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Introduction
A considerable number of patients in acute and intensive care settings are normally subjected to physical restraints. This number is said to range between 7% and 17% according to a research study done by Akansel (2007). Common types of physical restraints include: wrist restraint, ankle restraint, chest restraint, chest and leg restraint, and whole body restraints. Materials used to physically restrain patients include sheets, belts, and gloves. The use of physical restraint on patients is associated with harm not only on the patients but also on their families. The harm done is not only physical but also emotional and psychological in nature. This paper is a review and critical analysis of studies that have been conducted on the adverse effects of physical restraints on patients.
Review and Critical Analysis of the Literature
Mott, Poole and Kenrick (2005) were interested in examining the use of both physical and chemical restraints in acute care and particularly their effect on the rehabilitation of the aged. They argued that patients who are admitted in rehabilitation centers usually have pre-existing illnesses or trauma which led to impairments and limit their activity. Rehabilitation thus helps to optimize the patients strength and protect them from further loss. However, the ability to recover completely and become productive is dependent on the patients ability to take part in the programs. The authors further state that older patients admitted in acute care centers have higher risks for psychosocial, physical and cognitive decline.
These risks are aggravated when physical restraints are used on them. Mott et al. (2005) also found that physical restraints fail to completely play their purpose but instead enhance the risk of agitation. They found that physically restrained patients are more likely than non-restrained patients to suffer from falls and strangulation. They are more likely to spend more time in hospitals, less likely to be discharged, and higher risks of complications and death.
In addition, physical restraints encourage social isolation and disorientation in the acute care centers. Hence, when such patients are enrolled in rehabilitation programs, they may present anger, irritation, confusion and dissatisfaction feelings. Worse still, the physical restraints may make them immobile and acquiescent. Immobilization in turn leads to a loss in the patients physiological and functional capabilities. All these have negative impact on the patients ability to benefit well from the rehabilitation programs. This study thus supports the need to reduce the use of physical restraints on acute care patients.
The use of physical restraints in acute and intensive care settings can be justified by the ratio of nurses to patients. A study conducted by Demir (2007) indicated that some intensive care units are understaffed. This study was conducted to examine the rate and types of physical restraints commonly used by nurses in ICUs, the nurses opinions towards physical restraints and the adverse effects of restraints on patients. The author argues that understaffing limits the abilities of the nurses to pay close attention to the patients or to reassess the restraints. This occurred especially if the nurse in charge of a restrained patient has to leave the patient to attend to other patients.
The absence of the nurse in the restrained patients room provides the patient with the opportunity to harm themselves as they try to free themselves form the restraints. The researchers gave a good illustration of how patients can be harmed by physical restraints as a result of a low nurse: patient ratio. In one case observed by Demir (2007), a patient suffered from arm paralysis after being restrained. In this particular case, the nurse, being busy with other patients, had requested an inexperienced aide to restrain the patient in question but the nurse forgot to assess the patient for a whole weekend.
When the nurse returned back to work after the weekend she found the patient still restrained and suffering from paralysis. Besides this case, nurses in the study also admitted to finding patients suffering from armpit and chest ulcers due to prolonged restraints.
The study by Demir (2007) lends support to the need to reduce the use of physical restraints on acute care patients. The study shows that instead of protecting patients, physical restraints do just the opposite by causing physical harm. Moreover, nurses in this study use physical restraints for all the wrong reasons. Because they are understaffed and have high work load, the use of physical restraints is seen as a way to make their work easier and their patients more manageable. Instead of using physical restrained, other alternatives should be used to solve the problem of understaffing.
Akansel (2007) also carried out his study to examine the use of physical restraints on ICU patients, the current practices on the use of physical restraints and nurses attitudes towards the use of physical restraints. The study was conducted in a Turkish university hospital. The study was conducted through a questionnaire administered to 63 ICU nurses. The researcher found that nurses in the ICU used mainly four point restraints and bilateral wrist restraints on their patients.
Patients who were most likely to be restrained were those who were agitated, delirious, unconscious, and sedated. A sign of violence was the most common determining factor of the use of physical restraints. Nevertheless, Akansel (2007) discovered that the use of physical restraints continued even in cases where the patients coordinated fully with the nurses and posed no risk.
Physical restraints use had thus become a habit. Like in the previous studies, Akansel found many complications associated with physical restraints including arm paralysis, shoulder dislocations and humerus breaks. Majority of the nurses believed that the use of physical restraints enhanced safety in their working environment. However, safety in the acute care settings can be improved through other means other than using physical restraints on the patients.
In their study, Hamers, Gulpers and Strik (2002) aimed at looking into the frequency of the use of physical restraints on nursing home residents who are cognitively impaired, (p. 246). Other aims included examining the means through which the physical restraints are used, the justifications given by nurses for using them and the association between the application of physical restraints and residents characteristics. Data was collected through questionnaires administered to the nurses. The researchers came up with several findings. First, physical restraints were used in almost half of all the residents (49 percent).
Second, bed rails and belts were the most commonly used restraints while in majority of the cases restraints were used on both the bed and the chair, (Hamers et al., 2002, p. 250). Majority of the restrained patients had been restrained for at least three months. The restraints were applied on the residents as a routine measure while the most common justification given by the nurses for using physical restraints was to protect the residents from falling. Other common reasons included reducing restlessness and enabling the safe use application of medical devices.
Examining the relationship between restraints use and residents characteristics revealed that the restrained residents were more likely to be older, more severely impaired cognitively and with poorer psychosocial performance than their counterparts. They were also more reliant on care and had higher fall risk than their counterparts. As a result, the nurses decisions to use physical restraints were dependent on the mobility, care reliance and fall risk of the residents.
It can be argued that the use of physical restraints in this studys setting was mostly influenced by the need to reduce falls among the patients (Hamers et al., 2002). However, research studies show that physical restraints are not adequate to prevent falls and thus the use of physical restraints should be reduced and instead alternative measures should be taken to achieve this purpose. The study thus gives support to the need for reduction in the use of physical restraints on patients.
All the studies examined in this paper lend support to the need to reduce the use of physical restraints in acute care settings. This thesis is further supported by ethical considerations. Seriously ill patients rely on nurses and other healthcare professionals to care for their fundamental and complex needs. When patients become delirious, they may unintentionally interfere with their treatment and therapy devices thus endangering their lives.
Protecting patients from dangers is one of the most essential responsibilities of nurses. The use of physical restraints is considered to be one of the simplest solutions to this challenge. However, the use of restraints is linked with potential and actual harm and hence the ability of the nurses to obtain consent from the patients is a requirement. However, consent is rarely obtained by nurses when administering physical restraints on patients. This violates the Human Rights Act which states that human beings have the right to be free from unconstitutional force to limit their mobility, unless they are subject to lawful imprisonment. Additionally, people should not be put through affliction or undignified treatment (Kielb, Hurlock-Chorostecki & Sipprell, 2005).
Theory
The theory that will be used to support the project is the theory of reasoned action. This is a theory of human behavior that helps to explain why individuals behave the way they do. It posits that human behavior is influenced by the attitudes that individuals have towards that particular behavior. The attitudes entail beliefs, perceptions of the outcomes of the behavior and motivation. The theory further states that human beings are rational beings and thus apply the information they have to their behaviors.
In addition, human beings premeditate on their behavior before they engage in it (Glanz, Rimer & Viswanath, 2008). The theory of reasoned action is applicable to this project in one major way. Majority of the studies analyzed in this paper link the use of physical restraints on patients to the attitudes of nurses. Specifically, majority of nurses believe that using physical restraints promotes safety in the care setting and also makes it easy for them to manage patients. Thus, in order to enable nurses reduce the use of physical restraints, their beliefs about this practice need to be changed. This can be done through education.
The education of the medical staff concerning the use of physical restraints can be done using different media of communication. First and foremost, the education program should begin by reviewing the current literatures that address the effect of physical restraints on patients. The literature review should then be made available to the medical staff for evidence-based practice. The second channel of education can entail a video presentation.
The presentation should be prepared by medical experts in the field of physical restraints. It would be advisable for the video presentation to contain visual illustrations of the negative effects of using physical restraints on patients. Third, interactive face-to-face sessions should be held for the medical staff in conjunction with administrative, legal and risk management professionals. In such sessions, the medical staff can be educated on the legal, ethical and social issues that pertain to physical restraints use and advice given on the best precautions to take when faced with such situations. Staff education can also be conducted through posters.
Large posters with graphical illustrations can be made and placed strategically within the facility so as to create awareness among the medical staff, patients and patients families (Testad, Aasland & Aarsland, 2005).
In conclusion, the use of physical restraints by nurses is done based on several reasons such as understaffing, high work load and safety concerns. Besides educating nurses on the adverse effects of physical restraints, managers of care settings should address the underlying issues faced by nurses and promote a safe working environment. Without addressing these issues, it would be difficult for nurses to reduce the use of physical restraints.
Reference List
Akansel, N. (2007). Physical restraint practices among ICU nurses in one university hospital in Western Turkey. Health Science Journal 4, 1-8.
Demir, A. (2007). Nurses use of physical restraints in four Turkish hospitals. Journal of Nursing Scholarship, 39(1), 38-45.
Glanz, K., Rimer, B., & Viswanath, K. (2008). Health behavior and health education: Theory, research, and practice. London: SAGE Publications.
Hamers, J. P. H., Gulpers, M. J. M., & Strik, W. (2004). Use of physical restraints with cognitively impaired nursing home residents. Journal of Advanced Nursing, 45(3), 246-251.
Kielb, C., Hurlock-Chorostecki, C., & Sipprell, D. (2005). Can minimal patient restraint be safely implemented in the intensive care unit? Canadian Association of Critical Care Nurses, 16(1), 16-19.
Mott, S., Poole, J., & Kenrick, M. (2005). Physical and chemical restraints in acute care: Their potential impact on the rehabilitation of older people. International Journal of Nursing Practice, 11, 95-101.
Testad, I., Aasland, A. M., & Aarsland, D. (2005). The effect of staff training on the use of restraint in dementia: a single-blind randomized controlled trial. International Journal of Geriatrics Psychiatry, 20, 587-590.
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