Journal of Gerontological Nursing

Evidence-Based Practice Guideline 

Changing the Practice of Physical Restraint Use in Acute Care

Helen W. Lach, PhD, RN, CNL, FAAN; Kathy M. Leach, PhD, RN; Howard K. Butcher, RN, PhD

Abstract

Physical restraints continue to be used in acute care settings, despite the challenges and calls to reduce this practice. The current guideline on restraint use is updated with evidence that includes critical care settings and issues related to restraint use in acute care units. Nurses play a significant role in the use of restraints. Factors such as nurse's knowledge and patient characteristics combined with the culture and resources in health care facilities influence the practice of physical restraint use. Nurses can identify patients at high risk for restraint use; assess the potential causes of unsafe behaviors; and target interventions in the areas of physiological, psychological, and environmental approaches to address those unsafe behaviors. Members of the interdisciplinary team can provide additional consultation, and institutions can provide resources and education and implement monitoring processes and quality improvement practices to help reduce the practice of physical restraint use. [Journal of Gerontological Nursing, 42(2), 17–26.]

Abstract

Physical restraints continue to be used in acute care settings, despite the challenges and calls to reduce this practice. The current guideline on restraint use is updated with evidence that includes critical care settings and issues related to restraint use in acute care units. Nurses play a significant role in the use of restraints. Factors such as nurse's knowledge and patient characteristics combined with the culture and resources in health care facilities influence the practice of physical restraint use. Nurses can identify patients at high risk for restraint use; assess the potential causes of unsafe behaviors; and target interventions in the areas of physiological, psychological, and environmental approaches to address those unsafe behaviors. Members of the interdisciplinary team can provide additional consultation, and institutions can provide resources and education and implement monitoring processes and quality improvement practices to help reduce the practice of physical restraint use. [Journal of Gerontological Nursing, 42(2), 17–26.]

The use of physical restraints in health care institutions has been challenged for more than 2 decades by nurses and health professionals who considered the practice overused, unethical, and inappropriate in many cases (Antonelli, 2008; Martin, 2002; McCabe, Alvarez, McNulty, & Fitzpatrick, 2011; Tolson & Morley, 2012; Whitman, Davidson, Sereika, & Rudy, 2001). Devices that reduce or prevent patient movement are considered restraints when the patient is unable to remove the device (Centers for Medicare & Medicaid Services [CMS], 2009). Physical restraints have not been shown to prevent the key problems for which they are used most often (i.e., falls or pulling out devices), and in fact, continue to be associated with negative outcomes for patients, including death (Maccioli et al., 2003; Titler, Shever, Kanak, Picone, & Qin, 2011). Significant strides in reducing physical restraint use have been made in long-term care settings, but research shows restraint use continues to be a routine practice in hospitals (Mion, 2008; Titler et al., 2011).

The Joint Commission for the Accreditation of Healthcare Organizations (2009), CMS (2009), U.S. Food and Drug Administration (FDA; 2010), and American Nurses Association (2012) call for minimizing the use of physical restraint in patient care settings. Despite the continued evidence of restraint problems and lack of efficacy, restraint use continues to be common and misunderstood. As a result of this continued practice, the current article is an update to the prior guideline (Park & Tang, 2007) on how to reduce the use of physical restraint in acute care settings. The complete guideline, Changing the Practice of Physical Restraint Use in Acute Care (Lach & Leach, 2014), which incorporates new evidence-graded recommendations for care, behavior monitoring tools and logs, and outcome measures can be purchased from the Hartford/Csomay Center for Geriatric Nursing Excellence (access http://www.iowanursingguidelines.com).

Method

A literature search was conducted to evaluate current evidence. PubMed, Medline, CINAHL, SCOPUS, PsycInfo, and EMBASE were searched from 2005 when the last version of the current guideline was developed through December 2014. The following search terms were used: restraint, physical restraint, hospital, physical restraint, and acute care. After identifying several articles related to the critical care setting, it was determined to add this content to the guideline. An additional search was conducted back to 2000 for these articles. For the final guideline, articles were included if they addressed the use of restraints in acute care and were written in English, and excluded if they addressed psychiatric, geropsychiatric, rehabilitation, or pediatric settings.

The initial search resulted in 527 articles. After reviewing titles and abstracts, 196 articles were retrieved, and 78 articles met inclusion and exclusion criteria. In addition, an ancestry search was conducted and an additional 29 papers were included. Where no new literature addressed specific contents of the prior guideline, the older references and content were retained when considered relevant to current nursing care (n = 5). A total of 112 articles provided evidence for the updated guideline; most are referenced herein. Information from 11 professional and government websites and several books were also used for reference materials. Newer research included some large descriptive and epidemiological and multisite studies; however, intervention studies and quality improvement projects tended to have small samples or be single-site studies and some content included only expert opinion papers. The following background describes the state of restraint use.

Restraint Use

Restraint use has declined and varies widely among hospitals, as do reporting measures, but studies continue to document that it is a routine practice in the United States as well as some other countries (Krüger, Mayer, Haastert, & Meyer, 2013; Martin & Mathisen, 2005). Researchers have consistently found wide variability in restraint use both within hospitals and across hospitals (Kruger et al., 2013; Minnick, Mion, Johnson, Catrambone, & Leipzig, 2008; Mion, 2008; Titler et al., 2011), suggesting that factors affecting restraint use are multifactorial. Mion (2008) found rates of restraint use from 4.7 to 94 restraint days per 1,000 patient days, and suggested that 27,000 individuals are physically restrained in U.S. hospitals every day. A slightly higher rate was reported for side rails (Minnick et al., 2008). In another report, an average of 50 restrained days per 1,000 patient hospital days was reported (Minnick, Mion, Johnson, Catrambone, & Leipzig, 2007). Titler et al. (2011) reported restraint use was documented in 8.5% of the medical records of more than 10,000 older adults identified as at risk for falls. Kruger et al. (2013) reported 11.8% of patients were restrained among 64 wards in four German acute care hospitals.

Intensive care units are increasingly addressed in the literature on restraints. Mion (2008) found critical care settings in the United States had higher use of restraints than general medical–surgical units, accounting for 56% of restrained days, even though they made up less than 20% of the total patient days. Martin and Mathisen (2005) found 39% of critical care patients restrained in U.S. hospitals. Overall, studies report high rates of intensive care patients are restrained in studies from the United States, as well as Europe, South Africa, and the Middle East (Ankesel, 2007; Benbenbishty, Adam, & Endacott, 2010; De Jonghe et al., 2013; Eser, Khorshid, & Hakverdioglu, 2007; Kandeel & Attia, 2013; Langley, Schmollgruber, & Egan, 2011).

The decision to restrain patients rests primarily with nurses (Choi & Song, 2003; Goethals, Dierckx de Casterlé, & Gastmans, 2012), despite needing a physician's order. Studies on nurses' attitudes toward restraints have been mixed, finding them somewhat positive toward using restraints (Janelli, Stamps, & Delles, 2006), but less so in the most recent study by McCabe et al. (2011). Patient safety is a significant concern for nurses (Ludwick, Meehan, Zeller, & O'Toole, 2008) and the dominant influence on nurses' decision making about restraint use (Goethals et al., 2012; Lane & Harrington, 2011; Langley et al., 2011; Ludwick et al., 2008). Prevention of falls is a primary reason for restraint use on medical–surgical units, whereas preventing removal of medical devices and confusion are primary reasons in critical care settings (Bradas, Sandhu, & Mion, 2011). These are legitimate concerns and fall under the responsibility of nurses; however, evidence does not support the efficacy of physical restraints for many of the purposes for which they are used.

In some studies, nurses reported feeling more secure when patients are restrained (Chuang & Huang, 2007) and do not perceive that there are effective alternatives or resources to do anything else besides use a physical restraint (Lane & Harrington, 2011; Ludwick et al., 2008). Other nurses experience negative emotional responses to use of restraints, including sadness and guilt, and often report feeling ethical conflicts about the practice (Chuang & Huang, 2007; Yamamoto & Aso, 2009; Yamamoto, Izumi, & Usui, 2006). Reports of inappropriate reasons for use of physical restraint continue to surface occasionally, including convenience of the nurse (Choi & Song, 2003; Langley et al., 2011) and insufficient staffing (Evans & FitzGerald, 2002); however, these reports have been less frequent over the past decade. A recent meta-synthesis (Goethals et al., 2012) found nurses' decisions about restraint use are also influenced by family demands, physician orders, and other staff members. Another study found family members' perceptions of restraints somewhat negative (Kang, Lee, Park, Lee, & Lee, 2013). Further, nurses reported lack of time to discuss their options for addressing unsafe behaviors in patients with other staff as a factor in use of restraints.

Physician orders for restraints are usually provided after a request from a nurse (Mion et al., 2010). In a survey study, younger, less experienced physicians reported lower knowledge about restraints than older, more experienced physicians (Sandhu et al., 2010), and knowledge was positively associated with increased likelihood of ordering restraints. Patient behaviors led to decisions to order restraints, including climbing out of bed, being tremulous, picking at medical devices, or having dementia (Mion et al., 2010). Other factors lowered the likelihood of ordering restraints, including patient tachycardia or fever and physician lack of trust in the nurse's judgment. More than one half of physicians surveyed inappropriately believed that physical restraint was effective at preventing falls and disruption of therapies (Sandhu et al., 2010).

Despite two decades of work, the current authors find that physical restraint is still a misunderstood and regular practice in hospital settings. Nurses continue to have misconceptions of restraint use, and believe they do not have satisfactory alternative options. Nurses report significant ambiguity and moral dilemma between applying restraints and allowing patients freedom of movement (Bower, McCullough, & Timmons, 2003; Chuang & Huang, 2007; Yamamoto & Aso, 2009). Protocols and position papers continue to call for reduction of restraint use (American Academy of Nursing [AAN], 2014). Restraint use should be considered as a last resort intervention in cases where patients pose a danger to themselves or others. As a result, changing the practice of physical restraint use and striving toward restraint-free care in hospitals remain important goals. The guideline was updated and revised and provides approaches that nurses can take to understand and assess the problem with individual patients and institutions can take to change the culture and practice of physical restraint use.

Nurse-Driven Approaches To Reducing Restraint Use

Assessment

Because nurses play a central role in restraint use, they need knowledge and skills to identify patients at risk and manage patient behaviors and problems that often lead to restraint use. Patient characteristics continue to be the best predictors of physical restraint use (Minnick, Fogg, Mion, Catrambone, & Johnson, 2007), particularly behaviors nurses perceive as high risk for patients, such as falls and extubations. Unsafe behaviors are the principle concerns of nurses leading to restraint use. The goal of nursing care is early identification of patients who are at risk for unsafe behaviors and restraints, when interventions are most likely to be successful in preventing problem behaviors. Several factors are associated with restraint use (Benbenbishty et al., 2010; Chang, Wang, & Chao, 2008; Evans & Cotter, 2008; Heinze, Dassen, & Grittner, 2012; Hine, 2007; Hofsø & Coyer, 2007; Martin & Mathisen, 2005; McCabe et al., 2011; Minnick, Fogg, et al., 2007; Minnick, Mion, et al., 2007; Mott, Poole, & Kenrick, 2005; Titler et al., 2011; Turgay, Sari, & Genc, 2009):

  • Age (less so in critical care areas).
  • Interfering with or pulling out medical devices, such as intravenous lines, catheters, nasogastric tubes, and endotracheal tubes.
  • Falls and fall risk, particularly getting up without calling for needed assistance.
  • Delirium, cognitive impairment, or altered mental status with potential for elopement or combativeness or other unsafe behavior.
  • Agitated state or restless behaviors.
  • Physical dependence.
  • Incontinence or elimination problems.
  • Polypharmacy.

Risks of Using Restraints

Restraint use has no known benefit. In addition to the evidence that physical restraint does not reduce safety problems they are often used to prevent, there continues to be evidence that physical restraint has adverse physical effects that range from minor injury to death (American Nurses Association, 2001; Capezuti & Braun, 2001; Capezuti, Maislin, Strumpf, & Evans, 2002; Capezuti & Wexler, 2003; Demir, 2007; Evans, Wood, & Lambert, 2003; FDA, 1992; Talerico & Capezuti, 2001; Tolson & Morley, 2012). Therefore, nurses should consider the evidence and risks of using restraints when addressing unsafe patient behaviors. The following are problems that have resulted from the use of physical restraint (Chang, Liu, Huang, Yang, & Chang, 2011; Chang et al., 2008; Demir, 2007; FDA, 2010; Jones et al., 2007; Kandeel & Attia, 2013; Laursen, Jensen, Bolwig, & Olsen, 2005; Martin & Mathisen, 2005; Strout, 2010):

  • Death from strangulation, asphyxiation, or trauma.
  • Increased risk for extubation.
  • Deep venous thrombosis and pulmonary embolism.
  • Local skin or nerve injury, such as bruises, swelling, redness, skin tears, or scrapes.
  • Increased risk for falls.
  • Increased levels of chronic confusion (e.g., dementia), agitation, or acute confusion (e.g., delirium).
  • Risks associated with immobilization (e.g., pressure ulcers, pneumonia, urinary incontinence, functional decline, contractures).
  • Emotional distress.
  • Violation of patients' rights.

Assessment

Nurses need to conduct a thorough nursing assessment to evaluate for treatable and reversible causes of unsafe behaviors, including physiological, psychological, and environmental causes. Identifying factors underlying patient behaviors may lead to interventions to reduce or eliminate unsafe behaviors (Bradas, Sandhu, & Mion, 2012; Bray et al., 2004; Gatens, 2007; Hine, 2007; Maccioli et al., 2003; Registered Nurses' Association of Ontario, 2012; Struck, 2005).

Reasons for unsafe behaviors could include responses to a physical stress (e.g., hunger, pain, need to toilet, fatigue due to sleep deprivation) or a physiological change (e.g., acute physical illness, infection precipitating delirium). One study found an intervention to prevent delirium improved these rates and also reduced restraint use (Vidan et al., 2009). For patients with some degree of cognitive impairment, stress (e.g., over- or understimulation, a change in care-givers or routine), excess demand (e.g., procedures, pain, expected activity beyond their capacity), or unmet needs may lead to unsafe behavior. Table 1 provides an overview of strategies for assessing the patient and environment for factors related to unsafe behaviors.

Nursing Assessment to Identify Underlying Causes of Unsafe Behavior

Table 1:

Nursing Assessment to Identify Underlying Causes of Unsafe Behavior

Interventions

When considering restraint use, factors related to the patient's unsafe behavior should be assessed to develop an individualized plan of care to target interventions. Nurses also need to identify and address underlying physiological, psychological, and environmental causes of unsafe behaviors leading to restraint use (Bray et al., 2004; Kielb, Hurlock-Chorostecki, & Sipprell, 2005; Maccioli et al., 2003; Mion et al., 2001). The severity of the risk related to the patient's behavior should factor into decision making about potential interventions, including restraint (Mion, 2008; Vance, 2003). Appropriate interventions (Table 2) should be instituted to address patient preferences, and specific unsafe behavior, and include the following:

  • Removing underlying causes of behavior.
  • Managing the behavior to prevent accident or injury.
  • Changing the environment based on the individual's behaviors and abilities.
Nursing Interventions to Reduce Need for Restraints

Table 2:

Nursing Interventions to Reduce Need for Restraints

The last step is to monitor and evaluate the effectiveness of the nursing interventions and possible changes in patient behaviors and needs (Registered Nurses' Association of Ontario, 2012). If the interventions are not effective, nurses should continue as appropriate and try additional interventions and evaluate their effectiveness until the patient's needs are met, ideally without requiring restraint use.

Facility-Driven Approaches to Reducing Restraint Use

Nurses individually play a role in restraint use; however, health care facilities carry a large part of the responsibility for restraint use in the culture, training, expectations, and resources provided to nursing staff. Strong administrative support is essential for a restraint-free culture (AAN, 2014). Acute care facilities need to assess and modify their entire approach to care, including mission, philosophy, policies, and procedures (Chuang & Huang, 2007; Goethals et al., 2012; Ludwick et al., 2008), staffing, interdisciplinary collaboration, and staff education to support a restraint-free care environment. A variety of factors related to staff characteristics may be targets for interventions to encourage practice change (Huang, Chuang, & Chiang, 2009; Janelli et al., 2006; Lane & Harrington, 2011; Langley et al., 2011; Ludwick et al., 2008; Mion, Halliday, & Sandhu, 2008), including:

  • Lack of knowledge about restraints.
  • The belief of nurses in the efficacy of physical restraints.
  • High patient-to-nursing staff ratios.
  • Fear of litigation.

Several reports of successful quality improvement initiatives with education or combined with other interventions have identified approaches to move toward restraint-free care (Antonelli, 2008; Enns et al., 2014; Huang et al., 2009; Hurlock-Chorostecki & Kielb, 2006; Kielb et al., 2005; Markwell, 2005; Yeh et al., 2004). Facilities must also address other patient care issues related to restraints, particularly falls, extubation, and delirium, as nurses often resort to restraints to address these problems because they do not perceive they have alternative options. Engaging staff in addressing the issue supports ongoing efforts to support the continued movement toward reducing the practice of restraint use. Table 3 lists approaches facilities can use to foster the movement toward a restraint-free environment.

Health Care Facility Approaches to Restraint Reduction

Table 3:

Health Care Facility Approaches to Restraint Reduction

Conclusion

The use of physical restraint continues to be an issue in acute care facilities. Nurses play a role in the use of restraints and can play a role in reducing their use. Nurses can identify patient risks and implement interventions that address unsafe behaviors that provide patient-centered care that reduces the practice of physical restraint. Facilities can provide resources and supports that will build a culture where alternatives to restraint are easy to implement and changing this practice is a clear goal.

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Nursing Assessment to Identify Underlying Causes of Unsafe Behavior

AssessmentStrategy
Behavior historyObtain background about unsafe behavior from patient, family, and prior caregivers (e.g., nursing home staff).
Physiological factorsAssess for sedation levels; pain; electrolyte disturbances; infection; orthostatic hypotension; syncope; urinary symptoms or urinary or fecal retention; inadequate sleep; and difficulties with walking, balance, or mobility.
Psychological concernsAssess communication ability (i.e., in regard to stroke, dementia, and different primary language); depression; anxiety; impulsivity; agitation; fear; grief; posttraumatic stress disorder; substance abuse, including drugs, alcohol, or nicotine; and stressors, support systems, and coping strategies.
MedicationsIdentify medications that may contribute to confusion, delirium, movement disorders, and falls, such as reaction to a new medication or adverse reaction or drug interaction (see updated Beers Criteria for Determining Potentially Inappropriate Medication Use in Older Adults [American Geriatrics Society 2015 Beers Criteria Update Expert Panel, 2015]).
EnvironmentExamine bed appropriateness and safety, medical devices and necessity of use (e.g., ventilator tube, IV, urinary catheter), equipment and furniture (e.g., IV pole, bedside commode, bedside chair, tables, trapeze), lighting, noise levels, room temperature, and floor surface.

Nursing Interventions to Reduce Need for Restraints

ApproachIntervention
Physical/Physiological
Eliminate bothersome treatments or devices as soon as possible

Facilitate weaning to decrease the duration of mechanical ventilation

Move to oral feedings or medications instead of intravenous (IV) and nasogastric routes

Implement measures to reduce treatment interference and disguise equipment

Ensure appropriate, secure anchoring of tubes

Use long sleeve robes or gowns or IV skin sleeves to hide catheter sites

Guide the patient to feel tubes or equipment for familiarity

Overdress wounds and use abdominal binders to cover wound dressings

Keep IV solution bags and tubing out of the patient's field of vision

Implement evidence-based fall prevention and injury prevention measures

Tailor fall interventionstopatient'sspecificrisks (e.g., assistive devices, lighting, no-slip shoes, bed alarm, hip protectors, sitters)

Provide appropriate pain management

Offer pain medicationregularlyandintimeforittotakeeffect prior to potentially painful procedures, such as bathing, ambulating, or other activities, as pain can contribute to agitation

Address elimination needs proactively

Conduct frequent toileting rounds

Use equipment, such as bedside commode

Develop individualized voiding schedules

Psychological
Maximize communication

Explain devices, goals of care

Use active listening to elicit patient's feelings, concerns, and fears

Use translators, family as needed

Include family in care

Provide familiarity

Ask to bring pictures or other familiar objects

Provide distractions and activities

Television

Music per preference

Activities, exercise, puzzles

Squeeze ball, towels, or other for using hands

Address confusion, delirium, and agitation

Reorient confused patient

Use techniques to promote relaxation (e.g., massage, therapeutic touch, music, warm drinks), provide rest periods

Verbally redirect target behavior

Introduce self every time when entering patient's room

Provide reality links (e.g., radio, calendar, clock)

Environmental
Remove hazards

Remove clutter, items, spills, or equipment that could cause injury

Support appropriate sensory input

Ensure patient has eyeglasses and hearing aids when possible so he/she can interpret the environment

Provide adequate lighting

Provide increased surveillance as dictated by patient condition and risks

Conduct frequent nursing rounds or checks

Place patients in an area where they can be observed frequently

Provide one-on-one companionship and constant observation (explore family, staff, sitters, friends, volunteers)

Consider delirium room ward with continuous observation

Reduce excessive or annoying environmental stimuliMonitor:

Noise

Glare

Temperature

Lighting

Health Care Facility Approaches to Restraint Reduction

ApproachIntervention
Identify a task force or quality improvement team or committee to increase buy-in of stakeholders

Assess organizational supports and barriers

Assist with educational activities

Solicit input from staff on successful interventions

Engage staff in continuous quality improvement and practice redesign to reduce restraint use

Monitor the use of restraints

Collect data by unit and facility

Collect data across days of the week and times of the day

Compare to national benchmarks

Provide feedback to units and staff

Provide staff education

Inservices, training, simulations

Laminated card with suggested restraint alternatives and approaches (see Figure)

Promote sharing of successful interventions among staff

Interdisciplinary consultations

Provide adequate staffing

Consider assignments (i.e., consistent assignment for patients with cognitive impairment)

Address patient needs for surveillance (i.e., consider delirium room ward with continuous observation)

Provide readily available equipment and supplies to support alternative interventions

Diversion or distraction activities (e.g., magazines, puzzles, cards, squeeze balls, markers and paper) or equipment identified by staff

Low bed, reclining chair, bedside commode, and other furniture

Consider other equipment, such as cushions, bed/chair alarms, hip protectors, and skin sleeves, to support interventions

Consultations

Resource nurses with expertise who can help in challenging situations (advanced practice nurses, clinical nurse leaders)

Interdisciplinary team (i.e., physician for medical consultation; pharmacist for medication issues; physical therapy for gait/balance issues; occupational therapist for seating issues)

Regular rounds to address patient care challenges

Authors

Dr. Lach is Professor, Saint Louis University School of Nursing, and Dr. Leach is Manager of Research & Outcomes, Missouri Baptist Medical Center, St. Louis, Missouri.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Copyright © 2016 The University of Iowa John A. Hartford Foundation Center for Geriatric Nursing Excellence.

Address correspondence to Helen W. Lach, PhD, RN, CNL, FAAN, Professor, Saint Louis University School of Nursing, 3525 Caroline Mall, St. Louis, MO 63104; e-mail: lachh@slu.edu.

10.3928/00989134-20160113-04

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