuss involuntary treatment with the specialised nurse were described as facilitators.

CONCLUSIONS

Prevention and reduction of involuntary treatment at home is feasible in home care practice and contributes to changing professional caregivers' subjective norms and perceived behavioural control, prerequisites for behavioural change in order to prevent and reduce involuntary treatment. A follow-up study on the effectiveness of PRITAH on actual use, prevention and reduction of involuntary treatment in home care is needed. Future studies should emphasise the role of family caregivers and GPs and actively involve them in the prevention and reduction of involuntary treatment.

RELEVANCE TO CLINICAL PRACTICE

Involuntary treatment is commonly used in dementia home care and professional and family caregivers need to be supported in prevention and reduction of involuntary treatment in people with dementia.

Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings

BACKGROUND

Physical restraints, such as bedrails, belts in chairs or beds, and fixed tables, are commonly used for older people in general hospital settings. Reasons given for using physical restraints are to prevent falls and fall-related injuries, to control challenging behavior (such as agitation or wandering), and to ensure the delivery of medical treatments. Clear evidence of their effectiveness is lacking, and potential harms are recognised, including injuries associated with the use of physical restraints and a negative impact on people's well-being. There are widespread recommendations that their use should be reduced or eliminated.

OBJECTIVES

To assess the best evidence for the effects and safety of interventions aimed at preventing and reducing the use of physical restraint of older people in general hospital settings. To describe the content, components and processes of these interventions.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (Clarivate), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register the International Clinical Trials Registry Portal on 20 April 2022.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials that investigated the effects of interventions that aimed to prevent or reduce the use of physical restraints in general hospital settings. Eligible settings were acute care and rehabilitation wards. We excluded emergency departments, intensive care and psychiatric units, as well as the use of restrictive measures for penal reasons (e.g. prisoners in general medical wards). We included studies with a mean age of study participants of at least 65 years. Control groups received usual care or active control interventions that were ineligible for inclusion as experimental interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the articles for inclusion, extracted data, and assessed the risk of bias of all included studies. Data were unsuitable for meta-analysis, and we reported results narratively. We used GRADE methods to describe our certainty in the results.

MAIN RESULTS

We included four studies: two randomised controlled trials (one individually-randomised, parallel-group trial and one clustered, stepped-wedge trial) and two controlled clinical trials (both with a clustered design). One study was conducted in general medical wards in Canada and three studies were conducted in rehabilitation hospitals in Hong Kong. A total of 1709 participants were included in three studies; in the fourth study the number of participants was not reported. The mean age ranged from 67 years to 84 years. The duration of follow-up covered the period of patients' hospitalisation in one study (21 days average length of stay) and ranged from 4 to 11 months in the other studies. The definition of physical restraints differed slightly, and one study did not include bedrails. Three studies investigated organisational interventions aimed at implementing a least-restraint policy to reduce physical restraints. The theoretical approach of the interventions and the content of the educational components was comparable across studies. The fourth study investigated the use of pressure sensors for participants with an increased falls risk, which gave an alarm if the participant left the bed or chair. Control groups in all studies received usual care. Three studies were at high risk of selection bias and risk of detection bias was unclear in all studies. Because of very low-certainty evidence, we are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on our primary efficacy outcome: the use of physical restraints in general hospital settings. One study found an increase in the number of participants with at least one physical restraint in the intervention and control groups, one study found a small reduction in both groups, and in the third study (the stepped-wedge study), the number of participants with at least one physical restraint decreased in all clusters after implementation of the intervention but no detailed information was reported. For the use of bed or chair pressure sensor alarms for people with an increased fall risk, we found moderate-certainty evidence of little to no effect of the intervention on the number of participants with at least one physical restraint compared with usual care. None of the studies systematically assessed adverse events related to use of physical restraint use, e.g. direct injuries, or reported such events. We are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on the number of participants with at least one fall (very low-certainty evidence), and there was no evidence that organisational interventions or the use of bed or chair pressure sensor alarms for people with an increased fall risk reduce the number of falls (low-certainty evidence from one study each). None of the studies reported fall-related injuries. We found low-certainty evidence that organisational interventions may result in little to no difference in functioning (including mobility), and moderate-certainty evidence that the use of bed or chair pressure sensor alarms has little to no effect on mobility. We are uncertain about the effect of organisational interventions on the use of psychotropic medication; one study found no difference in the prescription of psychotropic medication. We are uncertain about the effect of organisational interventions on nurses' attitudes and knowledge about the use of physical restraints (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether organisational interventions aimed at implementing a least-restraint policy can reduce physical restraints in general hospital settings. The use of pressure sensor alarms in beds or chairs for people with an increased fall risk has probably little to no effect on the use of physical restraints. Because of the small number of studies and the study limitations, the results should be interpreted with caution. Further research on effective strategies to implement a least-restraint policy and to overcome barriers to physical restraint reduction in general hospital settings is needed.

A Cross-Sectional Study to Assess the Frequency of Restraint, and Knowledge and Attitudes of the Caregivers of Patients Toward Restraint in a General Hospital Psychiatry Setting from South India

Background

There is limited Indian data on the epidemiology of hospital-based restraint practices and the knowledge and attitude of caregivers toward restraint. Therefore, this study aimed to report the frequency and pattern of restraints in a general hospital psychiatry setting and assess the knowledge and attitude about restraint practices among caregivers of patients.

Methods

We calculated the frequency of restraints (physical and chemical) over one year. The knowledge and attitude toward restraint were assessed in 75 caregivers each of patients from inpatient and outpatient settings, using a questionnaire designed by the authors and pretested in a pilot study.

Results

The frequency of any form of restraint was 19%. The frequency of chemical and physical restraints was 19% and 0.5%, respectively. Less than 20% of caregivers in both groups reported that restraint was either stigmatizing (5.33% inpatient caregivers vs. 12% outpatient caregivers), cruel (8% inpatient caregivers vs. 15.33% outpatient caregivers), or a measure of punishment (9% inpatient caregivers vs. 16% outpatient caregivers). No significant difference was found between knowledge and attitude about restraint between caregivers of outpatients and inpatients, except for a significantly greater number of caregivers of outpatients reporting that the restraint practices in the hospital were similar to those adopted by faith healers or religious/spiritual centers.

Conclusion

The frequency of either physical or chemical restraint was less compared to the existing international and Indian data. In addition, most caregivers of patients of both outpatients and inpatients did not report a negative attitude toward restraints.

Evaluation of patient relatives’ opinions on physical restraint

Background

Most of the research on physical restraint is focused on determining patients’ experiences of restraint, the consequences of restraint, and healthcare professionals’ perceptions and attitudes. The aim of this study was to determine the opinions of the relatives of patients, who are a critical component of care, about physical restraint. The study used the mixed methods research approach, which combines quantitative and qualitative data collection methods.

Method

The study population consisted of 984 relatives of patients hospitalized in units where physical restraint was commonly applied between January 2018 and December 2018, and the sample consisted of 277 relatives of patients. The qualitative sample of the study consisted of 22 patient's relatives who were interviewed using the maximum diversity sampling method, a purposive sampling method. The quantitative data were analyzed using frequency, percentage, Chi Square (X2-Chi Square) test, and the qualitative data were analyzed using content analysis.

Results

The results showed that consent for physical restraint was generally obtained from spouses, physical restraint was applied to prevent self-harm, but relatives of the patients were insufficiently informed and worried about complications. It was also found that the most frequent reasons for physical restraint were self-harm and facilitation of treatment and care for the male patients and the feeling of helplessness for the female patients.

Conclusion

It was determined that the relatives of patients regarded physical restraint for treatment positively, but they were worried about complications, and they were mostly insufficiently informed before the intervention.

Restraining patients in acute care hospitals-A qualitative study on the experiences of healthcare staff

AIM

The focus was to explore the perceptions and experiences of healthcare workers with respect to the use of restraints in acute care hospitals.

DESIGN

The study followed a qualitative design.

METHODS

Three topic-based focus group interviews were conducted, involving 19 participants from the fields of nursing, physical therapy and medicine. For data collection and analysis, the method of mapping techniques for rapid qualitative data analysis was used. After discussing and validating the individual mind maps, all data were condensed to identify the key findings.

RESULTS

Participants described restraints as safety measures for the patients. The implementation of most restraints was led by nurses. The use of restraints differed significantly, even in the interprofessional team. Attitudes and experiences were the main determinants for restraint use. Nurses asked for more discussion about restraints in the team, for more support at an interprofessional level and for better guidelines to help with the decision-making process.

Physical Restraint Use in Intensive Care Units: Exploring the Decision-Making Process and New Proposals. A Multimethod Study

Aim: The general aim of this study was to explore the decision-making process followed by Intensive Care Unit (ICU) health professionals with respect to physical restraint (PR) administration and management, along with the factors that influence it. Method: A qual-quant multimethod design was sequenced in two stages: an initial stage following a qualitative methodology; and second, quantitative with a predominant descriptive approach. The multicenter study was undertaken at 17 ICUs belonging to 11 public hospitals in the Madrid region (Spain) across the period 2015 through 2019. The qualitative stage was performed from an interpretative phenomenological perspective. A total of eight discussion groups (DG) were held, with the participation of 23 nurses, 12 patient care nursing assistants, and seven physicians. Intentional purposive sampling was carried out. DG were tape-recorded and transcribed. A thematic analysis of the latent content was performed. In the quantitative stage, we maintained a 96-h observation period at each ICU. Variables pertaining to general descriptive elements of each ICU, institutional pain-agitation/sedation-delirium (PAD) monitoring policies and elements linked to quality of PR use were recorded. A descriptive analysis was performed, and the relationship between the variables was analyzed. The level of significance was set at p ≤ 0.05. Findings: A total of 1070 patients were observed, amounting to a median prevalence of PR use of 19.11% (min: 0%–max: 44.44%). The differences observed between ICUs could be explained by a difference in restraint conceptualization. The various actors involved jointly build up a health care culture and a conceptualization of the terms “safety-risk”, which determine decision-making about the use of restraints at each ICU. These shared meanings are the germ of beliefs, values, and rituals which, in this case, determine the greater or lesser use of restraints. There were different profiles of PR use among the units studied: preventive restraints versus “Zero” restraints. The differences corresponded to aspects such as: systematic use of tools for assessment of PAD; interpretation of patient behavior; the decision-making process, the significance attributed to patient safety and restraints; and the feelings generated by PR use. The restraint–free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family.

Association between the duration of physical restraint and pulmonary embolism in psychiatric patients: A nested case-control study using a Japanese nationwide database

BACKGROUND

Pulmonary embolism is the most life-threatening adverse event following physical restraint. However, little is known about the associaton between the duration of physical restraint and pulmonary embolism in psychiatric patients.

OBJECTIVE

The purpose of this study is to evaluate whether more total days of physical restraint is associated with a higher risk of pulmonary embolism.

METHOD

This is a retrospective nested case-control study using a Japanese nationwide administrative inpatient database. We identified patients who were admitted to psychiatric departments from July 2010 to March 2017. One-to-four case-control matching was performed with patients with and without pulmonary embolism. We performed multivariable conditional logistic regression analyses to assess the odds ratios of total days of physical restraint regarding pulmonary embolism.

RESULTS

We identified 223,285 eligible psychiatric patients; 132 (0.059%) patients developed pulmonary embolism during hospitalization. Overall, 13.2% of the psychiatric patients experienced physical restraint for at least 1 day. More total days of physical restraint was significantly associated with a higher risk of pulmonary embolism.

CONCLUSIONS

Longer exposure to physical restraint may increase the risk of pulmonary embolism in psychiatric patients.

Nurses' experiences of using restraint in neurosurgical care - A qualitative interview study

AIM AND OBJECTIVES

To describe nurses' experiences of using restraint in neurosurgical care.

BACKGROUND

Despite reports of negative consequences, and conflicts with key values in healthcare, restraint measures are still practised in somatic healthcare worldwide. When using restraint, basic principles of nursing collide, creating dilemmas known to be perceived as difficult for many nurses. Patients in neurosurgical care are at high risk of being subjected to restraint, but research on nurses' experiences of using restraint in neurosurgical care are scarce.

DESIGN

A qualitative, descriptive design guided by a naturalistic inquiry was used.

METHODS

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden were analysed with inductive qualitative content analysis. COREQ reporting guidelines were used as reporting checklist.

RESULTS

The analysis resulted in one overarching theme, The struggling professional, and two categories. The category Internal struggle describes nurses' conflicting emotions and internal struggle when engaging in restraint. The category The struggle in clinical practice, describes how nurses struggle with handling restraint in clinical practice, and how the use of restraint is based on individual assessment rather than guidelines.

CONCLUSION

Nurses' experience restraint in neurosurgical care as a multi-layered struggle, ranging from inner doubts to practical issues. In order to enhance patient safety, there is a need for policies and guidelines regarding the use of restraint, as well as structured discussions and reflections for nurses engaged in the practice.

RELEVANCE TO CLINICAL PRACTICE

The results highlight the importance of clear guidelines, openness, support and teamwork for nurses working with patients at risk to be subjected to restraint, in order to create a safer care for patients as well as healthcare personnel. When developing guidelines and policies concerning restraint in somatic care, both practical issues such as the decision-making process, and the emotional effect on nurses should be considered.

Adherence with an Acute Agitation Algorithm and Subsequent Restraint Use

Timely use of pharmacological interventions to treat acute agitation has the potential to decrease physical restraint use. The aim of this study is to determine if adherence to standardized pharmacological recommendations for the treatment of acutely agitated pediatric patients decreases physical restraint use. Additionally, this study aims to identify predictors of physical restraint use and describe treatment related adverse events. This is a retrospective chart review of patient visits between September 1, 2016 and August 31, 2017. Patient visits were included if the patient presented to the pediatric emergency department, met ICD-10 codes, and received pharmacologic management or physical restraint to treat acute agitation. The differences in rate of physical restraint was assessed between patients treated according to the standardized pharmacological recommendations and patients who were not. 447 patients were included with a mean age of 13 years. No significant difference in physical restraint use was found when standardized pharmacological recommendations were followed compared to when they were not (P = 0.16). Only presentation on day shift when compared to evening shift resulted in increased odds of being restrained (OR 2.03; 95% CI 1.18, 3.50). Nine adverse events possibly related to medications were identified with none considered to be of significant clinical concern. Standardized pharmacological treatment recommendations was not associated with a decrease in physical restraint use for agitated patients presenting to the pediatric emergency department. The pharmacologic strategies utilized were generally safe and well tolerated in this patient population.

Physical Restraints in Critically Ill Children: A Multicenter Longitudinal Point Prevalence Study

OBJECTIVES

We elucidate to investigate the prevalence of and factors associated with the use of physical restraints among critically ill or injured children in PICUs.

DESIGN

This was a multicenter, longitudinal point prevalence study.

SETTING

We included 26 PICUs in Japan.

PATIENTS

Included children were 1 month to 10 years old. We screened all admitted patients in the PICUs on three study dates (in March, June, and September 2019).

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

We collected prevalence and demographic characteristics of critically ill or injured children with physical restraints, as well as details of physical restraints, including indications and treatments provided. A total of 398 children were screened in the participating PICUs on the three data collection dates. The prevalence of children with physical restraints was 53% (211/398). Wrist restraint bands were the most frequently used means (55%, 117/211) for potential contingent events. The adjusted odds of using physical restraint in patients 1-2 years old was 2.3 (95% CI, 1.3-4.0) compared with children less than 1 year old. When looking at the individual hospital effect, units without a prespecified practice policy for physical restraints management or those with more than 10 beds were more likely to use physical restraints.

CONCLUSIONS

The prevalence of physical restraints in critically ill or injured children was high, and significant variation was observed among PICUs. Our study findings suggested that patient age, unit size, and practice policy of physical restraint could be associated with more frequent use of physical restraints.

Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident technique analysis

Background

Health care workers (HCWs) are at high risk of occupational injuries and approximately 10–15% of patients are affected by an adverse event during their hospital stay. There is scarce scientific literature about how HCWs manage these risks in practice and what support they need. This knowledge is needed to improve safety for patients and HCWs. This study explores HCWs’ experiences of workplace incidents that led to injury or posed a risk of patient and worker injury, with focus on HCWs’ emotions and actions.

Methods

This study employed a qualitative design using the critical incident technique. Semi-structured individual interviews were held with 34 HCWs from three regions in Sweden. Data were analysed using inductive category development.

Results

Altogether 71 workplace incidents were reported. The analysis of two dimensions – the emotions HCWs feel and the actions team members and managers take when a workplace incident occurs – yielded two categories each: Anxiety during the incident, Persistent distress after the incident, Team interplay for safety actions and Support and ratification from managers and colleagues. Health care workers risked their own safety and health to provide patient safety. Teamwork and trustful relationships were critical for patient and worker safety. Support and validation from colleagues and managers were important for closure; unsatisfactory manager response and insufficient opportunities to debrief the incident could lead to persistent negative emotions. Participants described insecurity and fear, sadness over being injured at work, and shame and self-regret when the patient or themselves were injured. When the workplace had not taken the expected action, they felt anger and resignation, often turning into long-term distress.

Conclusions

Work situations leading to injury or risk of patient and worker injury are emotionally distressing for HCWs. Team interplay may facilitate safe and dynamic practices and help HCWs overcome negative emotions. Organizational support is imperative for individual closure. For safety in health care, employers need to develop strategies for active management of risks, avoiding injuries and providing support after an injury.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06517-x.

Definition and Measurement of Physical and Chemical Restraint in Long-Term Care: A Systematic Review

This systematic review aimed to identify thematic elements within definitions of physical and chemical restraint, compare explicit and implicit definitions, and synthesize reliability and validity of studies examining physical and/or chemical restraint use in long-term care. Studies were included that measured prevalence of physical and/or chemical restraint use, or evaluated an intervention to reduce restraint use in long-term care. 86 papers were included in this review, all discussed physical restraint use and 20 also discussed chemical restraint use. Seven themes were generated from definitions including: restraint method, setting resident is restrained in, stated intent, resident capacity to remove/control, caveats and exclusions, duration, frequency or number, and consent and resistance. None of the studies reported validity of measurement approaches. Inter-rater reliability was reported in 27 studies examining physical restraint use, and only one study of chemical restraint. Results were compared to an existing consensus definition of physical restraint, which was found to encompass many of the thematic domains found within explicit definitions. However, studies rarely applied measurement approaches that reflected all of the identified themes of definitions. It is necessary for a consensus definition of chemical restraint to be established and for measurement approaches to reflect the elements of definitions.

Predictors of physical restraint use on critical care units: An observational structural equation modeling approach

BACKGROUND

Modifiable unit characteristics, including nurse work environment, education, certification, and staffing have been shown to impact patient safety. Physical restraints are an important patient safety issue, however the relationships between these modifiable unit characteristics and physical restraint use on critical care units has not been explored.

OBJECTIVES

Our objective was to determine the role of nursing work environment, nurse education and certification, and nurse staffing on physical restraint use.

DESIGN

The study was a secondary analysis of 2017-2018 unit-level restraint rates from the National Database of Nursing Quality Indicators linked to Registered Nurse survey and hospital characteristics data.

METHODS

Work environment was examined at the unit-level using total Practice Environment Scale of the Nursing Work Index and subscale scores. Unit-level nurse expertise included the percent of nurses with at least a Bachelor of Science in Nursing degree and percent with certification. Nurse staffing was the unit-level Registered Nurse hours per patient day and skill mix. Analyses included descriptive statistics, bivariate correlations, and Structural Equation Modeling. We used a first order model to estimate predicted restraint use from the five subscales of the Practice Environment Scale of the Nursing Work Index. A higher order model predicted restraint use from a total work environment factor score.

RESULTS

The sample included 408 critical care units from 226 hospitals. Mean restraint rate was 15% (SD 12, range 0-53%). In the first-order model, the Collegial Nurse-Physician Relations subscale had a positive relationship with restraint use (β = 0.167, 95% confidence interval 0.010-0.333). In the higher order model, the total work environment score had a negative relationship with restraint use (β = -0.088, 95% confidence -0.178- -0.014). Registered Nurse hours per patient day had a negative relationship to restraint use in both the first order (β = -0.114, 95% confidence interval -0.222--0.025) and higher order models (β = -0.117, 95% confidence interval -0.223- -0.012).

CONCLUSION

We found that better nurse-physician relationships were associated with higher restraint use. This finding is supported by previous literature and may reflect physician trust in nursing judgement when using restraints. However, a better work environment overall was associated with lower restraint rates. Further, Registered Nurse hours per patient day, but not skill mix, was associated with lower restraint rates. We conclude that improving the overall nurse work environment and nurse staffing, as well as using interprofessional interventions, may be successful in decreasing restraint use on critical care units.

Reducing the use of physical restraints in home care: development and feasibility testing of a multicomponent program to support the implementation of a guideline

BACKGROUND

A validated evidence-based guideline was developed to reduce physical restraint use in home care. However, the implementation of guidelines in home care is challenging. Therefore, this study aims to systematically develop and evaluate a multicomponent program for the implementation of the guideline for reducing the use of physical restraints in home care.

METHODS

Intervention Mapping was used to develop a multicomponent program. This method contains six steps. Each step comprises several tasks towards the design, implementation and evaluation of an intervention; which is theory and evidence informed, as well as practical. To ensure that the multicomponent program would support the implementation of the guideline in home care, a feasibility study of 8 months was organized in one primary care district in Flanders, Belgium. A concurrent triangulation mixed methods design was used to evaluate the multicomponent program consisting of a knowledge test, focus groups and an online survey.

RESULTS

The Social Cognitive Theory and the Theory of Planned Behavior are the foundations of the multicomponent program. Based on modeling, active learning, guided practice, belief selection and resistance to social pressure, eight practical applications were developed to operationalize these methods. The key components of the program are: the ambassadors for restraint-free home care (n = 15), the tutorials, the physical restraint checklist and the flyer. The results of the feasibility study show the necessity to select uniform terminology and definition for physical restraints, to involve all stakeholders from the beginning of the process, to take time for the implementation process, to select competent ambassadors and to collaborate with other home care providers.

CONCLUSIONS

The multicomponent program shows promising results. Prior to future use, further research needs to focus on the last two steps of Intervention Mapping (program implementation plan and developing an evaluation plan), to guide implementation on a larger scale and to formally evaluate the effectiveness of the multicomponent program.

Nurses' knowledge and practices of physical restraints in intensive care units: An observational study

Aim

To investigate the knowledge and practice of physical restraints (PR) among Jordanian intensive care unit (ICU) nurses.

Design

A descriptive, observational design was used.

Methods

A convenience sampling was used to recruit participants. We examined the knowledge of PR in 301 nurses (knowledge check) and the real-time practice of PR in 81 nurses (direct observation) in ICU. A knowledge questionnaire was used to collect data on knowledge about PR use, and data on their practice of PR were observed and documented using an observation checklist.

Results

The mean scores of nurses' knowledge and practices were 61.5 (SD = 12.1) and 57.4 (SD = 9.7), respectively. More than half of nurses had poor knowledge of PR use and incorrect practice of implementing PR (51.5% and 60.5%, respectively). Results indicated a positive correlation between nurses' knowledge and their use of PR.

Overcoming the Use of Mechanical Restraints in Psychiatry: A New Challenge in the Everyday Clinical Practice at the Time of COVID-19

Restraining interventions, which comprise physical (PR) and mechanical restraint (MR), have a long history in mental health services [...].

Patient safety and bedrail use as a global phenomenon: A prevalence study

Background: Although bedrail use may increase the risk of accidents among patients, bedrails are still extensively used in healthcare facilities. Therefore, the field calls for a review of bedrail use in practice. Objective: This report examined the prevalence and implications of bedrail use in rehabilitation facilities in Hong Kong. The findings are compared with the current state of bedrail use worldwide. Design and methods: This work is a cross-sectional, observational study. A secondary analysis was conducted on the database of a prospective trial. Bilateral bedrail use was observed in two Hong Kong rehabilitation hospitals. Logistic regression was performed to examine the factors associated with bedrail use. Results: A total of 3,384 restraint observations were made. The bedrail rate was 31.34%, which revealed that bedrail use was the second most commonly used physical restraint. The fall history (OR: 2.84), cognitive impairment (OR: 0.91) and functional dependency (OR: 0.79) of patients were significant predictors of bedrail use, p < .05. Conclusion: This study examines bedrail prevalence through direct observation, which is the preferred method for examining bedrail use in practice. We found that actual bedrail use is higher than the numbers reported in previous studies in Hong Kong. In addition, our research reveals that bedrails are commonly used for vulnerable patients. This finding highlights the need to change nurses' beliefs on bedrail use through education. The management of these health facilities should also aim to create an institutional environment that promotes the reduction of bedrail use. Implementation strategies on restraint reduction should also fit the culture of the organisation and local nursing practices, as well as the staff's values. Impact Statement: This study provides preliminary information about the widespread use of bedrails in Hong Kong and other countries. The research also introduces effective ways to achieve the reduction of bedrail use.

Involuntary treatment in dementia care at home: Results from the Netherlands and Belgium

Aims and objectives

To gain insight into the request, use and associated factors of involuntary treatment in people with dementia (PwD) receiving professional home care in the Netherlands and Belgium.

Background

Most of the PwD remain living at home as long as possible. Due to complex care needs, this can result in an increased risk for care provided against the wishes of the client and/or to which the client resists, referred to as involuntary treatment.

Design

Secondary data analyses of two cross‐sectional surveys.

Methods

Dementia case managers and district nurses filled in a questionnaire for each PwD in their caseload. This study included data of 627 PwD receiving professional home care in the Netherlands and 217 in Belgium. The same methodology (questionnaire and variables) was used in both samples. Descriptive statistics and multi‐level logistic regression analyses were used to analyse the data. The study adhered to the STROBE checklist.

Results

More than half of the PwD (50.7%) living at home received involuntary treatment (Belgium 68.2% and the Netherlands 44.7%). Nonconsensual care (82.7%) was the most common, followed by psychotropic medication (40.7%) and physical restraints (18.5%). Involuntary treatment use was associated with living alone, greater ADL dependency, lower cognitive ability, higher family caregiver burden and receiving home care in Belgium versus the Netherlands. Involuntary treatment was most often requested by family caregivers.

Conclusions

Involuntary treatment is often used in PwD, which is in line with previous findings indicating dementia as a risk factor for involuntary treatment use. More research is needed to gain insight into variations in prevalence across other countries, which factors influence these differences and what countries can learn from each other regarding prevention of involuntary treatment.

Relevance to clinical practice

To provide person‐centred care, it is important to study ways to prevent involuntary treatment in PwD and to stimulate dialogue between professional and family caregivers for alternative interventions.

Reducing physical restraints by older adults in home care: development of an evidence-based guideline

Background

Restraint use is a complex and challenging issue in home care. Due to socio-demographic trends, worldwide home healthcare providers are faced with an increasing demand for restraint use from informal caregivers, patients and healthcare providers, resulting in the use of various types of restraints in home care. Awareness and knowledge of restraint use in home care, its implications and the ethical challenges surrounding it are of crucial importance to its reduction. This research aimed to describe the development process of an evidence-based practice guideline to support caregivers to optimize home care.

Method

The practice guideline was developed according to the framework of the Belgian Centre for Evidence-Based Medicine and AGREE II. The guideline was developed over several stages: (1) determination of the target population and scope, (2) literature search, (3) drafting and (4) validation. A multidisciplinary working group determined the proposed purpose, target group, and six clinical questions for the guideline. A consensus procedure and consultation by experts were used to develop the guideline.

Results

The guideline provides an answer to six clinical questions and contains ten key recommendations based on the classification of GRADE, with the objective of increasing healthcare providers’ awareness, knowledge and competence to adequately deal with situations or questions related to restraint use. The guideline also includes a flowchart for dealing with complex situations where the use of restraints is requested, already present or considered.

Conclusions

The guideline was validated by the Belgian Centre for Evidence-Based Medicine. Increasing competence, awareness and knowledge related to restraint use are key objectives of the guideline for reducing restraint use in home care. A multicomponent intervention to support healthcare workers in implementing the guideline in clinical practice needs to be developed.

Ethical and Practical Issues in Video Surveillance of Psychiatric Units

OBJECTIVES

Video surveillance is used in inpatient psychiatry in many countries and institutions. However, its use varies considerably because of a lack of research, discussion, and agreement on best practice. This review provides an overview of current issues in the use of video surveillance in psychiatry, with a focus on ethical questions and their practical implications.

METHODS

A narrative review of literature on video surveillance in psychiatry was conducted. References were identified through searches of PubMed, CINAHL, MEDLINE, PsycINFO, and Google Scholar for articles published before December 2018. Sixteen articles in English and German were reviewed.

RESULTS

The ethical challenges and practical implications differ between surveillance of public spaces versus private areas, such as bedrooms or seclusion rooms. The most common reason for video surveillance was to increase security and safety. However, empirical evidence suggests that it is not useful in increasing security of shared spaces on psychiatric wards. Some evidence exists for clinical benefits of video surveillance in private spaces (e.g., allowing patients to sleep undisturbed). Video surveillance can increase patients' choices regarding monitoring options. The main ethical conflict lies in balancing patients' autonomy and privacy versus patient and staff security and safety.

CONCLUSIONS

Whether video monitoring is used in the most effective and ethical manner needs to be reconsidered. Available evidence does not support its use as a security measure. More research is needed to evaluate the benefits, risks, and best practices of using video monitoring for patient observation, with consideration given to increasing the role of patient consent.

Nurses' Perception of the Bed Alarm System in Acute-Care Hospitals

Introduction

In hospitals, the nurse uses the bed alarm system for patients' safety, which may have some forms of physical restraints included, depending on the situation. However, the nurses' perceptions of the bed alarm system with reference to restraints are yet to be clarified. Moreover, there were no reports that can shed light upon the factors that relate to nurses' perceptions about the bed alarm system in Japan. The objective of this study is to investigate the nurses' perception on whether the bed alarm can be considered as a form of physical restraint and to elucidate the factors that pertain to the nurses' perceptions regarding the bed alarm.

Methods

This study conducted a quantitative cross-sectional survey. We used bivariate logistic regression analyses to investigate the nurses' perception and the factors affecting these perception. Ethical approval was obtained from the research ethics committee of the Kyoto University. Participants opted for answering the questionnaire voluntarily.

Results

The sample population comprised of 289 nurses from 10 acute-care hospitals. Out of these, 214 (74.0%) nurses considered the bed alarm system as a form of restraint, and 75 nurses (26.0%) did not. Furthermore, the nurses' perception was relevant to the hospitals that they belonged to, their years of experience, and the content of education. It was especially interesting that the group of nurses with little experience had the consciousness of being considered the bed alarm as restraint compared with nurses with many years of experience.

Conclusion

The alarm systems are gradually being considered to be classified as a restraint. Hospitals should ensure providing an ethically sensitive climate and appropriate educational opportunities to help nurses build these perceptions for patient care. An ethically sensitive climate and appropriate educational opportunities would lead to an environment that nurtures nurses with the ability to recognize problems in daily care.

Prevention and reduction of involuntary treatment at home: A feasibility study of the PRITAH intervention

Sometimes care is provided to a cognitively impaired person against the person's will, referred to as involuntary treatment. We developed the PRITAH intervention, aimed at prevention and reduction of involuntary treatment at home. PRITAH consists of a policy discouraging involuntary treatment, workshops, coaching by a specialized nurse and alternative interventions. A feasibility study was conducted including 30 professional caregivers. Feasibility was assessed by attendance lists (reach), a logbook (dose delivered and fidelity), evaluation questionnaires and focus group interviews (dose received, satisfaction & barriers). The workshops and coach were positively evaluated and the average attendance rate was 73%. Participants gained more awareness and knowledge and received practical tips and advice to prevent involuntary treatment. Implementation of the intervention was feasible with minor deviations from protocol. Recommendations for improvement included more emphasis on involvement of family caregivers and general practitioners and development of an extensive guideline to comply with the policy.

Physical and Pharmacological Restraints in Hospital Care: Protocol for a Systematic Review

BACKGROUND

Physical and pharmacological restraints, defined as all measures limiting a person in his or her freedom, are extensively used to handle unsafe or problematic behavior in hospital care. There are increasing concerns as to the extent with which these restraints are being used in hospitals, and whether their benefits outweigh their potential harm. There is currently no comprehensive literature overview on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in the hospital setting.

METHODS

A systematic review of the existing literature will be performed on the beneficial and/or adverse effects of physical and pharmacological restraints in the hospital setting. Relevant databases will be systematically searched. A dedicated search strategy was composed. A visualization of similarities (VOS) analysis was used to further specify the search. Observational studies, and if available, randomized controlled trials reporting on beneficial and/or adverse effects of physical and/or pharmacological restraints in the general hospital setting will be included. Data from included articles will be extracted and analyzed. If the data is suitable for quantitative analysis, meta-analysis will be applied.

DISCUSSION

This review will provide data on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in hospital care. With this review we aim to guide health professionals by providing a critique of the available evidence regarding their choice to either apply or withhold from using restraints. A limitation of the current review will be that we will not specifically address ethical aspects of restraint use. Nevertheless, the outcomes of our systematic review can be used in the composition of a multidisciplinary guideline. Furthermore, our systematic review might determine knowledge gaps in the evidence, and recommendations on how to target these gaps with future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42019116186.

The role of physical exercise and rehabilitation in delirium

PURPOSE

This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research.

METHODS

In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other.

RESULTS

This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function.

CONCLUSION

The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.

The Adverse Effects of Physical Restraint Use among Older Adult Patients Admitted to the Internal Medicine Wards: A Hospital-Based Retrospective Cohort Study

OBJECTIVES

To evaluate the negative effect of physical restraint use on the hospital outcomes of older patients.

DESIGN

A retrospective cohort study.

SETTING

Internal medicine wards of a tertiary medical center in Taiwan.

PARTICIPANTS

Subjects aged 65 years and over who were admitted during April to Dec 2017 were recruited for study.

MEASUREMENTS

Demographic data, geriatric assessments (polypharmacy, visual impairment, hearing impairment, activities of daily living before and after admission, risk of pressure sores, change in consciousness level, mood condition, history of falls in the previous year, risk of malnutrition and pain) and hospital conditions (admission route, department of admission, length of hospital stay and mortality) were collected for analysis.

RESULTS

Overall, 4,352 participants (mean age 78.7±8.7 years, 60.2% = male) were enrolled and 8.3% had physical restraint. Results of multivariate logistic regression showed that subjects with physical restraints were at greater risk of functional decline (adjusted odds ratio 2.136, 95% confidence interval 1.322-3.451, p=0.002), longer hospital stays (adjusted odds ratio 5.360, 95% confidence interval 3.627-7.923, p<0.001) and mortality (adjusted odds ratio 4.472, 95% confidence interval 2.794-7.160, p<0.001) after adjustment for covariates.

CONCLUSION

The use of physical restraints during hospitalization increased the risk of adverse hospital outcomes, such as functional decline, longer length of hospital stay and mortality.