Research-based practice: reducing restraints in an acute care setting--phase I

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

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

[Descriptive study of the attitudes of family caregivers to the use of physical restraints: preliminary results]

OBJECTIVE

To evaluate the attitudes of families caring for elderly dependents to the use of physical restraints and to identify the factors that could influence these attitudes.

MATERIAL AND METHODS

A descriptive, cross sectional study was carried out in a consecutive sample of the population, using a questionnaire investigating the various aspects that influence attitudes to restraints. Responses were obtained from 50 family caregivers, of which seven were discarded due to lack of knowledge about restraints (N=43). The characteristics of the sample, frequencies, the main trends and dispersion measures were analyzed.

RESULTS

Most of the family caregivers considered the use of restrains to be appropriate and 90.7% were willing to use them with a relative; 41.9% believed that their use was unavoidable and were unaware of alternatives, while 23.3% were unaware that physical restraints can cause physical and psychological problems. None of the family caregivers believed that this method of restraint was a form of abuse.

CONCLUSIONS

Relatives had a positive attitude to physical restraints and considered their use appropriate. This finding could be related to their limited knowledge of alternatives and of the complications that can be caused by restraints. Training programmes on alternatives to these devices should be instigated.

The use of physical restraint in critical care

Critically ill patients are at high risk for the development of delirium and agitation, resulting in non-compliance with life-saving treatment. The use of physical restraint appears to be a useful and simple solution to prevent this treatment interference. In reality, restraint is a complex topic, encompassing physical, psychological, legal and ethical issues. This article briefly discusses the incidence of delirium and agitation in critically ill patients and examines in detail the method of physical restraint to manage treatment interference. The historical background of physical restraint is discussed and the prevalence of its use in critical care units across the world examined. Studies into the use of physical restraint are analysed, and in particular the physical effects on patients discussed. The use of physical restraint raises many legal, ethical and moral questions for all health care professionals; therefore, this study aims to address these questions. This article concludes by emphasizing areas of future practice development in intensive care units throughout the UK.

Development of the Video Assessment of Propensity to Use Emergency Restraints Scale (VAPERS): results of the VAPERS Study Group

BACKGROUND

Emergency physicians (EPs) may disagree on when or whether patients need restraints. There is no good objective measure of the likelihood of EPs to restrain patients.

OBJECTIVES

To 1) develop a scale to determine the likelihood that an EP would restrain a patient, 2) develop subscale scoring, and 3) determine a shortened version that correlates highly with the full scale.

METHODS

This was a prospective cross sectional study. The Video Assessment of Propensity to use Emergency Restraints Scale (VAPERS), consisting of 17 scenarios utilizing actors, was videotaped to produce a research video assessment tool. The VAPERS was designed by development experts to reflect the spectrum of patients who are considered for restraint in an emergency department. The VAPERS was piloted among a 22-member pilot panel of EPs (faculty and residents). The pilot panel was asked to determine the degree to which each video patient possessed the following patient characteristics: medical instability, trauma, belligerence, agitation, and altered mental status. Each "degree of characteristic" was measured on a separate 100-mm visual analog scale. Participants were then asked whether or not they would restrain each patient and whether the patient exhibited the potential to harm him- or herself or others. VAPERS subscales were developed for the likelihood to restrain patients with each of the patient characteristics. Spearman correlations were used for all comparisons. Linear regression was used to determine which patient characteristics were most related to likelihood to restrain and to develop a reduced scale to predict the overall likelihood to restrain.

RESULTS

The overall VAPERS score ranged from 0 to 100, with a median of 50 (interquartile range [IQR], 24-88). The visual analog scale results of how likely each video patient possessed specific characteristics were as follows: medical instability ranged from 0 to 100 (median, 32; IQR, 12-64), trauma ranged from 0 to 69 (median, 0; IQR, 0-31), belligerence ranged from 20 to 93 (median, 28; IQR, 14-63), agitation ranged from 3 to 84 (median, 52; IQR, 23-72), and altered mental status ranged from 1 to 93 (median, 29; IQR, 16-69). Linear regression indicated that two characteristic variables (danger to self and degree of agitation) in the video scenarios were highly correlated (0.87) with overall likelihood to restrain. Based on the results, the authors developed a shortened video assessment tool consisting of five of the original videos that were highly correlated (R = 0.94) with the full VAPERS scale on overall likelihood to restrain.

CONCLUSIONS

The VAPERS scale covers a wide range of important variables in emergency situations. It successfully measured likelihood to restrain in this pilot study for overall situations, and for subgroups, based on patient characteristics. A shortened five-video VAPERS also successfully measured the overall likelihood to restrain.

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

PURPOSE

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

CONCLUSIONS

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

IMPLICATIONS

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

Effect of a treatment interference protocol on clinical decision making for restraint use in the intensive care unit: a pilot study

The literature is replete with articles describing restraint reduction strategies used in long-term care settings, geriatric specialty units, and medical/surgical units in the acute care setting. The feasibility, effectiveness, and appropriateness of such strategies cannot be capriciously applied to the intensive care setting. This article provides an overview of the implementation and outcomes of a pilot study using an algorithmic approach that is clinically appropriate and justifiable for restraint use in the intensive care environment. It provides the critical care nurse with a standardized method for decision analysis when managing patients at risk for treatment interference.

Elements of successful restraint and seclusion reduction programs and their application in a large, urban, state psychiatric hospital

In recent years, there has been a strong desire on the part of inpatient psychiatric programs to reduce the use of seclusion and mechanical restraint. There is a consensus among those who have published descriptions of successfully implemented restraint and seclusion reduction programs that the essential elements of such programs are high level administrative endorsement, participation by recipients of mental health services, culture change, training, data analysis, and individualized treatment. This article describes these elements and their application in a successful restraint reduction program at Creedmoor Psychiatric Center, a large, urban, state-operated psychiatric hospital that reduced its combined restraint and seclusion rate by 67% over a period of 2 years.

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

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

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

AIM OF THE STUDY

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

RATIONALE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Moving toward restraint-free patient care

After reviewing the literature and regulatory requirements, a multidisciplinary team developed a comprehensive restraint reduction program that has reduced the use of restraints by more than 60% in the acute care setting. The authors discuss the research-based restraint education program and the implementation of a restraint consultant role.

Confusion and aggression in restrained elderly persons undergoing hip repair surgery

The purpose of this pilot study was to observe and describe the behaviors of confusion and aggression in physically restrained elderly hospitalized persons following hip repair surgery. Five elderly persons who were 75-95 years of age and physically restrained following hip repair surgery comprised the sample of this descriptive study. Descriptive data including age, sex, medical diagnosis, current medications, serum electrolyte and arterial blood gas results, date/time of hip fracture, subsequent surgical repair, and restraint application were obtained from the medical record. Observations of behaviors associated with confusion and aggression were conducted at six separate observation times lasting approximately 20 to 30 minutes each. The observation periods were divided into two mornings, two afternoons, and two evening sessions. These behaviors were assessed by utilizing a combined observational tool developed by the researcher, and was created from the Clinical Assessment of Confusion--A, by Vermeersch, and Ryden Aggression Scale. After data analysis, three patterns of confusion emerged. These were the major pattern of confusion, the minor pattern of confusion, and pattern of confusion relative to time. All patients experienced low serum sodium levels immediately prior to the application of physical restraints. Based on the results of the pilot study, further investigation is needed.

Utilization of the Iowa Model in establishing evidence-based nursing practice

Clinical practice based on tradition or established rituals appears to be widespread amongst a variety of nurses and practice settings. However, tradition-based practice may not necessarily be based on sound scientific evidence and could potentially be harmful to patients or result in inappropriate utilization of resources. Conversely, evidence-based practice is the utilization of the best available empirical evidence in the practice setting, to facilitate sound clinical decision-making. Suctioning ventilated patients is a necessary and important aspect of patient care. However, normal saline instillation prior to suctioning, in order to loosen secretions, remains a common nursing procedure despite research suggesting that there is no clear benefit and in some instances may be harmful. Several models have been developed over the past few years to facilitate nursing practice that is based on research or the best available evidence. The Iowa Model, developed at the University of Iowa Hospitals and Clinics, serves as a framework to improve patient outcomes, enhance nursing practice and monitor health care costs. Moreover, it facilitates the application of empirical evidence to clinical practice. This paper will discuss the utilization of the Iowa Model to promote evidence-based nursing practice, with regard to normal saline instillation prior to suctioning, in the critical care unit of a 100-bed hospital in Hong Kong. Patient, staff and fiscal outcomes will also be reported.

Nurses' perceptions of chemical restraint use in long-term care

The purpose of this pilot study is to validate the use of the Perceptions of Restraint Use Questionnaire (PRUQ) in assessing chemical restraint perceptions among nurses working in long-term care. The convenience sample includes 60 licensed nurses working in six long-term care facilities in Illinois. The reliability analysis for a modified version of the PRUQ, based on the research sample chosen, was found to have a Cronbach's coefficient alpha of .9450. Study findings reflect a moderately positive attitude toward chemical restraint use by nurses in long-term care.

The role of the clinical forensic nurse in critical care

Forensic nursing deals with the population of people whose lives have been affected by societal violence. The clinical forensic nurse (CFN) is seen as a means of coping with the resultant increased complexity of nursing practice, society, and the law. Critical care areas are clinical forensic domains where the CFN addresses the needs of living forensic patients through activities involving physical and non-physical evidence collection, crisis intervention, and documentation. Within a health care team, the CFN enhances patient care management, resulting in clinical service, legal order, and forensic protocol.

Establishing evidence-based practice: issues and implications in critical care nursing

Evidence-based practice is the application of the best available empirical evidence, including recent research findings to clinical practice in order to aid clinical decision-making. The implementation of these findings is vital for optimizing patient outcomes, improving clinical practice, providing cost-effective high quality care and enhancing the credibility of nurses. The use of research findings to improve practice has been discussed and promoted for the last 20 years. The author argues that Rogers' theoretical model of the Diffusion of Innovations may prove useful in understanding the problem of the slow diffusion of the application of research evidence in clinical nursing practice. Many authors have discussed potential barriers to using research in clinical practice in order to facilitate utilization of findings. However, recent studies all document that a gap between research findings and their implementation in clinical practice still exists. This appears to hold true across a variety of practice settings, including nurses working in critical care. The diffusion of innovations in current critical care nursing practice at each stage of Rogers' theory will be examined, with recommendations given to facilitate the establishment of evidence-based practice (EBP).