Perceptions of older people who have experienced physical restraint

Experience of patients with restraints in acute care hospitals and the view of their relatives: A qualitative study

AIM

To describe the experiences of patients and relatives with any form of restraints in somatic acute care hospitals.

DESIGN

Qualitative explorative design.

METHODS

Qualitative research methods were used. Participants were recruited through clinical nursing specialists in participating departments of a university hospital between June and August 2020. Individual interviews were conducted and analysed using content analysis.

RESULTS

Four interviews with patients and five interviews with relatives were conducted with a mean duration of 25 min. The following three topics emerged in the analysis as important: What was perceived as restraints, Assessing the experiences of restraint use on a continuum, and Lack of information about restrictive measures. Patients and relatives defined restraint very broadly and assessed the experiences of restraint on a continuum from positive to negative, with a more critical view from patients. Relatives clearly seemed to approve of the use of restraints in acute care hospitals because it provided them with a sense of security. In general, there seemed to be a lack of information about the use of restraint and its effects on patients and relatives alike.

CONCLUSION

The involvement of patients and relatives in the decision-making process about restraint use seems to be low. Healthcare professionals need to be better educated to be able to pass on adequate information and to involve patients and their relatives adequately in all processes of restraint use. However, when relatives are involved in decision-making as proxies for patients, it is important to consider that patients' and relatives' opinions on restraints may differ.

PATIENT OR PUBLIC CONTRIBUTION

Patients and relatives agreed to participate in the study and shared their experiences with us.

Comprehensive Reform Urgently Needed in Hospital Shackling Policy for Incarcerated Patients in the United States

Approximately 2.2 million people are incarcerated in the United States. The carceral population is aging due to strict sentencing laws, which has increased the frequency and acuity of off-site medical care. Inpatient providers must follow departments of correction procedures when treating incarcerated patients, which often prevents adherence to standards of care and puts the health of patients at risk. Shackling is a common requirement during hospitalization and is associated with increased risk for complications. Current state and federal policies regarding shackling lack specifics to prevent patient harm. Incarcerated people have a constitutionally protected right to health care, but with current policy, we are not meeting this essential responsibility. Updates to policy are needed to ensure that patients receive compassionate, safe, and constitutionally mandated health care.

Restraint in a Neurosurgical Setting: A Mixed-Methods Study

OBJECTIVE

To investigate the extent to which restraint is used in neurosurgical care, under what circumstances, and how it is documented.

METHODS

A cross-sectional study with a mixed-methods approach was used to identify neurosurgical inpatients subjected to restraint. The data were collected in 2 phases: (1) a study-specific questionnaire was distributed to nurses in which they identified if restraints had occurred during their shifts, and if so, which restraint and to which patient; and (2) scrutinizing of electronic medical records of patients identified by the questionnaires. Numeric data were analyzed using descriptive and analytic statistical methods, and textual data were analyzed using qualitative content analysis. The findings from the different data sources were compared and merged.

RESULTS

Of the 517 patients admitted to the studied department during the study period, 58 (11%) were reported to have been subjected to restraint and most of the restraining events occurred in the neurointensive care unit. Most restraint measures were not documented in the electronic medical records. The identified patients were predominantly diagnosed with traumatic brain injury or subarachnoid hemorrhage. The qualitative content analysis showed the circumstances when restraints were used: when patients were considered a danger to self or others (theme) and which symptoms and behaviors (categories) were observed in relation to the use of restraint.

CONCLUSIONS

Restraint in neurosurgical care is mostly used to prevent patients from harming themselves or others. Because of the lack of documentation, restraint measures cannot be openly assessed, thus putting patients' safety at risk.

Alternatives to use of restraint: A path toward humanistic care

Restraint and seclusion are measures to restrict the movement of a person. The predominant reason cited for the use of restraint in mental health settings is the safety of the staff and the patient in times of aggression and to control problem behaviors. However, there have been significant issues in terms of ethics, rights of the patient, and the harmful effects of restraint. Recently, there has been a move in Western countries to decrease its use by incorporating alternative methods and approaches. In India, the Mental Healthcare Act of 2017 advocates the use of least restrictive measures and alternatives to restraint in providing care and treatment for person with mental illness. In this context, approach to restraints is all the more relevant. This article looks to overview the types of restraints, complications of restraints, and the alternatives to restraint in diverse settings.

Physical restraints and associations with neuropsychiatric symptoms and personal characteristics in residential care: a cross-sectional study

BACKGROUND

Physical restraints are widely used in residential care. The objective was to investigate restraint use and its associations with neuropsychiatric symptoms and personal characteristics in residential care.

METHODS

Data were collected in the South Savo Hospital District from 66 of 68 public or private institutions providing long-term residential care. Nurses assessed the use of physical restraints and neuropsychiatric symptoms (NPS) included in the symptom list of the Neuropsychiatric Inventory (NPI). Drug use was obtained from medical records, and activities of daily living (ADL) were assessed by the nurses according to the Barthel Index.

RESULTS

The total number of persons in residential care was 1386. Any restraint was used for 721 patients (52%) in the preceding 24 h. Bedrails were the most common restraints. In the multivariate analysis, psychotic symptoms (OR 1.94, 95% CI 1.14-3.31) and use of benzodiazepines (OR 1.69, 95% CI 1.18-2.41) were positively associated with restraint use, whereas antipsychotic (OR 0.62, 95% CI 0.44-0.87) and antidepressant drug use (OR 0.64, 95% CI 0.45-0.90) and higher ADL score (OR 0.9, 95% CI 0.92-0.93) were negatively associated. Concomitant use of at least two restraints was associated with high prevalence of hyperactivity NPS symptoms.

CONCLUSIONS

More than half of the residents were exposed to some physical restraint, most frequently bedrails, within the last 24 h. Psychotic symptoms and benzodiazepine use increased while good ADL and antipsychotic or antidepressant use decreased the risk of restraint use. Bedridden persons were the most frequently restrained which may pose an ethical problem. Copyright © 2016 John Wiley & Sons, Ltd.

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.

Restraint use in home care: a qualitative study from a nursing perspective

Background

Despite the growing demand for home care and preliminary evidence suggesting that the use of restraint is common practice in home care, research about restraint use in this setting is scarce.

Methods

To gain insight into the use of restraints in home care from the perspective of nurses, we conducted a qualitative explorative study. We conducted semi-structured face-to-face interviews of 14 nurses from Wit-Gele Kruis, a home-care organization in Flanders, Belgium. Interview transcripts were analyzed using the Qualitative Analysis Guide of Leuven.

Results

Our findings revealed a lack of clarity among nurses about the concept of restraint in home care. Nurses reported that cognitively impaired older persons, who sometimes lived alone, were restrained or locked up without continuous follow-up. The interviews indicated that the patient’s family played a dominant role in the decision to use restraints. Reasons for using restraints included “providing relief to the family” and “keeping the patient at home as long as possible to avoid admission to a nursing home.” The nurses stated that general practitioners had no clear role in deciding whether to use restraints.

Conclusions

These findings suggest that the issue of restraint use in home care is even more complex than in long-term residential care settings and acute hospital settings. They raise questions about the ethical and legal responsibilities of home-care providers, nurses, and general practitioners. There is an urgent need for further research to carefully document the use of restraints in home care and to better understand it so that appropriate guidance can be provided to healthcare workers.

The use of physical restraints in neurologic patients in the inpatient setting

Neurologists are commonly asked to make decisions concerning the use of physical restraints on hospitalized patients. These decisions are determined within the context of medical risk to the patient, including falls and the disruption of medical therapies (eg, self-extubation, removal of nasogastric tubes), risk to the caregivers, and the wishes of patients and their families. Familiarity with the medicolegal issues involved, including regulations of the local hospital and governmental agencies, as well as current evidence concerning the efficacy and harms that can occur with these interventions, is paramount to determining whether to use devices designed to restrict patients' freedom of movement in order to control their behavior.

Nurses' decision-making process in cases of physical restraint in acute elderly care: a qualitative study

BACKGROUND

The increasing vulnerability of patients in acute elderly care requires constant critical reflection in ethically charged situations such as when employing physical restraint. Qualitative evidence concerning nurses' decision making in cases of physical restraint is limited and fragmented. A thorough understanding of nurses' decision-making process could be useful to understand how nurses reason and make decisions in ethically laden situations.

OBJECTIVES

The aims of this study were to explore and describe nurses' decision-making process in cases of physical restraint.

DESIGN

We used a qualitative interview design inspired by the Grounded Theory approach. Data analysis was guided by the Qualitative Analysis Guide of Leuven.

SETTING

Twelve hospitals geographically spread throughout the five provinces of Flanders, Belgium.

PARTICIPANTS

Twenty-one acute geriatric nurses interviewed between October 2009 and April 2011 were purposively and theoretically selected, with the aim of including nurses having a variety of characteristics and experiences concerning decisions on using physical restraint.

RESULTS

In cases of physical restraint in acute elderly care, nurses' decision making was never experienced as a fixed decision but rather as a series of decisions. Decision making was mostly reasoned upon and based on rational arguments; however, decisions were also made routinely and intuitively. Some nurses felt very certain about their decisions, while others experienced feelings of uncertainty regarding their decisions.

CONCLUSIONS

Nurses' decision making is an independent process that requires nurses to obtain a good picture of the patient, to be constantly observant, and to assess and reassess the patient's situation. Coming to thoughtful and individualized decisions requires major commitment and constant critical reflection.

[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.

Belt restraint reduction in nursing homes: effects of a multicomponent intervention program

OBJECTIVES

To test the effects of a multicomponent intervention program to reduce the use of belt restraints in psychogeriatric nursing homes.

DESIGN

A quasi-experimental longitudinal design. Study duration was 8 months.

SETTING

Twenty-six psychogeriatric nursing home wards in 13 Dutch nursing homes were assigned to intervention or control groups.

PARTICIPANTS

Seven hundred fourteen residents were selected for participation. Legal representatives of 520 residents agreed on participation; complete data are available for 405 residents.

INTERVENTION

The intervention program included four major components: promotion of institutional policy change that discourages use of belt restraint, nursing home staff education, consultation by a nurse specialist aimed at nursing home staff, and availability of alternative interventions.

MEASUREMENTS

The primary outcome measure was the frequency of belt restraint use. Secondary outcomes included other types of physical restraints, psychoactive drug use, falls, and fall-related injuries. These data were collected at baseline and after 4 and 8 months. A trained, blinded observer measured the use of belts and other physical restraints types four times during a 24-hour period.

RESULTS

The intervention resulted in a 50% decrease in belt use (odds ratio = 0.48, 95% confidence interval = 0.28-0.81; P = .005). No increase occurred in the use of other types of restraints. No marked differences between the groups were found regarding psychoactive drugs, falls, and fall-related injuries.

CONCLUSION

A multicomponent intervention program led to a substantial reduction in use of belts, full-enclosure bedrails, and sleep suits without increasing the use of other physical restraints, psychoactive drugs, or falls and fall-related injuries.

Belt restraint reduction in nursing homes: design of a quasi-experimental study

Background

The use of physical restraints still is common practice in the nursing home care. Since physical restraints have been shown to be an ineffective and sometimes even hazardous measure, interventions are needed to reduce their usage. Several attempts have been made to reduce the use of physical restraints. Most studies used educational approaches and introduced a nurse specialist as a consultant. However, the success rate of these interventions has been inconsistent. We developed a new multi-component intervention (EXBELT) comprising an educational intervention for nursing home staff in combination with a policy change (belt use is prohibited by the nursing home management), availability of a nurse specialist and nursing home manager as consultants, and availability of alternative interventions. The first aim of this study is to further develop and test the effectiveness of EXBELT on belt restraint reduction in Dutch psychogeriatric nursing homes. However, the reduction of belts should not result in an increase of other restrictive restraints (such as a chair with locked tray table) or psychoactive drug use. The overall aim is an effective and feasible intervention that can be employed on a large scale in Dutch nursing homes.

Methods and design

Effects of EXBELT will be studied in a quasi-experimental longitudinal study design. Alongside the effect evaluation, a process evaluation will be carried out in order to further develop EXBELT. Data regarding age, gender, use of physical restraints, the number of falls and fall related injuries, psychoactive drug use, and the use of alternative interventions will be collected at baseline and after four and eight months of follow-up. Data regarding the process evaluation will be gathered in a period of eight months between baseline and the last measurement. Furthermore, changing attitudes will become an important addition to the educational part of EXBELT.

Discussion

A quasi-experimental study is presented to investigate the effects of EXBELT on the use of belts on wards in psychogeriatric nursing homes. The study will be conducted in 26 wards in 13 psychogeriatric nursing homes. We selected the wards in a manner that contamination between control- and intervention group is prevented.

Trial registration

(NTR2140)

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.

Falls in somatic and dementia wards at Community Care Units

INTRODUCTION

Falls and fall injuries are common problems for patients at nursing homes in Sweden. Impaired cognitive function, a poor sense of orientation and a high intake of medicine, can lead to an increase in falls among older people.

AIM

The objective of this study was to investigate the associations between falls and: fall risks, fractures, the use of physical restraints and the use of certain medications in somatic and dementia wards, respectively.

METHOD

The study design is ecological, and aggregated data regarding falls, fall risk assessments, fractures, the use of physical restraints and medication were collected between 2000 and 2003. The Pearson correlation analysis and regression analyses were used to investigate associations between fall risks, medication, fractures, wheelchair-bound situations, bed rails and falls.

RESULTS

The total number of reported fall incidents was 2651; of these, 737 incidents were registered in dementia wards and 1914 in somatic wards. Dementia wards and somatic wards differed regarding falls and fractures, as it was only in dementia wards that falls were associated with fractures. There was also a significant correlation between falls and assessed risk of falling, the use of certain medication, and physical restraints such as wheelchairs and bed rails in dementia wards. Falls at somatic wards were associated with the use of sleeping pills with benzodiazepines.

CONCLUSION

For dementia wards there were associations between falls and fractures, physical restraints and the use of certain medications. Fractures were associated with the use of neuroleptics, sleeping pills and sleeping pills with benzodiazepines. At somatic wards, falls correlated with the use of sleeping pills with benzodiazepines, and with the use of wheelchairs and bed rails.

Nurses' feelings and thoughts about using physical restraints on hospitalized older patients

AIM

To explore nurses' feelings and thoughts about physically restraining older hospitalized patients.

BACKGROUND

The use of physical restraints is still highly prevalent in hospitals; furthermore, older patients are most likely to be so restrained. Studies in acute care settings have focused mainly on nurses' knowledge, attitudes, or practice concerning physical restraints, on physical restraint reduction programmes, on nurses' perceptions about the use of physical restraints, or on elderly patients' experiences with physical restraints. To the best of our knowledge no studies have been conducted on hospital nurses' feelings and thoughts about the use of physical restraints in Taiwan.

DESIGN AND METHODS

A qualitative approach was used to understand this phenomenon. Semi-structured interviews were carried out, from August 2002 to March 2003, with 12 nurses working in three hospitals. The interviews were audiotaped and transcribed verbatim; content analysis was used to analyse the data.

RESULTS

Nurses reported a variety of emotional responses regarding the use of physical restraints, including sadness, guilt, conflicts, retribution, absence of feelings, security, and pity for the restrained older people. Rationalization, sharing with colleagues, and compensating behaviours were ways that nurses used to manage their negative feelings.

CONCLUSIONS

Most nurses had negative feelings towards the use of physical restraints. Among these nurses there was a struggle between patients' autonomy and the practice of care. However, other nurses said they had 'no feelings' or 'feeling of security' while using physical restraints.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study may contribute to filling the gaps in nursing knowledge, to improving protocols for physical restraint use in hospitals, and may also assist nurse managers to create a supportive practice environment. It is recommended that in-service training programmes should cover misconceptions regarding physical restraint use, ethical issues and how to cope with feelings while using physical restraints.

Does access to bed-chair pressure sensors reduce physical restraint use in the rehabilitative care setting?

BACKGROUND

The common use of physical restraints in older people in hospitals and nursing homes has been associated with injurious falls, decreased mobility and disorientation. By offering access to bed-chair pressure sensors in hospitalized patients with perceived fall risk, nurses may be less inclined to resort to physical restraints, thereby improving clinical outcomes.

AIMS AND OBJECTIVES

To investigate whether the access of bed-chair pressure sensors reduces physical restraint use in geriatric rehabilitation wards.

DESIGN

Randomized controlled trial.

METHODS

Consecutively, patients admitted to two geriatric wards specialized in stroke rehabilitation in a convalescent hospital in Hong Kong, and who were perceived by nurses to be at risk of falls were randomly assigned to intervention and control groups. For the intervention group subjects, nurses were given access to bed-chair pressure sensors. These sensors were not available to control group subjects, as in usual practice. The trial continued until discharge. The primary outcomes were the proportion of subjects restrained by trunk restraint, bedrails or chair-board and the proportion of trial days in which each type of physical restraint was applied. The secondary outcomes were the proportions of those who improved in the mobility and transfer domains of modified Barthel index on discharge and of those who fell.

RESULTS

One hundred and eighty subjects were randomized. Fifty (55.6%) out of the 90 intervention group subjects received the intervention. There was no significant difference between the intervention and control groups in the proportions and duration of having the three types of physical restraints. There was also no group difference in the chance of improving in mobility and transfer ability, and of having a fall.

CONCLUSION

Access to bed-chair pressure sensor device neither reduced the use of physical restraints nor improved the clinical outcomes of older patients with perceived fall risk.

RELEVANCE TO CLINICAL PRACTICE

The provision of bed-chair pressure sensors may only be effective in reducing physical restraints when it is combined with an organized physical restraint reduction programme.

Patient Choice: An Influencing Factor on Policy-Related Research to Decrease Bedrail Use as Physical Restraint

BACKGROUND

This paper shows patients' enactment of choice in mixed methods, multidisciplinary study on the use of bedrails as restraints.

APPROACH

Under the pressure of the implementation of impending legislation, patients from a Canadian elderly care rehabilitation unit were recruited to be part of this study and assigned to either a study or control group. Study group patients were exposed to a new facility policy on restraints in which bedrails were not to be used on a patient's bed except under specified conditions. Patients in the control group continued to have bedrails on a routine basis according to the facility's old policy. Following group assignments, patients could choose to crossover to either the control or study group based on their opinions about bedrails.

FINDINGS

After patients crossed over into either the study or control group, findings for the new groups differed significantly. Participants in the rails-up group had lower admission Functional Independence Measure scores (p = .001) and higher admission Cumulative Illness Rating scores (p = .000) compared to those in the rails-down group.

CONCLUSIONS

Patients have specific concerns related to the use of bedrails that might affect implementing bedrail minimization policies. Additionally, the authors conclude that patients' input into research design may increase patients' support of the protocol and help maintain study integrity.