What Nursing Staff Members Really Know About Physical Restraints Linda M. Janelli, EdD RN C; Yvonne K. Scherer, EdD RN, Genevieve W. Kanski, EdD RN, Mary Anne Neary, EdD RN

Although the use ofphysical or mechanical restraintsis decreasing in long-termcarefacilities,there always will be some patients who require.them.Ifa restraint is to be employed at all, it needs to be used correctly.A convenience sample of 118 nursing staff members who work in a county nursing home was asked to complete an I 8-item knowledge questionnaire regarding restraint usage.Scores rangedfrom6 to 17 (potentialrange 0-18), with a mean score of 13.2 (SD = 2.1). Overall, the staffs knowledge level can be considered good; however, there were some areas of concern. For example, a majority of the respondents (82.2%) believed that it was appropriate to keep a patient restrained lying flat in bed. Implicationsfor administrators and rehabilitation nurse clinicians are identified.

physical or mechanical restraint can be defined as any A article, device, or garment that interferes with a person's free movement and secures him or her to a bed or chair. Almost all nursinghome facilitiesrely on someform of physicalrestraint. Evans and Strumpf (1989) reported that in the course of a year, more than 500,000 older persons are tied to their beds and chairs in hospitals and nursing homes. The Health Care Financing Administration(1988)pointedoutthat from 1976to 1988,theuse of restraints had increased from 25% to 41% in nursing home settings. The Omnibus Budget Reconciliation Act (OBRA) of 1987 legislated a mechanism for decreasing the use of restraints by protecting patients from being restrained for discipline or convenience purposes. The declining reliance on physical restraints certainly is a goal that rehabilitation nurses can support. However,when restraints arerequired,can nursing staff use them in a safe and knowledgeable manner?

Need for the study A literature review on physical restraints demonstrated that research in this area has been sparse.However, numerous studies have been conducted in an attempt to identify predictive characteristics of older persons who fall. A number of factors have been associatedwith falls, such as the person's age, use of drugs, and alterations in sensory perception (Barbieri, 1983; Louis, 1983;Morse, Tylko, & Dixon, 1985).What is less understood is nursing staff's understanding and knowledge about ways to assess who should be restrained, the best methods of applying Address correspondence to Lincf'aM . Janelli, EdD RhJ C, Assistant Professor,School ofNursing, State University of New York at Buffalo,Buffalo,NY14214.

Earn continuing education contact hours RehabilitationNursing is pleased to offer the opportunity to earn continuing education credit to those who read this article a d complete the form immediately following it. This continuing education offering will provide 1 contact hour to those who complete it appropriately. (See form for further details.)

Intended audience This independent study offering is appropriate for all rehabilitation nurses. Objectives By reading this article, the learner will achieve the following objectives: 1. Discuss areas in which nursing staff's knowledgeof the use of restraints is most likely to be lacking. 2. Describe how rehabilitation nurses can provide guidance in the proper use of restraints.

restraints, and how to care for someone in restraints. According to Stillwell (1988), nursing staff's education about the use of restraints often is limited to an hour or less during orientationto the nursing home facility. Staff members often are not tested on their learning this information. Based on this, one of the objectives of the research described here was to determinethe knowledge level of nursing home staff regarding the proper use and application of physical restraints. This was part of a larger descriptive study that also examined nursing practice and staff attitudes about restraints.

Methodology The subjects consisted of 118 nursing staff members, including 63 aides, 38 LPNs, and 17 RNs. The participants, who all volunteered for the study, work at a county nursing home in western New York. The sample is representative of all three working shifts. The staff members who participated in the study represent approximately 24% of the total working staff of this nursing home. Data were gathered using a questionnaire developed by the authors. The entire questionnaireconsists of 70 questions; section I deals with demographic characteristics, section II addressesknowledge about physicalrestraints, section

Vol. 16, No. 6/Rehabilitation NursingDlov-Dec 1991/345

Physical Restraints

111pertains to nursing practice issues, and section IV ascertains attitudes toward physical restraints. The questionnaire initially was submitted to a panel of experts to enhance its content validity. The instrumentthen was tested in another nursing home using five staff members who volunteered to participate. Revisions in the questionnairewere made following the panel review and the pilot test. A cover letter accompaniedeach questionnaire,explainingthe purpose of the study, assuring confidentiality, and explaining that participation was voluntary. The questionnaires were distributed to the different nursing units by one of the investigators. A stamped self-addressed envelope was attached to each questionnaire. Before administering any, questionnaires, the researchersobtainedclearancefromthe human subjectscommittees at their institution and the nursing home. This article focuses only on the section of the questionnaire that deals with nursing staffs knowledge about the use of physical restraints. Response options to the 18 items in this section included “True,” “False,” and “Not sure.” To analyze the data, percentaged frequency distributions of responses to each of the 18knowledge questions were examined first. Correct responses were given a score of 1 and incorrect responses a score of 0, with “Not sure” answers included in the incorrectcategory. Thus, a score of 18represented 100%correct responses. As knowledge could be influenced by the level of nursing practice, the number of years worked in geriatrics, the participant’s age, and the participant’s work shift, an analysis of variance (ANOVA) was conductedto determineif there was any relationship between the knowledge scores and the variables described.

Results Table 1 describes the nursing staff members who participated in the study accordingto their age, as well as the number of years they have worked in geriatrics.The mean age of the nursing staff was 35 years. It was expected that the total years that the staff worked in geriatrics would be high. In fact, the mean was 6 to 10 years. The “Knowledge About Physical Restraints” section of the questionnaire as presented in Figure 1 shows the breakdown of correct and incorrect responses to each question. Some of the items demonstrated variability in nursing staff‘s knowledge about restraints. Comparisons of the proportions of “Not sure” and incorrect responses indicated an overall trend for subjects to have insufficient information rather than misinformation. The distribution of total knowledge scores, calculated as described earlier, is presented in Table 2. Scores ranged from 6 to 17; the mean score was 13.2 with a standard deviation of 2.1 As one might anticipate, the RNs performed significantlyhigher on the knowledge componentof the questionnaire(c:14.5) than either the LPNs (c= 13.4) or the aides (c= 12.8). There were no significant correlations between the mean knowledge score and the total years participants had worked in geriatrics. There also was no significant relationship between the age of participants, the shift they worked, and their mean knowledge score.

Discussion The sample in this study represented only 24% of the total nursing staff of the facility. Those who did not participate may have responded differently on the knowledge section of the questionnaire. Overall, the nursing staff in this study did fairly well in the knowledge component of the questionnaire,with the majority missing only 5 of the 18 questions. Despite their favorable scores, there are some areas of concern. Thirty-eight percent still believed that restraints are appropriate when the patient cannot be closely observed. Only 69 (58.5%) agreed with the statement that patients can refuse to be placed in a restraint. More alarming was that 97 (82.2%) believed it was acceptable to restrain a patient who was lying flat in bed. Sixty staff members (50.8%) also believed that sheet restraints may be necessary at times. Finally, 66 staff members (55.9%) were not aware of the relationship between the improper use of vest restraints and death from choking. Ninety-two (79%) of the staff members in this study acknowl-

Table 1. Distribution of Nursing Staff’s Age and Years in Geriatric Nursing Number Age Range Under 20 20-29 30-39 40-49 50-59 Total Total Years in Geriatrics 0-5 6-10 11-15 16-20 21-25 31 and over Total

Percentage

2 33 48 26 8

1.7 28.2 41 22.2 6.8

117*

99.9

47 31 25 9 4 1

39.8 26.3 21.2 7.6 3.4 .8

117*

99.1

*One participant did not respond to either question.

Table 2. Distribution of Total Knowledge of Nursing Staff Score 6-8 9-11 12-14 15-17

Number 4 14 67 33

Total

118

346mov-Dec 1991BehabilitationNursingNol. 16, No. 6

Percentage 3.4 11.8 56.8 28 100

1 edged that they are required to attend a yearly inservice program on restraints. It may not be enough to attend an inservice on

restraint use. What this study seems to suggest is that it may be beneficial to test for knowledge level on the topic and to observe for the transmission .of knowledge into actual practice. Rehabilitation nurses,inservicecoordinators,and administratorsshould find the test results and observations helpful in providing some insightintothe staff‘suse andunderstandingofphysicalrestraints. Rehabilitation nurses are in an ideal position to act as role

Contact Hour

[J

models for other staff members and can provide guidance as to which patients really require restraints and which would do better without restraints. Inservice coordinators can reassess how best to deliver knowledge about restraints. Attendance at inserviceeducationcan be mandated,but that does not guarantee that information will be retained or used. Perhaps more creative methods-such as role playing, demonstration, or involving family members in discussions about restraints-can be used. Administrators need to be concerned about staff members’

Figure 1. Knowledge About Physical Restraints

1. Physical restraints are safety vests or garments designed to prevent injury.t

True 113*

False 4

Percenl Correct 96.6

Percent Incorrect 3.4

2. A restraint is legal only if it is necessary to protect the patient or others from harm.

103‘

15

87.3

12.7

3. Restraints should be used when one cannot watch the patient c1osely.t

43

73*

61.9

38.1

4. Patients are allowed to refuse to be placed in a restraint.

69*

49

58.5

41.5

5. A physical restraint (safety vest, garments) requires a physician’s order.

114*

4

96.6

3.4

6. Confusion or disorientation is the major reason for using a restraint.

72*

46

61.O

39.0

7. A restraint should be released every 2 hours, if the patient is awake.

79’

39’

66.9

33.1

8. Restraints should be put on snugly so that there is no space between the restraint and the patient’s skin.

10

108*

91.5

8.5

9. A patient should never be restrained while lying flat in bed because of the danger of choking.

21 *

97

17.8

82.2

10. When a patient is restrained, skin can break down or restlessness can increase.

1oo*

18

84.7

15.3

11. When a patient is restrained in a bed, the restraint should not be attached to the side rail.

116*

2

98.3

1.7

60

58*

49.2

50.8

91

27

77.1

22.9

14. A record should be kept on every shift of patients in restraints.

111*

7

94.1

5.9

15. A physician’s order to restrain a patient must be specific regarding the purpose of the restraint, the type of restraint used, and length of time it may stay in place.

115*

3

97.5

2.5

16. In an emergency, a nurse can legally restrain a patient without a physician’s order.

94 ‘

24

79.7

20.3

17. Good alternatives to restraints doJnot exist.

41

77*

65.3

34.7

18. Deaths have been linked to the use of vest restraints.

52

66

44.1

55.9

I

12. Sheet restraints may be necessary at times. ,13. A nurse can be charged with assault if he or she applies restraints when they are not needed.

t = Not answered by all respondents * =’Correct response

Vol. 16, No. 6/Rehabilitation Nursing/Nov-Dec 1991/347

Physical Restraints

knowledge of restraint uses from both legal and ethical perspectives.Increasingnursingstaff sknowledgebaseregardingtheuse of physical restraints is the first step to improving the quality of care that patientsin nursing homes receive. The second step in the educationalprocessis to diminishthestaff'srelianceonrestraints. Alternativemethods of preventingfalls need to be explored. One study conducted in a Canadian hospital (Mitchell-Pedersen, Edmund, Fingerote, & Powell, 1986) demonstrated that once restraints were discontinued,there was no significantincrease in the frequency of falls resulting in serious injuries. However, as legislation such as OBRA provides the impetus for the reevaluation of physicalrestraint use, clinicians also will need to become alert to the possibility of chemical restraints being used as a substitute for physical restraints. Drugs might be considered a necessary intervention for patients displaying psychiatric symptoms. Unfortunately, they also may be viewed as a quick solution in dealing with patients displaying disruptive social behavior. Inservice programs on physical restraints, therefore, also should include information on when chemical restraints might be appropriate.

Stillwell, E.M. (1988). Use of physical restraints in older adults. Journal of Gerontological Nursing, 14,42-43.

Authors' Note Copies of the questionnaire used in this study are available from the principal author. The study was supported in part by a research development fund award from the State University of New York Research Foundation.

Conclusion This study explored the knowledge level of 118 nursing home staff members regarding the use of physical restraints. Although the overall scores were high, there were knowledge gaps that easily could be closed with an instructive inservice program. Legislation probably will never mandate the total elimination of physical restraints. It is important, then, for rehabilitationnurses and other staff members to be cognizant of how to use physical restraints in a safe manner while preserving the dignity of the patient. The authors all are afsiliated with the school of nursing of the

State University of New York ( S U M )at Buffaloin Buffalo,M : Linda M.Janelli and Yvonne K . Scherer are assistantprofessors; Genevieve W .Kanski isan associate clinicalprofessor; andMary Anne Neary is an assistant clinical professor.

References Barbieri, E.B. (1983). Patient falls are not patient accidents. Journal of Gerontological Nursing, 9, 164-113. Evans, L.K., & Strumpf, N.E. (1989). Tying down the elderly: A review of the literature on physical restraint. Journal of the American Geriatrics Society, 37,65-14. Health Care Financing Administration. (1988). Medicare/Medicaid nursing homes information: 1987-1988 (ISSN 0364-6150). Washington, DC: U.S. Government Printing Office. Louis, M. (1983). Falls and their causes. Journal of Gerontological , Nursing, 9, 142-156. Mitchell-Pedersen, L., Edmund, L., Fingerote, E., & Powell, C. (1986). Reducing reliance on physical restraints. Today'sNursing Home, 7,4047. Morse, J.M., Tylko,$.J., & Dixon, H.A. (1985). The patient who falls...and falls again: Defining the aged at risk. Journal of Gerontological Nursing, 1I , 15-18.

M/Nov-Dec 1991/Rehabilitation NursingNol. 16, No. 6