Original Manuscript
Nurses’ perceptions and practice of physical restraint in China
Nursing Ethics 1–9 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014557118 nej.sagepub.com
Hui Jiang Tongji University School of Medicine, China
Chen Li Shanghai University, China
Yan Gu and Yanan He Tongji University School of Medicine, China
Abstract Background: There is controversy concerning the use of physical restraint. Despite this controversy, some nurses still consider the application of physical restraint unavoidable for some of their clients. Aim: Identify the perceptions and practice of physical restraint in China. Research design: This was a descriptive study that combined qualitative interviews with a quantitative cross-sectional survey. Participants: A total of 18 nurses were interviewed and 330 nurses were surveyed. Ethical considerations: Approval of the study was obtained from the hospital ethics committee. Permission to conduct the study was obtained from the director of nursing. Participants were assured that their participation is voluntary. Results: Physical restraint was commonly used to protect patients’ safety. Naturally, intensive care unit nurses used physical restraint much more frequently than general medical/surgical ward nurses (p < 0.01). In addition, night shift nurses tended to use physical restraint more frequently. Conclusion: Nursing managers should be aware of the role nurses play in the use of physical restraint. In-service training regarding the proper use of physical restraint should be strengthened and nurse staffing levels should be improved in order to minimize the use of physical restraint in China. Keywords China, hospital, nursing management, nursing practice, physical restraint
Introduction The practice of physical restraint in patients is considered unacceptable and immoral in many countries as it conflicts with patients’ rights, dignity, and comfort.1–3 However, in other countries, physical restraint is still considered part of nursing care and is accepted as unavoidable intervention to protect patients and hospital staff.4,5 Nurses are closely involved in the decision making and implementation of physical restraint.6 In Hui Jiang and Chen Li contributed equally to this work. Corresponding author: Hui Jiang, Nursing Department of Shanghai East Hospital, Tongji University School of Medicine, No. 150, Jimo Road, Pudong New Area, Shanghai 200120, China. Email: [email protected]
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China, not much is known about the efficacy, morality, and legality of physical restraints. This study was undertaken to determine nurses’ perceptions and the clinical practice of physical restraints in China.
Background Physical restraint is defined as a physical device attached to the patient’s body that the patient cannot remove, prevents him from moving and restricts his access to his body.7,8 Commonly used physical restraints include wrist, ankle, chest, and waist restraints.9,10 Physical restraints interfere with patient’s autonomy and are inconsistent with preserving patient’s dignity. There is growing evidence that physical restraints are associated with negative physical, psychological, and social consequences in patients.11 Such negative effects include loss of muscle strength, orthostatic hypotension, urinary and fecal incontinence, increased risk of nosocomial infection, bruises, edema, pressure ulcers, strangulation, increased confusion/agitation, sleeplessness, loss of self-trust and respect, resistance or objection to daily routine activities, and disturbance in body image.9,12,13 However, many nurses still believe that the use of physical restraints is an effective strategy to protect patients’ safety.10 Nurses cite many reasons for the frequent use of physical restraints. These include insure patients’ safety, prevent interference with treatment, falls, avoid disturbing others, short staffing, control agitated or restless patients, and protect patients from injury secondary to wandering.6,14 Of these reasons, fall prevention and prevention of patient-initiated disruption of treatment are the main reasons for using physical restraint.15 The most common treatment instruments removed by patients are endotracheal and nasogastric tubes.3,4 Studies have indicated that physical restraints are more likely to be used in patients who are 65 years or older,16 in patients with poor mobility and impaired cognitive status, and in patients who require extensive and complicated therapy and have a history and risk of falls.15 Men are more likely to be physically restrained than women.17 Nurses most often are the initiators of restraint use.6 Although research has addressed the practice of physical restraint in various countries, this type of research is scarce in China. Currently, there are no available guidelines or legal regulations concerning the use of physical restraints in China. Hence, the aim of this study was to investigate nurses’ perceptions and the practice of physical restraints in China.
Methods The study combined qualitative interviews with a quantitative cross-sectional survey. Two tools were used: (1) semi-structured interview questions and (2) structured survey. Data collected were based on a literature review and to support the purpose of the study.17,18 The data included demographics, educational level, and type of working unit. The following questions were asked during the interviews: (1) What are your perceptions regarding the use of physical restraints? (2) Under what circumstances can you restrain a patient? (3) What do you think about the ethical issues surrounding the use of physical restraints? (4) Would you notify the family or obtain consent before applying physical restraints? (5) Do you try alternative procedures before applying physical restraint? (6) What you think would/could help you reduce the use of physical restraints in practice? The nurses’ perceptions and practice of physical restraint were also determined using self-designed questionnaire which included 28 items. The survey questionnaire was developed by the researcher based on careful literature review. The survey respondents were asked to rate the frequency of their work roles on a 5-point Likert scale, ranging from 5 (very frequent) to 1 (never). The higher the average, the more favorable the overall perception an individual has toward physical restraint use. The questionnaire was tested for content-related validity by 10 experts in the area of nursing management, research, and education who assessed the content validity of the questionnaire. The content validity index of the questionnaire was 0.93. A pilot study was conducted on 30 nurses to test the clarity and applicability of the tools, and Cronbach’s alpha was 0.81. The reliability and validity of the instrument were at acceptable levels. 2
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Setting and participants The study was conducted in a tertiary general hospital in Shanghai which has 1800 beds and 1200 nurses. The intensive care unit (ICU) and medical–surgical nursing staff were recruited as participants in the focus interview and the survey using convenience sampling. The participants were selected based on the following criteria: (1) fulltime registered nurses, (2) had experience in applying physical restraint in hospitalized patients, (3) had working experience in the surveyed unit for more than 6 months, (4) were willing to share their experiences on the use of physical restraint, and (5) could give informed consent. In total, 18 employed nurses (9 from the ICU and 9 from general medical–surgical wards) were interviewed and 330 nurses (149 from the ICU and 181 from general medical–surgical wards) consented to participate in the survey.
Data collection and analysis Data were collected from January to March 2014. A total of 18 nurses were invited for in-depth interviews. The interviews were held in a quiet meeting room, and each interview lasted 1 h. All the interviews were tape-recorded with the consent of the participants. The interviews were transcribed verbatim by the researcher within 48 h of completion. Content analysis was used to identify major categories and themes using Colaizzi’s phenomenological method of data analysis.19 The questionnaires were distributed manually by the researcher to potential respondents and collected immediately after completion. Each questionnaire took about 10 min to complete. Data collection and analysis were done anonymously. The survey data were analyzed using the Statistical Package for Social Sciences Version 17.0 software for Windows (SPSS Inc., Chicago, IL, USA). Descriptive statistics were performed to summarize the data. The mean and standard deviation were used to show the frequency of response to each item given by the participants. Single sample t-test was used to compare the difference between the ICU and the general medical–surgical ward nurses. Statistical significance was set at p < 0.05 (two-sided).
Ethical considerations Approval of the study was obtained from the ethics committee of the hospital. Permission to conduct the study was obtained from the director of nursing and the head nurses of the surveyed units. All participants were given a detailed explanation of the study objectives and methods to be used. Participating nurses were assured that their participation was voluntary and they were free to withdraw at any time without comment or penalty. Anonymity and confidentiality were guaranteed, and consent was obtained from each participant.
Findings Demographics All 18 nurses who took part in the qualitative interview were female, age 24 to 37 years (mean 29.17 + 3.94 years) with hospital working experience ranging from 2 to 13 years (mean 6.28 + 3.66 years). In total, 12 nurses (66.67%) were married. A total of 10 nurses (55.56%) had associate degree level, and the other 8 nurses (44.44%) had bachelor degree. The 330 nurses who answered the quantitative questionnaire were mostly females, 327 females (99.09%) and 3 males (0.01%); age 21 to 32 years (mean 26.89 + 4.86 years). Their working experience ranged from 1 to 23 years (mean 6.29 + 5.51 years). Over half of the nurses (56.06%) were married. Their educational background was diploma 29 (8.79%), associate 239 (72.42%), bachelor 61 (18.49%), and only 1 nurse (0.003%) had master’s degree level. 3
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Focus interview findings Theme 1: nurses’ perceptions on the use of physical restraint. Nurses expressed that in their clinical nursing practice, physical restraint was normally used for unconscious, restless, and agitated patients; patients with important invasive tubes after surgery; patients with endotracheal intubation; noncooperative patients; or patients with a high risk of falls. They all considered physical restraint an important and effective measure to restrain patients in order to ensure patient cooperation with medical treatment without patient-initiated disruption, such as unplanned tube removal and preventing the patient from falling from the bed. Most nurses considered physical restraint an acceptable and routine practice in their daily nursing care and relied on it to restrain the movement of patients for necessary treatment and to protect patients from harm. Physical restraint also prevented patients harming other patients and nursing staff. The nurses thought that physical restraint was an important measure in patients, as it prevented them from removing important tubes, shortened the length of hospital stay, and accelerated patients’ recovery; for nurses, they relied on physical restraint to decrease unnecessary workload and to avoid incidents due to their negligence; for doctors, they did not want to repeat tube insertion procedures; for relatives, most considered the results more important than the process, and physical restraint was accepted by them to ensure patients’ safety. When asked about the ethical issues and interference with the human rights of patients, most nurses said they needed to consider patient safety as the first priority rather than ethicality, human rights, and dignity. A shortage of nursing staff was the main reason for physical restraint in China and was mentioned by all the interviewed nurses when asked about methods to minimize physical restraint. Subtheme 1: nurses considered physical restraint as an accepted practice to secure patients’ safety. If I am the patient, I am unconscious, nurses did it for my safety. I can understand after I recover. Although the process is tough and difficult, the result is good. When they recover and discharge, they can understand, we do it with good intension and for the patient’s sake.
Subtheme 2: nurses considered physical restraint as a considerate practice guided by patients’ or relatives’ wishes and willingness. I individually oppose the use of physical restraint. Physical restraint affect patient’s dignity. If there is no freedom, then no way to talk about the human rights and dignity. In my own view, patient’s wishes and willingness should be respected. If patients were unconscious and got mental dysfunction, then relatives’ opinion should be respected. If we use the physical restraint without the relatives’ consent, we will be blamed and complained. Thus, from our view, I will follow the relatives’ suggestions. If they sign the consent, I will use the physical restraint.
Subtheme 3: nurses considered physical restraint as a necessary practice caused by heavy workload and inadequate nurse staffing. We have no time to think about ethical issues regarding the physical restraint. We have to finish the work first, save patients’ life and protect patients’ safety. We think more about to finish the job but not the ethical issues. In China, I think it is difficult to stop the physical restraint use. We take care of much more patients than other countries. If we have more nurses, we will spend more time with the patients, try not to use the physical restraints. But we are always short of nursing staff and we are too busy. If patient remove the tubes, we will have trouble. They will think we don’t do a good job. So for patients’ sake, for our own sake, we’d better restraint the patients properly for patients’ safety and for the purpose of protecting the patient. 4
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Theme 2: nursing practice of physical restraint. Nurses expressed that physical restraint was very common in their daily work, especially in the ICU as patients in the ICU were more critically ill, received more treatment, and were without relatives’ companionship. The wrist and ankle restraints were most frequently used. Nurses are the main decision makers in assessing the need for physical restraint and the application of physical restraint in patients. Nurses need to explain to patients or their relatives the reasons for and the purpose of physical restraint. Consent needs to be obtained from patients or their relatives before nurses can apply physical restraint. Family members are normally understanding and supportive of the use of physical restraint. Some relatives even ask for physical restraint to protect patients’ safety. Sedatives and relatives’ close companionship are the most common alternative methods used by nurses if patients or relatives refuse the use of physical restraint. Nurses use physical restraint more often in the evening and night shift than in the day shift as the day shift has more nurses to take care of the patients. Nurses assess the restrained patient every 2 h or even more frequently to relax the restrained area for 10 min to check the circulation and the skin condition in order to avoid negative consequences such as redness, bruising, and edema. Subtheme 1: nurses considered the use of physical restraint as common intervention and played a key role in decision making to initiate the use of restraints. We normally assess the patients’ conscious level, acuity, inserted tubes and risks for tube removal. If the patient is unconscious and not cooperate with the treatment, after the relative’s agreement, we normally use the protective physical restraint. In other words, we need to obtain the consent before we use the physical restraint. The purpose of the physical restraint was used to protect the patient, but not to control the patient. Some relatives may ask for the physical restraint. When they leave the patient in the ward they will remind the nurses that the patient is not alert and cooperate, they ask the nurses to use the physical restraint for them if necessary. Some relatives even remind us to use the physical restraint at the time when the patient was admitted. For the new admissions, we assess the patients’ condition and explain the purpose of the physical restraint and ask the relative to sign the consent right away. If there is emergency, we need to call the family to get the relatives’ verbal permission for the physical restraint use. So far I didn’t encounter the relatives’ refuse for the physical restraint use. Normally we explain the reason to them and tell them the reason to use the physical restraint, they can understand and accept. It is very rare here for relatives to refuse the physical restraint use.
Subtheme 2: sedatives and relatives’ close companionship were used as alternatives if the physical restraint use was rejected by patients or relatives. If the relatives reject the use of the physical restraint, we won’t use it. China is a country with multiple customs, we need to consider different customs, different preference. There are two ways to solve this problem here. One way is that we call the relative to help us to stay by the bedside and look after the patient and the other way is to call the doctor to give the sedation for the patient. Day time we got more nurses, we consider remove the physical restraint and night shift we have less nurses, we need to put the restraint back. When the relative is around, we release the restraint and let the relative to help take care of the patients.
Questionnaire survey findings The survey clearly showed a significant increase in the use of restraints by the ICU nurses compared to general medical/surgical wards (p < 0.01) (Table 1). However, this trend is reversed during night shift. Night shift nurses in the general medical/surgical ward had a higher tendency to use physical restraint than ICU nurses (p < 0.01). The main purpose of using physical restraints in the ICU was to prevent accidental 5
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Table 1. Comparison of physical restraint use between nurses in the ICU and nurses in the general medical/surgical ward (n ¼ 330).
Survey items 1. The frequency of restraint in patients 2. Protect from falling out of bed 3. Protect from falling out of a chair 4. Prevent pulling out an endotracheal tube 5. Prevent pulling out a catheter 6. Prevent pulling out a feeding tube 7. Prevent pulling out an intravenous line 8. Prevent pulling out drainage tube after operation 9. Manage impaired post anesthesia 10. Manage impaired overdose 11. Manage impaired confusion 12. Manage impaired agitation 13. Manage impaired restlessness 14. Manage impaired psychology 15. When observation is difficult in evening shift 16. When observation is difficult in night shift 17. When work is busy 18. When high nurse/patient ratio 19. To protect staff/other patients from physical combativeness 20. I use mittens 21. I use wrist ties 22. I use ankle ties 23. I use body belts 24. I monitor extremity color/temperature/sensation/ swelling 25. I write a narrative note if complications occur 26. I think restraint is convenient for the nursing work 27. I feel sympathy for the patient with physical restraint 28. I think nurses should stop physical restraint
ICU (n ¼ 149)
General medical/ surgical ward (n ¼ 177)
t value
p value
3.79 + 1.18 3.07 + 1.64 1.58 + 1.12 4.32 + 1.15 3.66 + 1.47 3.93 + 1.34 3.57 + 1.52 4.00 + 1.34 3.93 + 1.44 3.22 + 1.58 4.30 + 1.11 4.53 + 0.93 3.92 + 1.23 4.14 + 1.14 2.67 + 1.27 2.67 + 1.24 3.75 + 1.31 3.66 + 1.31 2.81 + 1.40
2.76 + 0.95 2.95 + 1.43 1.76 + 0.95 2.89 + 1.57 3.73 + 1.20 3.86 + 1.17 3.81 + 1.21 3.08 + 1.59 2.54 + 1.48 2.74 + 1.51 3.98 + 1.12 4.19 + 1.00 3.60 + 1.29 3.60 + 1.54 2.94 + 1.27 3.09 + 1.28 3.52 + 1.36 3.63 + 1.22 2.47 + 1.27
8.727 0.735 1.406 9.277 0.483 0.534 1.535 5.52 8.394 2.738 2.537 3.128 2.319 3.544 0.274 2.827 1.579 0.256 2.289
0.000* 0.463 0.161 0.000* 0.629 0.593 0.126 0.000* 0.000* 0.007* 0.012* 0.002* 0.021* 0.000* 0.065 0.005* 0.115 0.798 0.023*
2.29 + 1.13 4.38 + 1.06 3.40 + 1.32 2.44 + 1.03 4.57 + 0.75
1.92 + 1.27 3.81 + 1.21 3.43 + 1.33 2.51 + 2.19 4.46 + 0.69
2.622 4.525 0.217 0.383 1.416
0.009* 0.000* 0.829 0.702 0.158
3.99 + 1.28 3.94 + 1.14 3.68 + 1.12 1.63 + 1.04
3.92 + 1.33 3.39 + 1.00 3.66 + 1.01 1.77 + 0.91
0.469 4.586 0.124 1.304
0.639 0.000* 0.901 0.193
ICU: intensive care unit. *p < 0.05.
extubation, but in the general medical/surgical ward it was to prevent pulling out the feeding tubes. The use of physical restraint was higher in agitated patients and influenced by nurse/patient ratio. Wrist restraints were the most commonly used physical restraints in the ICU and wards (p ¼ 0.00). With the exception of patients’ safety, nurses in both groups considered the use of physical restraints as essential tool for their own work convenience (Table 1, item 26). Even though nurses had high sympathy for patients with physical restraints, they still used physical restraint (Table 1, item 28).
Discussion The use of physical restraints appears to be a useful and simple solution to prevent treatment interference.12 But in reality, it is a complex concept, which encompasses physical, psychological, legal, ethical, and moral 6
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issues,13 and had been considered as an intrusive and risky procedure which is only legally permitted in very specific circumstances.12,14 Our study showed that physical restraints are commonly used by nurses both in the ICU and the general medical/surgical wards despite the reported potential harm to the patient and the controversy concerning the effectiveness of physical restraints.20 In China, the use of physical restraints was considered as a nursing intervention, and nurses in China made the decision and applied physical restraint. Doctors’ involvement and support for use of the physical restraint is not needed unless conflicts rise up with the relatives; then, the doctors become involved in discussions with the family. As the patient’s autonomy is breached by the application of physical restraints, patients or relatives were informed about the effects and potential dangers of physical restraint and their consent was sought to avoid potential conflict. The most commonly used physical restraints were wrist restraints, followed by ankle restraints. The reasons for using physical restraint and the most frequent shift (night shift) in which physical restraint was used in China were consistent with those reported from other countries.1,3,14,16,21 However, we observed a slight difference in nurses’ perceptions and practice in China compared with other countries.22,23 In the qualitative study, nurses’ perception toward the use of physical restraint in clinical care was predominately characterized by their main concern of protecting patient’s safety, and the use of restraints apparently provided a certain sense of security to the nurses. This perception led to an automatic response for physical restraints when nurses were unable to control patients’ behavior or when patients were in dangerous situations. In our study, nearly all nurses considered the use of physical restraints as part of their duty to protect the patient from harm and injury. From the questionnaire survey, it was observed that although nurses had high sympathy for physically restrained patients, they continued to use physical restraint (Table 1). This study revealed that nurses in China feel secure and relieved while using physical restraints. In addition, nurses in China showed little awareness of the multiple alternatives to physical restraints. The literature offers many alternatives to the use of restraints, such as offering physical and diversion activities, environment manipulation, playing soft background music, and using care plans to meet the needs of individual clients.8,24 However, except for the use of sedatives and relatives, many Chinese nurses are not aware of the other alternatives. In order to minimize the use of physical restraints, clinical training needs to be enforced and nurses need to receive in-service training on alternatives to physical restraint and the application of physical restraint as a last resort in patients.
Implications for clinical practice As nurses play a significant role in the decision to restrain patients and in the restraining process, insufficient nursing staff may lead to patient restraints.6,10 In China, family members play an important role in supporting their hospitalized relatives, and the majority of patients have family members or family paid caregivers accompanying them during hospitalization.25 However, various socioeconomic factors, such as smaller family size and dual income status, make it very difficult for family members to care for dependent older relatives. As a result, despite a long-held sense of filial piety and traditional values, increasing numbers of patients in China are being placed in hospitals without relatives. In this study, most of the relatives were supportive based on their trust on the expertise of nurses and approved of physical restraint as a safety measure for patients. From the interview results and the questionnaire findings in Table 1, it can be seen that nurses’ heavy workload and high nurse/patient ratio are the main reasons for the frequent use of physical restraint. A lack of nurses to support a reduction in the use of physical restraints was mentioned by nearly all of the participants. Some nurses are resistant to a reduction in physical restraints due to the perception that a reduction in physical restraints requires that patients receive closer supervision and will definitely increase their workload. Nurses mentioned that it was unreasonable to talk about physical restraint reduction without increasing the number of nurses. Therefore, nurse staffing level is an important issue in the reduction of physical restraint. In order to reduce the use of physical restraint, nursing managers should increase the nurse staffing levels and allocate them properly to reduce nursing workload and allow nurses to spend more time taking care 7
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of their clients. Moreover, there is an expectation that ‘‘best practice’’ means practitioners will strive to deescalate behavior and so avoid restraint while maintaining a safe environment.12 And, the ethical dimension of care is an essential part of good nursing practice.26 Therefore, strengthening the ethical education to nurses and improving nurses’ capabilities to reflect ethically on their nursing practices are important issues in clinical care in order to ensure the least use of the physical restraint for the patients.
Conclusion This study provided a well-rounded picture of nurses’ perceptions and the practice of physical restraint in China. Protecting patients’ safety was considered the nurse’s responsibility, and the use of physical restraints was a means to enable nurses to shoulder this responsibility. Nurses in China were overburdened with patient care responsibilities, and they were highly stressed and under-staffed. Thus, physical restraint is common in hospitals in China. Physical restraints should not be used routinely in all healthcare settings. Therefore, the education of nursing staff to ensure correct knowledge and skills regarding physical restraints and improving nurse staffing levels are necessary to reduce the use of physical restraint. There is also a need for standard guidelines and policies in China on the use of physical restraints to guide nurses’ practice on the need for physical restraint, the use of physical restraint, and constant reassessment of the use of physical restraint to create a restraint-free environment, and physical restraints should only be considered as a last resort in hospitalized patients.
Limitation The data in this study were obtained from nurses recruited from only one tertiary hospital in Shanghai, which limits the generalizability of the findings. Future research requires larger samples to ensure representativeness. Acknowledgments The authors are grateful to all participants for their involvement in the study. The authors would also like to thank the Shanghai health and family planning commission and the Shanghai Science and Technology Committee for the funding support for this project. Author contributions Hui Jiang was responsible for all aspects of the research study, including conceptualization of the design, drafting, and revision of the article. Chen Li assisted with the design of the research and revisions of the article. Yan Gu and Yanan He assisted with the data collection and analysis. Conflict of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. The views expressed in this article are those of the authors. Funding This project was funded by the Shanghai health and family planning commission (Grant-in-Aid No. 20134061) and the Shanghai Science and Technology Committee (Grant-in-Aid No. 14401932100). References 1. Haut A, Kolbe N, Strupeit S, et al. Attitudes of relatives of nursing home residents toward physical restraints. J Nurs Scholarsh 2010; 42(4): 448–456. 8
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2. Stevens JC. The use of physical restraints in neurologic patients in the inpatient setting. Continuum 2012; 18(6): 1422–1426. 3. Huang HC, Huang YT, Lin KC, et al. Risk factors associated with physical restraints in residential aged care facilities: a community based epidemiological survey in Taiwan. J Adv Nurs. Epub ahead of print 4 June 2013. DOI: 10. 1111/jan.12176. 4. Weiner C, Tabak N and Bergman R. The use of physical restraints for patients suffering from dementia. Nurs Ethics 2003; 10(5): 512–525. 5. Kandeel NA and Attia AK. Physical restraints practice in adult intensive care units in Egypt. Nurs Health Sci 2013; 15: 79–85. 6. Gelkopf M, Roffe Z, Werbloff N, et al. Attitudes, opinions, behaviors, and emotions of the nursing staff toward patient restraint. Issues Ment Health Nurs 2009; 30: 758–763. 7. Wang WW and Moyle W. Physical restraint use on people with dementia: a review of the literature. Aust J Adv Nurs 2005; 22(4): 46–52. 8. Suen LKP, Lai CKY, Wong TKS, et al. Use of physical restraint in rehabilitation settings: staff knowledge, attitudes and predictors. J Adv Nurs 2006; 55(1): 20–28. 9. Demir A. Nurses’ use of physical restraints in four Turkish hospitals. J Nurs Scholarsh 2007; 39(1): 38–45. 10. Huang HT, Chuang YH and Chiang KF. Nurses’ physical restraint knowledge, attitudes, and practices: the effectiveness of an in-service education program. J Nurs Res 2009; 17(4): 241–248. 11. Hamers JPH and Huizing AR. Why do we use physical restraints in the elderly? Z Gerontol Geriat 2005; 38: 19–25. 12. Perkins E, Prosser H, Riley D, et al. Physical restraint in a therapeutic setting; a necessary evil? Int J Law Psychiatry 2012; 35: 43–49. 13. Hine K. The use of physical restraint in critical care. Nurs Crit Care 2007; 12(1): 6–11. 14. Letizia M, Babler C and Cockrell A. Repeating the call for restraint reduction. Medsurg Nurs 2004; 13(1): 9–12. 15. Minnick AF, Mion LC, Johnson ME, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh 2007; 39(1): 30–37. 16. Saarnio R and Isola A. Nursing staff perceptions of the use of physical restraint in institutional care of older people in Finland. J Clin Nurs 2010; 19: 3197–3207. 17. McCabe DE, Alvarez CD, McNulty SR, et al. Perceptions of physical restraints use in the elderly among registered nurses and nurse assistants in a single acute care hospital. Geriatr Nurs 2011; 32: 39–45. 18. Hurlock-Chorostecki C and Kielb C. Knot-so-fast: a learning plan to minimize patient restraint in critical care. Can Assoc Crit Care Nurs 2006; 17(3): 12–18. 19. Colaizzi PF. Psychological research as the phenomenologist views it. In: Valle RS and King M (eds) Existential-phenomenological alternatives for psychology. New York: Oxford University Press, 1978, pp. 48–71. 20. Cheung PP and Yam BM. Patient autonomy in physical restraint. J Clin Nurs 2005; 14(Suppl. 1): 34–40. 21. Mamun K and Lim J. Use of physical restraints in nursing homes: current practice in Singapore. Ann Acad Med Singapore 2005; 34(2): 158–162. 22. Chuang YH and Huang HT. Nurses’ feelings and thoughts about using physical restraints on hospitalized older patients. J Clin Nurs 2007; 16: 486–494. 23. Ralph M and Gabriele M. Attitudes of nurses towards the use of physical restraints in geriatric care: a systematic review of qualitative and quantitative studies. Int J Nurs Stud 2014; 51: 274–288. 24. Antonie H, Nina K, Steve S, et al. Attitudes of relatives of nursing home residents toward physical restraints. J Nurs Scholarsh 2010; 42(4): 448–456. 25. Hui J, Wenqin Y and Yan G. Family paid caregivers in hospital healthcare in China. J Nurs Manag 2013; 21: 1026–1033. 26. Goethals S, Casterle´ BD and Gastmans C. Nurses’ decision-making process in cases of physical restraint in acute elderly care: a qualitative study. Int J Nurs Stud 2013; 50: 603–612.
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Nurses’ perceptions and practice of physical restraint in China
Nursing Ethics 1–9 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014557118 nej.sagepub.com
Hui Jiang Tongji University School of Medicine, China
Chen Li Shanghai University, China
Yan Gu and Yanan He Tongji University School of Medicine, China
Abstract Background: There is controversy concerning the use of physical restraint. Despite this controversy, some nurses still consider the application of physical restraint unavoidable for some of their clients. Aim: Identify the perceptions and practice of physical restraint in China. Research design: This was a descriptive study that combined qualitative interviews with a quantitative cross-sectional survey. Participants: A total of 18 nurses were interviewed and 330 nurses were surveyed. Ethical considerations: Approval of the study was obtained from the hospital ethics committee. Permission to conduct the study was obtained from the director of nursing. Participants were assured that their participation is voluntary. Results: Physical restraint was commonly used to protect patients’ safety. Naturally, intensive care unit nurses used physical restraint much more frequently than general medical/surgical ward nurses (p < 0.01). In addition, night shift nurses tended to use physical restraint more frequently. Conclusion: Nursing managers should be aware of the role nurses play in the use of physical restraint. In-service training regarding the proper use of physical restraint should be strengthened and nurse staffing levels should be improved in order to minimize the use of physical restraint in China. Keywords China, hospital, nursing management, nursing practice, physical restraint
Introduction The practice of physical restraint in patients is considered unacceptable and immoral in many countries as it conflicts with patients’ rights, dignity, and comfort.1–3 However, in other countries, physical restraint is still considered part of nursing care and is accepted as unavoidable intervention to protect patients and hospital staff.4,5 Nurses are closely involved in the decision making and implementation of physical restraint.6 In Hui Jiang and Chen Li contributed equally to this work. Corresponding author: Hui Jiang, Nursing Department of Shanghai East Hospital, Tongji University School of Medicine, No. 150, Jimo Road, Pudong New Area, Shanghai 200120, China. Email: [email protected]
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China, not much is known about the efficacy, morality, and legality of physical restraints. This study was undertaken to determine nurses’ perceptions and the clinical practice of physical restraints in China.
Background Physical restraint is defined as a physical device attached to the patient’s body that the patient cannot remove, prevents him from moving and restricts his access to his body.7,8 Commonly used physical restraints include wrist, ankle, chest, and waist restraints.9,10 Physical restraints interfere with patient’s autonomy and are inconsistent with preserving patient’s dignity. There is growing evidence that physical restraints are associated with negative physical, psychological, and social consequences in patients.11 Such negative effects include loss of muscle strength, orthostatic hypotension, urinary and fecal incontinence, increased risk of nosocomial infection, bruises, edema, pressure ulcers, strangulation, increased confusion/agitation, sleeplessness, loss of self-trust and respect, resistance or objection to daily routine activities, and disturbance in body image.9,12,13 However, many nurses still believe that the use of physical restraints is an effective strategy to protect patients’ safety.10 Nurses cite many reasons for the frequent use of physical restraints. These include insure patients’ safety, prevent interference with treatment, falls, avoid disturbing others, short staffing, control agitated or restless patients, and protect patients from injury secondary to wandering.6,14 Of these reasons, fall prevention and prevention of patient-initiated disruption of treatment are the main reasons for using physical restraint.15 The most common treatment instruments removed by patients are endotracheal and nasogastric tubes.3,4 Studies have indicated that physical restraints are more likely to be used in patients who are 65 years or older,16 in patients with poor mobility and impaired cognitive status, and in patients who require extensive and complicated therapy and have a history and risk of falls.15 Men are more likely to be physically restrained than women.17 Nurses most often are the initiators of restraint use.6 Although research has addressed the practice of physical restraint in various countries, this type of research is scarce in China. Currently, there are no available guidelines or legal regulations concerning the use of physical restraints in China. Hence, the aim of this study was to investigate nurses’ perceptions and the practice of physical restraints in China.
Methods The study combined qualitative interviews with a quantitative cross-sectional survey. Two tools were used: (1) semi-structured interview questions and (2) structured survey. Data collected were based on a literature review and to support the purpose of the study.17,18 The data included demographics, educational level, and type of working unit. The following questions were asked during the interviews: (1) What are your perceptions regarding the use of physical restraints? (2) Under what circumstances can you restrain a patient? (3) What do you think about the ethical issues surrounding the use of physical restraints? (4) Would you notify the family or obtain consent before applying physical restraints? (5) Do you try alternative procedures before applying physical restraint? (6) What you think would/could help you reduce the use of physical restraints in practice? The nurses’ perceptions and practice of physical restraint were also determined using self-designed questionnaire which included 28 items. The survey questionnaire was developed by the researcher based on careful literature review. The survey respondents were asked to rate the frequency of their work roles on a 5-point Likert scale, ranging from 5 (very frequent) to 1 (never). The higher the average, the more favorable the overall perception an individual has toward physical restraint use. The questionnaire was tested for content-related validity by 10 experts in the area of nursing management, research, and education who assessed the content validity of the questionnaire. The content validity index of the questionnaire was 0.93. A pilot study was conducted on 30 nurses to test the clarity and applicability of the tools, and Cronbach’s alpha was 0.81. The reliability and validity of the instrument were at acceptable levels. 2
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Setting and participants The study was conducted in a tertiary general hospital in Shanghai which has 1800 beds and 1200 nurses. The intensive care unit (ICU) and medical–surgical nursing staff were recruited as participants in the focus interview and the survey using convenience sampling. The participants were selected based on the following criteria: (1) fulltime registered nurses, (2) had experience in applying physical restraint in hospitalized patients, (3) had working experience in the surveyed unit for more than 6 months, (4) were willing to share their experiences on the use of physical restraint, and (5) could give informed consent. In total, 18 employed nurses (9 from the ICU and 9 from general medical–surgical wards) were interviewed and 330 nurses (149 from the ICU and 181 from general medical–surgical wards) consented to participate in the survey.
Data collection and analysis Data were collected from January to March 2014. A total of 18 nurses were invited for in-depth interviews. The interviews were held in a quiet meeting room, and each interview lasted 1 h. All the interviews were tape-recorded with the consent of the participants. The interviews were transcribed verbatim by the researcher within 48 h of completion. Content analysis was used to identify major categories and themes using Colaizzi’s phenomenological method of data analysis.19 The questionnaires were distributed manually by the researcher to potential respondents and collected immediately after completion. Each questionnaire took about 10 min to complete. Data collection and analysis were done anonymously. The survey data were analyzed using the Statistical Package for Social Sciences Version 17.0 software for Windows (SPSS Inc., Chicago, IL, USA). Descriptive statistics were performed to summarize the data. The mean and standard deviation were used to show the frequency of response to each item given by the participants. Single sample t-test was used to compare the difference between the ICU and the general medical–surgical ward nurses. Statistical significance was set at p < 0.05 (two-sided).
Ethical considerations Approval of the study was obtained from the ethics committee of the hospital. Permission to conduct the study was obtained from the director of nursing and the head nurses of the surveyed units. All participants were given a detailed explanation of the study objectives and methods to be used. Participating nurses were assured that their participation was voluntary and they were free to withdraw at any time without comment or penalty. Anonymity and confidentiality were guaranteed, and consent was obtained from each participant.
Findings Demographics All 18 nurses who took part in the qualitative interview were female, age 24 to 37 years (mean 29.17 + 3.94 years) with hospital working experience ranging from 2 to 13 years (mean 6.28 + 3.66 years). In total, 12 nurses (66.67%) were married. A total of 10 nurses (55.56%) had associate degree level, and the other 8 nurses (44.44%) had bachelor degree. The 330 nurses who answered the quantitative questionnaire were mostly females, 327 females (99.09%) and 3 males (0.01%); age 21 to 32 years (mean 26.89 + 4.86 years). Their working experience ranged from 1 to 23 years (mean 6.29 + 5.51 years). Over half of the nurses (56.06%) were married. Their educational background was diploma 29 (8.79%), associate 239 (72.42%), bachelor 61 (18.49%), and only 1 nurse (0.003%) had master’s degree level. 3
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Focus interview findings Theme 1: nurses’ perceptions on the use of physical restraint. Nurses expressed that in their clinical nursing practice, physical restraint was normally used for unconscious, restless, and agitated patients; patients with important invasive tubes after surgery; patients with endotracheal intubation; noncooperative patients; or patients with a high risk of falls. They all considered physical restraint an important and effective measure to restrain patients in order to ensure patient cooperation with medical treatment without patient-initiated disruption, such as unplanned tube removal and preventing the patient from falling from the bed. Most nurses considered physical restraint an acceptable and routine practice in their daily nursing care and relied on it to restrain the movement of patients for necessary treatment and to protect patients from harm. Physical restraint also prevented patients harming other patients and nursing staff. The nurses thought that physical restraint was an important measure in patients, as it prevented them from removing important tubes, shortened the length of hospital stay, and accelerated patients’ recovery; for nurses, they relied on physical restraint to decrease unnecessary workload and to avoid incidents due to their negligence; for doctors, they did not want to repeat tube insertion procedures; for relatives, most considered the results more important than the process, and physical restraint was accepted by them to ensure patients’ safety. When asked about the ethical issues and interference with the human rights of patients, most nurses said they needed to consider patient safety as the first priority rather than ethicality, human rights, and dignity. A shortage of nursing staff was the main reason for physical restraint in China and was mentioned by all the interviewed nurses when asked about methods to minimize physical restraint. Subtheme 1: nurses considered physical restraint as an accepted practice to secure patients’ safety. If I am the patient, I am unconscious, nurses did it for my safety. I can understand after I recover. Although the process is tough and difficult, the result is good. When they recover and discharge, they can understand, we do it with good intension and for the patient’s sake.
Subtheme 2: nurses considered physical restraint as a considerate practice guided by patients’ or relatives’ wishes and willingness. I individually oppose the use of physical restraint. Physical restraint affect patient’s dignity. If there is no freedom, then no way to talk about the human rights and dignity. In my own view, patient’s wishes and willingness should be respected. If patients were unconscious and got mental dysfunction, then relatives’ opinion should be respected. If we use the physical restraint without the relatives’ consent, we will be blamed and complained. Thus, from our view, I will follow the relatives’ suggestions. If they sign the consent, I will use the physical restraint.
Subtheme 3: nurses considered physical restraint as a necessary practice caused by heavy workload and inadequate nurse staffing. We have no time to think about ethical issues regarding the physical restraint. We have to finish the work first, save patients’ life and protect patients’ safety. We think more about to finish the job but not the ethical issues. In China, I think it is difficult to stop the physical restraint use. We take care of much more patients than other countries. If we have more nurses, we will spend more time with the patients, try not to use the physical restraints. But we are always short of nursing staff and we are too busy. If patient remove the tubes, we will have trouble. They will think we don’t do a good job. So for patients’ sake, for our own sake, we’d better restraint the patients properly for patients’ safety and for the purpose of protecting the patient. 4
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Theme 2: nursing practice of physical restraint. Nurses expressed that physical restraint was very common in their daily work, especially in the ICU as patients in the ICU were more critically ill, received more treatment, and were without relatives’ companionship. The wrist and ankle restraints were most frequently used. Nurses are the main decision makers in assessing the need for physical restraint and the application of physical restraint in patients. Nurses need to explain to patients or their relatives the reasons for and the purpose of physical restraint. Consent needs to be obtained from patients or their relatives before nurses can apply physical restraint. Family members are normally understanding and supportive of the use of physical restraint. Some relatives even ask for physical restraint to protect patients’ safety. Sedatives and relatives’ close companionship are the most common alternative methods used by nurses if patients or relatives refuse the use of physical restraint. Nurses use physical restraint more often in the evening and night shift than in the day shift as the day shift has more nurses to take care of the patients. Nurses assess the restrained patient every 2 h or even more frequently to relax the restrained area for 10 min to check the circulation and the skin condition in order to avoid negative consequences such as redness, bruising, and edema. Subtheme 1: nurses considered the use of physical restraint as common intervention and played a key role in decision making to initiate the use of restraints. We normally assess the patients’ conscious level, acuity, inserted tubes and risks for tube removal. If the patient is unconscious and not cooperate with the treatment, after the relative’s agreement, we normally use the protective physical restraint. In other words, we need to obtain the consent before we use the physical restraint. The purpose of the physical restraint was used to protect the patient, but not to control the patient. Some relatives may ask for the physical restraint. When they leave the patient in the ward they will remind the nurses that the patient is not alert and cooperate, they ask the nurses to use the physical restraint for them if necessary. Some relatives even remind us to use the physical restraint at the time when the patient was admitted. For the new admissions, we assess the patients’ condition and explain the purpose of the physical restraint and ask the relative to sign the consent right away. If there is emergency, we need to call the family to get the relatives’ verbal permission for the physical restraint use. So far I didn’t encounter the relatives’ refuse for the physical restraint use. Normally we explain the reason to them and tell them the reason to use the physical restraint, they can understand and accept. It is very rare here for relatives to refuse the physical restraint use.
Subtheme 2: sedatives and relatives’ close companionship were used as alternatives if the physical restraint use was rejected by patients or relatives. If the relatives reject the use of the physical restraint, we won’t use it. China is a country with multiple customs, we need to consider different customs, different preference. There are two ways to solve this problem here. One way is that we call the relative to help us to stay by the bedside and look after the patient and the other way is to call the doctor to give the sedation for the patient. Day time we got more nurses, we consider remove the physical restraint and night shift we have less nurses, we need to put the restraint back. When the relative is around, we release the restraint and let the relative to help take care of the patients.
Questionnaire survey findings The survey clearly showed a significant increase in the use of restraints by the ICU nurses compared to general medical/surgical wards (p < 0.01) (Table 1). However, this trend is reversed during night shift. Night shift nurses in the general medical/surgical ward had a higher tendency to use physical restraint than ICU nurses (p < 0.01). The main purpose of using physical restraints in the ICU was to prevent accidental 5
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Table 1. Comparison of physical restraint use between nurses in the ICU and nurses in the general medical/surgical ward (n ¼ 330).
Survey items 1. The frequency of restraint in patients 2. Protect from falling out of bed 3. Protect from falling out of a chair 4. Prevent pulling out an endotracheal tube 5. Prevent pulling out a catheter 6. Prevent pulling out a feeding tube 7. Prevent pulling out an intravenous line 8. Prevent pulling out drainage tube after operation 9. Manage impaired post anesthesia 10. Manage impaired overdose 11. Manage impaired confusion 12. Manage impaired agitation 13. Manage impaired restlessness 14. Manage impaired psychology 15. When observation is difficult in evening shift 16. When observation is difficult in night shift 17. When work is busy 18. When high nurse/patient ratio 19. To protect staff/other patients from physical combativeness 20. I use mittens 21. I use wrist ties 22. I use ankle ties 23. I use body belts 24. I monitor extremity color/temperature/sensation/ swelling 25. I write a narrative note if complications occur 26. I think restraint is convenient for the nursing work 27. I feel sympathy for the patient with physical restraint 28. I think nurses should stop physical restraint
ICU (n ¼ 149)
General medical/ surgical ward (n ¼ 177)
t value
p value
3.79 + 1.18 3.07 + 1.64 1.58 + 1.12 4.32 + 1.15 3.66 + 1.47 3.93 + 1.34 3.57 + 1.52 4.00 + 1.34 3.93 + 1.44 3.22 + 1.58 4.30 + 1.11 4.53 + 0.93 3.92 + 1.23 4.14 + 1.14 2.67 + 1.27 2.67 + 1.24 3.75 + 1.31 3.66 + 1.31 2.81 + 1.40
2.76 + 0.95 2.95 + 1.43 1.76 + 0.95 2.89 + 1.57 3.73 + 1.20 3.86 + 1.17 3.81 + 1.21 3.08 + 1.59 2.54 + 1.48 2.74 + 1.51 3.98 + 1.12 4.19 + 1.00 3.60 + 1.29 3.60 + 1.54 2.94 + 1.27 3.09 + 1.28 3.52 + 1.36 3.63 + 1.22 2.47 + 1.27
8.727 0.735 1.406 9.277 0.483 0.534 1.535 5.52 8.394 2.738 2.537 3.128 2.319 3.544 0.274 2.827 1.579 0.256 2.289
0.000* 0.463 0.161 0.000* 0.629 0.593 0.126 0.000* 0.000* 0.007* 0.012* 0.002* 0.021* 0.000* 0.065 0.005* 0.115 0.798 0.023*
2.29 + 1.13 4.38 + 1.06 3.40 + 1.32 2.44 + 1.03 4.57 + 0.75
1.92 + 1.27 3.81 + 1.21 3.43 + 1.33 2.51 + 2.19 4.46 + 0.69
2.622 4.525 0.217 0.383 1.416
0.009* 0.000* 0.829 0.702 0.158
3.99 + 1.28 3.94 + 1.14 3.68 + 1.12 1.63 + 1.04
3.92 + 1.33 3.39 + 1.00 3.66 + 1.01 1.77 + 0.91
0.469 4.586 0.124 1.304
0.639 0.000* 0.901 0.193
ICU: intensive care unit. *p < 0.05.
extubation, but in the general medical/surgical ward it was to prevent pulling out the feeding tubes. The use of physical restraint was higher in agitated patients and influenced by nurse/patient ratio. Wrist restraints were the most commonly used physical restraints in the ICU and wards (p ¼ 0.00). With the exception of patients’ safety, nurses in both groups considered the use of physical restraints as essential tool for their own work convenience (Table 1, item 26). Even though nurses had high sympathy for patients with physical restraints, they still used physical restraint (Table 1, item 28).
Discussion The use of physical restraints appears to be a useful and simple solution to prevent treatment interference.12 But in reality, it is a complex concept, which encompasses physical, psychological, legal, ethical, and moral 6
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issues,13 and had been considered as an intrusive and risky procedure which is only legally permitted in very specific circumstances.12,14 Our study showed that physical restraints are commonly used by nurses both in the ICU and the general medical/surgical wards despite the reported potential harm to the patient and the controversy concerning the effectiveness of physical restraints.20 In China, the use of physical restraints was considered as a nursing intervention, and nurses in China made the decision and applied physical restraint. Doctors’ involvement and support for use of the physical restraint is not needed unless conflicts rise up with the relatives; then, the doctors become involved in discussions with the family. As the patient’s autonomy is breached by the application of physical restraints, patients or relatives were informed about the effects and potential dangers of physical restraint and their consent was sought to avoid potential conflict. The most commonly used physical restraints were wrist restraints, followed by ankle restraints. The reasons for using physical restraint and the most frequent shift (night shift) in which physical restraint was used in China were consistent with those reported from other countries.1,3,14,16,21 However, we observed a slight difference in nurses’ perceptions and practice in China compared with other countries.22,23 In the qualitative study, nurses’ perception toward the use of physical restraint in clinical care was predominately characterized by their main concern of protecting patient’s safety, and the use of restraints apparently provided a certain sense of security to the nurses. This perception led to an automatic response for physical restraints when nurses were unable to control patients’ behavior or when patients were in dangerous situations. In our study, nearly all nurses considered the use of physical restraints as part of their duty to protect the patient from harm and injury. From the questionnaire survey, it was observed that although nurses had high sympathy for physically restrained patients, they continued to use physical restraint (Table 1). This study revealed that nurses in China feel secure and relieved while using physical restraints. In addition, nurses in China showed little awareness of the multiple alternatives to physical restraints. The literature offers many alternatives to the use of restraints, such as offering physical and diversion activities, environment manipulation, playing soft background music, and using care plans to meet the needs of individual clients.8,24 However, except for the use of sedatives and relatives, many Chinese nurses are not aware of the other alternatives. In order to minimize the use of physical restraints, clinical training needs to be enforced and nurses need to receive in-service training on alternatives to physical restraint and the application of physical restraint as a last resort in patients.
Implications for clinical practice As nurses play a significant role in the decision to restrain patients and in the restraining process, insufficient nursing staff may lead to patient restraints.6,10 In China, family members play an important role in supporting their hospitalized relatives, and the majority of patients have family members or family paid caregivers accompanying them during hospitalization.25 However, various socioeconomic factors, such as smaller family size and dual income status, make it very difficult for family members to care for dependent older relatives. As a result, despite a long-held sense of filial piety and traditional values, increasing numbers of patients in China are being placed in hospitals without relatives. In this study, most of the relatives were supportive based on their trust on the expertise of nurses and approved of physical restraint as a safety measure for patients. From the interview results and the questionnaire findings in Table 1, it can be seen that nurses’ heavy workload and high nurse/patient ratio are the main reasons for the frequent use of physical restraint. A lack of nurses to support a reduction in the use of physical restraints was mentioned by nearly all of the participants. Some nurses are resistant to a reduction in physical restraints due to the perception that a reduction in physical restraints requires that patients receive closer supervision and will definitely increase their workload. Nurses mentioned that it was unreasonable to talk about physical restraint reduction without increasing the number of nurses. Therefore, nurse staffing level is an important issue in the reduction of physical restraint. In order to reduce the use of physical restraint, nursing managers should increase the nurse staffing levels and allocate them properly to reduce nursing workload and allow nurses to spend more time taking care 7
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of their clients. Moreover, there is an expectation that ‘‘best practice’’ means practitioners will strive to deescalate behavior and so avoid restraint while maintaining a safe environment.12 And, the ethical dimension of care is an essential part of good nursing practice.26 Therefore, strengthening the ethical education to nurses and improving nurses’ capabilities to reflect ethically on their nursing practices are important issues in clinical care in order to ensure the least use of the physical restraint for the patients.
Conclusion This study provided a well-rounded picture of nurses’ perceptions and the practice of physical restraint in China. Protecting patients’ safety was considered the nurse’s responsibility, and the use of physical restraints was a means to enable nurses to shoulder this responsibility. Nurses in China were overburdened with patient care responsibilities, and they were highly stressed and under-staffed. Thus, physical restraint is common in hospitals in China. Physical restraints should not be used routinely in all healthcare settings. Therefore, the education of nursing staff to ensure correct knowledge and skills regarding physical restraints and improving nurse staffing levels are necessary to reduce the use of physical restraint. There is also a need for standard guidelines and policies in China on the use of physical restraints to guide nurses’ practice on the need for physical restraint, the use of physical restraint, and constant reassessment of the use of physical restraint to create a restraint-free environment, and physical restraints should only be considered as a last resort in hospitalized patients.
Limitation The data in this study were obtained from nurses recruited from only one tertiary hospital in Shanghai, which limits the generalizability of the findings. Future research requires larger samples to ensure representativeness. Acknowledgments The authors are grateful to all participants for their involvement in the study. The authors would also like to thank the Shanghai health and family planning commission and the Shanghai Science and Technology Committee for the funding support for this project. Author contributions Hui Jiang was responsible for all aspects of the research study, including conceptualization of the design, drafting, and revision of the article. Chen Li assisted with the design of the research and revisions of the article. Yan Gu and Yanan He assisted with the data collection and analysis. Conflict of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. The views expressed in this article are those of the authors. Funding This project was funded by the Shanghai health and family planning commission (Grant-in-Aid No. 20134061) and the Shanghai Science and Technology Committee (Grant-in-Aid No. 14401932100). References 1. Haut A, Kolbe N, Strupeit S, et al. Attitudes of relatives of nursing home residents toward physical restraints. J Nurs Scholarsh 2010; 42(4): 448–456. 8
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2. Stevens JC. The use of physical restraints in neurologic patients in the inpatient setting. Continuum 2012; 18(6): 1422–1426. 3. Huang HC, Huang YT, Lin KC, et al. Risk factors associated with physical restraints in residential aged care facilities: a community based epidemiological survey in Taiwan. J Adv Nurs. Epub ahead of print 4 June 2013. DOI: 10. 1111/jan.12176. 4. Weiner C, Tabak N and Bergman R. The use of physical restraints for patients suffering from dementia. Nurs Ethics 2003; 10(5): 512–525. 5. Kandeel NA and Attia AK. Physical restraints practice in adult intensive care units in Egypt. Nurs Health Sci 2013; 15: 79–85. 6. Gelkopf M, Roffe Z, Werbloff N, et al. Attitudes, opinions, behaviors, and emotions of the nursing staff toward patient restraint. Issues Ment Health Nurs 2009; 30: 758–763. 7. Wang WW and Moyle W. Physical restraint use on people with dementia: a review of the literature. Aust J Adv Nurs 2005; 22(4): 46–52. 8. Suen LKP, Lai CKY, Wong TKS, et al. Use of physical restraint in rehabilitation settings: staff knowledge, attitudes and predictors. J Adv Nurs 2006; 55(1): 20–28. 9. Demir A. Nurses’ use of physical restraints in four Turkish hospitals. J Nurs Scholarsh 2007; 39(1): 38–45. 10. Huang HT, Chuang YH and Chiang KF. Nurses’ physical restraint knowledge, attitudes, and practices: the effectiveness of an in-service education program. J Nurs Res 2009; 17(4): 241–248. 11. Hamers JPH and Huizing AR. Why do we use physical restraints in the elderly? Z Gerontol Geriat 2005; 38: 19–25. 12. Perkins E, Prosser H, Riley D, et al. Physical restraint in a therapeutic setting; a necessary evil? Int J Law Psychiatry 2012; 35: 43–49. 13. Hine K. The use of physical restraint in critical care. Nurs Crit Care 2007; 12(1): 6–11. 14. Letizia M, Babler C and Cockrell A. Repeating the call for restraint reduction. Medsurg Nurs 2004; 13(1): 9–12. 15. Minnick AF, Mion LC, Johnson ME, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh 2007; 39(1): 30–37. 16. Saarnio R and Isola A. Nursing staff perceptions of the use of physical restraint in institutional care of older people in Finland. J Clin Nurs 2010; 19: 3197–3207. 17. McCabe DE, Alvarez CD, McNulty SR, et al. Perceptions of physical restraints use in the elderly among registered nurses and nurse assistants in a single acute care hospital. Geriatr Nurs 2011; 32: 39–45. 18. Hurlock-Chorostecki C and Kielb C. Knot-so-fast: a learning plan to minimize patient restraint in critical care. Can Assoc Crit Care Nurs 2006; 17(3): 12–18. 19. Colaizzi PF. Psychological research as the phenomenologist views it. In: Valle RS and King M (eds) Existential-phenomenological alternatives for psychology. New York: Oxford University Press, 1978, pp. 48–71. 20. Cheung PP and Yam BM. Patient autonomy in physical restraint. J Clin Nurs 2005; 14(Suppl. 1): 34–40. 21. Mamun K and Lim J. Use of physical restraints in nursing homes: current practice in Singapore. Ann Acad Med Singapore 2005; 34(2): 158–162. 22. Chuang YH and Huang HT. Nurses’ feelings and thoughts about using physical restraints on hospitalized older patients. J Clin Nurs 2007; 16: 486–494. 23. Ralph M and Gabriele M. Attitudes of nurses towards the use of physical restraints in geriatric care: a systematic review of qualitative and quantitative studies. Int J Nurs Stud 2014; 51: 274–288. 24. Antonie H, Nina K, Steve S, et al. Attitudes of relatives of nursing home residents toward physical restraints. J Nurs Scholarsh 2010; 42(4): 448–456. 25. Hui J, Wenqin Y and Yan G. Family paid caregivers in hospital healthcare in China. J Nurs Manag 2013; 21: 1026–1033. 26. Goethals S, Casterle´ BD and Gastmans C. Nurses’ decision-making process in cases of physical restraint in acute elderly care: a qualitative study. Int J Nurs Stud 2013; 50: 603–612.
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