Physical restraints are commonly used for patient safety, especially for the prevention of device removal, self-harm and harm to others, and to avoid the use of chemical restraint (Luk, Burry, Rezaie, Mehta, & Rose, 2015). Many studies have started to examine the rationality of this intervention because of the disadvantages of using physical restraints, particularly the complications of immobility, negative psychological consequences, serious injuries, and death (Hulatt, 2014; Minnick, Mion, Johnson, Catrambone, & Leipzig, 2007; Mott, Poole, & Kenrick, 2005; Pérez de Ciriza Amatriain et al., 2012; Simpson, Joesch, West, & Pasic, 2014). Moreover, no substantial evidence shows that the use of physical restraints effectively reduces the risk of accidental device removal (Curry, Cobb, Kutash, & Diggs, 2008; Mehta et al., 2015; Zhang, Pan, Deng, Ni, & Xu, 2014). Government legislation, hospital accreditation standards, and professional society guidelines abroad recommend physical restraint minimization (Acevedo-Nuevo et al., 2016; Bai et al., 2014; Chen et al., 2015). No such guidelines are currently available in China, although the handbook of nursing-sensitive quality indicators (Yao, Feng, & Zhu, 2016) recommends the minimal use of physical restraints for patient safety.
Physical restraints remain in frequent use in hospitals and nursing homes, especially in intensive care units (ICUs) (van der Kooi et al., 2015; Bai et al., 2014; Chiba, Yamamoto-Mitani, & Kawasaki, 2012; Goethals, Dierckx de Casterlé, & Gastmans, 2012). A cross-sectional survey was conducted in 34 ICUs from nine countries in Europe; the results showed that usage rates of physical restraints in Switzerland, Italy, Spain, and France ranged from 43% to 100%, whereas rates in the United Kingdom and Portugal were almost zero (Benbenbishty, Adam, & Endacott, 2010). A study compared physical restraint practices on 50 patients in one unit in the United States with use on 50 patients in one unit in Norway, showing no use in Norway compared with a 39% rate of use in the United States (Martin & Mathisen, 2005). In China, the usage rates of physical restraints in ICUs ranges from 39.4% to 45.7% (Shengchun, Yumei, Zhihong, Fengying, & Na, 2009; Lu, Xing, & Xiangyu, 2014).
The use or removal of physical restraints primarily depends on nurses (De Jonghe et al., 2013). The knowledge and attitudes of nurses are ultimately the most powerful determinants of physical restraint use (Möhler & Meyer, 2014). Several studies demonstrated that the knowledge of nurses regarding physical restraint use is inadequate and that they have negative attitudes or ambivalent feelings regarding the use of physical restraints (Kandeel & Attia, 2013; Möhler & Meyer, 2014). An assessment scale for the measurement of knowledge, attitudes, and practices of nurses in ICUs (Chinese version) was constructed in 2016 (Qiaoling et al., 2016). The scale has good reliability and validity and is a good tool for the investigation of the knowledge, attitudes, and practices of nurses in ICUs. In China, the knowledge, attitudes, and practices of nurses in ICUs have not yet been explored in a multicenter and large sample study. Thus, in this study, we aimed to measure these variables in the ICUs of tertiary hospitals in China.
Design and Method
A multicenter, descriptive, cross-sectional study was performed in eight ICUs that were randomly selected from the 32 tertiary hospitals of Chongqing, China, according to the principle of stratified random sampling (two university-affiliated hospitals, two nonuniversity-affiliated hospitals, two military hospitals, and two district hospitals). RNs who worked in the selected ICUs were included in this study, whereas nurses who worked in the selected ICUs on rotation or for advanced studies were excluded. A total of 383 ICU nurses were enrolled in the study. The research ethics committees of the eight hospitals reviewed the study protocol and waived the need for signed consent.
Before the investigation, participants were asked for their consent to participate in the study, which they confirmed with their signature, initials, or some other code. An assessment scale for the knowledge, attitudes, and practices of nurses in ICUs regarding physical restraints was used in this study (Table A; available in the online version of this article). The first part of the scale includes general information, such as age, sex, education, nursing experience, nursing experience in the ICU, and position. The second part involves three dimensions, namely, knowledge, attitudes, and practices concerning physical restraint and 73 items. This scale is frequently used to test reliability and validity and has a total content validity index of 0.912. The Cronbach's alpha values of knowledge, attitude, and practice were .826, .923, and .947, respectively, and the test–retest reliability values were, respectively, 0.843, 0.845 and 0.869. The Bartlett spherical test was used in the scale. The Kaiser-Meyer-Olkin value was 0.88 > 0.5, and the Bartlett spherical test significance value was < 0.001. These results indicated that the scale is suitable for factor analysis. The eigenvalues of the three subscales were 8.32, 7.01, and 5.82. The cumulative contribution rate was 54%. These values showed that the scale has good reliability and validity (Qiaoling et al., 2016).
Scale of Knowledge, Attitude, and Practice of Nurses in Intensive Care Units (ICUs) Regarding Physical Restraints
The scoring arrangement of the scale consists of three dimensions—namely, knowledge, attitude, and practice. The score of the knowledge dimension was calculated by giving 1 to restraint, 2 to alternative, 3 to no restraint. The score for the attitude dimension was calculated as follows: 1 to strongly agree, 2 to agree, 3 to disagree, and 4 to strongly disagree. The score of the practice dimension was based on the following: 1 to usually, 2 to occasionally, 3 to sometimes, 4 to seldom, and 5 to rarely. The total score ranged from 73 to 281, and the knowledge, attitude, and practice scores were 37 to 111, 10 to 40, and 26 to 130, respectively. The higher the score, the better the knowledge, attitudes, and practices of nurses regarding the use of physical restraint.
SPSS® version 23 was used for data analysis. General data were described using frequencies, percentages, means, and standard deviations. Measurement data were expressed by means and standard errors, and group comparisons were performed using the t test or ANOVA. The chi-square test was used for enumeration data. A p value of less than .05 indicated a significant difference.
A total of 428 questionnaires were administered, and 383 questionnaires were received. The response rate was 89.49%. The ages of the nurses ranged from 21 to 45 years (M = 28.62, SD = 4.56). Of these nurses, 31 were male and 352 were female. Furthermore, 63.7% of the nurses had a bachelor's degree, 3.4% had a graduate degree, and 32.9% had a diploma. The average years of experience of the 383 nurses engaged in nursing and critical care nursing were 6.72 ± 4.943 and 5.34 ± 4.034, respectively. In addition, 64 nursing team leaders from the ICUs participated in the survey, and 211 participants were ICU specialist nurses among the 383 participants.
Knowledge Regarding Physical Restraint Use
Knowledge scores ranged from 48 to 105, and the mean score of the knowledge dimension was 74.33 (SD = 9.552). The item with the highest score in the knowledge dimension was the patient is independent, in nonlife-threatening treatment interruption, and has muscle weakness; for this item, 323 nurses selected no restraint, and the mean score was 2.83 ± 0.426. When the items involved muscle weakness, the mean score exceeded 2.75. The item with the lowest score in the knowledge dimension was the patient is semi-independent, in life-threatening treatment interruption, and has delirium; in this case, 304 nurses selected restraint, and the mean score was 1.29 ± 0.509. When the items involved delirium, the mean score was below 1.38. The knowledge dimension was divided into two parts. The first part included items 1 to 19, which involved alert, oriented, unconscious, muscle weakness, and constant observation. The second part consisted of items 20 to 37, which included disoriented, simple agitation, agitation, and delirium. The mean score of the first part (47.40 ± 5.674) was significantly higher than that of the second part (26.93 ± 6.405; t = 53.940, p < .05). According to whether the patients are in a life-threatening treatment interruption or not, the knowledge dimension was divided into two parts: life-threatening and nonlife-threatening treatment interruption. No significant difference was found in the mean scores of the two groups (first group: 37.07 ± 5.857, second group: 37.26 ± 5.079; t = 0.665, p > .05).
Attitude Toward Physical Restraint Use
Attitude scores ranged from 10 to 40, and the mean score of the attitude dimension was 24.41 (SD = 4.872). The results showed that the mean score barely exceed 60% of the total score. The item with the highest score in the attitude dimension was “I tend to restrain the patient because the other nurses use it” (3.27 ± 0.742). Moreover, 87.2% of the nurses selected strongly agree or agree for “I tend to restrain the patient to protect against unplanned extubation.” Eighty-two percent of nurses selected strongly agree or agree, and 74.7% stated that they use physical restraints because they take care of two to three patients simultaneously.
Practice of Physical Restraint Use
Practice scores ranged from 26 to 123, and the mean score of the practice dimension was 65.66 (SD = 20.880). The results showed that the mean score hardly passed 50% of the total score. Approximately 73.32% of the nurses selected usually or occasionally for the item “To protect the patient, I monitor my restrained patient with a tool made of soft and safe material,” and the mean score was 4.55 (SD = 0.842). The item “To provide safety when judgement is impaired by agitation” had the lowest score in the practice dimension, and its mean score was 1.84 (SD = 1.172). The practice dimension lists four parts as reasons for the use of physical restraint by nurses—namely, fall, unplanned extubation, patients' behavior, and lack of resources. The mean scores of the four parts were 6.12 (SD = 2.533), 16.68 (SD = 7.523), 8.63 (SD = 4.367), and 11.22 (SD = 4.576). Pairwise comparison showed that the difference between groups was statistically significant (p < .05). The most common restraint tool used by nurses was the wrist tie (2.14 ± 1.257), and the use of belts was the lowest (3.78 ± 1.215). A significant difference was found in the mean scores of the two kinds of restraint tools (H = −580.808, p < .05).
Characteristics Difference in Knowledge, Attitude, and Practice
The results showed significant differences in the attitude dimension between nurses who were 41 to 50 years old and those who were 20 to 30 and 31 to 40 years old. The mean score of the nurses who were 41 to 50 years old was higher than that of the nurses from the other age ranges (p < .05). In the attitude dimension, participants engaged in nursing for more than 20 years had a higher mean score than those with 6 to 10 and 11 to 15 years of engagement, and the difference was statistically significant (p < .05). Nurses with 16 to 20 years of experience in ICUs had a higher mean score in the attitude dimension than those with 1 to 5, 6 to 10, and 11 to 15 years of experience. In the attitude dimension, the scores of nurses' specialization in ICU care were higher than those who do not have this specialization, and the difference was statistically significant (p < .05). No statistically significant difference among the mean scores of knowledge, attitude, practice, sex, and academic qualification were observed (Table B; available in the online version of this article).
Characteristics Difference in Knowledge, Attitudes, and Practices
Knowledge Level of Critical Care Nurses Regarding Physical Restraint
All 383 nurses were working in ICUs, and their levels of knowledge about physical restraint were in the lower middle level (M = 74.33; SD = 9.552). Moreover, 11.2% of the nurses reported that they use restraints when patients are conscious and dependent and are undergoing a life-threatening treatment. Most nurses agreed that physical restraint is unnecessary when patients are stable. The levels of knowledge of nurses from different countries vary. Karagozoglu, Ozden, and Yildiz (2013) showed that the knowledge of intern nurses about physical restraint use was at an excellent level. The mean score of the first part (47.40 ± 5.674) was significantly higher than that of the second part (26.93 ± 6.405; t = 53.940, p < .05). However, the mean score of the life-threatening treatment interruption group and that of the nonlife-threatening treatment interruption group had no significant difference (t = 0.665, p > .05). The results showed that the decisions of nurses concerning physical restraint depend on patient behaviors. The results are in line with those of Acevedo-Nuevo et al. (2016) and Luk et al. (2015). Similarly, the mean scores of sex, academic qualification, position, age, years of working experience, and years of working in ICUs were not significantly different from one another. However, the relationship between these factors and knowledge needs to be further verified. The results reflect our lack of knowledge about physical restraint. In view of the lack of relevant guidelines on physical restraint in China, the most important task when considering restraint minimization is to develop a guideline and define the indication of physical restraint.
Attitudes of Nurses Toward Physical Restraint
The attitudes of nurses toward physical restraint were in the lower middle level (M = 24.41, SD = 4.872). Moreover, 87.2% of the nurses supported the statement that physical restraints prevent unplanned extubation; however, no available evidence shows that physical restraint is effective for maintaining safety, preventing disruption of treatment, or controlling behavior (Agens, 2010; Said & Kautz, 2013). One reason for the frequent use of physical restraint by nurses is the lack of nursing staff. Approximately 74.7% of the nurses stated that they use physical restraints because they care for two or three patients simultaneously. Furthermore, nurses who specialize in ICUs have a better attitude toward physical restraint than do those who do not focus on the ICU (F = 35.278, p = .021). This result shows that the high-level promotion of nurses reduces the use of physical restraint. Nurses aged 41 to 50 years had a better attitude than did nurses aged 20 to 30 or 31 to 40 years (both p < .05). Similarly, those with long nursing careers or who were involved in critical care nursing had a better attitude than those with less experiences.
Clinical Practice of Physical Restraint in the ICU
The level of practice of physical restraint was in the lower level (M = 65.66; SD = 20.880). In addition, 79.1% of the nurses used physical restraint on patients because they believe that agitation may lead to injury. Comparison of the two main reasons for the use of physical restraint—namely, to prevent unplanned extubation and inadequate nursing resources (p < .05)—indicated that the role of physical restraint on unplanned extubation in future nursing education requires additional exploration. Patient-to-nurse ratios in ICUs are also another problem that deserves attention. A high patient-to-nurse ratio and nursing workload are associated with increased mortality in adult ICUs (Knight, 2016). Close patient monitoring and a reduction in the prevalence of restraint can be achieved by providing an adequate number of nurses with manageable workloads (Whitman, Kim, Davidson, Wolf, & Wang, 2002). In Norway, physical restraints are not used (Martin & Mathisen, 2005). The high nurse-to-patient ratio in Norway is one of the reasons for the low use of physical restraint. The allocation of reasonable nursing resources is necessary to minimize the use of physical restraint.
The following are limitations of this study. First, although stratified random sampling was used in this study, all the ICUs were in Chongqing, and their nursing staff cannot be considered representative of all ICU nurses in China. Second, the assessment tool was a self-rating scale, and the results for the practice dimension may be subjective. A follow-up study constructing a scale that can objectively measure nurses' knowledge and practices regarding physical restraint would be worthwhile.
We investigated the knowledge, attitudes, and practices regarding physical restraint in central ICUs of tertiary hospitals in Chongqing, China. The results showed that the knowledge about physical restraint was inadequate, which might cause inappropriate attitudes and unsuitable practice. The use of physical restraint is mainly affected by patient behavior. Providing an adequate number of nurses is also important for the reduction of the prevalence of physical restraint. Further recommendations include qualitative research on the reasons why nurses use physical restraint for patients, continuing education of nurses that focuses strongly on the relationship between physical restraint and unplanned extubation, and the development of guidelines for the utilization of physical restraint.
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Scale of Knowledge, Attitude, and Practice of Nurses in Intensive Care Units (ICUs) Regarding Physical Restraints
|Please Circle the Number That Best Reflects Your Views|
|Knowledge Dimension||No Restraint||Alternative||Restraint|
|The patient is independent, in life-threatening treatment interruption and is/has||1. alert||3||2||1|
|4. muscle weakness||3||2||1|
|5. constant observation||3||2||1|
|The patient is semi-independent, in life-threatening treatment interruption and is/has||6. alert||3||2||1|
|9. muscle weakness||3||2||1|
|10. constant observation||3||2||1|
|The patient is semi-independent, in non-life-threatening treatment interruption and is/has||11. alert||3||2||1|
|14. muscle weakness||3||2||1|
|15. constant observation||3||2||1|
|The patient is independent, in non-life-threatening treatment interruption and is/has||16. alert||3||2||1|
|18. muscle weakness||3||2||1|
|19. constant observation||3||2||1|
|The patient is independent, in non-life-threatening treatment interruption and is/has||20. disoriented||3||2||1|
|21. simple agitation||3||2||1|
|The patient is semi-independent, in non-life-threatening treatment interruption and is/has||22. confused||3||2||1|
|24. simple agitation||3||2||1|
|The patient is semi-independent, in life-threatening treatment interruption and is/has||25. confused||3||2||1|
|27. simple agitation||3||2||1|
|The patient is dependent, in life-threatening treatment interruption and is/has||28. confused||3||2||1|
|30. simple agitation||3||2||1|
|The patient is independent, in non-life-threatening treatment interruption and has||31. agitation||3||2||1|
|The patient is semi-independent, in non-life-threatening treatment interruption and has||32. agitation||3||2||1|
|The patient is semi-independent, in life-threatening treatment interruption and has||34. agitation||3||2||1|
|The patient is dependent, in life-threatening treatment interruption and has||36. agitation||3||2||1|
|I tend to restrain the patient...||Strongly Agree||Agree||Disagree||Strongly Disagree|
|1. to protect from unplanned extubation||1||2||3||4|
|2. because of the requirements of doctors||1||2||3||4|
|3. to protect from falling or self-injury||1||2||3||4|
|4. to dispense medicines, monitor and record||1||2||3||4|
|5. to pay attention to the other patients||1||2||3||4|
|6. because I take care 2–3 patients simultaneously||1||2||3||4|
|7. because of the other nurses use it||1||2||3||4|
|8. to protect staff from physical combativeness||1||2||3||4|
|9. to make my work easily||1||2||3||4|
|10. to deal with personal things||1||2||3||4|
|1. In clinical practice, I restrain the patient||Usually||Occasionally||Sometimes||Seldom||Rarely|
|1.1 To protect from falling|
|i) after changing position||1||2||3||4||5|
|ii) out of bed||1||2||3||4||5|
|1.2 To protect a patient from|
|i) pulling out an endotracheal||1||2||3||4||5|
|ii) pulling out an IV line or arterial line||1||2||3||4||5|
|iii) pulling out a catheter||1||2||3||4||5|
|iv) pulling out a feeding tube||1||2||3||4||5|
|v) breaking open a wound||1||2||3||4||5|
|vi) removing a dressing||1||2||3||4||5|
|1.3 To provide safety when judgement impaired|
|i) post anesthesia||1||2||3||4||5|
|1.4 When observation is difficult|
|i) night shift||1||2||3||4||5|
|ii) breaks or meeting||1||2||3||4||5|
|iii) ICU is busy||1||2||3||4||5|
|iv) high nurse/patient ratio||1||2||3||4||5|
|1.5 To protect staff/other patients from physical combativeness, I use the following restraints|
|ii) ankle ties||1||2||3||4||5|
|iii) wrist ties||1||2||3||4||5|
|v) self-made devices||1||2||3||4||5|
|2 To protect the patient, I monitor my restrained patient with|
|i) appropriate restraint tools||1||2||3||4||5|
|ii) a tool made of soft and safe material||1||2||3||4||5|
|iii) constant observation||1||2||3||4||5|
|iv) standard record||1||2||3||4||5|
|v) removal prompt||1||2||3||4||5|
Characteristics Difference in Knowledge, Attitudes, and Practices
| Bachelor's degree and above||257||74.87±9.197||24.59±4.673||65.95±20.474|
| Intensive care unit specialist nurses||211||74.26±9.974||——||——||24.72±5.086||——||——||67.19±21.582||——||——|
| Registered nurse||108||73.87±8.477||0.386||.734||23.38±4.664||35.278*||0.021||61.96±19.134||5.231*||.034|
| Nurse team leaders||64||75.34±9.908||−1.088||.426||25.13±4.256||−5.644||0.720||66.81±20.895||0.382||.898|
|Years of working in nursing|
|Years of working in critical care nursing|