A national survey of the use of physical restraint in long-term care hospitals in Japan

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.

An Application of the Theory of Planned Behavior to Predict the Intention and Practice of Nursing Staff Toward Physical Restraint Use in Long-Term Care Facilities: Structural Equation Modeling

PURPOSE

Understanding the factors that affect nursing staffs' intention and practice of physical restraint (PR) on older adults help develop restraint-reduction programs. This study aimed to identify the relationship between the Theory of Planned Behavior (TPB) constructs and nursing staffs' practice to use PR in long-term care (LTC) facilities.

PATIENTS AND METHODS

A cross-sectional survey was conducted via convenience sampling among 316 nursing staff in six Chinese LTC facilities. PR-TPB questionnaire and the practice subscale of the Chinese version of the Staff Knowledge, Attitudes and Practices Questionnaire regarding PR were used to collect the data. Structural equation modeling (SEM) was used to examine the relationship between variables.

RESULTS

The SEM fit well with the data (χ2/df =1.639, RMSEA = 0.045, CFI= 0.955, GFI=0.945). Attitude (β=0.536, P<0.001) and perceived behavioral control (PBC) (β=0.139, P<0.05) predicted intention (R2 =0.359). PBC was a significant predictor of practice, with R2 accounting for 0.151.

CONCLUSION

TPB provided useful insight into better understanding nursing staffs' PR practices, although it did not support all the TPB principles significantly. Prospective studies may be conducted to design and implement multi-component interventions based on TPB and explore the effectiveness of PR reduction in LTC facilities in-depth.

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.

The use of physical restraints in Chinese long-term care facilities and its risk factors: An observational and cross-sectional study

AIM

To investigate the use of physical restraints among Chinese long-term care facilities older adults and to identify its risk factors.

DESIGN

Observational and cross-sectional study.

METHODS

A total of 1,026 older adults from six long-term care facilities in Chongqing were recruited by cluster sampling method from July - November 2019. Data on physical restraint use and older adults' characteristics were collected using physical restraints observation forms and older adults' records. Organizational data were collected by questionnaires asking nursing managers. The independent risk factors for physical restraints use were assessed using chi-square test and binary logistic regression.

RESULTS

The study found that the prevalence of physical restraints in six long-term care facilities in China was 25.83%. Waist belt (55.47%) and wrist restraint (52.83%) were most frequently used. Only 61.51% of physical restraints were signed with informed consent. 71.70% of physical restraints were caused by the prevention of falls, 89.06% of physical restraints were without nursing documentation, and 13.58% restrained older adults were observed to have physical complications. According to the binary logistic regression analysis, facility type and ownership, older adults per nursing assistant, length of residence, cognitive impairment, care dependency, mobility restriction, fall risk, physical agitation, and indwelling tubes emerged as important risk factors for the use of physical restraints.

CONCLUSION

The use of physical restraints among Chinese long-term care facilities older adults was at a relatively high level and lack standardized and regulated practices. Moreover, Physical restraint use was associated with facility type and ownership, older adults per nursing assistant, length of residence, cognitive impairment, care dependency, mobility restriction, fall risks, physical agitation, and indwelling tube.

IMPACT

This study will provide an effective reference for nursing staff in long-term care facilities to assess high-risk older adults in their use of physical restraints, which can support them to implement effective minimized restraint approaches to targeted people.

The effect of psychoeducation given to psychiatry nurses on level of knowledge, attitudes, and practices regarding physical restraint: A randomized controlled study

PURPOSE

This study aims to determine the effect of psychoeducation, given to nurses working in a psychiatry clinic, on level of knowledge, attitudes, and practices regarding physical restraint.

DESIGN AND METHODS

This study was conducted with a randomized-controlled-study design. A total of 111 nurses were recruited and randomly assigned to experimental (n = 53) and control (n = 58) groups. The experimental group received psychoeducation, while no intervention was applied to the control group. This study was conducted in a psychiatric hospital located in the Eastern Anatolia of Turkey. A Descriptive Form and the Levels of Knowledge, Attitudes, and Practices of Nurses Regarding Physical Restraints Questionnaire were used to collect data.

FINDINGS

Statistically significant differences were found between the pretest and posttest total mean scores on the level of knowledge (P = .000), attitudes (P = .000), and practices (P = .000) of the nurses in the control group and the study group.

PRACTICE IMPLICATIONS

An increase in the level of knowledge and positive improvement in attitudes and practices were observed in the nurses who received psychoeducation. Providing nurses with psychoeducation on physical restraint can positively contribute to improving their level of knowledge and to eliminating their negative attitudes and practices on this subject.

The Attitudes Towards the Use of Restraint and Restrictive Intervention Amongst Healthcare Staff on Acute Medical and Frailty Wards-A Brief Literature Review

Restraint in modern non-psychiatric-based healthcare is often regarded as a rare occurrence. It is deemed to be used as a last resort to prevent patients from directly harming themselves. However, techniques are used in modern day practice which are considered direct and indirect restraints with the justification of maintaining patient safety, but they are often not classified as “restraints”. Examples of these include the use of bed rails or tables to prevent patients from “wandering” and to reduce the risk of falls and injuries. More indirect techniques would involve passive interactions with patients or leaving mobility aids out of reach. Staff subconsciously restrain patients and reduce their liberties despite agreeing that patient autonomy should be upheld—a necessary evil to maintain a duty of care. Whilst the use of restraints is often justified to ensure patient care and prevent injury, it is not without consequence. There are physical and psychological health risks such as pressure sores from the inability to mobilise, or the brewing of anger and frustration when denied access to everyday actions. The reasons why restraints are used, whilst stemming from maintaining patient safety, are often due to low staffing levels and the inability to constantly watch at-risk patients due to a large workload. Inadequate training is another factor; by improving education in direct and indirect restraint and providing alternative methods, more ethical decisions and positive outcomes can be implemented. Healthcare professionals are reluctant to use restraint but often conduct it without realising it; assessing their understanding of restraint and providing education to raise awareness of the consequences of direct and indirect methods would result in positive steps toward reducing their use at the same time as looking to provide alternatives to uphold patient care whilst maintaining their dignity and liberty.

Knowledge, Attitudes, and Practices of Chinese Critical Care Nurses Regarding Physical Restraint

BACKGROUND

This multicenter cross-sectional study sought to determine the knowledge, attitudes, and practices regarding the use of physical restraints by Chinese nurses in intensive care units (ICUs) of tertiary hospitals.

METHOD

A scale technique was used to measure the knowledge, attitudes, and practices of 383 RNs from eight tertiary hospitals in Chongqing, China.

RESULTS

A total of 383 valid questionnaires were returned, for a response rate of 89.49%. Approximately 8.1% of the nurses were male, 67.1% had a bachelor's degree or above, and 55.09% were ICU specialists. The average age was 28.62 years (SD = 4.56). The mean scores were 74.33 of 111 (SD = 9.552), 24.41 of 40 (SD = 4.872), and 65.66 of 130 (SD = 20.880) regarding knowledge, attitudes, and nursing practices, respectively. For the attitude scale, the scores of nurses who were certified ICU specialists and had extensive working experience were higher than those with less experience; the difference was statistically significant (p < .05).

CONCLUSION

Results indicated that nurses employed in the ICUs of tertiary hospitals in Chongqing, China, have relatively insufficient knowledge, comparatively incorrect attitudes, and unreasonable means of practicing physical restraint. Continuing education should focus strongly on the relationship between physical restraint and unplanned extubation, and guidelines on physical restraint urgently need to be developed. [J Contin Educ Nurs. 2019;50(3):121-126.].

Physical restraint: perceptions of nurse managers, registered nurses and healthcare assistants

AIM

To examine the perceptions of nurse managers, registered nurses and healthcare assistants of physical restraint use on older people in a long-term care setting in the Republic of Ireland.

BACKGROUND

The use of physical restraint, although controversial, persists in long-term care settings, despite recommendations for restraint-free environments. Perception and attitude of staff can influence use of physical restraint.

METHODS

A descriptive cross-sectional design was used. A total of 250 nursing and healthcare assistant staff were recruited. A questionnaire incorporating demographics and the Perceptions of Restraint Use Questionnaire was used. Descriptive and inferential statistical analyses were conducted.

RESULTS

Mean age of respondents (n = 156) was 41 years, and the majority were female. Overall, a low level of importance was attached to the use of restraint. Nurse managers and registered nurses compared favourably with healthcare assistants who attached a higher importance to use of restraint. Across all three staff groups, greatest importance was attached to the use of physical restraint for reducing falls, followed by prevention of treatment interference. Restraint was least favoured as a means of impairment management. Education was not an explanatory factor in perceived importance of physical restraint use.

CONCLUSION

Nurse managers and registered nurses are unlikely to use physical restraint. However, there is concern regarding perception of healthcare assistants on use of restraint.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Results from this study compare favourably with those in countries that have no policy on physical restraint use. Educational programmes alone are insufficient to address use of physical restraint. Attention to skill mix with adequate support for healthcare assistants in long-term care settings is recommended.

Restraint use among selected hospitalized elderly patients in Cairo, Egypt

Objective

This study’s primary objective was to investigate the prevalence of physical and chemical restraint use in selected elderly hospitalized patients.

Results

This study was conducted in April 2014 in four major acute care hospitals. Trained data collectors assessed the use of physical and chemical restraint among all admitted elderly patients. There were 287 elderly patients (median age 64 years, 46% women). 32 patients were restrained. The overall prevalence of restraints was 11.1%, with physical restraint use alone at 3.2% and chemical restraints use alone at 7.3%. Restraint use varied by hospital type, with the highest at the private hospital (22.9%) and the lowest at the two university hospitals (< 6%). In conclusion the prevalence of physical and chemical restraint use among admitted elderly patients in Egypt is comparable to that seen in developed countries. However, the use appears to vary widely by hospital type. The use of restraints in the elderly remains an important question considering the increasing number of elderly.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-2978-x) contains supplementary material, which is available to authorized users.

The use of physical restraints in long-term care in Spain: a multi-center cross-sectional study

BACKGROUND

Physical restraint is a procedure used frequently in long-term care. It is a controversial practice because its use is associated with numerous complications and also affects freedom and individual autonomy. The objective of this study was to examine the use of physical restraint of long-term care residents with the ability to move voluntarily.

METHODS

We conducted a cross-sectional observational and correlational multi-center study. Nine centers agreed to participate. Of the 1,200 people present at the time of data collection, those without voluntary movement or in the facility for less than a month were excluded. Thus, the final sample was 920 residents. Data on the use of restraints was collected by direct observation. Information about the age, gender, length of stay, falls, mobility, cognition and functional status of residents was gathered by reviewing clinical records and interviewing nursing staff. A descriptive analysis of the data obtained was conducted. The generalized linear model was used, considering only the principal effects of each variable and using the logit link function. The model has been adjusted for clusters and for other possibly confounding factors. For all analyses, a confidence interval (CI) of 95% was estimated.

RESULTS

The prevalence of residents with at least one physical restraint was 84.9% (95% CI: 81.7-88.1), with variability between centers of 70.3 to 96.6% (p-value Kruskal Wallis test <0.001). Full-enclosure side rails were most often used (84.5; 95% CI: 81.1-87.9), but other types of restraints were also used frequently. Multivariate analysis showed that the degree of functional impairment increased the probability of the use of restraint. A significant association was also found between restraint use and the impaired cognitive status of residents.

CONCLUSIONS

The prevalence was higher than in studies from other countries. The results emphasize the need to improve the training of nursing staff in the care of residents with impairments in functional and cognitive status. The use of alternative devices and nurse consultants need to be evaluated, and the introduction of specific laws considered.

Incidence Rate and Patterns of Physical Restraint Use Among Adult Patients in Malaysia

Incidence rate and patterns of physical restraint use were examined based on a cross-sectional study in 22 wards of a large teaching hospital in Malaysia. Results indicated that the highest rate of physical restraint (19.7%) was reported from neurology-neurosurgery wards. "Un-cooperative for electroconvulsive therapy" and "trying to pull out catheters" were the most commonly reported reasons to use restraint in psychiatric and non-psychiatric wards, respectively. There were some relationships between patterns of physical restraint in this study. Exploring the incidence rate and patterns of physical restraint is important so that effective strategies can be formulated to minimize using restraint in hospitals.

Use of physical restraints in nursing homes: a multicentre cross-sectional study

Background

Although many countries have implemented strict legal rules, the prevalence of physical restraints in nursing homes seems to remain high. In Switzerland, data related to the frequency of physical restraints are scarce and little is known about associations with resident and nursing home characteristics. The aim of this study was to investigate the prevalence and types of physical restraints in nursing homes in two Swiss cantons and to explore whether resident-related and organisational factors are associated with the use of physical restraints.

Methods

We conducted a multicentre cross-sectional study. Twenty nursing homes with 1362 residents from two culturally different cantons were included. Data on physical restraints and residents’ characteristics were extracted from residents’ records (11/2013 to 2/2014). Organisational data were collected by questionnaires addressing nursing home directors or nursing managers. Sample size calculation and outcome analysis took cluster-adjustment into account. Descriptive statistics and multiple logistic regression analysis with nursing homes as random effect were used for investigation.

Results

The prevalence of residents with at least one physical restraint was 26.8 % (95 % confidence interval [CI] 19.8–33.8). Centre prevalence ranged from 2.6 to 61.2 %. Bilateral bedrails were most frequently used (20.3 %, 95 % CI 13.5–27.1). Length of residence, degrees of care dependency and mobility limitation were significantly positively associated with the use of physical restraint, but none of the organisational characteristics was significantly associated.

Conclusion

Approximately a quarter of the nursing home residents included in our study experienced physical restraints. Since variation between nursing homes was pronounced, it seems to be worthwhile to explore nursing homes with particularly low and high use of physical restraints in future research, especially by using qualitative methods. There is a need for effective interventions aiming at restraint-free nursing care. Development of interventional approaches should consider specific residents’ characteristics associated with restraint use.

Knowledge, perceptions, and experiences of family caregivers and home care providers of physical restraint use with home-dwelling elders: a cross-sectional study in Japan

BACKGROUND

The use of physical restraints by family caregivers with home-dwelling elders has not been extensively studied but it might be widespread. Furthermore, it is also not clear how home care providers who support family caregivers perceive the use of physical restraint in elders' homes. This study assessed family caregivers' and home care providers' knowledge and perceptions of physical restraint used with elders living at home in Japan, a country with the highest proportion of elders in the world and where family caregiving is common.

METHODS

We undertook a cross-sectional study of 494 family caregivers, 201 home helpers, 78 visiting nurses, 131 visiting physicians, and 158 care managers of home-dwelling frail elders needing some care and medical support in Japan, using questionnaires on knowledge of 11 physical restraint procedures prohibited in institutions and 10 harmful effects of physical restraints, perceptions of 17 reasons for requiring physical restraints, and experiences involving physical restraint use.

RESULTS

Family caregivers were aware of significantly fewer recognized prohibited physical restraint procedures and recognized harmful effects of physical restraint than home care providers, and differences among home care providers were significant. The average importance rating from 1 (least) to 5 (most) of the 17 reasons for requiring physical restraints was significantly higher among family caregivers than home care providers, and significantly different among the home care providers. Moreover, these differences depended in part on participation in physical restraint education classes. While 20.1% of family caregivers had wavered over using physical restraints, 40.5% of home care providers had seen physical restraints used in elders' homes and 16.7% had advised physical restraint use or used physical restraints themselves.

CONCLUSIONS

Knowledge and perceptions of physical restraints differed between family caregivers and home care providers and were also diverse among home care providers. Because both groups might be involved in physical restraint use with home-dwelling elders, home care providers should acquire standardized and appropriate knowledge and perceptions of physical restraints to help family caregivers minimize abusive physical restraint use.

Knowledge, attitudes, and practices of Turkish intern nurses regarding physical restraints

OBJECTIVE

This study was carried out to determine knowledge, attitudes, and practices of intern nurses who completed the nursing internship program on the use of physical restraints.

DESIGN

This research was conducted using descriptive and cross-sectional research design.

METHODS

The study sample comprises 91 fourth-grade students who took an integrated curriculum and completed the nursing internship program. The data were collected with the Demographic Characteristics Questionnaire and the Levels of Knowledge, Attitudes and Practices of Staff Regarding Physical Restraints Questionnaire. For the assessment of the data, percentages, the arithmetic mean, and t test were used.

RESULTS

The findings indicated that, of the intern nurses, 95.6% observed the use of physical restraints during their education, and 69.2% applied physical restraints. The mean knowledge, attitude, and practice scores of the nurses for physical restraint were 9.38 ± 1.19 (0-11 points), 34.70 ± 5.62 (12-48 points), and 37.95 ± 2.32 (14-42 points), respectively.

CONCLUSIONS

Intern nurses' knowledge about how to use physical restraints was at a very good level; they displayed positive attitudes, and they used their knowledge and attitudes in their practices to a great extent.

IMPLICATIONS

Although there are studies on the knowledge, attitudes, and practices of nurses working in the fields of elderly care, rehabilitation, and psychiatry in acute care units, there are no studies investigating intern nurses and other nursing students. However, intern nurses about to begin their careers should make accurate decisions regarding the use of physical restrains if they are to ensure patient safety and to fulfill this application effectively in their professional lives.

Nursing staff views of barriers to physical restraint reduction in nursing homes

PURPOSE

There are few studies globally regarding the barriers to restraint-reduction. The purpose of this study was to describe the views of nursing staff (both nurses and geriatric care assistants) regarding the barriers to reducing physical restraint use in Korean nursing homes.

METHODS

Forty registered nurse and geriatric care assistant informants participated in the first round of interviews and 16 of them participated in second confirmatory interviews. All interviews were conducted on site, one-on-one and face-to-face, using semi-structured interview protocols. Qualitative descriptive method was used and qualitative content analysis was employed.

RESULTS

Six themes were identified: (a) being too busy, (b) lack of resources, (c) beliefs and concerns, (d) lack of education, (e) differences and inconsistencies, and (f) relationship issues.

CONCLUSION

The findings of this study provide a valuable basis for developing restraint reduction education programs. Korean national leaders and nursing homes should develop and employ practice guidelines regarding restraints, support nursing staff to follow the guidelines, provide more practical and professional education, employ alternative equipment, use a multidisciplinary team approach, and engage volunteers in care support as well as employ more nursing staff to achieve restraint-free care.