Journal of Nursing & Patient CareISSN: 2573-4571

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Research Article, J Nurs Patient Care Vol: 1 Issue: 2

Registered Nurses’ Use of Physical Restraints on the Medical Floor in a Jamaican Hospital

Lawrence ES, Dawkins PE and Barton-Gooden A*
UWI School of Nurs ing, UWI, Mona Campus, Jamaica
Corresponding author : Antoinette Barton-Gooden
MSN, BSc, CEN, RN, Lecturer, UWI School of Nurs ing, UWI, Mona Campus, Jamaica
Tel: 876-9703304
E-mail: [email protected]
Received: October 21, 2016 Accepted: December 27, 2016 Published: December 31, 2016
Citation: Lawrence ES, Dawkins PE, Barton-Gooden A (2017) Registered Nurs es’ Use of Physical Restraints on the Medical Floor in a Jamaican Hospital. J Nurs Patient Care 1:2.doi:10.4172/2573-4571.1000108

 

Abstract

Objectives: To explore registered nurses use of physical restraints on the medical floor of an acute care hospital in Kingston, Jamaica

Methods: This descriptive cross-sectional study included 90 registered nurses working on the medical floor. Data collection utilized a 17-item self – administered adapted version of the Perceptions of Restraint Use Questionnaire (PRUQ). Data were analyzed using the Statistical Package for Social Sciences SPSS® version 20 for Windows®.

Results: The response rate was 85.7% f (N=90). Participants were female (97%) and ages ranged between 20-29 years (60%). The majority (88%) had baccalaureate degree (88%) and 40% of this number had worked as a registered nurse for less than two years. Registered nurses reported using physical restraints to reduce the likelihood of patients either falling out of bed (4.41±0.95), breakage of sutures (4.26±0.88) or pulling out intravenous line (4.14±0.79) out of a maximum score of 5. Nurses indicated that the time of day influenced physical restraint usage with the night shift accounting for 71.1%. Confused patients were more likely to be restrained (78.9%). The majority (76.7%) of study participants were knowledgeable of the institution’s physical restraint policy but (83% reportedly received no training in its application.

Conclusion: Nurses on the medical wards utilized physical restraints to ensure patient safety and facilitate treatment continuation. Patient characteristics, lack of training and institutional support were contributing factors to physical restraint usage. When institutional support is inadequate, nurses’ intention to prevent patient harm and meet professional obligation might contribute to the reliance on the use of physical restraint.

Keywords: Acute care hospital; Physical restraint usage; Registered Nurses; Medical floor

Keywords

Acute care hospital; Physical restraint usage; Registered Nurs es; Medical floor

Introduction

Medical floors in acute health care settings tend to have long stay patients with concomitant co-morbidities. Such complexities of care require competent staff, adequate nurse-patient ratio, organizational support to promote patient safety and favourable health outcomes [1,2]. Arguably, the problem of restraint usage is not only a function of patient to nurse ratio, but involves the staff mix which should be taken into consideration as this affects patient outcomes [2,3].
A thematic review of factors that influenced nurses’ use of physical restraints reveal that workload, treatment continuation and inadequate legislation were often major contributors to the practice [4-8]. Furthermore, evidence has shown that there is an inverse relationship between registered nurses presence, level of educational attainment and restraint usage. When such an environment exists, less attempts to use alternatives are initiated and this negatively impacts patient care and outcomes [8-10]. However, despite research evidence about the dangers of physical restraint usage [11-13], the practice remains endemic in some settings as nurse and families have positive attitude to the usage [5,13-15] and decision making about physical restraint is not a linear process [16,17].
High use of restraint have been documented in the United States of America and Jamaica is no different [18,19]. As restraints are being used as a nursing intervention and with adverse effects [12,13,20,21]. The risk of restraint usage is more likely in resource stricken settings like Jamaica, in which the government spends between 4 and 5.5 percent of the national budget on health care, which is less than the required 10-15 percent [22]. As a result, there is inadequate staff, high patient-staff ratio and occupational stress [23]. Additionally, the lack of institutional support and integration of evidence-based information into nursing practice pose a threat to patient safety in low resource settings.
Restraint usage is associated with an increase in patient confusion, falls, decubitus ulcers, length of hospital stay and can sometimes result in death [11,24,25] and usage was more likely is cognitively impaired groups such as the elderly [21,26]. Adverse events like these contribute to nurses being ambivalent about the practice of restraint usage and often experience moral dilemma such as sadness, guilt, and fears when restraints are used [19,27-29]. Although the evidence disprove that restraint is beneficial, some nurses consistently perceive that restraints are protective [13,30,31] and argued that alternatives were unavailable [32]. This contributed to call for improved nursing education to support quality [33] and organizational and system re-orientation that are supportive of change [34]. However, even with systems change like restraint policy implementation or strengthening that supports restraint reduction, inadequate institutional support may thwart implementation [14]. This demonstrates that the problem is multifactorial and there is no easy solution unless the root causes are elucidated.
This study was guided by the Theory of Reasoned Action [35] and Planned Behaviour [36] to explore registered nurses use of physical restraint on the medical floor. The extended theory of reasoned action includes the following components to explain behaviour [35]. It includes: (1) Attitude to the behaviour comprising of the strength of the expectancy (beliefs) that the act will be followed by a consequence and the value of that consequence to the individual. 2) Subjective norms and 3) Perceived control, such as situational or internal obstacles to performing the behaviour [37]. The theory explains that individuals make decisions about performing certain actions based on their intention. Werner & Mendelsson identified that the TRA accounted for 48% of the variance in nurses’ intention to use physical restraint. This supports the argument that intention is an important antecedent for a behavior [38]. However, behaviour can be modified either positively or negatively by subjective norms [38,39], especially with a supportive or unsupportive organizational culture [29,40].
There is a plethora of research evidence in Europe, Asia, Canada, and North America about physical restraints use and the effects of how nurses felt about physical restraint use [7,18,26,29]. However, a mixed-methods pilot study about physical restraint explored the views of nurses and medical doctors on the medical-surgical floor and a psychiatric unit at a teaching hospital in Jamaica [19]. It showed a high prevalence of physical restraint usage on the medical-surgical units. This study sought to identify the reasons registered nurses’ on the medical floor used physical restraint.
Definition of physical restraint
Physical restraint is defined as “any device, material or equipment attached to or near a person’s body and which cannot be controlled or easily removed by the person and which deliberately prevents or is deliberately intended to prevent a person’s free body movement to a position of choice and/or a person’s normal access to their body” [41].

Study Design, Setting, Participants and Methods

This study utilized a descriptive cross sectional study design among registered nurses to explore the use of physical restraint on the medical floor at the University Hospital of the West Indies (UHWI).
Setting
The medical floor of the UHWI, a quasi-government tertiary healthcare institution was selected as the setting to conduct this study as it is a type A teaching hospital which provides multi-disciplinary services to the people of the Caribbean and is a referral hospital for the entire island. It is well known for the quality of service delivery and high standards of nursing care. The medical floor was selected because these wards tend to have long stay patients with multiple co-morbidities, who by the nature of their medical conditions are more likely to be at risk for the use of physical restraints and the literature identified a high prevalence in this setting [18,19]. Jamaica is experiencing an epidemiological transition and chronic non communicable diseases (CNCDs) result in high healthcare utilization [42], coupled with an aging population of 11% [43]. These contribute to an increased patient acuity, multiple comorbidity and longer staying patients on the medical units.
Population and sample size
The population included 105 registered nurses who enjoyed full or part-time employment at the institution, were working on the medical floor for at least three months and have used physical restraint on patients. A census was undertaken for the study. Registered Nurs es were excluded if they did not meet these criteria, were on leave of absence such as vacation leave, maternity leave, sick leave, study leave, as well as nurses not directly involved in patient care.
Ethical approval
Ethical approval was received from the University Hospital of the West Indies/University of the West Indies/Faculty of Medical Sciences (UHWI/UWI/FMS) Ethics Committee. Approval was obtained from the developers of the tools for its use. Institutional approval and written informed consent from the participants was received prior to data collection. Recruitment of the registered nurses for the study was undertaken May 21, 2013 to June 14, 2013. The nurses were sensitized to the study by the researcher and supported by the clinical nurse manager for the medical floor during the monthly meeting. Eligible participants were approached at the beginning of each shift and the purpose of the study was explained. Prospective participants were given the opportunity to ask questions and any concerns raised were addressed. Anonymity and confidentially was maintained by pre-coding the questionnaires and the participants were not required to place their names either on the tools or on the envelopes. Completed questionnaires were placed in a sealed envelope, dropped in a designated box behind the nurses’ station and were collected daily.
Instrument
A self-administered tool was administered to 90 nurses during May-June 2013.
The Perceptions of Restraint Use Questionnaire (PRUQ) was developed by Evans and Strumpf [44] and adapted and revised by the Centre for Integrative Science in Aging [45]. The tool assessed the relative importance caregivers ascribe to reasons for using physical restraints with the elderly. The tool was developed as a Likert scale (originally 3-point, now 5-point) from a review of the literature that included reasons for and attitudes about restraint use [45]. The PRUQ tool consisted of 17-items that assessed the most commonly cited reasons for using restraint, socio-demographic characteristics, educational level attained and experience of respondents. The PRUQ consisted of a likert scale ranging from ‘1—not at all important’ to ‘5— most important’ was used gather information about the commonly cited reasons for using physical restraint. The values ranged from a minimum of 17 to a maximum of 85. Higher values indicate the likelihood of a behaviour occurring.
Validity and reliability
The Perceptions of Restraint Use Questionnaire (PRUQ) has been tested for use in acute care settings and many countries to assess perceptions of staff members regarding the use of physical restraints [15,20]. The adapted version of the tool used in this study has a coefficient alpha of .96 which compares favorably with a sample of 87 American nursing home staff and a coefficient alpha of .94 [44]. The tool was pretested on six (6) ICU nurses and face validity was assessed by two (2) nursing faculty to check the appropriateness of phrases related to physical restraints practices in the Jamaican setting. Permission to modify the tool was granted by the developers of the tool to make it culturally appropriate. Additional questions about the characteristics of the restrained patients, data about the most likely shift in which physical restraints are used, whether a doctor’s order was obtained and institutional support for physical restraint practice was also assessed.
In the present study, the Cronbach’s α coefficient for the adapted PRUQ was 0.735.
Data analysis
The Statistical Package for Social Sciences Software (SPSS), version 20.0 was used to analyze the data. Categorical variables were analyzed using measures of central tendencies such as means and standard deviation. Nominal and ordinal variables were analyzed using frequencies and percentages.

Results

Description of socio-demographic variables
There was a response rate of (86%) n=90/105. The sample consisted of mainly females (97%) ages ranged from 20-49 years, with the majority being ages 20-29 (60 %) and worked at regular staff nurses (87.9%). Most were trained at the baccalaureate level (88%). Professional characteristics revealed a plurality had less than two years’ experience (40%). This was followed closely by (34.4%) having 2-5 years’ experience, with the remainder having 6 years’ experience. The demographic characteristics of the nurses are represented in Table 1.
Table 1: Demographic and Professional Characteristics of Study Participants on the Medical Floor of the at University Hospital of the West Indies.
The Physical restraint practices among registered nurses on the medical floor
The nurses reported on their actions and observations while on the medical floor. Physical restraint usage was highest on the night shift 71.1%, followed by the morning shift 47.8% and afternoon shift 34.4 %. Confused patients were more likely to be restrained (78.9%), followed by patients who were agitated (33.3%). The characteristics of patients who are restrained are represented in Table 2. In situations where restraints were applied, nurses reported that restraint orders were received 60% of the time, sometimes 34.4% and none 4.4%.
Table 2: Physical restraint practices among the registered nurses on the medical floor.
Registered nurses’ reasons for restraint use
Using the Perceptions of Physical Restraint Use Questionnaire (PRUQ), the top 10 reasons for using physical restraint were falling out of the chair (͞x 4.42), falling out of bed (͞x = 4.41), breaking out sutures (͞x =4.26), pulling out IV (͞x =4.14), pulling out catheter (͞x =4.13), unsafe ambulation (͞x =4.06), pulling out feeding tube (͞x =3.99), removing dressing (͞x =3.93) protecting staff and other patient ( ͞x =3.91) and protecting the patient from getting into dangerous places ( ͞x =3.80) are represented in Table 3. The mean total score for all 17 PRUQ questions for all nurses was 61.89 (out of a total possible score of 85), or an average of 3.64 of 5.
Table 3: Perceptions of (Physical ) Restraint Use Questionnaire (PRUQ) scores of registered nurses.
The level of institutional support for registered nurses in the use of physical restraints
Institutional support for restraint usage on the medical units was captured by the nurses’ knowledge of the restraint policy and training provided by the institution is this study. The majority of the nurses reported being knowledgeable about the restraint policy (76.7%). Most (83.3%) reported that they had not received training in the application of physical restraints by the institution (Table 4).
Table 4: Institutional support for the registered nurses.

Discussion

Interpretation of findings
This study identified the reasons and contributing factors registered nurses’ on the medical floor applied physical restraint and was guided by theory of reasoned action to understand this phenomenon. Nurs es had a positive view toward physical restraint application and used it among confused or agitated patients, more often on the night shift [16]. Nurs es cited concerns for patient safety and continuation of medical treatment as the main reasons for usage. This is supported by the literature [13,20,29]. Although the majority identified an awareness of the institutional restraint policy, there was inadequate institutional support in the form of training opportunities for restraint application and the resources used for restraining patients.
These findings are consistent with some of the results from a pilot study about physical restraint usage in Jamaica [19]. Findings from that mixed methods study identified inadequate institutional support through training in restraint application and lack of awareness of the policy existed among nurses on the medical and surgical floor and one psychiatric unit. However, contrary to Barton-Gooden et al., majority of the nurses on the medical wards were aware of the policy. It is possible that the purposive sampling method used in the earlier study might have created some bias in data collection.
The theory of reasoned action is a useful framework for examining nurses’ use physical restraints. It supports the argument that knowledge is not sufficient to change behaviour. Despite evidence-based information consistently highlight the negative effect of restraint, nurses’ attitude appear to be supportive of restraint application. In this study although majority of the nurses reported being knowledgeable of the policy, they were not trained to apply physical restraint safely. Yet they continued to apply restraints in their practice. It is possible that this is due to their moral obligation to maintaining patient safety. Similar findings were reported after implementation of fall reduction policy [29]. This demonstrates that the organization’s mandate can thwart the effort to reduce restraint usage especially if nurse feel they might be penalized if patients experience harm. Werner and Mendelsson identified that staff attitudes were an important antecedent to restraint usage, therefore it is possible that the favourable attitudes toward restraint application resulted in high usage among nurses on the medical wards. This supports the theory that intention is an important predictor of behaviour [38].
This study revealed that several factors contributed to restraint usage by nurses on the medical such as patient characteristics, shift, inadequate institutional support, possibly staff age and duration in the clinical setting. Without doubt, the main reason to use physical restraints on the medical floor is for safety precaution and treatment continuation. These findings are consistent with studies conducted in Turkey, Thailand [26] and Belgium [17]. Although Oersakul et al. highlighted the perception that physical restraints use minimized fall, no research could be found to support the assumption that the use of restraints prevent falls or injury [11,34].
Maintaining the safety of patient is a fundamental nursing responsibility and institution often have sanctions if the patient is harmed. This culture of punitive sanctions may contribute to over reliance of physical restraint as a nursing intervention to protect the patient [6,29], and likely to be used more in the elderly [26]. The nurses’ fear of litigation when patients are harmed may have contributed to the high use of restraint on the night shift, particularly because staffing tends to be lower. This was supported by the literature [4,6]. The effect of inadequate staffing impacts workload and this is demonstrated by increased physical restraint usage and less attempts to use alternatives [6,8,16].
The characteristic of the patients admitted on the medical floor is an important factor that may result in high usage of physical restraints. Hofmann & Hahn identified an association with cognitive status and restraint usage. During hospitalization, the elderly are more likely to be confused and agitated thus are more likely to disturb therapeutic devices. In situations such as this, restraints are used as nursing interventions [26,27,29]. Sometimes the lack of continuation of therapy is blamed on the nurses if devices are removed prematurely, therefore social pressure from the healthcare team may support the nurses’ intention to use restraint.
The literature also shows that educational approach to the reduction of restraint use has been unsuccessful [29], and recommends that efforts to support restraint reduction should include competency development, especially for front line staff. It is necessary to also have changes in organizational practice to support and ensure sustained change in behavior [34].
Although this study did not assess patient outcome, the complexities of care for the elderly and agitated patients especially at nights, require adequate nurse-patient ratio to promote patient safety and favourable outcomes [1,16]. Evidence has shown that patient care is negatively affected by reduced registered nurse and restraint usage is increased when such environment exists [8-10]. Also, the benefit of adequate nurse mix is important to enhance patient safety [3], especially when the majority of the staff have limited professional experience.

Limitations of the Study

This study will only examine the reasons registered nurses’ use of physical restraints on the medical floor and used the theory of reasoned action to examine the phenomenon. Therefore due to the limited sample size, the findings cannot be generalized to other departments or institution. Also, social desirability bias could have affected the result as they may fear repercussion from the organization. It is recommended that since the study was specific to the Jamaican context, generalization of findings may be more relevant to resource stricken countries.

Conclusion

Nurs es had a favourable view of physical restraint usage to maintain treatment and increases patient safety. Organizations have a responsibility to ensure patient safety through the integration of evidence-based instruction and provide support for front-line staff for implementation. Therefore, steps should be taken to reduce restraint usage as evidence-based information supporting the practice is lacking and recommends alternatives.

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