Researchers have shown that the nurses continue to rely on use of physical restraint in care of patients that are cognitively impaired despite growing evidence that the use of physical restraint is traumatic, against the philosophy of nursing, potentially counter-therapeutic, and unnecessary (Duxbury, 2015). First of all, the literature review for this DNP project will explore the effects of educational intervention in reducing the use of physical restraint. Second, it will analyze the implication of alternative modes of action in reducing the use of physical restraint. Third, it will outline the effects of organizational interventions in reducing the use of physical restraint. Finally, it will compare studies on evidence-based nursing protocols for best practice in reducing physical restraint.
De-Bellis et al. (2011) investigated the effects of staff educational training in reducing the rate of restraint use through a systematic review of 72 peer-reviewed descriptive and qualitative studies. Their analysis revealed that the educational interventions enhance the use of alternative strategies to reduce the use of physical restraint. One of the limitations of the study is that most of the studies they reviewed were non-randomized clinical trials, therefore, they might have potential selection bias. The strengths of the study were that all the articles were peer-reviewed, and the outcome measures were conducted by independent reviewers. In a similar study, Barton-Gooden, Dawkins & Bennett (2015), using a cross-sectional descriptive pilot design study involving a convenience sample (n) of 172 adult patients and 47 charts for audits, concluded that the rate of restraint was reduced. One limitation of the study is that its findings cannot be generalized since it was a pilot study at a single institution. Moreover, the reliability of the data might have suffered due to cross-sectional area of the study and changes to patient-to-staff ratio. The strengths of the study included a convenience sample, large sample size, lack of influence of external validity. These studies were similar in the sense that none of them were randomized and they had the same outcome measure. However, while De-Bellis et al. (2011) study involved a systematic review of descriptive and qualitative studies, could be generalized, and was likely affected by external validity, Barton-Gooden, Dawkins & Bennett (2015) conducted a cross-sectional descriptive pilot design study at a single institution. The result might have been affected by external validity but it cannot be generalized easily.
Kontio et al. (2010) analyzed the effects of alternative approaches in reducing the use of physical restraint using a descriptive approach with open-ended focused interview. Data was collected through focused interviews of patients (n = 30) from six acute closed wards at two psychiatric hospitals in Southern Finland. The investigators concluded that the patients’ needs were unmet while on restraint, and the alternative approaches reduced the need for restrictions. The limitations of the study included small sample size, poorly reported results, and potential selection bias. One of the strengths of the study is that it took into consideration the quality of life of patients and patients’ experience while on restraint. Saarnio, Isola & Laukkala (2008) also conducted a study in Finland that employed a quantitative survey to collect responses from nurses (n = 1148) at 70 institutions. The researchers concluded that the use of alternative techniques decreases the use of physical restraint. The strengths of the study included a large representative sample size and significant internal consistency with value of Cronbach’s alpha coefficient between 0.53-0.66. The limitations of the study were lack of randomization that might have resulted in potential selection bias and an inadequate account of cofounders. Both studies lacked randomization and were likely affected by external validity. Unlike the study by Kontio et al. (2010), the study by Saarnio, Isola & Laukkala (2008) did have a large representative sample population and reliable internal consistency.
Gulpers et al. (2011) investigated the effects of Six Core Strategies in reducing the use of belt and other physical restraints in care of older adults using a quasi-experimental longitudinal design. The sample consisted of twenty-six psychogeriatric with 403 residents assigned to intervention group and 311 residents to control group. The intervention resulted in a 50% reduction in belt use (odds ratio = 0.48, 95% confidence interval = 0.28-0.81; p = .005) without an increase in fall related injuries. One of the strengths of the study is that the controlled study provided comparison to the usual care, making it possible to replicate the study. One of the limitations of the study is that the samples were assigned by quasi-experimental design which might have introduced selection bias due to lack of randomization.
The Substance Abuse and Mental Health Services Administration (SAMHSA) of the United States Government (2010) conducted a meta-analysis of randomized controlled trials (RCTs) to investigate the effects of multicomponent intervention strategies (Six Core Strategies) in reducing the restraint rates. Data was collected from 43 of the 52 facilities that participated in the SAMHSA-fund. Frequency of restraint use was measured by a fidelity scale called Inventory of Seclusion and Restraint Reduction Intervention (ISRRI). Results revealed that the restraint hours per 1000 treatment hours declined by 55% (p=.083). The limitation of the study is the difficulty in implementing it due to extraneous variables that may impact the outcomes. The strengths of the study include the fidelity to intervention (using the ISRRI) and the ability to measure the effects of the intervention.
Gulpers et al.’s (2011) multicomponent strategies utilized a quasi-experimental longitudinal design with four strategies while SAMHSA (2010) multicomponent strategies conducted meta-analysis of randomized controlled trials (RCTs) involving Six Core Strategies. The strategies for both studies provide a prevention-based framework for nurses to expect challenge, engage in early intervention, and assess the factors that precipitate the cycle of violence if restraint is inevitably used.
Bradas, Sandhu & Milon (2012) investigated evidence-based nursing protocols for best practice to reduce the use of physical restraint in healthcare settings using a systematic review. The researchers concluded that the use of alternative techniques and organizational approaches through educational training reduces the use of physical restraint. One of the strengths of this study is the high methodological quality of the studies. In addition, the studies were limited to meta-analysis. The limitation of the study is lack of information on sample size. Registered Nurses’ Association of Ontario (2012) also conducted a study to find evidence-based best nursing practices that minimize restraint rate in healthcare settings. The systematic review by the researchers involved 290 published meta-analysis and the researchers reached the same conclusion. One of the strengths of this study is that all the researched papers focused on the best practice guidelines. The additional strengths of this study are large sample size, identification of the type of evidence for each study, and grading for recommendation. A study by Bradas, Sandhu & Milon (2012) provided no clinical algorithm while a study by RNAO (2012) did enlist the clinical algorithm. Nevertheless, the overall quality of the studies is high and both studies demonstrate significant clinical homogeneity in terms of components of intervention and definition of physical restraint.
No single method will be effective in reducing the rate of physical restraint. Interventions to reduce restraint use should be evidence-based, related to patient-centered care, policy-driven with goals of dispelling the myths of restraint, and adopt alternative means of caring for patients with altered mental status (De-Bellis et al., 2011).