Nurses' use of physical restraints in four Turkish hospitals

Nursing Ethical Decision Making on Adult Physical Restraint: A Scoping Review

OBJECTIVE

to map the existing knowledge on nursing ethical decision making in the physical restraint of hospitalised adults. (1) Background: physical restraint is a technique that conditions the free movement of the body, with risks and benefits. The prevalence of physical restraint in healthcare suffers a wide variation, considering the environment or pathology, and it raises ethical issues that hinders decision making. This article intends to analyse and discuss this problem, starting from a literature review that will provoke a grounded discussion on the ethical and legal aspects. Inclusion criteria are: studies on physical restraint (C) and ethical nursing decision making (C) in hospitalized adults (P); (2) methods: a three-step search strategy was used according to the JBI. The databases consulted were CINAHL Plus with Full Text (EBSCOhost), MEDLINE Full Text (EBSCOhost), Nursing and Allied Health Collection: Comprehensive and Cochrane Database of Systematic Reviews (by Cochrane Library, RCAAP and Google Scholar. All articles were analysed by two independent reviewers; (3) results: according to the inclusion criteria, 18 articles were included. The categories that influence ethical decision in nursing are: consequence of the decision, the context, the nature of the decision in terms of its complexity, the principles of the ethical decision in nursing, ethical issues and universal values; (4) conclusions: the findings of this review provide evidence that there is extensive knowledge regarding nursing ethical decision making in adult physical restriction, also, it is considered an ethical issue with many associated assumptions. In this article we aim to confront all these issues from a legal perspective.

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.

Hospital Restraints: Safe or Dangerous? A Case of Hospital Death Due to Asphyxia from the Use of Mechanical Restraints

Asphyxia can be defined as an impediment to the influx of air into the respiratory tract, leading to tissue hypoxia. By restraint, we mean the use of physical, pharmacological and/or environmental means to limit the subject's ability to move. Fall prevention is the main reason restraint is used. Unfortunately, restraint can sometimes be fatal. There are few studies in the literature on this subject. We report the case of a man with Down syndrome in a psychiatric clinic found dead between the bed and the floor of the room where he was hospitalized. The analysis of the scene showed the presence of a means of a restraint, located around the man's chest and neck, which kept him tied to the bed and applied a constricting mechanical action. There was doubt as to the cause of death. For this reason, an inspection of the scene and an autopsy were carried out. Upon opening the chest, blood infiltration of the left intercostal muscles that was topographically compatible with external cutaneous excoriation (sign of restraint) became evident. In view of the danger of using restraint, it is necessary to evaluate the means of restraint as an extraordinary and not an ordinary procedure in patient management. Each patient undergoing restraint measures must be carefully monitored by specialized personnel. Greater surveillance of the nurse/patient ratio is necessary to reduce the use of restraints. In this case report, we highlight the lack of surveillance of patients subjected to restraint.

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.

Use of Physical Restraints in Critical Care Units: Nurses' Knowledge, Attitudes, and Practices

BACKGROUND

Various factors affect the use of physical restraints in the intensive care unit, with nurses' knowledge and attitudes being the strongest determinants.

OBJECTIVE

To determine Turkish intensive care unit nurses' knowledge, attitudes, and practices regarding physical restraints and factors influencing them.

METHODS

This cross-sectional, correlational study was conducted in the intensive care units of state and university hospitals. A total of 191 nurses provided information on their sociodemographic and professional characteristics and completed a questionnaire on their knowledge, attitudes, and practices regarding physical restraints.

RESULTS

Statistically significant differences were found between average knowledge scores according to type of intensive care unit, weekly working hours, work shift, and frequency of using physical restraints, with the highest scores found in nurses who worked in the surgical unit, worked 40 hours a week, worked only during the day, and used physical restraints every day. Significant differences were found between average attitude scores according to type of intensive care unit, with the highest scores found in nurses who worked in the cardiology unit. Significant differences were found between average practice scores according to level of education and use of physical restraints without a physician's order, with the highest scores found in nurses with undergraduate and postgraduate degrees and those who did not use physical restraints without a physician's order.

CONCLUSIONS

This study revealed inadequate knowledge about physical restraints and some unsafe practices among participants. Evidence-based guidelines and laws regarding physical restraints are needed, as well as regular training programs for involved personnel.

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.

Interventions to reduce physical restraints in general hospital settings: A scoping review of components and characteristics

AIMS AND OBJECTIVES

To describe the characteristics of interventions for reducing physical restraints in general hospital settings.

BACKGROUND

Physical restraints, such as bedrails and belts in beds and chairs, are commonly used in general hospital settings. However, there is no clear evidence on their effectiveness but some evidence on potential risks for harm.

DESIGN

Scoping review.

METHODS

We conducted a systematic database search (MEDLINE via PubMed, CINAHL, Cochrane Library; March 2020) and snowballing techniques. We included both interventional studies and quality improvement projects conducted in general hospital settings and published in English or German language. Two reviewers independently performed the study selection and data extraction. The Scoping Reviews (PRISMA-ScR) Checklist was used.

RESULTS

We included 31 articles (published between 1989 and 2018), 15 quality improvement projects and 16 intervention studies. Only five studies used a controlled design. Most studies and quality improvement projects investigated multicomponent interventions including education (predominantly for nursing staff) and additional components (e.g. case conferences). Three studies examined simple educational programmes without additional components.

CONCLUSIONS

A large number of multicomponent interventions for preventing and reducing physical restraints in general hospital settings have been developed. The interventions differed widely regarding the components, contents and settings. Well-designed evaluation studies investigating the effects of such interventions are lacking.

RELEVANCE TO CLINICAL PRACTICE

Multicomponent educational interventions might be one approach to change clinical practice, but only insufficient information is available about potential effects of these approaches.

Predictors of New-Onset Physical Restraint Use in Critically Ill Adults

BACKGROUND

Physical restraints are frequently used for intensive care patients and are associated with substantial morbidity. The effects of common evidence-based critical care interventions on use of physical restraints remain unclear.

OBJECTIVE

To identify independent predictors of new-onset use of physical restraints in critically ill adults.

METHODS

Secondary analysis of a prospective cohort study involving 5 adult intensive care units in a tertiary care medical center in the United States. Use of physical restraints was determined via daily in-person assessments and medical record review. Mixed-effects logistic regression analysis was used to examine factors associated with new-onset use of physical restraints, adjusting for covariates and within-subject correlation among intensive care unit days.

RESULTS

Of 145 patients who were free of physical restraints within 48 hours of intensive care unit admission, 24 (16.6%) had restraints newly applied during their stay. In adjusted models, delirium (odds ratio [OR], 5.09; 95% CI, 1.83-14.14), endotracheal tube presence (OR, 3.47; 95% CI, 1.22-9.86), and benzodiazepine administration (OR, 3.17; 95% CI, 1.28-7.81) significantly increased the odds of next-day use of physical restraints. Tracheostomy was associated with significantly lowered odds of next-day restraint use (OR, 0.13; 95% CI, 0.02-0.73). Compared with patients with a target sedation level, patients who were in a coma (OR, 2.56; 95% CI, 0.80-8.18) or deeply sedated (OR, 2.53; 95% CI, 0.91-7.08) had higher odds of next-day use of physical restraints, and agitated patients (OR, 0.08; 95% CI, 0.00-2.07) were less likely to experience restraint use.

CONCLUSION

Several potentially modifiable risk factors are associated with next-day use of physical restraints.

The challenges of using physical restraint in intensive care units in Iran: A qualitative study

Background

Physical restraint is widely used in intensive care units to ensure patient safety, manage agitated patients, and prevent the removal of medical equipment connected to them. However, physical restraint use is a major healthcare challenge worldwide.

Aim

This study aimed to explore nurses' experiences of the challenges of physical restraint use in intensive care units.

Methods

This qualitative study was conducted in 2018-2019. Twenty critical care nurses were purposively recruited from the intensive care units of four hospitals in Tehran, Iran. Data were collected via in-depth semi-structured interviews, concurrently analyzed via Graneheim and Lundman's conventional content analysis approach, and managed via MAXQDA software (v. 10.0).

Findings

Three main themes were identified (i) organizational barriers to effective physical restraint use (lack of quality educations for nurses about physical restraint use, lack of standard guidelines for physical restraint use, lack of standard physical restraint equipment), (ii) ignoring patients' wholeness (their health and rights), and (iii) distress over physical restraint use (emotional and mental distress, moral conflict, and inability to find an appropriate alternative for physical restraint).

Conclusion

Critical care nurses face different organizational, ethical, and emotional challenges in using physical restraint. Healthcare managers and authorities can reduce these challenges by developing standard evidence-based guidelines, equipping hospital wards with standard equipment, implementing in-service educational programs, supervising nurses' practice, and empowering them for finding and using alternatives to physical restraint. Nurses can also reduce these challenges through careful patient assessment, using appropriate alternatives to physical restraint, and consulting with their expert colleagues.

The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-Behavioral Intervention Package

BACKGROUND

Invasive interventions can produce fear, anxiety, and pain in children. This may negatively affect the children's treatment and care.

AIM

This study was conducted to determine the effects of procedural restraint (PR) and cognitive-behavioral intervention package (CBIP) on venipuncture pain in children between 6-12 years of age.

DESIGN

Quasi-experimental study.

SETTINGS

The study was conducted in the pediatric blood collection service of the hospital in Turkey between October 1, 2015, and April 1, 2016.

PARTICIPANTS/SUBJECTS

The population of the study consisted of children admitted to the blood collection service during the study period who met the inclusion criteria.

METHODS

The children included in the study were divided into two groups. Group 1 (n = 31) received PR in accordance with routine clinical practice. Group 2 (n = 30) received the CBIP. The data were collected by the researchers using a questionnaire, the visual analog scale (VAS), and the Wong-Baker FACES (WB-FACES) Pain Rating Scale.

RESULTS

The children in the PR group had a mean VAS score of 5.90 ± 3.22 and a mean WB-FACES score of 8.70 ± 2.22. The children in the CBIP group had a mean VAS score of 2.43 ± 2.02 and a mean WB-FACES score of 2.80 ± 2.49. A statistically significant difference was found between the mean VAS and WB-FACES pain scores of the groups (p < .05).

CONCLUSIONS

The results of this study showed that the children in the CBIP group had a lower pain level during venipuncture compared to those restrained for the procedure.

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.

Physical restraining: Nurses knowledge and practice in Tertiary Care Hospital of Eastern Nepal

AIM

The aim was to assess the level of knowledge and practice on physical restraints.

DESIGN

A descriptive cross-sectional study design was adopted.

METHODS

A total enumerative sampling technique was used to select 117 nurses working in ICU, medical wards, psychiatric ward and emergency unit of Tertiary Care Hospital, Nepal. After obtaining written consent from each participant, self-administered questionnaires on socio-demographic profile, knowledge and practice about physical restraints were distributed.

RESULTS

Most nurses (55.6%) were from age group of 18-25 years. Most of the participants (82.1%) had completed their Diploma Nursing, and 33.3% of the nurses were working in the ICU. Maximum of the participants (74.4%) had previous exposure to physical restraints. In knowledge of physical restraints, the score of 52.1% showed above the median range (Median [IQR] = 43 [54-30]). In the case of practice, 54.7% of the nurses showed adequate practice (mean = 80.1, SD 7.7).

The effect of physical restraint on neurovascular complications in intensive care units

BACKGROUND

To reduce the neurovascular complications caused by physical restraint in intensive care patients, there is a need to examine the occurrence of neurovascular complications and their rate.

OBJECTIVES

The objective of this research was to investigate the effect of physical restraint on the occurrence of neurovascular complications and their rate.

METHODS

A prospective observational cohort study was carried out. A total of 90 patients from anaesthesia and internal intensive care units participated in this study. Patients were assessed at intervals of 24 h for 4 days using the following instruments: Individual Characteristics Form, Richmond Agitation-Sedation Scale (RASS), Behavioral Pain Scale, and Complication Diagnostic Diary.

RESULTS

Redness (p < 0.001), limb movement (p < 0.001), oedema (p < 0.001), and colour complication (p < 0.001) increased, whereas pulse strength (p < 0.001) decreased in physically restrained sites on the arm from day 1 to day 4. Redness was increased in patients physically restrained with all types of materials (p < 0.001; p < 0.001; p = 0.020). Although there was a statistically significant difference in terms of movement (p = 0.006; p = 0.003) and oedema (p < 0.001; p < 0.001), both with a roll of gauze and tough cuff, these complications were not significantly different in patients restrained with green foam tie (p > 0.05). According to logistic regression analysis, material type, position of the limb, space between the physical restraint and limb, age, RASS, and pain were independent risk factors for neurovascular complications. RASS and pain were independent protective factors against movement complications.

CONCLUSIONS

The duration of physical restraint increases neurovascular complications. This study revealed that nurses did not regularly check the restrained wrist and did not focus on the peripheral circulation. It is necessary to develop training programs, standards, and appropriate follow-up strategies in intensive care units in Turkey.

Analysis of a nurses' knowledge survey on the use of physical restraint in intensive care units

OBJECTIVES

To determine nurses' knowledge level regarding physical restraint use in intensive care units and its associated factors.

METHOD

A cross-sectional multicentre study was carried out in 12 critical care units of 8 hospitals in Spain (n=354 nurses). An 'ad-hoc' knowledge survey was developed, and their content was validated by experts. The survey obtained a test-retest stability of ICC=.71 (95% CI: .57-.81) in a previous pilot study. A final 8-item tool was designed. Sociodemographic and professional variables from the participants were collected; as well as structural and clinical variables from the units analyzed. A descriptive and association analysis between variables was performed. A p-value <.05 was deemed statistically significant.

RESULTS

Two hundred and fifty nurses answered the survey (70.62%). Mean age of the participants was 36.80 (SD 9.54) with 10.75 (SD 8.38) years of professional experience in critical care. Seventy-three point six percent had never received previous training about physical restraints. Knowledge mean value was 4.21 (SD 1.39) (range 0-8). Knowledge level was associated with the referral hospital (p<.001). Nurses with a higher knowledge level are more likely to work in units with informed consent sheets for physical restraint use (p<.001); flexible family visiting (p<.001); analgo-sedation protocol (p=.011), and units in which nurses had autonomy to manage analgo-sedation (p<.001). Individual sociodemographic and professional data was not associated with knowledge level.

CONCLUSIONS

Further training regarding physical restraint use is needed for critical care nurses. The work environment where nursing care is given has a great influence on nurses' knowledge level about this intervention.

The Conditions for Ethical Application of Restraints

Despite the lack of evidence for the effectiveness of physical restraints, their use in patients is widespread. The best ethical justification for restraining patients is that it prevents them from harming themselves. We argue that even if the empirical evidence supported their effectiveness in achieving this aim, the use of restraints would nevertheless be unethical, so long as well-known exceptions to informed consent fail to apply. Specifically, we argue that ethically justifiable restraint use demands certain necessary and sufficient conditions. These conditions are that the physician obtained informed consent for their application, that their application be medically appropriate, and that restraints be the least liberty-restricting way of achieving the intended benefit. It is a further question whether their application is ever medically appropriate, given the dearth of evidence for their effectiveness.

Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles

CONTEXT

The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods.

EVIDENCE ACQUISITION

This review was conducted by searching "Violence," "Aggression," and "workplace violence" keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review.

RESULTS

Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint.

CONCLUSION

In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.

Nurses' Information, Attıtude and Practices towards Use of Physical Restraint in Intensive Care Units

Introduction: Physical restraint may seem to be a useful and simple procedure to help the treatment but is a complex practice including physical, psychological, judicial, ethical and moral issues. Research was made on description basis in order to determine the knowledge, attitude and application levels of nurses working in critical care units about physical restraint applied on patients. Methods: The study was performed as a descriptive and correlation study. Working in ICUs, 158 nurses constituted the sampling. "Levels of Knowledge, Attitudes and Practices of Staff Regarding Physical Restraints Questionnaire" was used to collect data. Results: For information, attitude and practice scores, participants' scores were 7.1(1.7), 31.8 (4.6) and 36.6 (3.2), respectively. No association was found between information subscale, and age, professional years, working time in ICUs and weekly working hours. However, for attitude subscale, a negative and weak association was found between age (r=-0.229) and professional years (r=-0.174), and increasing these variables decreased attitude score. No association was found between attitude score, and working time in ICUs and weekly working hours. While there was no association between practice score, and age, professional years and working time in ICUs, the increase in weekly working hours (r=-0.243) was found to decrease practice score, and this association was found weak. Conclusion: In conclusion, we consider nurses' level of information is sufficient, but attitudes and practice were not at a positive level. It is recommendable that out of such conditions, novel approaches should be developed to decrease the use of physical restraint.

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.

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 restraint in hospital patients: A descriptive study in a tertiary hospital in South Africa

Background

The use of physical restraint in patient management is a common and emotive issue, and has legal and ethical dimensions.

Objective

To document the prevalence of physical restraint use, patient characteristics associated with physical restraint use, and nurses’ and doctors’ knowledge and perceptions towards the practice.

Methods

A cross-sectional study of 572 patients, of whom 132 were physically restrained, was conducted in acute wards of a tertiary hospital. Data were collected on the 132 physically restrained patients. Fifty-nine doctors and 159 nurses completed a specially constructed questionnaire. Descriptive statistics were derived and expressed as numbers and percentages.

Results

Prevalence of restraint use was 23% (132/572). The distribution in acute wards was: medical 54.5%; surgical 44.7%; maternity 0.8%; psychiatry none. Mean age (SD) of the restrained patients was 49 years (20.5); 53.8% were male. The commonest types of restraints used were bed rails 93% and wrist belts 12%. Restraints were used largely to protect medical devices and as protection from harm. Less than 15% of the nurses reported having received training and 36% of the doctors reported having received some guidance on the use of restraints. Only a minority of nurses and doctors knew of a hospital policy on restraint use. Documentation on the prescription and indication for the use of restraint was poor.

Conclusion

Prevalence of restraint use is high and poorly coordinated. A policy on the use of restraint and comprehensive guidelines should be developed to guide health care practitioners in the management of patients where restraint cannot be avoided.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life: An Analysis of Data from the BEACON Trial

BACKGROUND

The use of physical restraints in dying patients may be a source of suffering and loss of dignity. Little is known about the prevalence or predictors for restraint use at end of life in the hospital setting.

OBJECTIVE

The objective was to determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults.

METHODS

Secondary analysis was performed on data from the "Best Practices for End-of-Life Care for Our Nation's Veterans" (BEACON) trial conducted between 2005 and 2011. Medical record data were abstracted from six Veterans Administration Medical Centers (VAMCs). Data on processes of care in the last seven days of life were abstracted from the medical records of 5476 who died in the six VAMCs. We prospectively identified potential risk factors for restraint use at the time of death from among the variables measured in the parent trial, including location of death, medications administered, nasogastric tube, intravenous (IV) fluids, family presence, and receipt of a palliative care consultation.

RESULTS

Physical restraint use at time of death was documented in 890 decedents (16.3%). Restraint use varied by location of death, with patients in intensive settings being at higher risk. Restraint use was significantly more likely in patients with a nasogastric tube and those receiving IV fluids, benzodiazepines, or antipsychotics.

CONCLUSIONS

This is the first study to document that one in six hospitalized veterans were restrained at the time of death and to identify predictors of restraint use. Further research is needed to identify intervention opportunities.

Nurses' perceptions and practice of physical restraint in China

BACKGROUND

There is controversy concerning the use of physical restraint. Despite this controversy, some nurses still consider the application of physical restraint unavoidable for some of their clients.

AIM

Identify the perceptions and practice of physical restraint in China.

RESEARCH DESIGN

This was a descriptive study that combined qualitative interviews with a quantitative cross-sectional survey.

PARTICIPANTS

A total of 18 nurses were interviewed and 330 nurses were surveyed.

ETHICAL CONSIDERATIONS

Approval of the study was obtained from the hospital ethics committee. Permission to conduct the study was obtained from the director of nursing. Participants were assured that their participation is voluntary.

RESULTS

Physical restraint was commonly used to protect patients' safety. Naturally, intensive care unit nurses used physical restraint much more frequently than general medical/surgical ward nurses (p < 0.01). In addition, night shift nurses tended to use physical restraint more frequently.

CONCLUSION

Nursing managers should be aware of the role nurses play in the use of physical restraint. In-service training regarding the proper use of physical restraint should be strengthened and nurse staffing levels should be improved in order to minimize the use of physical restraint in China.

Examination of ethical dilemmas experienced by adult intensive care unit nurses in physical restraint practices

Nurses are more likely to face the dilemma of whether to resort to physical restraints or not and have a hard time making that decision. This is a descriptive study. A total of 55 nurses participated in the research. For data collection, a question form developed by researchers to determine perceptions of ethical dilemmas by nurses in the application of physical restraint was used. A descriptive analysis was made by calculating the mean, standard deviation, and maximum and minimum values. The nurses expressed (36.4%) having difficulty in deciding to use physical restraint. Nurses reported that they experience ethical dilemmas mainly in relation to the ethic principles of nonmaleficence, beneficence, and convenience. We have concluded that majority of nurses working in critical care units apply physical restraint to patients, although they are facing ethical dilemmas concerning harm and benefit principles during the application.

Contextual influences on nurses' decision-making in cases of physical restraint

BACKGROUND

In order to fully understand nurses' ethical decision-making in cases of physical restraint in acute older people care, contextual influences on the process of decision-making should be clarified.

RESEARCH QUESTIONS

What is the influence of context on nurses' decision-making process in cases of physical restraint, and what is the impact of context on the prioritizing of ethical values when making a decision on physical restraint?

RESEARCH DESIGN

A qualitative descriptive study inspired by the Grounded Theory approach was carried out.

PARTICIPANTS AND RESEARCH CONTEXT

In total, 21 in-depth interviews were carried out with nurses working on acute geriatric wards in Flanders, Belgium.

ETHICAL CONSIDERATIONS

The research protocol was approved by the Ethics Committee of the Faculty of Medicine, Leuven.

FINDINGS

Relationships with nursing colleagues and the patient's family form an inter-personal network. Nurses also point to the importance of the procedural-legal context as expressed in an institutional ethics policy and procedures, or through legal requirements concerning physical restraint. Furthermore, the architectural structure of a ward, the availability of materials and alternatives for restraint use can be decisive in nurses' decision-making. All interviewed nurses highlighted the unquestionable role of the practical context of care. Context can have a guiding, supportive, or decisive role in decision-making concerning the application of physical restraint.

DISCUSSION

The discussion focuses on the role of the inter-personal network of nurses on the process of decision-making.

CONCLUSION

An institutional ethics policy and a value-supportive care environment can support nurses in their challenge to take ethically sound decisions.

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.

Practices used in Israel by nurses who care during hospitalization for older patients with dementia or who are bedridden

The study's purpose was to examine (a) bedside nurses' care practices when providing care to patients with dementia or those who are physically disabled and (b) the extent to which these actions vary by type of hospital, type of ward, and nurse's characteristics. The sample included 265 nurses in internal medicine and geriatric wards in 2 general hospitals in Israel. The results showed that the most prevalent practices were giving greater attention to these patients, locating them in a room near the nurses' station and asking family members to stay with the patient or to hire paid carers. Use of restraints was more prevalent in patients with dementia than those who were physically disabled. Use of specific practices significantly varied by type of ward and hospital, suggesting that nurses' care practices are more connected with organizational characteristics than other factors.

Public sector residential aged care: identifying novel associations between quality indicators and other demographic and health-related factors

Objective To explore associations among quality indicators (QI; e.g. pressure ulcers, falls and/or fractures, physical restraint, use of multiple medications, unplanned weight loss) of the Victorian Public Sector Residential Aged Care Services (VPSRACS) with other demographic and health-related factors. Methods Data for 380 residents over a 3-month period were extracted retrospectively from client databases at four VPSRAC facilities. Results Four significant logistic regression models were developed. The strongest models related to falls and polypharmacy. Significant associations for these models included the following: (1) residents with a higher body mass index were 6% less likely (95% confidence interval (CI) 1%–11%) to fall, whereas high levels of cognitive impairment increased the risk of falling by 8% (95% CI 2%–14%); (2) being ambulant with a gait aid more than doubled the risk of falling compared with non-ambulant residents (95% CI 19%–546%); and (3) higher cognitive impairment was associated with a 6% (95% CI 1%–11%) reduction in the likelihood of polypharmacy. Conclusions Identification of significant relationships between the VPSRACS QI and other demographic and health-related factors is a preliminary step towards a more in-depth understanding of the factors that influence the QI and predict adverse events. What is known about the topic? Currently, the VPSRACS report on five QI. Previous research has shown associations between several of these indicators, but not all. What does this paper add? This paper examines associations between the five VPSRAC QI as well as other key demographic and health-related factors. Novel findings from regression analyses included an increased risk of falls associated with recommended body mass index and using gait aids, but no association between pressure ulcers and the Norton score. Regression models for other QI were limited by the small occurrences of the QI. However, significant associations were identified indicating that residents using a gait aid had a lower level of unplanned weight loss and residents with polypharmacy had higher unplanned weight loss. What are the implications for practitioners? This paper reinforces the value of collecting VPSRAC QI data to enable facilities to consider how these variables could impact on care quality and to proactively plan to reduce the risk of adverse events. Although QI data can be used to benchmark with other settings, this paper shows how QI data can be used to inform practice within a facility and help identify patient-related factors that may warrant further investigation.

Morbidity and mortality associated with the utilization of restraints : a review of literature

Use of physical restraints remains a highly controversial topic. Even with proven efficacy in restraint usage across multiple settings, for years, investigators have debated whether or not the risks outweigh the benefits. There is a growing concern regarding restraints-related negative consequences. Although over the past two decades, with new regulations, education and training, there has been a reduction in the prevalence of restraint episodes, morbidity and mortality are still disconcerting. Given this subject remains an issue today, a more up-to-date review of available literature is warranted. This article reviews the current literature surrounding the utilization of restraints that has been published over last 10 years with particular emphasis on restraints-related adverse outcomes. The vast amount of literature during the past decade demonstrates an increased awareness in potential dangers, as well as highlights new areas of research in restraint utilization. Despite the proliferation of studies, there continues to remain a lack of evidence from prospective studies that would elucidate the dangers from theory to practice.

Physical Restraint Usage at a Teaching Hospital

This mixed method study examines the prevalence of restraint usage; perception of nurses and doctors about the practice and whether they were trained to apply physical restraints. The physical restraint prevalence tools were used to observe 172 adult patients and conduct 47 chart audits in the medical-surgical wards and a psychiatric unit in November 2011. Focus group discussions with nurses and doctors were conducted. Quantitative data were analyzed using the SPSS and focus group discussions thematically analyzed. The prevalence of physical restraints between the medical-surgical wards was 75%. Nurses and medical doctors were not formally trained to apply restraint, and had learnt from peer observation. They expressed sadness, guilt, and fear when restraints are used and identified that inadequate institutional support existed. Restraint usage was high, and nurses and doctors experienced moral dilemma when they perceived that lack of formal training and inadequate institutional support may contribute to patient injury.

Physical restraints practice in adult intensive care units in Egypt

Physical restraints are commonly used in intensive care units to reduce the risk of injury and ensure patient safety. However, there is still controversy regarding the practice of physical restraints in such units. The purpose of this study was to investigate the practices of physical restraints among critical care nurses in El-Mansoura City, Egypt. The study involved a convenience sample of 275 critically ill adult patients, and 153 nurses. Data were collected from 11 intensive care units using a "physical restraint observation form" and a "structured questionnaire." The results revealed that physical restraint was commonly used to ensure patient safety. Assessment of physical restraint was mainly restricted to peripheral circulation. The most commonly reported physically restrained site complications included: redness, bruising, swelling, and edema. The results illustrated a lack of documentation on physical restraint and a lack of education of patients and their families about the rationale of physical restraint usage. The study shed light on the need for standard guidelines and policies for physical restraint practices in Egyptian intensive care units.

[Physical restraint use in critical care units. Perceptions of patients and their families]

INTRODUCTION

The use of physical restraints in Intensive Care Units (ICU) is common although little is known about patients' and relatives' perceptions of this use.

OBJECTIVES

1) To analyze the prevalence and use of physical restraints in a general adult ICU; 2) to know the perceptions of patients who experienced use of physical restraints and; 3) to know the perceptions of relatives of patients who used physical restraints.

METHODS

This descriptive study, which used both quantitative and qualitative methods, was carried out in an adult ICU. For the first objective, all the patients (101) who had used any kind of physical restraint were analysed. For the second and third objectives, 30 patients and 30 relatives were interviewed using the guidelines of Strumpf & Evans as modified by Hardin (1993). All interviews were recorded, fully transcribed and then submitted to a language content analysis using the method of Hsieh & Shannon.

RESULTS

The only physical restraint used was the wrist restraint with a prevalence of 43.47%. Seventy-two percent of patients wore the restraint ≤12h and 28%>12h. Analysis of the patient interviews revealed 4 main themes: acceptance of the restraint conditioned by beliefs and information provided; feelings and sensations caused by the use of the restraint; alternatives proposed and future repercussions. Three themes emerged from the interviews with relatives: impressions caused by the use of the restrictions; reasons for accepting or rejecting them; alternatives to the use of restraints.

CONCLUSIONS

Most patients used physical restraints for a short period of time and only the wrist restraint was used. Patients using physical restraints and their relatives expressed a wide range of feelings and sensations, with no negative future repercussions. In general, they agreed with the use of restraints although more precise information would lead to greater acceptance.

Care needs of older patients in the intensive care units

AIMS

To explore the care needs of older patients in the intensive care units. Background.  As the numbers of older patients admitted to the intensive care units are growing, care quality of critically ill older patients has become an important issue. However, there are few studies directly investigating perceived care needs of hospitalised older patients and the studies on care needs of older patients in the intensive care units are even fewer. The identification of care needs from older patients' perspective will help develop qualified nursing practice.

DESIGN

A qualitative exploratory design.

METHODS

Purposive sampling was performed to recruit 35 older patients from three hospitals in Taiwan. The interview transcripts were analysed by qualitative content analysis.

RESULTS

The results revealed that care needs of older patients in the intensive care units are multidimensional, including physical, informational and psychosocial dimensions. Older patients' needs of the physical dimension included relieving pain and discomfort, starting oral intake as soon as possible and having continuous sleep. Informational needs included adequate explanations about their disease progression and prognosis and information on recovery-promoting activity. Psychosocial needs included caring behaviour of intensive care units staff, flexible visiting hours, increase in control ability and maintenance of good communication with intensive care units staff.

CONCLUSION

The findings can assist nurses in understanding the interventions necessary to meet care needs of critically ill older patients. The critically ill older adults need more than medical-technical care. They need more holistic care. The psychosocial and informational needs must be considered commensurate with the presenting physical needs.

RELEVANCE TO CLINICAL PRACTICE

Nurses have an important role in meeting intensive care units older patients' care needs. Intensive care units nurses should conduct comprehensive assessment regarding older patients' needs at the beginning and at various points in their intensive care units stay and match these needs with appropriate nursing interventions.

[Safety problems associated with using physical restraint devices on the elderly]

The use of physical restraint devices on frail elderly could have significant negative consequences on their health. Apart from complications due to prolonged immobility, the use of this procedure is associated with other serious adverse effects which occur when a person is restricted in a position which carries a risk of asphyxiation. The devices most implicated in these incidents are bedrails, vests and restraining belts. Physical restraint could also be associated as much with the sudden death of patients, due to the stress that it causes, as with injuries from falling. This article presents the recommendations which experts, manufacturers and institutions dealing with the quality of health care have issued for the safest use of this procedure. It stresses the need for better training of professionals, as well as the importance of investigating the factors which can lead to accidents with the aim of preventing them.

Nurses' physical restraint knowledge, attitudes, and practices: the effectiveness of an in-service education program

BACKGROUND

Physical restraints are commonly used to reduce treatment interference risk and protect patient safety. However, nurses still hold misconceptions about the use of physical restraints in acute care settings. Teaching nursing staff accurate knowledge and proper skills, cultivating positive attitudes, and rectifying irregularities in physical restraint use are all necessary to improve patient care.

PURPOSE

The aim of this study was to examine the effectiveness of a short-term in-service education program in improving nurses' knowledge, attitudes, and self-reported practices related to physical restraint use.

METHODS

Convenience sampling was used in this quasi-experimental study at two different branches of one hospital in southern Taiwan. The two branches were randomly assigned as either the intervention or control group. Fifty-nine nurses at one branch were assigned to the intervention group, and 70 nurses in the other branch were assigned to the control group. The developed 90-minute in-service education program was given to nurses in the intervention group. The questionnaire included demographic data and three scales (Knowledge of Physical Restraint Use, Attitudes of Physical Restraint Use, and Practice of Physical Restraint Use). These scales were used to measure critical study variables prior to and 2 weeks after the intervention.

RESULTS

Results found a significant improvement in the intervention group in terms of knowledge (p = .000), attitudes (p = .007), and self-reported practices (p = .048) related to physical restraint use after program completion. However, there were no significant differences in participant attitudes toward the use of physical restraints between intervention and control groups after program completion. CONCLUSIONS AND IMPLICATIONS FOR PRACTICES: Physical restraint knowledge and skills improved after the 90-minute in-service education program. Findings highlight the need to provide a short-term in-service education program on physical restraint use in acute care settings.