Use of physical restraints. 1: consequences

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.

Nurses' knowledge, attitudes and practices related to physical restraint: a cross-sectional study

AIM

To investigate nurses' knowledge, attitudes and practices related to physical restraint in tertiary hospitals and identify the factors that influence physical restraint use.

BACKGROUND

Physical restraint is used to maintain patient safety. Nurses play an important role in the restraint process. It is important to identify their understanding, feelings and approach regarding the use of physical restraint.

INTRODUCTION

Physical restraint is widely practiced in hospitals in China. However, it results in a range of serious negative consequences. This article provides a clear description of nurses' knowledge, attitudes and practices related to physical restraint.

METHODS

A cross-sectional survey was conducted. The participants were asked to complete a questionnaire examining their knowledge, attitudes and practices related to physical restraint use. A total of 200 questionnaires were distributed in four tertiary hospitals in Hubei Province, China between August and October 2014.

RESULTS

The nurses' responses indicated a good level of knowledge regarding physical restraint use. However, they held some misconceptions. The nurses' attitudes towards physical restraint tended to be neutral. The nurses were well experienced in the use of physical restraint. Nurses who had received on-the-job training performed better than those who had received no training related to knowledge and practices regarding physical restraint use.

CONCLUSIONS AND IMPLICATION FOR NURSING/HEALTH POLICY

In-service training is highly recommended for nursing managers to improve nurses' physical restraint related knowledge and practices. Regulations regarding the use of restraints should be established as soon as possible by healthcare administration system.

IMPLICATIONS FOR NURSING

Nurses should be open to evaluate and improve their views and attitudes regarding effective physical restraint use via multidimensional interventions.

Nurses’ perceptions of the use of restraint in pediatric somatic care

Background:

The interest in the children’s role in pediatric care is connected to children’s health-related autonomy and informed consent in care. Despite the strong history of children’s rights, nurses’ role in the everyday nursing phenomenon, that is, restraint in somatic pediatric care, is still relatively seldom reported.

Aim:

The aim of this study is to describe nurses’ perceptions of the use of restraint in somatic pediatric care. The ultimate aim is to deepen the understanding of the phenomenon of restraint, whose previous study has been fragmented.

Methods:

Qualitative approach was selected because of the lack of previous information. Due to the sensitivity of the research question, individual interviewees were selected among voluntary nurses (n = 8). All participants were registered nurses with general work experience as nurses of 5–16 years on average and specifically 1.5–10 years in pediatric nursing. Inductive content analysis was used for aiming to produce a synthesis of the research phenomenon.

Ethical considerations:

The research received organizational approval by the university hospital, and informed consent and confidentiality were ensured.

Results:

Restraint in pediatric nursing was process-like, but occurred without advanced planning. The restraint-related process included five categories: (a) identification of the situations where restraint may occur, (b) finding preventive methods, (c) identification of different forms of restraint, (d) rationing the use of restraint, and (e) post-restraint acts. Restraint was seen as a part of pediatric nursing which occurred daily and involved several professionals. According to the nurses’ illustrations, restraint means doing things even when a child is not agreeable.

Conclusion:

Restraint is part of somatic pediatric nursing, described as the last, but in some cases, the only resort for carrying out care or treatment. Restraint is not a goal in itself, but an instrumental tool and procedure in carrying out care. In the future, more information about nurses’ role and the use of restraint in pediatric nursing is still needed.

[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.

Use of physical restraint in institutional elderly care in Finland: perspectives of patients and their family members

The purpose of this qualitative study was to describe the use of physical restraint and the perspectives of elderly patients and their family members on the use of physical restraint in long-term institutional care. Data were collected in three elderly care units through participant observation and theme interviews. The results revealed that in addition to traditional means of restraint, such as restraint belts and raising the sides of the bed, the nursing staff used indirect methods of restraint as well. These included a mode of operation that promoted passivity, such as removing the patient's mobility aid and keeping the patient inadequately clothed. The results also revealed that the patients felt so unsafe in the nursing environment that they voluntarily locked themselves in their rooms. Another interesting finding was that patients' family members were active in restraint situations. The study findings provide information that can be applied in the development of long-term institutional care.

Child Restraint in the Acute Setting of Pediatric Nursing: An Extraordinarily Stressful Event

Lack of clarity regarding when or how to use restraint in pediatric nursing is in direct contrast to international legislation and children's rights activists, who continuously support increased safeguards to protect children and improved health-care services for children. The aim of this article is to present a review of available literature with the purpose of stimulating discussion on the topic of this extraordinarily stressful event in the lives of hospitalized children and their parents. Studies for this literature review were identified using library catalogues and computerized searches of the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Mbase, psychLIT, and Medline. Keywords used included restraint, immobilisation, acute restraint, child restraint, p(a)ediatric restraint, and elderly restraint. The majority of the articles reviewed were secondary sources that advocated awareness and encouraged the use of restraint alternatives when managing the care of a child during a procedure. The results of the review accentuates the dearth of research in relation to the use of restraints in pediatric nursing, and highlights the need for pediatric nurses and allied health-care professionals to explore this sensitive topic further. By failing to address these issues, it could be argued that researchers in child health are ignoring an extraordinarily stressful event in pediatric health care.

Overcoming Restraint Use: EXAMINING BARRIERS IN AUSTRALIAN AGED CARE FACILITIES

The purpose of this article is to discuss the outcomes of a project that sought to identify alternatives to restraint use in aged care facilities. (In Australia, the term aged care facility refers to those facilities previously known as hostels and nursing homes.) A literature review was conducted and discussion forums and individual interviews were held with interested stakeholders in Australian capital cities, as well as in a rural city in each state. Site visits were conducted at 16 aged care facilities. Participants identified legal concerns, existing organizational culture, and lack of alternatives as barriers to implementing restraint-minimization practices. Recommendations to facilitate minimal restraint are implementing national policy guidelines, adopting a best practice philosophy in relation to restraint minimization, continuing staff education related to alternatives, and maintaining constant communication with families.

Of human bondage. Dealing with vulnerable patients in theatre

The ethical dilemmas surrounding the use of physical and chemical restraint in the acute care arena are highlighted in project work currently in progress within the University Hospital Birmingham NHS Trust. The impetus for this work has emerged from a multidisciplinary group of trust colleagues who are attempting to develop guidelines for good practice in this area. Their work relating to the theatre setting has been presented at the RCN Critical Care Conference and is outlined in this article.

Mesures de contrôle en milieu psychiatrique : trois perspectives pour en guider la réduction, voire l’élimination

Cet article présente dans un premier temps, le contexte dans lequel se situent les orientations ministérielles en matière de mesures de contrôle en psychiatrie telles la contention et l’isolement. Les auteurs exposent les connaissances concernant l’utilisation et la réduction des mesures et proposent trois perspectives pour en guider la réduction et l’élimination. La première perspective est orientée vers le contrôle de l’agir violent, la seconde, guidée par une meilleure compréhension de l’expérience vécue par les acteurs impliqués dans l’agir violent. La troisième perspective proposée par les auteurs est dirigée vers l’intégration du traumatisme comme expérience et prend en compte les différentes dimensions du cycle de la violence auquel contribuent les mesures de contrôle. Enfin, les auteurs concluent sur des pistes d’intervention pour réduire, sinon éliminer les mesures de contrôle en psychiatrie.

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

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

Constructive risk in the care of the older adult: a concept analysis

There is much talk within health care at present of the need to manage risk; indeed, it is a cornerstone of the Government's clinical governance policy (Department of Health (DOH), 1998). However, by only concentrating on the dangers associated with risk, the positive effects engendered in the process of taking calculated risk. By analyzing risk as a constructive concept, particularly in the care of the older adult, it is possible to not only identify those attributes that define the phenomenon, but also explore the necessary antecedents and consequences of pursuing this approach to care. Using the work of Walker and Avant (1998), model cases are used to illustrate how the concept may be recognized in practice.

Use of physical restraints on elderly patients: an exploratory study of the perceptions of nurses in Hong Kong

A qualitative study was designed to explore nurses' perceptions of the use of physical restraints on elderly patients in Hong Kong. Content analysis of semi-structured interviews with 20 registered nurses working in medical and geriatric settings of two regional hospitals revealed that although nurses generally had mixed feelings about the use of physical restraints on elderly patients, they did not question this 'routine' practice and their knowledge about the consequences and alternatives to the use of restraint was limited. It was found that nurses had an overriding concern in ensuring elderly patients' physical safety and using restraints therefore provided them with a sense of security. The deleterious impact of restraint on the care received by elderly patients was largely unrecognized. Implications for practice and future studies are discussed in the light of these findings.

Breaking loose. Use of physical restraints in nursing homes in Queensland, Australia

A survey was completed by 123/203 (61%). Directors of Nursing of Queensland's nursing homes, to obtain information about the use of physical restraints. Of a total of about 6500 (4693 females; 1807 males) nursing home residents in Queensland, Australia, 23.6% (1536) were reported to have been physically restrained at the time the survey was completed. Of this group, females comprised 72.9% (1120) and males 27.1% (416). The commonest forms of physical restraint were bedrails (38.2%) and restraining belts (23.7%). The commonest patient-oriented reason for using physical restraints was to "prevent falls" (85.4%) and the commonest nurse-oriented reason was "because no alternative exists" (39.8%). The correlation between the size of nursing homes (bed numbers) and the number of residents was strong and positive, indicating that Queensland nursing homes were functioning at full capacity (r = 0.999, a = 0.05). The correlation between the size of nursing homes (bed numbers) and the number of residents who were physically restrained was weak and negative (r = 0.002, a = 0.05), suggesting that nursing home size did not predict the use of physical restraints. Correlations between the total number of staff, the total number of untrained staff (assistants in nursing) and the number of residents who were physically restrained were also weak (r = 0.0427; 0.0695 respectively; a = 0.05), suggesting that these factors also had little predictive influence on the use of physical restraints. The findings of this research indicate that the extent to which physical restraints are currently being used in nursing homes in Queensland should be of concern, particularly in the context of a general, contemporary professional belief that the use of physical restraints in nursing homes should be minimised, if not entirely avoided.

The use of restraint in the care of elderly patients

The use of physical and chemical restraint in elderly care settings to restrict mobility and control behaviour is not a new concept. However, until the 1980s, it was an area that was neglected in nursing research. In 1989, Evans and Strumpf carried out an extensive literature review on restraint in an attempt to consolidate the state of knowledge regarding its use in care of the elderly settings. This article aims to evaluate how far the discussion surrounding restraint has progressed since that time and in what direction. It also reviews the extent of restraint use and rationale for its application, the consequences of restraint and progress in developing alternatives.