A further exploration of the use of physical restraints in hospitalized patients

Nursing practice with hospitalised older people: Safety and harm

BACKGROUND

Nursing teams work with hospitalised older people in institutions, which prioritise a biomedical model of care. This model does not fit the needs of older people because it emphasises efficacy and a narrow definition of patient safety, but does not prioritise functional needs. Nursing care is provided around the clock within the context of fiscal restraints as well as negative societal and nursing perspectives about ageing and old people. Yet, nursing perceptions of managing safety and potential harms to older patients within these hospital institutions are not well understood.

METHODS

An integrative review was conducted to examine nursing perspectives of safety and harm related to hospitalised older people.

RESULTS

The majority of included papers focused on restraint use. Findings reveal that nurses are using restraints and limiting mobility as strategies to manage their key priority of keeping older patients safe, reflecting a narrow conceptualisation of safety. Policy, administrative support and individual nurse characteristics influence restraint use. Safety policies that nurses interpret as preventing falls can encourage the use of restraints and limiting mobility, both of which result in functional losses to older people.

CONCLUSIONS

This complex issue requires attention from clinical nurses, leaders, policy makers and researchers to shift the focus of care to preservation and restoration of function for older people in hospital as a safety priority.

IMPLICATIONS FOR PRACTICE

Clinical leaders and nursing teams should engage in developing processes of care that incorporate maintaining and restoring older people's function.

Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review

Background: Determining the clinical effects of coercion is a difficult challenge, raising ethical, legal, and methodological questions. Despite limited scientific evidence on effectiveness, coercive measures are frequently used, especially in psychiatry. This systematic review aims to search for effects of seclusion and restraint on psychiatric inpatients with wider inclusion of outcomes and study designs than former reviews. Methods: A systematic search was conducted following PRISMA guidelines, primarily through Pubmed, Embase, and CENTRAL. Interventional and prospective observational studies on effects of seclusion and restraint on psychiatric inpatients were included. Main search keywords were restraint, seclusion, psychiatry, effect, harm, efficiency, efficacy, effectiveness, and quality of life. Results: Thirty-five articles were included, out of 6,854 records. Studies on the effects of seclusion and restraint in adult psychiatry comprise a wide range of outcomes and designs. The identified literature provides some evidence that seclusion and restraint have deleterious physical or psychological consequences. Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions. Effectiveness and adverse effects of seclusion and restraint seem to be similar. Compared to other coercive measures (notably forced medication), seclusion seems to be better accepted, while restraint seems to be less tolerated, possibly because of the perception of seclusion as "non-invasive." Therapeutic interaction appears to have a positive influence on coercion perception. Conclusion: Heterogeneity of the included studies limited drawing clear conclusions, but the main results identified show negative effects of seclusion and restraint. These interventions should be used with caution and as a last resort. Patients' preferences should be taken into account when deciding to apply these measures. The therapeutic relationship could be a focus for improvement of effects and subjective perception of coercion. In terms of methodology, studying coercive measures remains difficult but, in the context of current research on coercion reduction, is needed to provide workable baseline data and potential targets for interventions. Well-conducted prospective cohort studies could be more feasible than randomized controlled trials for interventional studies.

Effectiveness of bedrails in preventing falls among hospitalized older adults: a systematic review

BACKGROUND

Falls are a major problem today affecting adults of any age, but the elderly are a population that is more susceptible to falls. Falls are the leading cause of injury or death among older adults. Hospitalized older people are particularly vulnerable to falls. Falls cause direct injuries (minor injuries, severe wounds of the soft tissues and bone fractures) to patients and increased length of stay. The prevention of falls is commonly considered an indicator of the quality of care. Therefore, health institutions and professionals treat the identification and implementation of strategies to prevent or minimize their effects as a high priority. Fall prevention interventions involving physical restraints are still common and considered a primary preventative measure, despite controversy in their use. One of the most frequently used restraint interventions is bedrails. The question of the effectiveness of bedrails in preventing falls cuts across all societies and cultures and has with significant implications for the clinical practice of nurses.

OBJECTIVES

The objective of this review was to identify the effectiveness of the use of bedrails in preventing falls among hospitalized older adults when compared with no use of bedrails or any type of physical restraints.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered studies that included hospitalized adults (female and male), 65 years and over with any clinical condition in a non-intensive care unit (ICU).

TYPES OF INTERVENTION(S)

The current review considered studies that evaluated the use of bedrails as a restraint to prevent falls among older adults in non-ICUs compared to no use of bedrails or any type of physical restraints, for example, bedrails versus no bedrails, and bedrails versus no wrist or ankle ties.

TYPES OF STUDIES

The current review considered any randomized controlled trials (RCTs). In the absence of RCTs, other research designs such as non-RCTs, before and after studies, cohort studies, case-control studies, descriptive studies, case series/reports and expert-opinion were considered.

OUTCOMES

The current review considered studies that included primary outcomes (number of patients who fell or the number of falls per patient) and secondary outcomes (number of head trauma, bone fractures or soft tissue injuries).

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished articles. A three-step search strategy was utilized in 13 databases. Articles published in Portuguese, English and Spanish beginning from 1980 were considered for inclusion.

METHODOLOGICAL QUALITY

Assessment of methodological quality was not conducted as no articles were identified that met the inclusion criteria.

DATA EXTRACTION AND DATA SYNTHESIS

Data extraction and synthesis was not performed, because no articles were included in this systematic review.

RESULTS

The search identified a total of 875 potentially relevant articles. Sixteen articles were identified through the reference lists of all identified articles. One hundred and thirteen full-text papers were assessed by two independent reviewers to determine eligibility. However, 11 articles were not found (despite all the efforts), and 102 articles did not meet the inclusion criteria.

CONCLUSION

There is no scientific evidence comparing the use of bedrails in preventing falls among hospitalized older adults to no use of bedrails or any type of physical restraints.

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.

Physical Restraints: Consensus of a Research Definition Using a Modified Delphi Technique

OBJECTIVES

To develop an internationally accepted research definition of physical restraint.

DESIGN

Comprehensive literature search followed by a web-based, three-round, modified Delphi technique comprising reviews and feedback.

SETTING

Clinical care settings.

PARTICIPANTS

An international group of 48 experts consisting of researchers and clinicians from 14 countries who have made sustained contribution to research and clinical application in the field of physical restraint in clinical care.

MEASUREMENTS

Data were collected using an online survey program and one in-person meeting. Results of the online survey and the in-person meeting were used for distribution in subsequent rounds until consensus on a definition was reached. Consensus was defined as 90% of the participating experts agreeing with the proposed definition of physical restraint.

RESULTS

Thirty-four different definitions were identified during the literature search and served as a starting point for the modified Delphi technique. After three rounds, 45 (95.7%) of 47 remaining experts agreed with the newly proposed definition: "Physical restraint is defined as any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to his/her body by the use of any method, attached or adjacent to a person's body that he/she cannot control or remove easily."

CONCLUSION

A multidisciplinary, internationally representative panel of experts reached consensus on a research definition for physical restraints in older persons. This is a necessary step toward improved comparisons of the prevalence of physical restraint use across studies and countries. This definition can further guide research interventions aimed at reducing use of physical restraints.

Outcomes of nighttime physical restraint removal for severely impaired nursing home residents

There is ample evidence that physical restraint reduction does not lead to increased falls or injuries. This study tests the effect of removing nighttime restraints by comparing two groups: Restrained in bed at pre- but not postintervention (n = 51), or restrained in bed at both pre- and post-intervention (n = 11). No differences in nighttime fall rates between the two groups were detected.

Nighttime physical restraint removal does not lead to increases in falls from bed in older nursing home residents. Although markedly reduced in nursing homes, restraint use remains a common practice among hospitalized older adults. We should continue to focus efforts on developing new, individualized approaches to reduce risk of falling from bed among frail elders.

Changes in Attitudes Toward Restraints Among Nursing Home Staff and Residents' Families Following Restraint Reduction

Changes in attitudes toward using physical restraints, and the benefits of restraint elimination were examined by interviewing 161 staff and 153 family members of residents in four long-term care facilities before and afterformal restraint reduction programs were instituted. The four sites were divided into two groups: one group was composed of two sites that had initiated restraint reduction prior to this study, while the other group initiated restraint reduction as a result of this study. Both groups experienced statistically significant declines in restraint prevalence rates from pre- to posttest. Although both staff and families cited fewer reasons for using restraints from pre- to posttest, staff along with families of previously restrained residents, did not perceive increased benefits to residents or their relatives following restraint reduction. Restraint reduc tion, therefore, could lead to an acceptance of nursing practices that emphasize dignity even without an accompanying perception of improvement in relatives' or residents'daily lives.

Physical restraint use and older patients' length of hospital stay

In both acute care and residential care settings, physical restraints are frequently used in the management of patients, older people in particular. Recently, the negative outcomes of physical restraint use have often been reported, but very limited research effort has been made to examine whether such nursing practice have any adverse effects on patients' length of stay (LOS) in hospitals. The aim of this study was to examine the association between physical restraint use on older patients during hospitalization and their LOS. Medical records of 910 older patients aged 60 years and above admitted to one of the Hong Kong public hospitals in 2007 were randomly selected and recorded during July to September 2011. The recorded items included patients' general health status, physical and cognitive function, the use of physical restraints, and patients' LOS. Hierarchical regression analysis was conducted to analyze the data. The results indicated that older patients' general health status, physical, and cognitive function were important factors affecting their LOS. Independent of these factors, the physical restraint use was still significantly predictive of longer LOS, and these two blocks of variables together served as an effective model in predicting older patients' LOS in the hospital. Since physical restraint use has been found to be predictive of longer hospital stay, physical restraints should be used with more caution and the use of it should be reduced on older patients in the hospital caring setting. All relevant health care staff should be aware of the negative effects of physical restraint use and should reduce the use of it in hospital caring and nursing home settings.

Level of agitation of psychiatric patients presenting to an emergency department

OBJECTIVES

The primary purpose of this study was to determine the level of agitation that psychiatric patients exhibit upon arrival to the emergency department. The secondary purpose was to determine whether the level of agitation changed over time depending upon whether the patient was restrained or unrestrained.

METHOD

An observational study enrolling a convenience sample of 100 patients presenting with a psychiatric complaint was planned, in order to obtain 50 chemically and/or physically restrained and 50 unrestrained patients. The study was performed in summer 2004 in a community, inner-city, level 1 emergency department with 45,000 visits per year. The level of patient agitation was measured using the Agitated Behavior Scale (ABS) and the Richmond Agitation-Sedation Scale (RASS) upon arrival and every 30 minutes over a 3-hour period. The inclusion criteria allowed entry of any patient who presented to the emergency department with a psychiatric complaint thought to be unrelated to physical illness. Patients who were restrained for nonbehavioral reasons or were medically unstable were excluded.

RESULTS

101 patients were enrolled in the study. Of that total, 53 patients were not restrained, 47 patients were restrained, and 1 had incomplete data. There were no differences in gender, race, or age between the 2 groups. Upon arrival, 2 of the 47 restrained patients were rated severely agitated on the ABS, and 13 of 47 restrained patients were rated combative on the RASS. There was a statistical difference (p = .01) between the groups on both scales from time 0 to time 90 minutes. Scores on the agitation scales decreased over time in both groups. One patient in the unrestrained group became unarousable during treatment.

CONCLUSION

This study demonstrated that patients who were restrained were more agitated than those who were not, and that agitation levels in both groups decreased over time. Some restrained patients did not meet combativeness or severe agitation criteria, suggesting either that use of other criteria is needed or that restraints were used inappropriately. Further study of the level of agitation and the effects of restraints is needed.

The effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes: a systematic review

BACKGROUND

Physical restraint was introduced as the primary measure to maintain patient safety in preventing falls. However, physical restraints may lead to complications such as functional loss, immobility, delirium, pressure sore, and even falls or injuries. Despite all these negative effects and many alternatives that are available, physical restraint is still commonly used in hospitals and nursing homes. Hence, it is crucial to understand the effectiveness of physical restraints in protecting adult patients from falling.

OBJECTIVE

The overall objective was to examine the effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes.

INCLUSION CRITERIA

This review considered quantitative designs, including randomised controlled trials, quasi-experimental studies, cohort studies, case control studies and case series/reports.The participants of this review were male and female adult patients aged 18 years or over who are on authorized physical restraints in acute care hospitals and nursing homes.This review focused on studies that investigated physical restraint as an intervention for reducing falls among adults in acute care hospitals and nursing homes.The outcomes of interest were the number of individuals receiving restraints who fall, or the rate or number of falls in acute hospitals and nursing homes.

SEARCH STRATEGY

A three-step search strategy was utilised in this review. An initial limited search of MEDLINE and CINAHL was undertaken, followed by a second search using all identified keywords and index terms across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. All searches were limited to English Language studies and there was no limit in the timeframe.

ASSESSMENT OF METHODOLOGICAL QUALITY

The quality of the included studies was subjected to assessment by two independent reviewers using the standardised critical appraisal tools from the Joanna-Briggs Institute from the JBI-MAStARI (Joanna Briggs Institute-Meta-Analysis of Statistics Assessment and Review Instrument).

DATA EXTRACTION

Data was extracted from included papers using the standardised extraction tool from the JBI MASTARI.

DATA SYNTHESIS

Due to the heterogeneous nature of the study methods, the findings of this review are presented in a narrative summary.

RESULTS

Nine studies were included in the review. The majority of the findings showed that physical restraints were not associated with the reduction in falls and decreased restraint use did not contribute to more falls.

CONCLUSION

From the overall results, physical restraints are not effective in reducing falls or injuries among adults in acute care hospitals and nursing homes.National standards and application guides for physical restraints are recommended. The use of physical restraints should be assessed by trained staff based on individualised need and consideration of patient's autonomy and integrity. The awareness of appropriate physical restraint usage should be enhanced among the healthcare professionals.Large multicentre research to determine the risk and benefit ratio of physical restraints and to examine the effectiveness of alternative measures, different number of bedrails, intermittent restraint use and restraint reduction programs are needed respectively.

Physical restraint use and falls in nursing homes: a comparison between residents with and without dementia

AIMS

To estimate the use of different types of physical restraints and assess their associations to falls and injuries among residents with and without Alzheimer's disease (AD) or dementia in US nursing homes.

METHODS

Data were from the 2004 National Nursing Home Survey. AD or dementia was identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. Analyses were conducted with the Surveyfreq and Surveylogistic procedures in SAS v.9.1.

RESULTS

Residents with either AD or dementia were more likely to be physically restrained (9.99% vs 3.91%, P < .001) and less likely to have bed rails (35.06% vs 38.43%, P < .001) than those residents without the disease. The use of trunk restraints was associated with higher risk for falls (adjusted odds ratio [AOR] = 1.66, P < .001) and fractures (AOR = 2.77, P < .01) among residents with the disease. The use of full bed rails was associated with lower risk for falls among residents with and without the disease (AOR = 0.67 and AOR = 0.72, Ps < .05, respectively).

CONCLUSIONS

The use of a trunk restraint is associated with a higher risk for falls and fractures among residents with either AD or dementia.

Perspectives on the experience of being physically restrained: an integrative review of the qualitative literature

Publications providing information on the safe use of physical restraints, guidelines for restraint use, and journal articles on the care of mental health patients are frequently devoid of information regarding patients' perspectives on physical restraint. As physical restraint is a common procedure in many settings, the purpose of this review is to examine and summarize the qualitative literature on patients' perspectives on being physically restrained, from 1966 through to 2009. A formal integrative review of existing qualitative literature on patients' perspectives of physical restraint was conducted. Studies were critiqued, evaluated for their strength, and analysed for key themes and meanings. Twelve studies were ultimately identified and included in the review. Four themes emerged from the review, including negative psychological impact, retraumatization, perceptions of unethical practices, and the broken spirit. While little qualitative research on patients' perceptions of physical restraint exists, findings within the current literature reveal serious implications for patients and nurses alike. Additional research into physical restraint implications for the patient-nurse dyad is needed, and nurses should approach the use of physical restraint with caution and awareness of their potential psychological impact.

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

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

A Longitudinal Evaluation of Restraint Reduction within a Multi-site, Multi-model Canadian Continuing Care Organization

Bien que la documentation américaine sur la réduction de l'usage des moyens de contention soit relativement importante, les travaux de recherche publiés sur cette même question sont moins nombreux sur les pensionnaires d'un établissement canadien de soins de longue durée. Les statistiques des plus importants établissements de ce type financés et exploités au Canada ont mis au jour des attitudes révélatrices envers les moyens mécaniques de contention. Durant les quatre années d'une étude comportant une campagne visant à réduire l'utilisation de moyens mécaniques de contention, la prévalence organisationnelle est passée de 24,68 % à 16,01 %. Il existait une variabilité substantielle en matière de contention parmi les 11 centres de l'organisation (échelle de 0 à 39,86 % des pensionnaires faisant l'objet de contention) et tous sauf un ont pu réduire la contention mécanique. Des facilitateurs particuliers à la réalisation et au maintien de la réduction de la contention sont indiqués, notamment les établissements de petite taille, la fourniture de soins spécialisés (par ex., maladie d'Alzheimer), et un «champion» résidant sur place. Des obstacles particuliers, comme la grande taille d'un établissement et un champion résidant à l'extérieur font aussi l'objet de discussion.

Prevalence and Variation of Physical Restraint Use in Acute Care Settings in the US

PURPOSE

To describe physical restraint (PR) rates and contexts in U.S. hospitals.

DESIGN

This 2003-2005 descriptive study was done to measure PR prevalence and contexts (census, gender, age, ventilation status, PR type, and rationale) at 40 randomly selected acute care hospitals in six U.S. metropolitan areas. All units except psychiatric, emergency, operative, obstetric, and long-term care were included.

METHODS

On 18 randomly selected days between 0500 and 0700 (5:00 am and 7:00 am), data collectors determined PR use and contexts via observation and nurse report.

FINDINGS

PR prevalence was 50 per 1,000 patient days (based on 155,412 patient days). Preventing disruption of therapy was the chief reason cited. PR rates varied by unit type, with adult ICU rates the highest obtained. Intra- and interinstitutional variation was as high as 10-fold. Ventilator use was strongly associated with PR use. Elderly patients were over-represented among the physically restrained on some units (e.g., medical) but on many unit types (including most ICUs) their PR use was consistent with those of other adults.

CONCLUSIONS

Wide rate variation indicates the need to examine administratively mediated variables and the promotion of unit-based improvement efforts. Anesthetic and sedation practices have contributed to high variation in ICU PR rates. Determining the types of units to target to achieve improvements in care of older adults requires study of PR sequelae rate by unit type.

Evidence-based treatment of psychiatric patient

There is controversy concerning the proper treatment of psychiatric patients in the emergency department. Emergency physicians commonly use physical or chemical restraints or both in the course of treating psychiatric patients. This review applies the rigors of an evidence-based evaluation of the literature concerning the choices of treatment for these patients.

Minimizing the use of restrictive devices in dementia patients at risk for falling

The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.

Physical restraint use among nursing home residents: A comparison of two data collection methods

Background

In view of the issues surrounding physical restraint use, it is important to have a method of measurement as valid and reliable as possible. We determined the sensitivity and specificity of physical restraint use a) reported by nursing staff and b) reviewed from medical and nursing records in nursing home settings, by comparing these methods with direct observation.

Methods

We sampled eight care units in skilled nursing homes, seven care units in nursing homes and one long-term care unit in a hospital, from eight facilities which included 28 nurses and 377 residents. Physical restraint use was assessed the day following three periods of direct observation by two different means: interview with one or several members of the regular nursing staff, and review of medical and nursing records. Sensitivity and specificity values were calculated according to 2-by-2 contingency tables. Differences between the methods were assessed using the phi coefficient. Other information collected included: demographic characteristics, disruptive behaviors, body alignment problems, cognitive and functional skills.

Results

Compared to direct observation (gold standard), reported restraint use by nursing staff yielded a sensitivity of 87.4% at a specificity of 93.7% (phi = 0.84). When data was reviewed from subjects' medical and nursing records, sensitivity was reduced to 74.8%, and specificity to 86.3% (phi = 0.54). Justifications for restraint use including risk for falls, agitation, body alignment problems and aggressiveness were associated with the use of physical restraints.

Conclusions

The interview of nursing staff and the review of medical and nursing records are both valid and reliable techniques for measuring physical restraint use among nursing home residents. Higher sensitivity and specificity values were achieved when nursing staff was interviewed as compared to reviewing medical records. This study suggests that the interview of nursing staff is a more reliable method of data collection.

A study into the use of restraint in nursing homes in Norway

The aim of this study was to describe the reasons for the use of restraint, the decision-making procedure for their use and the documentation of their use in Norwegian nursing home units. Structured interviews were carried out with the carers of 1362 patients in 160 regular nursing home units and 564 patients in 91 special care units for people with dementia. The reasons given for the use of restraint were to protect the patient or others, and to carry out necessary care or treatment. The main reason for the use of force or pressure in medical treatment was non-compliance of the patient. The nurse in charge (44%, n = 670) or a carer (13%, n = 201) most frequently decided that restraint should be used. In 65% (n = 892) of all the instances of restraint, no documentation was found in the patients' records. It was concluded that routines for quality assurance for decision-making about, and the documentation of, the use of restraint are lacking in Norwegian nursing homes.

Physical restraint use in a Korean ICU

This descriptive study investigated the patterns of use of physical restraints in a Korean Intensive Care Unit (ICU) with the aim of identifying the factors that would best discriminate the times of application and removal of restraints in the same patients. The subjects of the study were 23 physically restrained patients out of 51 patients who were admitted to a medical ICU in a university hospital admitted during a 6-week period, and the 29 nurses who applied or removed the restraints. Ninety-four incidents of restraint application and removal on the 23 patients were analysed. Data were collected using a self-reporting questionnaire of attitudes towards restraint application for nurses, restraint document sheets, ICU flowsheets and patient chart reviews. Restraint-related patient data were collected on a restraint document sheet by the nurse in charge at each instance of application and removal of restraint. The most common type of restraint was the bilateral wrist restraint. The mean number of restraint applications per patient was 3.62 +/- 3.56 (mean +/- SD), and the mean restrained period per incident was 22.64 +/- 58 hours. There were no significant differences in the frequency of restraint use during the day, evening and night shifts. The most significant discriminators for restraint application and removal were the restless-behaviour score and the presence of a nasogastric tube - the classification accuracy by these two factors was 70.2%. More than 90% of the decisions to apply restraints were made by nurses. Nurses reported that preventing the patient from removing medical devices (48.6%) was the primary reason for application, and improvement of cognitive status (29.3%) was the primary reason for removal of restraint. In conclusion, as the most discriminating factor of application or removal of restraints was the patient's restless behaviour, providing nurses with tools for the accurate evaluation of patient restlessness will shorten restraint application periods in ICUs.

Organizational characteristics and restraint use for hospitalized nursing home residents

OBJECTIVES

To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.

DESIGN

Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents.

SETTING

Eleven medical and surgical units in one 600-bed teaching hospital.

PARTICIPANTS

One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.

MEASUREMENTS

Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient-registered nurse (RN) ratio, patient-total nursing staff ratio, and skill mix.

RESULTS

Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient-RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38-2.68, P <.001; weekend day and patient-total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37-2.66, P <.001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37-2.67, P <.001).

CONCLUSION

Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.

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

PURPOSE

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

CONCLUSIONS

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

IMPLICATIONS

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

A prospective study of the complication rate of use of patient restraint in the emergency department

Patients are frequently involuntarily, physically restrained in the emergency department (ED). The purpose of this study was to determine the type and rate of complications experienced by patients physically restrained in the ED. A prospective, observational study was performed on consecutive patients who were restrained in a community, inner-city teaching hospital ED for a 1-year period. The ED nurses or physicians completed a restraint study checklist. The checklist included the reasons for restraints, restraint duration, method and number of restraints, use of chemical restraint, and complications resulting from the use of restraints. The 298 patients were accumulated during a 1-year period. The mean age was 36.5 years (range 14-89). Sixty-eight percent were men; 73% were African-Americans, 16% Hispanic, and 11% Caucasian. One hundred six patients had more than one indication for patient restraint. Patients were restrained for a mean of 4.8 h (range 0.2-25.0 h), with psychosis being the most frequent discharge diagnosis (33%). Patients were most frequently restrained on a cart with two restraints (59%), in the supine position (86%), and 27.5% had chemical restraint added. There were 20 complications (7%); getting out of restraints was the most common (10) and the remainder included vomiting (3), injured others (2), spitting (2), injured self (1), increased agitation (1), and other (1). These complications were not correlated with age, gender, race, number of restraints, use of chemical restraint, diagnosis, or duration of restraint. This study demonstrates a low rate of minor complications. We found that male patients were most often restrained for violent and disruptive behavior. Most commonly, two restraints were used in combination with chemical restraints for a duration of almost 5 h.

Change in the rate of restraint use and falls on a psychogeriatric inpatient unit: impact of the health care financing administration's new restraint and seclusion standards for hospitals

This chart review of 767 patients treated on a psychogeriatric inpatient unit over a 2-year period examined the impact of the Health Care Financing Administration's (HCFA) new restraint standards for hospitals on the rate of restraint use and falls. There was a marked decrease in the number of restraint episodes in the year after the introduction of the new standards compared with the year before (44 vs 212 restraint episodes per 1,000 patient-days). However, no notable differences were found in the number of total falls (18 vs 21 falls per 1,000 patient-days) or serious falls (2 vs 1 serious fall per 1,000 patient-days). If replicated, these findings of decreased restraint use without a concomitant increase in the number of falls demonstrate a change in practice patterns as a result of HCFA's action.

Patient injury and physical restraint devices: a systematic review

OBJECTIVE

To investigate physical restraint-related injuries. Areas of interest were the prevalence of injury, types of injuries, risk of sustaining an injury and specific restraint devices associated with injury.

DEFINITIONS

Injury in the context of this review was considered to be either direct injury, such as lacerations and strangulation, or indirect injury considered to be an adverse outcome such as increased mortality rates or duration of hospitalization.

METHOD

A comprehensive search was undertaken that involved all major databases and the reference list of all relevant papers. To be included in the review studies had to involve people in acute or residential care settings and report data related to injury caused by restraint devices. A number of different types of research designs were included in the review. The findings of studies were pooled using odds ratio and narrative discussion.

RESULTS

The search identified 11 papers reporting the findings of 12 observational studies. These studies were supplemented with the findings of a number of other types of studies that reported restraint-related data. The review highlights the potential danger of using physical restraint in acute and residential health care facilities. Observational studies suggest that physical restraint may increase the risk of death, falls, serious injury and increased duration of hospitalization. However, there is little information to enable the magnitude of the problem to be determined.

DISCUSSIONS

Many of the findings highlight the urgent need for further investigation into the use of physical restraint in health care facilities. Further research should investigate the magnitude of the problem and specific restraint devices associated with injury. However, given the limited nature of the evidence, this association should be investigated further using rigorous research methods.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

DISCUSSION

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

Reasons for physically restraining patients and residents: a systematic review and content analysis

OBJECTIVE

The purpose of this systematic review was to determine why people are physically restrained in the acute and residential care settings.

METHOD

A comprehensive search was undertaken of electronic databases to identify studies addressing the reasons for using physical restraint. Findings were synthesised using content analysis.

RESULTS

Twenty-three studies were identified. The most common reason for using restraints related to patient-oriented issues such as ensuring the safety of people. However, they are also commonly used to facilitate treatment, maintain the social environment and because of issues such as understaffing.

Restraint use, restraint orders, and the risk of falls in hospitalized patients

OBJECTIVES

To determine the relationship between physical restraints and falls in the acute hospital setting.

DESIGN

Matched case-control study.

SETTING

Inpatients at a 528-bed, urban, community based, acute care hospital.

PARTICIPANTS

Two hundred twenty-eight patients who fell during hospitalization and 228 controls matched to cases by nursing unit and length of stay.

MEASUREMENTS

Persons who fell were systematically evaluated at the time of fall by trained fall evaluators. For the cases, we sought to validate "orders for restraints" using "observed restraint use," defined as the use of restraints at the time of fall as determined through direct observation or interviews with nursing staff.

RESULTS

Patients with orders for restraints were more likely to fall than patients without orders for restraints (multivariate relative risk = 6.3, 95% confidence interval (CI) = 1.8-22.3). However, in the cases, there was poor correlation between "orders for restraints" and "observed restraint use" at the time of fall (kappa = 0.15, 95% CI-0.4-0.34).

CONCLUSION

Because orders for restraint use may not reflect actual restraint use at the time of a fall, observational studies relating use of restraints to the risk of falls should be interpreted with caution. Despite this caveat, we could find no evidence that restraints protect hospitalize patients from falling.

Perceptions regarding the use of physical restraints with elderly persons: comparison of Israeli health care nurses and social workers

In view of the difficulty involved in decision-making regarding the use or removal of physical restraints and the recent pattern encouraging the use of interdisciplinary teams for elder care issues, the present study compared the perceptions of Israeli nurses and social workers in health care settings regarding the use of physical restraints. Data were collected from a convenience sample of 50 nurses and 69 social workers working in long-term and acute care settings. The findings indicated that participants in all professions attributed moderate to low importance towards the use of physical restraints. Social workers' perceptions were similar to those of nurses in psychiatric hospitals and slightly more favourable to the use of physical restraints than those of nurses in nursing homes. Patients' safety (as reflected in the scores of the items related to protecting an older person from falling and protecting an older person from pulling out a catheter) was the most important reason for using physical restraints for both groups. Increased attention should be given to the role of social workers as team members in the process of decision-making regarding the use or removal of physical restraints, especially as mediators between the elderly person, family members and staff members.

Outcomes following physical restraint reduction programs in two acute care hospitals

BACKGROUND

Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities.

METHODS

The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists.

RESULTS

Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event.

DISCUSSION

Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns.

SUMMARY

Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.

Staffing and pattern of mechanical restraint use across a multiple hospital system

BACKGROUND

In an effort to enhance patient safety in acute care settings, governmental and regulatory agencies have established initiatives aimed at limiting the use of mechanical restraints. Concurrently, hospital staffing levels are undergoing changes raising concerns about the impact these changes may have on restraint use. No studies to date have described the impact these two initiatives have had on restraint use in acute care hospitals.

OBJECTIVES

To determine across a multiple hospital system: (a) the rates, frequencies, duration, and timing of restraint use, and (b) the relationship between restraint use and staffing.

METHODS

This was a secondary analysis of prospective, observational data from a large outcomes database for 10 acute care hospitals. Monthly data were obtained from 94 patient care units for periods ranging from 1-12 months for a total of 566 cumulative months during 1999.

RESULTS

The system restraint application duration rate (total restraint hours/total possible hours) was 2.8% (hospital ranges: 0.3-4.4%). More restraints were applied on night shifts (48.8%; n = 5,296) than on day (33.5%; n = 3,634) or evening shifts (17.7%; n = 1,926) (p < .0001) and most applied at midnight (31.7%; n = 3,441) followed by 0600-0900 (33.3%; n = 3,614). There was a weak positive relationship between staffing and restraint use (r = 0.276, p = .0001) at the system level and units with higher staffing levels also had higher baseline restraint use (p < .0001).

CONCLUSIONS

Restraint frequency, duration, and timing may have been altered by recent initiatives, and there is beginning evidence that differences exist between community, rural, and tertiary hospitals. While there is a weak positive relationship between higher staffing and restraint use at the system and unit level, further exploration of the influence of other factors, specifically patient acuity, are in order. The finding of unit variability and consistent restraint application times provides a starting point for further quality initiatives or research interventions aimed at restraint reduction.

Nursing staff members' intentions to use physical restraints with older people: testing the theory of reasoned action

AIM OF THE STUDY

To examine nursing staff members' attitudes, subjective norms, moral obligations and intentions to use physical restraints, using the Theory of Reasoned Action (TRA).

RATIONALE

During the last two decades an extensive body of research has examined nurses' attitudes as one of the main factors affecting the decision to use or not to use physical restraints with older persons. However, no studies have examined empirically the antecedents to nurses' intentions to use physical restraints within a theoretically based framework.

METHOD

A correlational design was used with 303 nursing staff members from an 800-bed elder care hospital in central Israel. Participants completed a questionnaire including questions based on the TRA as well as socio-demographic and professional characteristics.

RESULTS

Regression analyses found attitudes, subjective norms and moral considerations to be significantly associated to intention to use physical restraints with older people. The TRA explained 48% of the variance in nurses' intentions.

CONCLUSIONS

The TRA proved to be a useful framework for examining nurses' intentions to use physical restraints. Nurses' attitudes, beliefs and expectations of significant others should be examined before implementing educational programmes regarding the use of physical restraints.

Nurses' use of restraints and their attitudes toward restraint use and the elderly in an acute care setting

A descriptive correlation study was conducted in an acute-care hospital to explore the relationship between nurses' use of restraints and their attitudes toward restraint use and the elderly. A total of 201 nurses returned a questionnaire that collected demographic information and included two research instruments: (i) Perceptions of Restraint Use Questionnaire and (ii) Attitudes toward the Aged Semantic Differential. Results showed slightly positive attitudes towards the elderly and toward the use of restraints, although there was no correlation between scores on the two scales. Furthermore, nurses' attitudes did not predict their self-reported use of restraints.

Differences in nursing homes with increasing and decreasing use of physical restraints

OBJECTIVES

This article examines the organizational characteristics of nursing homes associated with increasing and decreasing use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA) in 1991.

METHODS

Nationally representative data from the 1992 and 1997 On-Line Survey Certification of Automated Records are used first to provide descriptive analyses and second for multinomial logistic regression analyses of organizational factors associated with an increase or decrease in physical restraint use.

RESULTS

The results show that 2,331 nursing homes increased their use of restraints by >4% and 2,100 decreased their use of restraints by >3%. Ownership, Alzheimer's special care units, and average occupancy rates have bidirectional influence and are associated with both decreases and increases in restraint use, depending on their values. Chain membership and staffing levels of rehabilitation services are associated with increases in restraint use, whereas Medicaid census and private-pay census are associated with decreases in restraint use. Change factors were also important. An increase in Medicaid census and a change to chain membership since 1991 have an unsettling effect on care practices, increasing restraint use.

CONCLUSIONS

Although the period used in this analysis represents a time frame in which the restraint reduction mandates of the NHRA were in effect, these results show that some nursing homes have increased their use of physical restraints. The organizational characteristics of these nursing homes differ from those that decreased their use of physical restraints.

Using a best practice approach to prevent treatment interference in critical care

Treatment interference, also known as therapy disruption, device disruption, or self extubation, is a common and especially difficult clinical problem in critical care. This paper presents creative and practical clinical innovations and relevant research findings as a "best practice approach" to prevent treatment interference in critical care settings. Key principles are presented to guide patient assessment and selection of nursing strategies. Nursing assessment parameters are described and a wide range of nonrestraint strategies are discussed.

Use of Physical Restraints on Hospitalized Psychogeriatric Patients

1. When making decisions about the use of physical restraints, minimizing the physical risk of patients was determined to be the most important obligation. 2. Nurses' understanding and consideration of important factors that influence restraint use are essential to its reduction. 3. Nurses should be aware of their ethical responsibilities to older patients and their families. They must ensure the patient's right to be informed and respect their dignity.

Preventing treatment interference: the nurse's role in maintaining technologic devices

BACKGROUND

Treatment interference, the disruption or self-removal of technologic devices, is a primary reason for application of physical restraints in acute and critical care settings. The processes of care surrounding treatment interference and the prevention of device disruption have not been comprehensively analyzed.

OBJECTIVES

To describe the processes used by critical care nurses to prevent treatment interference in critically ill older adults.

METHODS

Participant observation field research was conducted in medical and intermediate medical intensive care units. Data were analyzed by using the constant comparative method and event analysis.

RESULTS

Maintaining technologic devices is almost exclusively a nursing responsibility and involves the skillful assessment of patient awareness and trustworthiness and interpretation of behaviors. Critical care nurses are most protective of those devices for which accidental removal is perceived as life threatening: endotracheal tubes, arterial catheters, and central venous catheters. Nurses assess patients' cognitive status, mobility, strength, and trustworthiness, as well as device considerations such as replacement difficulty and device necessity. In addition to verbal strategies, such as explaining, nurses use distraction, deception, comfort measures, watchful family members, physical restraints, and sedation to prevent treatment interference.

CONCLUSION

This analysis considers the social context of the intensive care unit, including roles and the human-technology interaction. It illustrates the tremendous responsibility that nurses assume in maintaining technologic devices. Next steps in research and policy development are also considered.