The use of physical restraints poses dilemmas for die nursing staff. This is not surprising because the application of some form of restraint is practiced in almost all nursing home facilities. Several reports that used interviews reveal that nurses are very aware and concerned about the use of restraints.1 For example, a survey conducted by RN showed no ardent advocates for restraints.2 For the most part, their readership just considered them a necessary evil.
Another researcher interviewed 15 nurses who worked in a psychiatric setting to determine why restraining a patient was so disturbing to them. Responses indicated that the act of restraining caused the nurses to experience feelings of anxiety, inadequacy, frustration, dissatisfaction, being overwhelmed, being drained, and guilt. In summary, the nurses interviewed regarded restraining as a highly stressful emotional experience.2 The literature also reported that nurses empathize with patients who are restrained, recognizing that they themselves would not want to be in a similar position. At the saine time, the nurses feel the constraints of the work environment and the demands of other patients.3
Yarmesch and Sheafor4 conducted a study using 23 nurses employed in an 880-bed hospital. Their results demonstrated a lack of consensus among nurses regarding the use of restraints and the use of alternative measures. Also, the amount of continuing education earned by the surveyed nurses did appear to have an effect on their decisions to restrain or not to restrain a patient. Strumpf and Evans5 conducted a survey that included 18 nurses working with elderly in an acute setting. Their findings suggest that the decision to restrain posed a conflict between protection of the patient and beliefs about professional behavior on the part of the nursing staff. For example, their comments suggest a struggle to reconcile their decision to restrain or not to restrain with their value for patient autonomy and dignity.5
The results of the research suggest that the use of restraints does have a subjective impact on nursing staff. In addition, the lack of a sufficient amount of empirical data indicates that more comprehensive studies are needed to determine the current perceptions or attitudes of nurses regarding the use of physical restraints. The study reported here was designed to meet this research need and thus provide a data base for the development of intervention strategies aimed at helping nursing staff cope with their concerns regarding the use of restraints.
The sample includes 63 nursing assistants, 38 licensed practical nurses (LPNs), and 17 registered nurses (RNs). The sample was obtained from a large county nursing home facility that employed approximately 100 RNs, 200 LPNs, and 300 nursing assistants. All of the nursing staff working at the facility were invited to participate in the study. The study subjects included all three groups of nursing personnel because of their direct contact in caring for patients who may require restraints.
Data were gathered by a questionnaire developed by the researchers. The questionnaire was designed to elicit information about the personal and professional characteristics of respondents, knowledge about restraints, nursing practice regarding the use of physical restraints, and attitudes toward the use of restraints. This article focuses on the findings regarding nurses' attitudes.
In this study, a physical restraint is defined as a device or garment used to restrict the movement of a patient in a chair or bed. This definition was formulated based on a study conducted by Janelli6 in which nursing home administrators were surveyed as to their policies and procedures regarding the use of restraints. This definition of a physical restraint was not provided to the subjects because of the belief that it could have biased subjects' responses on the total questionnaire.
To obtain information on attitudes, subjects were asked to respond on a five-point Likert scale ranging from strongly agree to strongly disagree. The items addressed issues relating to patient and family rights concerning the use of restraints and the effects of using restraints on patients, families, and the nursing staff. The attitudinal items were generated from a review of literature and the recommendations of five gerontological nurses who had extensive background in the care and management of individuals requiring the use of restraints.
Prior to the implementation of the research, the questionnaire v*as pitot tested on five nursing staff members. Revisions were made to improve clarity of items. To evaluate content validity, the instrument was submitted for review to a panel of experts composed of five gerontological nurses. The suggestions of these individuals were incorporated in the final draft of the instrument. The reliability coefficient for the attitude scale was .67. Items were scored for each individual prior to analysis. The questionnaire was distributed by one of the investigators to the different nursing units. Each questionnaire was accompanied by a cover letter that identified the investigators, described the purpose of the study, and explained the voluntary nature of participation. A stamped, self-addressed envelope was included for return of the questionnaire. The questionnaires were anonymous and subjects were assured that their responses would be kept confidential. A time limit of 1 month was given for return of the questionnaire. Prior to testing the questionnaire, approval was obtained from the facility's Human Subjects Review Committee as well as from the School of Nursing.
To analyze the data, we first examined the overall frequency distribution of responses to the attitude items. For these analyses, data were collapsed into three categories (agree, undecided, disagree). We then conducted analysis of variance to determine whether mean scores on attitudes were significantly different for RNs, LPNs, and nursing assistants. Finally, we examined the association of subject characteristics (age, personal experience with elderly family members, shift worked, years in geriatrics, and knowledge) with attitude scores.
The demographic characteristics of the respondents indicated that subjects ranged in age from under 20 to 59, with a mean of 35. Most (88%) were women and more than half were married and had children. The majority were either of the Catholic (48%) or Protestant (36%) faith. Eighty-seven percent were white. Of the 118 who answered the questionnaire, 63 (53%) were nursing assistants, 38 (32%) were LPNs, and 17 (14%) were RNs. Fiftynine percent of the RNs had an associate degree, 29% had a diploma degree, and 12% had a baccalaureate degree. The mean number of years worked in geriatrics was 6 to 10 years. Ninety-six percent worked full-time with 59% working days, 31% evenings, 5% nights, and 4% rotating shifts.
In addition to the personal and professional characteristics cited, respondents were also queried as to their personai experience with elderly family members. Eighty-nine percent of the respondents had elderly members in their family. Sixteen percent had elderly family members living in their home and 24% had family members in a nursing home. A total of 18% had elderly family members who required the use of restraints.
ATTITUDES TOWARD THE USE OF RESTRAINTS
In terms of attitudes toward the use of restraints, a large percentage (62%) disagreed with the statement that family members have the right to refuse the use of restraints, 60% disagreed with the statement that staff members have the right to refuse to place patients in restraints, and 21% were undecided (Table 1). More than half (62%) agreed that if they were the patient, they should have the right to refuse/ resist the use of restraints. Almost all (97%) did not believe that restraints are a form of punishing the patient. Eighty-nine percent disagreed that the main reason restraints are used is that the nursing home is short-staffed. A majority (83%) did not feel embarrassed in front of family members of a patient in restraints.
More than half (64%) of the nursing staff felt that the nursing home is legally responsible to use restraints for patient safety even if it means that the patient loses dignity. In general, the nursing staff feels badly if the patient becomes more upset after restraints are applied. The vast majority (98%) felt that it is important to let patients in restraints know that they are cared about. As shown, fewer than half (43%) disagreed that patients become more disoriented after restraints have been applied, and 30% were undecided. Most (82%) felt comfortable taking care of a restrained patient.
ANALYSIS OF VARIANCE ON ATTITUDE BY LEVEL OF NURSING PRACTICE
Because attitudes could be influenced by level of nursing practice (nursing assistant, LPN, RN), we conducted an analysis of variance to determine if there was a difference in attitudes between the groups. Results indicated that no two groups were significantly different at the .05 level (Table 2). Likewise, analysis of variance did not show any significant difference (P <.05) between age and attitudes, shift worked and attitudes, and years worked in geriatrics and attitudes. Also, analysis of variance demonstrated that there was no significant difference between subjects who had personal experience with elderly family members and those subjects who did not. Personal experience with elderly family members included having elderly family members, having elderly family members in a nursing home, or having elderly family members who required the use of restraints. In addition, a Pearson product moment correlation revealed that knowledge scores and attitudes were not significantly related (r = -. 1 0, P = . 1 50) .
This study was designed to provide quantitative data regarding nursing staffs attitudes toward the use of restraints. In contrast to what has been reported in the literature,2·5 our data suggest that the nursing staff in this sample generally are comfortable taking care of a restrained patient. This conclusion, however, is open to interpretation because the term "comfortable' ' could have been perceived in different ways by the respondents. Subjects may have felt emotionally comfortable taking care of a restrained patient, or they could have felt comfortable because they considered themselves skilled in the general care of a patient in physical restraints.
For the most part, the respondents also believed that nursing homes need to restrain patients for their own safety even if it means loss of dignity for the patient. A majority did, however, feel badly if the patient became more upset after being restrained. Also, the staff believed that a caring manner should be conveyed to the patient in restraints. It was interesting to note that although a large percentage felt that family members did not have the right to refuse the use of restraints, the respondents believed that they should have the right to refuse the restraints if they were the patient. This dichotomy in responses suggests that the staff may have negative attitudes toward the use of restraints of which they are unaware.
Personal and professional characteristics such as age, knowledge about restraints, shift worked, years in geriatrics, experience with elderly family members, and level of practice (nursing assistant, LPN, RN) showed no significant relationship to attitudes. This may indicate that attitudes are shaped by the work environment and are displayed similarly by all.
Significance for Nursing Practice
Nursing staff and administrators in nursing homes are concerned with the issue of restraints and falls. The findings from this study can be shared with nursing home administrators, thereby providing insight into nursing staffs' attitudes regarding the use of restraints. Once the nursing staffs' perceptions of physical restraints are measured and quantified, intervention strategies can be developed that are targeted to meet the identified needs. It is important that attitudes as well as knowledge are considered when changes or improvements in nursing practice are being considered, because attitudes can influence practice.
In addition, it is important that opportunities are given to the nursing staff that allow them to reflect on their feelings about caring for restrained patients. This can provide the stimulus for discussion of questions and concerns regarding the use of restraints, which in torn can contribute to the improvement of quality care provided to patients in restraints.
Recommendations for future Research
It would be important to replicate this study using a larger sample size that would be more equally representative of nursing assistants, LPNs, and RNs. A larger sample would assist in making more definitive conclusions about attitudes toward the use of restraints. Likewise, it would be beneficial to expand the attitude items to explore more thoroughly such areas as nursing staffs' emotional feelings regarding the use of restraints, and whether they feel there are alternative measures to the use of restraints. Adding additional items may also help to more clearly delineate where areas of intervention are required to help nurses deal more effectively with the restrained patient. Also, this study can act as a spin-off for the development of further research to solve problems related to the use of physical restraints.
- 1 . Friedman FB. Restraints: When all else fails, there still are alternatives. RN. 1983; 83:7988.
- 2. DiFabio S. Nurses' reactions to restraining patients. AmJNurs. 198 1 ; 81 :973-975.
- 3. McHutchion E, Morse J. Releasing restraints: A nursing dilemma. Journal of Gerontological Nursing. 1989; 15(2): 16-21.
- 4. Yarmesch M, Sheafor M. The decision to restrain. Geriatr N ws. 1984;5:242-244.
- 5. Strumpf N, Evans L. Physical restraint of the hospitalized elderly: Perceptions of patients and nurses. NursRes. 1988; 37(3): 132-137.
- 6. Janelli, IJM. Physical restraints: How little we know. Nursing Homes and Senior Citizen Care. 1989;38:10-12.
ATTITUDES TOWARD THE USE OF RESTRAINTS
ANALYSIS OF VARIANCE ON ATTITUDE BY LEVEL OF NURSING PRACTICE