"Iliis stratified, random survey of nursing staff v*as undertaken at a large, urban, acute care hospital, to elicit views on the use of restraints, and perceptions of alternatives. Eighty-four members of the nursing staff, including unit managers, staff nurses and licensed practical nurses from all adult care areas, completed and returned the Perceptions of Restraint-Use Questionnaire for a response rate of 85.7%. Staff perceptions were, overall, consistent with similar published surveys: the promotion of safety was reported as the most important reason for restraint use. Significant differences in responses were observed, however, between the three levels of nursing staff and between the clinical areas. In contrast to other surveys, the respondents identified a wide range of alternatives to restraint use. The study identified many of the difficulties nurses face in their attempts to manage problematic behavior and ensure patient safety.
The use of physical restraints is a common, routine nursing intervention in acute and long-term care institutions. However, with growing recognition of the detrimental effects of restraint use, attempts are being made to modify this practice. Attention has focused on how nurses view the use of physical restraints and their awareness of alternative forms of safe and effective care. Published results are available from several studies addressing this topic; however, sample size is typically small and sampling is by convenience, limiting the generalizability of findings.
Evans and Strumpf (1989), in their comprehensive review of the literature, addressed many of the serious implications of physical restraints. They described reported prevalence rates between 7.4% and 22% in hospital settings and 25% to 84.6% in nursing homes. Furthermore, they noted that the efficacy of restraints is not supported by any scientific evidence; and, in fact, there is overwhelming potential for serious negative consequences such as emotional distress and multiple complications from immobility. Evans and Strumpf concluded that patientcentered goals must underlie every decision to use restraints.
Ashmore (1988) described the efforts made in a long-term care and rehabilitation hospital to reduce the 55% prevalence of restraint use by implementing a philosophy based on patient choice and rehabilitation, and by introducing clinical guidelines designed to assist staff with decision making. Morrison, CrinklawWiancko, King, Thibeault and Wells (1987) identified an overall restraint use incidence of 13.2% in an acute and extended care hospital. Again, nursing leaders in that setting worked to change practice through policy, education and the development of standards.
Efforts by nursing administrators and clinical experts to reduce the use of restraints seem to conflict with long-standing attitudes and beliefs among bedside caregivers. In one of the first reported staff surveys, Yarmesch and Sheafor (1984) asked 38 registered nurses from two nursing homes and four medical units to review patient vignettes and complete a questionnaire. The 23 staff who responded outlined 81 decisions to use a restraint and 10 decisions to use an alternative. More than half of the reasons given for the use of restraints were to protect the patient or others. Subsequent publications re-affirm these results.
There is general agreement that staff nurses, regardless of clinical setting, use restraints in well-intended efforts to protect patients from harm (particularly from falling), prevent patients from disrupting their medical treatments, and prevent harm to others. An overriding issue is the perceived threat of litigation if patient behavior is not controlled (Mion, Frengley, Jakovcic & Marino, 1989; Scherer, fanelli, Wu, & Kühn, 1993; Quinn, 1993). Despite these general commonalities, there is little consensus among staff regarding individual patient management.
Mion, Frengley, Jakovcic and Marino (1989) noted that the use of restraints varied from shift to shift. Macpherson, Lofgren, Granieri and Myllenbeck (1990) found there was little agreement between the nurse who initiated a restraint and the primary physician regarding the reason for the device. Yarmesch and Sheafor (1984) also identified a lack of consensus among the respondents regarding the choice of intervention and asked, "Is there not at least general agreement that good nursing mandates the use of alternative measures in almost every situation before turning to mechanical or pharmaceutical measures?" (p. 244).
Some surveys have also identified differences between categories of staff. For example, Schirm, Gray and Peoples (1993) found nursing attendants were more hesitant to reduce restraints than licensed nurses in a sample from three nursing homes. Scherer, Janelli, Wu and Kuhn (1993) suggested that experienced critical care nurses were more comfortable using restraints than were less experienced staff. Conversely, Janelli, Kanski. Scherer and Neary (1992) found that the attitudes of registered nurses, licensed practical nurses and nursing assistants were very similar and suggest that "... attitudes are shaped by the environment and working relationships" (p. 25).
In their 1988 study, Strumpf and Evans found that the decision to restrain a patient seemed to generate a conflict between professional practice beliefs and the perceived need to protect the patient. They proposed that nurses believe alternatives to restraintuse are limited and this belief serves as a coping mechanism. Quinn (1993) also addressed the use of restraints as an ethical dilemma for nurses and concluded that physical safety for patients has become such a priority "... that the psychological, emotional, or moral implications of restraint-use were either denied or justified ..." (p. 156) Clearly, the use of physical restraints is a complex practice issue that has not been resolved.
This study was undertaken to systematically determine how all levels of nursing staff in an 958-bed acute care hospital perceived restraint-use, and to identify their knowledge of alternatives. Using a random numbers table, 10% of the registered nurses, registered psychiatric nurses and licensed practical nurses were selected through stratified random sampling on all Medical, Surgical and Critical Care units, including Psychiatry and Emergency. A random sample was also obtained from the casual (float) nursing staff list. All of the unit managers were surveyed, as they hold a clinical leadership position. Initial non-respondents received a reminder letter within 2 weeks.
In total, 98 nurses were sampled. Eighty-four staff completed and returned the questionnaires: 51 registered nurses /registered psychiatric nurses, 12 licensed practical nurses and all 21 unit managers, for an 85.7% response rate. Two registered nurses and one registered psychiatric nurse did not respond. No responses were received from the 11 casual staff who were selected.
The Perceptions of Restraint-Use Questionnaire developed by Strumpf and Evans (1988) was revised slightly to reflect restraint use in the adult, acute care patient population by removing specific references to the elderly. Strumpf and Evans reported a Cronbach's alpha coefficient of .80 on the 17-item questionnaire. The revised questionnaire was reviewed by an internal panel of nurses for face validity and content validity.
The questionnaire was distributed with a cover letter that described the purpose of the study, identified the investigators and gave an assurance of confidentiality. Respondents were asked to rate each of the items on a five-point Likert scale from one (not at all important) to five (most important). The questionnaire included an openended section that asked respondents to identify and list measures which could be used as alternatives to physical restraints.
Rating of Total Area Results
The returned questionnaires were coded and the data entered into a statistical analysis software program (SPSS). The overall frequencies and mean responses to the items were examined and then the sample was divided into staff categories: Registered Nurse/Registered Psychiatric Nurse (RN/ RPN), Licensed Practical Nurse (LPN), and Unit Manager (UM); and clinical area: Medicine, Surgery and Critical Care. One-way analysis of variance tests were used to test for significant differences on item-mean scores between the three staff categories and the three clinical areas. Responses to the openended questions were collapsed into descriptive categories.
Mean scores for each questionnaire item were ranked from most to least important. The top three reasons for using restraints were: preventing a patient from falling out of a chair; falling out of bed; and pulling out an IV. Nurses ranked preventing a confused person from bothering others or taking things from others and providing a quiet time as the three least important reasons for restraints (Table).
STAFF CATEGORY RESULTS
Findings were further delineated into mean results for each questionnaire item by the category of respondents. Analysis of mean scores revealed a consistent order with LPNs attaching greater importance to the use of restraints than did RNs/ RPNs or UMs. Analysis of variance revealed a significant difference between several means (Figure 1).
Unit managers rated preventing a person from falling during unsafe ambulation, preventing a person from wandering, and preventing a person from taking things from others as significantly less important than did the LPN category. Unit managers also rated preventing a person from pulling out a catheter and providing quiet time or rest for an overactive person as significantly less important than did either the RN /RPN or LPN staff.
CLINICAL AREA RESULTS
Mean scores for each questionnaire item were also calculated by clinical area. Analysis of variance again revealed a significant difference between clinical area mean scores on several items. Medical area nurses rated the items preventing a person from pulling out a catheter and protecting staff and other patients from physical abusiveness as significantly less important than did the critical care nurses. The item providing a quiet time or rest for an overactive person was rated significantly less important by medical nurses than by staff in either Surgery or Critical Care (Figure 2).
Category Results for Importance of Restraints for Preventing Unsafe Ambulation
Category Results for Importance of Restraints for Preventing Wandering
Category Results for Importance of Restraints for Preventing Patients from Taking Things
Category Results for Importance of Restraints for Preventing Pulling Out Catheter
Category Results for Importance of Restraints for Providing Rest
Area Results for Importance of Restraints to Prevent Pulling Out Catheter
Area Results for Importance of Restraints for Protecting Others
Area Results for Importance of Restraints for Providing Rest
In response to the open-ended question on restraint alternatives, the respondents generated a list of 47 different measures for a total of 275 responses with a mean rate of 3.29 suggestions per respondent. The alternatives were categorized into seven areas: supervision; providing fall safety devices (ie, side rails); altering the environment (ie, door alarms); providing diversional activities; sedation; comprehensive patient assessment; and tamper-proofing treatments (ie, reinforcing dressings).
The most frequently cited, specific alternatives were: supervision by security staff (12.4%); sedation (10.5%); family supervision (8%); close supervision by nursing staff (7.3%); supervision by volunteers (7%); and diversional activities by nursing staff (4%). The responses were differentiated within the staff categories as follows: 60% of the responses were generated by RNs/RPNs, 30% by UMs and 10% by LPNs. Adjusting for respective sample sizes, one would expect 61% of responses from RNs/ RPNs, 25% from UMs, and 14% from LPNs.
In addition to listing alternatives, 33.3% of respondents added additional comments to the questionnaire related to precautions about sedation, concerns with staffing or budget cuts, negative statements regarding the use of restraints, and connotations regarding the term "restraint". Several respondents elaborated on alternative measures. Most comments centered around the expressed belief that restraints should be used as a last resort and then only to ensure patient safety. As one nurse wrote, "if all else fails, I do believe restraints should be used to prevent a patient from hurting him/herself or others". Several staff noted that restraints increase agitation or potential injury and give staff a false sense of security. Also, some of the respondents suggested that restraintuse is related to inadequate staffing and budget cuts as reflected in the comment: "insufficient staffing is a poor reason to use restraints; however, it is a reality."
The findings from this study, similar to the other reported surveys, identified protecting patients from falls and preventing interference with medical treatments to be the most important reasons for using restraints, whereas restraining a patient to promote rest or to prevent the individual from bothering others was less acceptable. These results suggest that nurses generally do not support the use of restraints to control difficult behavior unless there is a perceived threat to the patient or others.
A significant difference among categories of staff on the mean importance of restraint-use was noted. These differences could be indicative of higher educational levels or more developed critical thinking skills among unit managers and registered nurses /registered psychiatric nurses. The significantly higher rating of importance that critical care and surgical nurses gave to the protection of others suggests they may be more likely to encounter violent patients or to view treatments as essential for recovery.
The large list of alternatives generated by the respondents indicates that nurses possess more than a basic knowledge of other measures. The reasons why alternatives are so infrequently adopted may lie in the additional comments provided by some of the nurses indicating they may be considered impractical or impossible.
The aim of this study was to provide background information on acute care nurses' perceptions of restraint-use and its alternatives. Nurses know about potential alternatives, but knowledge is not enough. If the alternatives are considered impractical or unsuccessful, they are unlikely to be implemented. Further research into the efficacy of alternative measures is needed to give staff nurses a scientific base for practice changes. And, even more importantly, the goals of patient care must be explicit, accepted, and communicated. As long as nurses believe their first responsibility is to prevent possible falls and maintain medical treatments, patients will be restrained. Registered nurses, as the coordinators of patient care, are in an excellent position to take a leadership role in redefining the use of physical restraints.
- Ashmore, M. (1988). Reducing physical restraints. Canadian Health Care Management, 36, 28-35.
- Evans, L.K. & Strumpf, N.E. (1989). Tying down the elderly: A review of the literature on physical restraint, journal of the American Geriatrics Society, 37, 65-74.
- Janelli, L.M., Kanski, G.W., Scherer, Y.K., & Neary, M-A. (1992). Physical restraints: Practice, attitudes and knowledge among nursing staff. The Journal of Long Term Care Administration, 20, 22-25.
- Macpherson, D.S., Lofgren, R.P., Granieri, R-, & Myllenbeck, S. (1990). Deciding to restrain medical patients, journal of the American Geriatrics Society, 38, 516-520.
- Mion, L.C., Frengley, J.D., Jakovcic, C.A., & Marino, J.A. (1989). A further exploration of the use of physcial restraints in hospitalized patients, journal of the American Geriatrics Society, 37, 949-956.
- Morrison, J., Crinklaw-Wiancko, D., King, Thibeault, S., & Wells, D.L. (1987). Formulating a restraint use policy. Journal of Nursing Administration, 17, 39-42.
- Quinn, C.A. (1993). Nurses' perceptions about physical restraints. Western jouranl of Nursing Research, 15, 148-162.
- Scherer, Y.K., Janelli, L.M., Wu, Y.B., & Kühn, M.M. (1993). Restrained patients: An important issue for critical care nursing. Heart and Lung, 2, 77-83.
- Schirm, V., Gray, M., & Peoples, M. (1993). Nursing personnel's perceptions of physical restraint in long-term care. Clinical Nursing Research, 2, 98-110.
- Strumpf, N.E., & Evans, L.K. (1988). Physical restraint of the hospitalized elderly: Perceptions of patients and nurses. Nursing Research, 37, 132-137.
- Yarmesch, M., & Sheafor, M. (1984). The decision to restrain. Geriatrie Nursing, 5, 242244.
Rating of Total Area Results