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).
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 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
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.
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.
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
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
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
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.
- American Academy of Nursing. (2014). Choosing wisely: Ten things nurses and patients should question. Retrieved from http://www.aannet.org/choosing-wisely
- American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63, 2227–2246. doi:10.1111/jgs.13702 [CrossRef]
- American Nurses Association. (2012). Reduction of patient restraint and seclusion in health care settings. Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements/Reduction-of-Patient-Restraint-and-Seclusion-in-Health-Care-Settings.pdf
- Ankesel, N. (2007). Physical restraint practices among ICU nurses in one university hospital in western Turkey. Health Science Journal, 1, 1–7.
- Antonelli, M.T. (2008). Restraint management: Moving from outcome to process. Journal of Nursing Care Quality, 23, 227–232. doi:10.1097/01.NCQ.0000324587.53719.2f [CrossRef]
- Benbenbishty, J., Adam, S. & Endacott, R. (2010). Physical restraint use in intensive care units across Europe: The PRICE study. Intensive and Critical Care Nursing, 26, 241–245. doi:10.1016/j.iccn.2010.08.003 [CrossRef]
- Boustani, M.A., Campbell, N.L., Khan, B.A., Abernathy, G., Zawahiri, M., Campbell, T. & Callahan, C.M. (2012). Enhancing care for hospitalized older adults with cognitive impairment: A randomized controlled trial. Journal of General Internal Medicine, 27, 561–567. doi:10.1007/s11606-012-1994-8 [CrossRef]
- Bower, F.L., McCullough, C.S. & Timmons, M.E. (2003). A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update. The Online Journal of Knowledge Synthesis for Nursing, 10, 1.
- Bradas, C.M., Sandhu, S. & Mion, L.C. (2011). Physical restraints and side rails in acute and critical care setting. In Capezuti, E., Zwicker, D., Fulmer, T. & Boltz, M. (Eds.), Evidence-based geriatric nursing protocols for best practice. New York, NY: Springer.
- Bradas, C.M., Sandhu, S.K. & Mion, L.C. (2012). Use of physical restraints with elderly patients: Physical restraints and side rails in acute and critical care settings. Retrieved from http://consultgerirn.org/topics/physical_restraints/want_to_know_more
- Bray, K., Hill, K., Robson, W., Leaver, G., Walker, N., O'Leary, M. & Waterhouse, C. (2004). British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nursing in Critical Care, 9, 199–212. doi:10.1111/j.1362-1017.2004.00074.x [CrossRef]
- Capezuti, E. & Braun, J. (2001). Medico-legal aspects of hospital side rail use. In Kapp, M.B. (Ed.), Ethics, law, and aging review (Vol. 7, pp. 25–57). New York, NY: Springer.
- Capezuti, E., Maislin, G., Strumpf, N. & Evans, L.K. (2002). Side rail use and bed-related fall outcomes among nursing home residents. Journal of the American Geriatrics Society, 50, 90–96. doi:10.1046/j.1532-5415.2002.50013.x [CrossRef]
- Capezuti, E. & Wexler, S. (2003). Choosing alternatives to restraints. In Siegler, E.L., Mirafzail, S. & Foust, J.B. (Eds.), An introduction to hospitals and inpatient care. New York, NY: Springer.
- Centers for Medicare & Medicaid Services. (2009). CMS financial report. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CFOReport/Downloads/2009_CMS_Financial_Report.pdf
- Chang, L.C., Liu, P.F., Huang, Y.L., Yang, S.S. & Chang, W.Y. (2011). Risk factors associated with unplanned endotracheal self-extubation of hospitalized intubated patients: A 3-year retrospective case-control study. Applied Nursing Research, 24, 188–192. doi:10.1016/j.apnr.2009.09.002 [CrossRef]
- Chang, L.Y., Wang, K.K. & Chao, Y.F. (2008). Influence of physical restraint on unplanned extubation of adult intensive care patients: A case-control study. American Journal of Critical Care, 17, 408–415.
- Choi, E. & Song, M. (2003). Physical restraint use in a Korean ICU. Journal of Clinical Nursing, 12, 651–659. doi:10.1046/j.1365-2702.2003.00789.x [CrossRef]
- Chuang, Y.H. & Huang, H.T. (2007). Nurses' feelings and thoughts about using physical restraints on hospitalized older patients. Journal of Clinical Nursing, 16, 486–494. doi:10.1111/j.1365-2702.2006.01563.x [CrossRef]
- Collins, L.G., Haines, C. & Perkel, R.L. (2009). Restraining devices for patients in acute and long-term care facilities. American Family Physician, 79, 254, 256.
- Day, J., Higgins, I. & Koch, T. (2009). The process of practice redesign in delirium care for hospitalised older people: A participatory action research study. International Journal of Nursing Studies, 46, 13–22. doi:10.1016/j.ijnurstu.2008.08.013 [CrossRef]
- De Jonghe, B., Constantin, J.M., Chanques, G., Capdevila, X., Lefrant, J.Y., Outin, H. & Mantz, J. (2013). Physical restraint in mechanically ventilated ICU patients: A survey of French practice. Intensive Care Medicine, 39, 31–37. doi:10.1007/s00134-012-2715-9 [CrossRef]
- Demir, A. (2007). Nurses' use of physical restraints in four Turkish hospitals: Clinical scholarship. Journal of Nursing Scholarship, 39, 38–45. doi:10.1111/j.1547-5069.2007.00141.x [CrossRef]
- Edwards, N., Danseco, E., Heslin, K., Ploeg, J., Santos, J., Stansfield, M. & Davies, B. (2006). Development and testing of tools to assess physical restraint use. Worldviews on Evidence-Based Nursing, 3, 73–85. doi:10.1111/j.1741-6787.2006.00056.x [CrossRef]
- Enns, E., Rhemtulla, R., Ewa, V., Fruetel, K. & Holroyd-Leduc, J.M. (2014). A controlled quality improvement trail to reduce the use of physical restraints in older hospitalized adults. Journal of the American Geriatrics Society, 62, 541–545. doi:10.1111/jgs.12710 [CrossRef]
- Eser, I., Khorshid, L. & Hakverdioglu, G. (2007). The characteristics of physically restrained patients in intensive care units. International Journal of Human Sciences, 4(2), 1–12.
- Evans, D. & FitzGerald, M. (2002). Reasons for physically restraining patients and residents: A systematic review and content analysis. International Journal of Nursing Studies, 39, 735–743. doi:10.1016/S0020-7489(02)00015-9 [CrossRef]
- Evans, D., Wood, J. & Lambert, L. (2003). Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing, 41, 274–282. doi:10.1046/j.1365-2648.2003.02501.x [CrossRef]
- Evans, L.K. & Cotter, V.T. (2008). Avoiding restraints in patients with dementia: Understanding, prevention, and management are the keys. American Journal of Nursing, 108, 40–49. doi:10.1097/01.NAJ.0000311827.75816.8b [CrossRef]
- Flaherty, J.H. & Little, M.O. (2011). Matching the environment to patients with delirium: Lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. Journal of the American Geriatrics Society, 59(Suppl. 2), S295–S300. doi:10.1111/j.1532-5415.2011.03678.x [CrossRef]
- Fogel, J.F., Berkman, C.S., Merkel, C., Cranston, T. & Leipzig, R.M. (2009). Efficient and accurate measurement of physical restraint use in acute care. Care Management Journals, 10, 100–109. doi:10.1891/1521-09220.127.116.11 [CrossRef]
- Gatens, C. (2007). Restraints and alternatives. Retrieved from http://www.rehabnurse.org/pdf/GeriatricsRestraints.pdf
- Goethals, S., Dierckx de Casterlé, B. & Gastmans, C. (2012). Nurses' decision-making in cases of physical restraint: A synthesis of qualitative evidence. Journal of Advanced Nursing, 68, 1198–1210. doi:10.1111/j.1365-2648.2011.05909.x [CrossRef]
- Heinze, C., Dassen, T. & Grittner, U. (2012). Use of physical restraints in nursing homes and hospitals and related factors: A cross-sectional study. Journal of Clinical Nursing, 21, 1033–1040. doi:10.1111/j.1365-2702.2011.03931.x [CrossRef]
- Hine, K. (2007). The use of physical restraint in critical care. Nursing in Critical Care, 12, 6–11. doi:10.1111/j.1478-5153.2006.00197.x [CrossRef]
- Hofsø, K. & Coyer, F.M. (2007). Part 1. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: Contributing factors. Intensive and Critical Care Nursing, 23, 249–255. doi:10.1016/j.iccn.2007.04.003 [CrossRef]
- Hou, I.C., Chen, J., Lin, F.L., Yu, H.Z., Huang, S.F. & Huang, Y.J. (2013). The evaluation of integrating physical restraint report and care record system. Studies in Health Technology and Informatics, 192, 934.
- Huang, H.T., Chuang, Y.H. & Chiang, K.F. (2009). Nurses' physical restraint knowledge, attitudes, and practices: The effectiveness of an in-service education program. Journal of Nursing Research, 17, 241–248. doi:10.1097/JNR.0b013e3181c1215d [CrossRef]
- Hurlock-Chorostecki, C. & Kielb, C. (2006). Knot-so-fast: A learning plan to minimize patient restraint in critical care. Dynamics, 17(3), 12–18.
- Janelli, L.M., Stamps, D. & Delles, L. (2006). Physical restraint use: A nursing perspective. Medsurg Nursing, 15, 163–167.
- The Joint Commission for the Accreditation of Healthcare Organizations. (2009). Restraint/seclusion for hospitals that use the joint commission for deemed status purposes. Retrieved from http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=260&ProgramId=1
- Jones, C., Bäckman, C., Capuzzo, M., Flaatten, H., Rylander, C. & Griffiths, R.D. (2007). Precipitants of post-traumatic stress disorder following intensive care: Role and need of physical restraints. Reply by authors to Dr. Kapadia. Intensive Care Medicine, 33, 2227. doi:10.1007/s00134-007-0872-z [CrossRef]
- Kandeel, N.A. & Attia, A.K. (2013). Physical restraints practice in adult intensive care units in Egypt. Nursing & Health Sciences, 15, 79–85. doi:10.1111/nhs.12000 [CrossRef]
- Kang, J., Lee, E.N., Park, E.Y., Lee, Y. & Lee, M.M. (2013). Emotional response of ICU patients' family toward physical restraints. Korean Journal of Adult Nursing, 25, 148–156. doi:10.7475/kjan.2013.25.2.148 [CrossRef]
- Kielb, C., Hurlock-Chorostecki, C. & Sipprell, D. (2005). Can minimal patient restraint be safely implemented in the intensive care unit?Dynamics, 16, 16–19.
- Krüger, C., Mayer, H., Haastert, B. & Meyer, G. (2013). Use of physical restraints in acute hospitals in Germany: A multi-centre cross-sectional study. International Journal of Nursing Studies, 50, 1599–1606. doi:10.1016/j.ijnurstu.2013.05.005 [CrossRef]
- Lach, H.W. & Leach, K.M. (2014). Changing the practice of physical restraint use in acute care. In Butcher, H.K. (Series Ed.), Series on evidence-based practice for older adults. Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core.
- Lai, C.K.Y., Chow, S.K.Y., Suen, L.K.P. & Wong, I.Y.C. (2013). Reduction of physical restraints on patients during hospitalisation/rehabilitation: A clinical trial. Asian Journal of Gerontology and Geriatrics, 8, 38–43.
- Lane, C. & Harrington, A. (2011). The factors that influence nurses' use of physical restraint: A thematic literature review. International Journal of Nursing Practice, 17, 195–204. doi:10.1111/j.1440-172X.2011.01925.x [CrossRef]
- Langley, G., Schmollgruber, S. & Egan, A. (2011). Restraints in intensive care units: A mixed method study. Intensive and Critical Care Nursing, 27, 67–75. doi:10.1016/j.iccn.2010.12.001 [CrossRef]
- Laursen, S.B., Jensen, T.N., Bolwig, T. & Olsen, N.V. (2005). Deep venous thrombosis and pulmonary embolism following physical restraint. Acta Psychiatrica Scandinavica, 111, 324–327. doi:10.1111/j.1600-0447.2004.00456.x [CrossRef]
- Ludwick, R., Meehan, A., Zeller, R. & O'Toole, R. (2008). Safety work: Initiating, maintaining, and terminating restraints. Clinical Nurse Specialist, 22, 81–87. doi:10.1097/01.NUR.0000311672.03857.1b [CrossRef]
- Maccioli, G.A., Dorman, T., Brown, B.R., Mazuski, J.E., McLean, B.A., Kuszaj, J.M. & Peruzzi, W.T. (2003). Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: Use of restraining therapies—American College of Critical Care Medicine Task Force 2001–2002. Critical Care Medicine, 31, 2665–2676. doi:10.1097/01.CCM.0000095463.72353.AD [CrossRef]
- Markwell, S.K. (2005). Long-term restraint reduction: One hospital's experience with restraint alternatives. Journal of Nursing Care Quality, 20, 253–260. doi:10.1097/00001786-200507000-00011 [CrossRef]
- Martin, B. (2002). Restraint use in acute and critical care settings: Changing practice. AACN Clinical Issues, 13, 294–306. doi:10.1097/00044067-200205000-00013 [CrossRef]
- Martin, B. & Mathisen, L. (2005). Use of physical restraints in adult critical care: A bicultural study. American Journal of Critical Care, 14, 133–142.
- McCabe, D.E., Alvarez, C.D., McNulty, S.R. & Fitzpatrick, J.J. (2011). Perceptions of physical restraints use in the elderly among registered nurses and nurse assistants in a single acute care hospital. Geriatric Nursing, 32, 39–45. doi:10.1016/j.gerinurse.2010.10.010 [CrossRef]
- Minnick, A., Mion, L.C., Johnson, M.E., Catrambone, C. & Leipzig, R. (2007). Prevalence and variation of physical restraint use in acute care settings in the US. Journal of Nursing Scholarship, 39, 30–37. doi:10.1111/j.1547-5069.2007.00140.x [CrossRef]
- Minnick, A., Mion, L.C., Johnson, M.E., Catrambone, C. & Leipzig, R. (2008). The who and why's of side rail use. Nursing Management, 39(5), 36–39, 41–44. doi:10.1097/01.NUMA.0000318064.41092.f2 [CrossRef]
- Minnick, A.F., Fogg, L., Mion, L.C., Catrambone, C. & Johnson, M.E. (2007). Resource clusters and variation in physical restraint use: Health policy and systems. Journal of Nursing Scholarship, 39, 363–370. doi:10.1111/j.1547-5069.2007.00194.x [CrossRef]
- Mion, L.C. (2008). Physical restraint in critical care settings: Will they go away?Geriatric Nursing, 29, 421–423. doi:10.1016/j.gerinurse.2008.09.006 [CrossRef]
- Mion, L.C., Fogel, J., Sandhu, S., Palmer, R.M., Minnick, A.F., Cranston, T. & Leipzig, R. (2001). Outcomes following physical restraint reduction programs in two acute care hospitals. Joint Commission Journal on Quality Improvement, 27, 605–618.
- Mion, L.C., Halliday, B.L. & Sandhu, K. (2008). Physical restraints and side rails in acute and critical care settings: Legal, ethical, and practice issues. In Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds.), Evidence-based geriatric nursing protocols for best practice (3rd ed., pp. 503–520). New York, NY: Springer.
- Mion, L.C., Sandhu, S.K., Khan, R.H., Ludwick, R., Claridge, J.A., Pile, J. & Winchell, J. (2010). Effect of situational and clinical variables on the likelihood of physicians ordering physical restraints. Journal of the American Geriatrics Society, 58, 1279–1288. doi:10.1111/j.1532-5415.2010.02952.x [CrossRef]
- Mott, S., Poole, J. & Kenrick, M. (2005). Physical and chemical restraints in acute care: Their potential impact on the rehabilitation of older people. International Journal of Nursing Practice, 11, 95–101. doi:10.1111/j.1440-172X.2005.00510.x [CrossRef]
- Nawaz, H., Abbas, A., Sarfraz, A., Slade, M.D., Calvocoressi, L., Wild, D.M. & Tessier-Sherman, B. (2007). A randomized clinical trial to compare the use of safety net enclosures with standard restraints in agitated hospitalized patients. Journal of Hospital Medicine, 2, 385–393. doi:10.1002/jhm.273 [CrossRef]
- Park, M. & Tang, J.H.C. (2007). Evidence-based guideline: Changing the practice of physical restraint use in acute care. Journal of Gerontological Nursing, 33(2), 9–16.
- Registered Nurses' Association of Ontario. (2012). Promoting safety: Alternative approaches to the use of restraints. Retrieved from http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf
- Sandhu, S.K., Mion, L.C., Khan, R.H., Ludwick, R., Claridge, J., Pile, J.C. & Dietrich, M.S. (2010). Likelihood of ordering physical restraints: Influence of physician characteristics. Journal of the American Geriatrics Society, 58, 1272–1278. doi:10.1111/j.1532-5415.2010.02950.x [CrossRef]
- Stevens, J.C. (2012). The use of physical restraints in neurologic patients in the in-patient setting. Continuum (Minneapolis, Minn), 18, 1422–1426. doi:10.1212/01.CON.0000423855.55394.ad [CrossRef]
- Strout, T.D. (2010). Perspectives on the experience of being physically restrained: An integrative review of the qualitative literature. International Journal of Mental Health Nursing, 19, 416–427. doi:10.1111/j.1447-0349.2010.00694.x [CrossRef]
- Struck, B.D. (2005). Minimizing physical restraints in acute care. Journal of the Oklahoma State Medical Association, 98, 390–392.
- Talerico, K.A. & Capezuti, E. (2001). Myths and facts about side rails. American Journal of Nursing, 101(7), 43–48. doi:10.1097/00000446-200107000-00022 [CrossRef]
- Titler, M.G., Shever, L.L., Kanak, M.F., Picone, D.M. & Qin, R. (2011). Factors associated with falls during hospitalization in an older adult population. Research and Theory for Nursing Practice, 25, 127–148. doi:10.1891/1541-6518.104.22.168 [CrossRef]
- Tolson, D. & Morley, J.E. (2012). Physical restraints: Abusive and harmful. Journal of the American Medical Directors Association, 13, 311–313. doi:10.1016/j.jamda.2012.02.004 [CrossRef]
- Turgay, A.S., Sari, D. & Genc, R.E. (2009). Physical restraint use in Turkish intensive care units. Clinical Nurse Specialist, 23, 68–72. doi:10.1097/NUR.0b013e318199125c [CrossRef]
- Tzeng, H.M., Yin, C.Y. & Grunawalt, J. (2008). Effective assessment of use of sitters by nurses in inpatient care settings. Journal of Advanced Nursing, 64, 176–183. doi:10.1111/j.1365-2648.2008.04779.x [CrossRef]
- U.S. Food and Drug Administration. (1992). Potential hazards with restraint devices. Retrieved from http://www.fda.gov/MedicalDevices/Safety/Alertsand-Notices/PublicHealthNotifications/ucm242670.htm
- U.S. Food and Drug Administration. (2010). A guide to bed safety bed rails in hospitals, nursing homes and home health care: The facts. Retrieved from http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/HospitalBeds/ucm125857.pdf
- Vance, D.L. (2003). Effect of a treatment interference protocol on clinical decision making for restraint use in the intensive care unit: A pilot study. AACN Clinical Issues, 14, 82–91. doi:10.1097/00044067-200302000-00010 [CrossRef]
- Vidan, M.T., Sanchez, E., Alonso, M., Montero, B., Ortiz, J. & Serra, J.A. (2009). An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. Journal of the American Geriatrics Society, 57, 2029–2036. doi:10.1111/j.1532-5415.2009.02485.x [CrossRef]
- Whitman, G.R., Davidson, L.J., Sereika, S.M. & Rudy, E.B. (2001). Staffing and pattern of mechanical restraint use across a multiple hospital system. Nursing Research, 50, 356–362. doi:10.1097/00006199-200111000-00005 [CrossRef]
- Yamamoto, M. & Aso, Y. (2009). Placing physical restraints on older people with dementia. Nursing Ethics, 16, 192–202. doi:10.1177/0969733008100079 [CrossRef]
- Yamamoto, M., Izumi, K. & Usui, K. (2006). Dilemmas facing Japanese nurses regarding the physical restraint of elderly patients. Japan Journal of Nursing Science, 3, 43–50. doi:10.1111/j.1742-7924.2006.00056.x [CrossRef]
- Yeh, S.H., Hsiao, C.Y., Ho, T.H., Chiang, M.C., Lin, L.W., Hsu, C.Y. & Lin, S.Y. (2004). The effects of continuing education in restraint reduction on novice nurses in intensive care units. Journal of Nursing Research, 12, 246–256. doi:10.1097/01.JNR.0000387508.44620.0e [CrossRef]
Nursing Assessment to Identify Underlying Causes of Unsafe Behavior
|Behavior history||Obtain background about unsafe behavior from patient, family, and prior caregivers (e.g., nursing home staff).|
|Physiological factors||Assess 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 concerns||Assess 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.|
|Medications||Identify 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]).|
|Environment||Examine 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
|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
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|
Ask to bring pictures or other familiar objects
|Provide distractions and activities|
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)
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 stimuli||Monitor: |
Health Care Facility Approaches to Restraint Reduction
|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
|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
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