Crit Care Nurs Q
Vol. 42, No. 1, pp. 106–116
c 2019 Wolters Kluwer Health, Inc. All rights reserved.
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Effect of Interventional
Educational Programs on
Intensive Care Nurses’
Perception, Knowledge,
Attitude, and Practice About
Physical Restraints
A Pre-/Postclinical Trial
Mohamad Ahmadi, MSN; Mohammad Iraj Bagheri-Saweh, MSN;
Bijan Nouri, PhD; Omid Mohamadamini, MSN; Sina Valiee, PhD
The article reports results of an educational program designed to modify negative attitudes of
intensive care nurses regarding the use of physical restraints. Findings revealed that increased
knowledge about appropriate utilization of various types of restraints positively impacted perceptions, attitudes, and patient care practices. Authors also explore restraint use in several countries
and identify variations in use of restraining methods. Key words: attitude, knowledge, perception, physical restraints
B
ECAUSE of the critical condition of the
patients hospitalized in the intensive
care units (ICUs) and use of aggressive measures such as mechanical ventilation, patients
often experience anxiety, fatigue, pain, fear,
and delirium.1,2 The prevalence of delirium
Author Affiliations: Student Research Committee
(Mr Ahmadi), Clinical Care Research Center
(Mr Bagheri-Saweh and Dr Valiee), Social
Determinants of Health Research Center, Research
Institute for Health Development (Dr Nouri), and
Salahuddin Ayyubi Hospital (Mr Mohamadamini),
Kurdistan University of Medical Sciences, Sanandaj,
Iran.
The authors have disclosed that they have no significant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Sina Valiee, PhD, Clinical Care Research Center, Kurdistan University of Medical Sciences, Pasdaran St, 66177-13446, Sanandaj, Kurdistan,
Iran (Valiee@muk.ac.ir).
DOI: 10.1097/CNQ.0000000000000244
is significantly high among critical patients
and is associated with decreased cognitive
performance and increased rate of mortality.3
Occurrence of delirium in ICUs is usually unknown and unpredictable, and its rate could
increase to 70% to 87% among the elderly.4
Delirium and increased anxiety among patients hospitalized at ICUs, especially those
subjected to mechanical ventilation, could
become problematic. These patients have an
increased risk of self-harm and even death
from agitated behaviors resulting in the
dislodgment of the endotracheal tube or
interference with other medical devices.3
In addition, increased levels of delirium and
agitation could also lead to unplanned bed
exits and falls, which could interrupt medical therapies and result in serious patient
injuries.5,6
One of the care measures to prevent serious
harms for these patients is to use restraints.7
Restraints are any kind of equipment, drug,
106
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Restraint Use in ICU
or facility that would lead to immobility or
limited movement of the patient and derive patient’s freedom in movement in the
bed.8-10 Physical restraints are often used after attempting or exploring other alternatives. Alternative approaches for restraining
patients include bedside sitters, using distraction or de-escalation strategies, emotional reassurance, and bed exit alarms. There are also
various medications that help in reducing agitation and restricting spurious movements
that interfere with patient safety. If appropriate alternatives have been considered or
found to be insufficient, ineffective, or potentially unsuccessful, physical restraint may be
appropriate.11,12
Restraints are divided into 2 groups of
chemical and physical.13 Chemical restraints
include antipsychotic or sedative drugs
that could be administered orally or by
injection.11 Physical restraints are any kind
of wrist restraint, belts and vests for limiting patient’s movement in the bed.14 Using chemical agents are associated with suppression of the nervous and respiratory systems and have serious side effects. Among
these are depressions in vital functions, prolonged need for mechanical ventilation, increased risk of ventilator-related pneumonia,
exacerbated decrease in the level of consciousness, and eventually increased duration
of hospitalization.15,16 Since the use of physical restraints has less undesirable effects than
chemical restraints, in some cases, only physical restraints are used.17,18 Totally, If appropriate alternatives have been considered or
found to be insufficient, ineffective or potentially unsuccessful, physical restraint may be
appropriate.
STATISTICS ABOUT PHYSICAL
RESTRAINTS
In a study conducted in the United States,
it was revealed that on average, 44% of the
patients who were hospitalized in general
and intensive care units were restrained using
physical restraints to prevent accidental disconnection of intravenous lines and life sup-
107
port equipment connected to the patient.19
In another study of 21 ICUs in France,
50% of the patients who were mechanically
ventilated experienced restraint use at least
once.20 A Canadian report of 51 ICUs revealed that 53% of the intubated patients
were restrained for an average of 4 days.21 In
Iran, 47.6% of its ICU patients are typically
restrained and in 87.5 % of cases, wrist restraints are used.22
The literature suggests that using physical
restraints is often associated with undesirable
physical and mental outcomes.23,24 Some of
the negative outcomes of physical restraint
use are the occurrence of pressure ulcers, increased hospital infections, urinary retention
and decreased gastrointestinal movements,
edema of the extremities, increased risk
of falling from bed, and increased rate of
mortality.25-28 The psychological effects of
applying physical restraints are increased fear,
anger, depression, anxiety, sleep deprivation,
decreased self-esteem, and disturbed mental
image.23,24,29
PHYSICAL RESTRAINT STANDARDS
A physician is responsible for the patient’s
ongoing care and orders the use of restraint
in ICU and orders are renewed for a maximum of 24 consecutive hours.30 Nurses, as
health care team members who are in constant touch with patients in the ICU,31 investigate the need to use restraints in adult
patients every 4 hours and make decision
for going on using restraints to control patients’ behaviors.32-34 The process of decision making among nurses is affected by
their level of knowledge, attitudes, and perceptions of restraint use. Therefore, making
any decision for restraint application with
a limited knowledge base and a poor attitude could eventually result in severe physical
and mental complications for the patient.35-37
Studies about physical restraints have shown
that nurses’ knowledge, attitude, and perception of physical restraints are low and patients have reported a high prevalence of
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108
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2019
complications; therefore, education in this
field seems necessary.38-41
The study by Yeh et al42 indicated the
effect of education on the level of knowledge, perception, attitude, and practice of
nurses in the ICUs. Also, the study by Huang
et al7 showed the effectiveness of educational
programs in improving the level of knowledge, attitude, and practice of nurses about
the restraints. The study by Taha and Ali43 reported the effect of educational programs in
increasing the level of knowledge and practice in nurses and decreasing the complications in patients regarding the use of physical restraints. It was also revealed in the
study by Hooseinrezaee et al44 that performing educational programs had significantly increased the scores of knowledge and practice in nurses regarding the use of physical
restraints in Iran.
There is a permanent need for the promotion of nurses’ practices about physical
restraints.45 Therefore, the present study was
conducted to evaluate the effect of an interventional educational programs on the level
of perception, knowledge, attitude, and practice in nurses about applying physical restraints in the ICUs.
Setting
Salahuddin Ayyubi Hospital in Baneh, Iran,
has one 11-bed general ICU; typical patients hospitalized in this unit include those
with complex cardiovascular or cerebrovascular medical conditions, life-threatening infections, or who require complex postsurgical management.
Data collection and tools
METHODS
Data-gathering tools included a demographic characteristics questionnaire and perception, knowledge, attitude, and practice
scale (Table 1).
The perception questionnaire was used earlier in the study by Arai and Leibowitz46 and
was released to the researcher. After translation, its content validity was approved by 10
professors with expertise in critical care. To
evaluate its reliability, the questionnaire was
given to 10 nurses working in ICUs and using Cronbach α method; its reliability was approved with an α value of .72. Knowledge, attitude, and practice questionnaires that were
used in the study by Saeidi et al47 were released to the researcher. In their study, Cronbach α values for internal consistency of each
of the questions were 0.76, 0.72, and 0.82,
respectively, for knowledge, attitude, and
practice.
Study design
Intervention
The present study was a quasi-experimental
study with a pre-/postdesign. This study has
been registered at the Iranian Registry for
Clinical Trials (www.IRCT.ir) under the no.
IRCT2017070234859N1.
The intervention was based on a review of
the literature44,45 and was approved by relevant professors. Educational sessions were
conducted for the nurses during 2 consecutive days, and in the interventional educational program, education was provided
about types of restraints, definitions, types of
physical restraints, complications caused by
using physical restraints, and ethical and legal
issues related to the use of physical restraints
(Appendix Box 1). Educational content was
provided using lectures with audio-visual content, group discussion, and interlocution.
Two weeks after the end of the educational
sessions,44 perception, knowledge, attitude,
and practice of nurses were reevaluated.
Participants and sampling
All of the nurses working in the ICUs with
at least a bachelor’s degree and 1 year of
working experience in ICUs were selected
using census method. At the beginning of
the study, 33 nurses were working at this
unit from which, 30 completed the questionnaire. One did not participate in the study
and 2 were excluded for not completing the
questionnaire.
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Restraint Use in ICU
109
Table 1. Data-Gathering Tools
Number of
Questions
Scale
Range of
Score
Perception
19
6-point Likert: 0-5
19-95
Knowledge
13
Right (1)/Wrong (0)
0-13
Attitude
13
5-point Likert: 0-4
0-52
Practice
15
3-point Likert: 0-2
0-30
Ethical considerations
The present study is adapted from a
master’s thesis in Critical Care nursing that
was approved by the research committee
of the Kurdistan University of Medical Sciences. After gaining approval from the ethics
committee of the Kurdistan University of
Medical Sciences under the no. IR MUK
REC 1396.125, informed consent was obtained from the nurses for participating in
the study. All nurse subjects were assured
that participation in the study would be
voluntarily and that they would be permitted
to withdraw from the study at any desired
time. Participants were also assured that their
information would remain confidential.
Statistical analysis
After completing the questionnaires, data
were analyzed using SPSS software version
19. First Kolmogorov-Smirnov test was used
to evaluate data distribution and considering
the nonnormalized distribution of the data,
nonparametric Wilcoxon testing was used to
compare the scores of perception, knowledge, attitude, and practice of the nurses before and after the intervention.
RESULTS
The mean age of nurses was 31.3 ± 6.24
years and the mean of nurses’ working experience was 7.01 ± 5.56 years (Table 2).
Interpretation
Higher scores indicated lower
level of perception
Higher scores indicated higher
level of knowledge
Higher scores indicated
positive level of attitude
Higher scores indicated better
level of compliance
Twenty-three nurses (76.72%) were male; 25
of the participants (83.3%) had not participated in educational courses about physical restraints before. However, all participants
(100%) had used physical restraints before,
and 20 of them (66.7%) had experienced
complications caused by physical restraints
(Table 3).
The mean score of nurses’ perception of
physical restraints before the intervention
was 72.4 ± 11.54 and the mean score after
the intervention was 51.13 ± 11.81. Results
of statistical tests showed a significant difference between the mean scores of perception
before and after the educational intervention
(P < .0001). The mean score of knowledge
before the intervention was 7.06 ± 1.85 and
the mean score after the intervention was
11.2 ± 1.58. A significant difference was observed between the mean scores of knowledge before and after the intervention (P <
.0001). The mean score of attitude before
the intervention was 28.23 ± 4.91 and the
mean score after the intervention was 22.13
± 5.51. The statistical test revealed a significant difference between the mean scores of
attitude before and after the interventional
educational program (P < .0001). The mean
score of practice before the intervention was
21.20 ± 4.86 and the mean score after the
intervention was 26.33 ± 2.17. Statistical
tests showed a significant difference between
the mean scores of practice before and after
the intervention (P < .0001) (Table 4).
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110
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2019
Table 2. Demographic Characteristics
Variable
Age, y
Working experience, y
Working experience in
intensive care unit, y
Working hour (per month)
Number
Mean
Standard
Deviation
Minimum
Maximum
30
30
30
31.36
7.01
3.71
6.24
5.56
3.44
24
1.3
1
53
25
17
30
225.26
31.75
175
325
DISCUSSION
Perception
According to findings in this study, nurses’
perceptions of physical restraints were improved after the educational intervention.
The standards and guidelines for physical restraint use that were emphasized during the
educational sessions significantly impacted
the nurses’ perception of physical restraints.
The study by Lau48 reported that executing
therapeutic interventional protocols has decreased the use of physical restrains but it
made no change in nurses’ perception. In similar studies such as the study by Yeh et al42
that studied ICU nurses, it was revealed that
performing constant educational programs
for reducing the use of physical restraints has
Table 3. Demographic Characteristics and Experiencing the Complications Caused by Physical
Restraints
Variable
Gender
Male
Female
Marital status
Married
Single
Educational level
Bachelor’s degree
Master’s degree
History of passing educational courses about physical restraints
Yes
No
Experiencing the use of physical restraints
Yes
No
Experiencing the complications caused by physical restraints
Yes
No
Type of complication
No complication
Skin scar
Ecchymosis
Other complications
More than 1 complication
Frequency
Percentage
23
7
76.7
23.3
17
13
56.7
43.3
26
4
86.7
13.3
5
25
16.7
83.3
30
0
100
0
20
10
66.7
33.3
10
2
4
1
13
33.3
6.7
13.3
3.3
43.4
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111
Restraint Use in ICU
Table 4. Comparison of the Mean Scores of Perception, Knowledge, Attitude, and Practice
Before and After Intervention
Variable
Before the
Intervention
After the
Intervention
P
Perception
Knowledge
Attitude
Practice
72.43 ± 11.54
7.06 ± 1.85
28.23 ± 4.91
21.20 ± 4.86
51.13 ± 11.81
11.20 ± 1.58
22.13 ± 5.51
26.33 ± 2.17
.0001
.0001
.0001
.0001
also been helpful in improving nurses’ level of
perception. A study by Arai and Leibowitz46
revealed that nurses who have passed educational courses about the use of physical restraints had higher levels of perception than
other nurses. Nurses’ low level of perception of the use of physical restraints would
cause them to pay less attention to controlling patient’s behavior while using physical
restraint. Increasing the level of perception
of nurses about the use of physical restraints
would lead to the use of replacement methods and consequently decrease the use of
physical restraints and their complications.46
Meanwhile, educational interventions for the
improvement of nurses’ perception, based on
the results of the present study and other similar studies, could be helpful.42 The reason
for improvement of nurses’ level of perception of physical restraints in the present study
could be due to performing the educational
intervention about physical restraints with focus on using other relaxation techniques and
controlling patient’s behaviors. Strategies included not using force for limiting the patients, getting help from the family members
and patient’s close acquaintances, using familiar objects in the patient’s room, decreasing environmental stimuli, and using hearing
and visual aids equipment for patients hospitalized in the ICU.45,49-51 Therefore, performing the educational interventions in ICUs is
recommended.
Knowledge
The level of nurses’ knowledge about physical restraints showed a significant differ-
ence between before and after the intervention. In the present study, nurses’ knowledge
about physical restraints was increased after
the intervention. The study by Hooseinrezaee
et al44 conducted about ICU nurses revealed
that performing educational workshops on
the standards of restraints for the intervention group increased nurses’ knowledge in
this field. The study by Tahah and Ali43
also showed that performing educational sessions about restraints would increase the
level of knowledge in ICU nurses. Results of
the present study and previous studies have
shown that nurses’ level of knowledge about
the restraints is low. In the study by Hooseinrezaee et al,44 nurses’ knowledge level was
low. Also, Suen et al6 in a study that was conducted in Hong Kong to evaluate the knowledge and attitude of 80 nurses working at rehabilitation centers reported that the mean
score of nurses’ knowledge about physical
restraints was undesirable. But the study by
Karagozoglu et al52 showed that the knowledge of fourth-year nursing students about
physical restraints was desirable. It seems that
the inadequate level of knowledge and awareness about physical restraints in nurses might
be caused by not passing educational courses
and lack of developed guidelines and organizational policies by the medical and health
organizations. But in the study by Karagozoglu et al,52 higher levels of knowledge
about physical restraints in the nursing students might be due to providing constant education during their time of study and their updated information about physical restraints.
Performing educational interventions about
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112
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2019
the use of physical restraints seems necessary to improve the level of knowledge and
awareness in nurses. In the present study, educational intervention emphasized on issues
such as the physical and mental complications caused by restraints and legal and ethical issues caused by restraints for the patients.
Also, it emphasized the necessity of recording the use of physical restraints in nursing
reports and the necessity of recording physician’s order for agreeing to the use of physical
restraints for the patient and finally, educating
the right nursing cares during the use of physical restraints.
Attitude
Results about the attitude of nurses regarding the use of physical restraints showed
a significant difference in nurses’ attitude
between before and after the intervention.
Before the execution of the educational
program, nurses had a low level of attitude
toward the restraints. For example, in the
present study, before the intervention, most
of the nurses did not accept that “the patients and their families had the right to
reject the use of physical restraints,” which
could indicate nurses’ negligence about the
independence of the patients. This result is in
line with the result of Hooseinrezaee et al.44
Respecting the independence and maintaining the freedom of the patient are among the
main rights of the patients and their families
in ethical considerations. The patients and
their family members have the right to be
involved in the process of making medical
decisions about them. The fundamental step
toward respecting the patients’ and their
families’ right to make decisions is to obtain
informed consent from them.53 Results of the
study by Kaya et al54 showed that the attitude
of Turkish nurses toward the use of physical
restraints was negative and it was reported
that most of the nurses would not feel sad for
the patients while using physical restraints;
this might be caused by nurses’ unawareness
about the physical and mental complications
of the use of physical restraints and the fact
that they believe that physical restraints are
the best way to protect patients’ safety. It
was revealed in the study by Yeh et al42 that
conducting constant educational programs
about the use of restraints would lead to
a positive attitude in nurses. Also, in the
study by Saeidi et al,47 it was reported that
nurses had a negative attitude toward the
use of restraints and considering the effect
of performing educational programs in this
field, and the increase in nurses’ knowledge
about the use of restraints, executing educational programs would cause a positive
attitude in nurses. Considering the results of
the present study and previous studies, the
nurses’ attitude toward physical restraints is
negative. In the present study, after executing
the interventional educational program by
explaining the ethical and legal issues related
to the use of physical restraints, retraining the
charter of patient’s rights and emphasizing on
respecting the right of the patients and their
families in the process of decision making
for the use of physical restraints, nurses’
level of attitude was improved. Therefore,
educational interventions for increasing the
awareness of nurses about the complications
caused by the use of physical restraints and
about the patients’ charter of right regarding
the use of physical restraints could improve
their attitude and considering the importance
of nurses’ attitude toward physical restraints
by improvement of nurses’ attitude, the
complications caused by physical restraints
could be prevented.
Practice
It was also revealed in the present study
that the level of nurses’ practice was low
regarding the use of physical restraints for
patients of the ICU but following the execution of the educational program, nurses’
scores were increased. The study by Janelli
et al55 showed that nurses had a desirable
practice while using physical restraints. Their
study indicated that the nurses would use
replacement methods before using physical
restraints for the patients. However, nurses’
practice was undesirable in many other
studies.7,42,43,56,57 Regarding the effective-
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Restraint Use in ICU
ness of educational programs on the practice
of nurses in using physical restraints, the
study by Yeh et al42 showed that unlike the
variables of perception, knowledge, and
attitude, executing educational programs had
no significant effect on nurses’ practice in
using physical restraints. But similar studies
such as the study by Taha and Ali43 reported
that nurses had an undesirable level of practice regarding the use of physical restraints
and they also mentioned that the reason for
undesirable level of practice in nurses might
be due to their inadequate awareness in this
field and performing educational programs
had improved the level of nurses’ practice
in the intervention group and had decreased
the physical complications caused by the use
of restraints for the patients. The study by
Hooseinrezaee et al44 indicated that performing educational programs about the use of
physical restraints would improve the level of
nurses’ practice. It seems that nurses’ undesirable practice in using physical restraints for
patients is caused by their inadequate knowledge in this field and performing educational
interventions to increase the awareness and
knowledge of nurses could improve their
practice.43 In the present study by designing
and executing the interventional educational
program about the use of physical restraints,
nurses’ knowledge and also their practices
were improved, which could be caused by
matters that would address the nurses.
Limitations and recommendations
One of the limitations of the present study
was that considering the number of nurses
113
working in the ICU, the study was conducted
in 1 group at 1 center. Also, it was not possible to observe nurses’ practice regarding
the use of physical restraints at all 3 shifts
of the morning, afternoon, and night and
so, their performance was evaluated using
a self-report questionnaire. Considering the
short duration of the study, the complications
caused by the use of physical restraints in
patients could not be evaluated. Since the
present study was conducted at general ICU,
it is recommended to conduct the study
in specialized ICUs in future studies. It is
also recommended to evaluate the level of
delirium in the patients hospitalized at the
ICUs, and its relation to the use of physical restraints would be evaluated. Considering the
importance of using restraints and involved
people in the process of restraining, it is recommended that besides nurses, other groups
such as physicians and assistant nurses would
also participate in the study. Considering
the limitations of the present study, it is recommended that the effect of interventional
educational programs on nurses’ practice
would be evaluated through observation too.
CONCLUSIONS
Results showed that performing the interventional educational programs about the use
of physical restraints can improve the level
of knowledge and perception and would lead
to a positive attitude and improved practice in nurses of the ICUs. Therefore, the
present program could be applied for the ICU
nurses.
REFERENCES
1. Marino PL. Marino’s the ICU Book. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
2. Puntillo KA, Arai S, Cohen NH, et al. Symptoms experienced by intensive care unit patients at high risk of
dying. Crit Care Med. 2010;38(11):21-25.
3. Reade MC, Eastwood GM, Bellomo R, et al. Effect of dexmedetomidine added to standard care
on ventilator-free time in patients with agitated
delirium: a randomized clinical trial. JAMA. 2016;
315(14):1460-1468.
4. Mittal V, Muralee S, Williamson D, et al. Delirium in the elderly: a comprehensive review. Am J
Alzheimers Dis Other Demen. 2013;2(2):4-18.
5. Goethals S, Dierckx de Casterlé B, Gastmans C.
Nurses’ decision-making in cases of physical restraint: a synthesis of qualitative evidence. J Adv
Nurs. 2012;68(6):1198-1210.
6. Suen LK, Lai C, Wong T, et al. Use of physical restraints in rehabilitation settings: staff knowledge, attitudes and predictors. J Adv Nurs. 2006;55(1):20-28.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
114
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2019
7. Huang H-T, Chuang Y-H, Chiang K-F. Nurses’ physical restraint knowledge, attitudes, and practices: the
effectiveness of an in-service education program. J
Nurs Res. 2009;17(4):241-248.
8. Krüger C, Mayer H, Haastert B, Meyer G. Use of
physical restraints in acute hospitals in Germany: a
multi-centre cross-sectional study. Int J Nurs Stud.
2013;50(12):1599-1606.
9. Di Leonardi BC. Restraints: the last resort. 2010.
10. Bártlová S, Hajduchová H, Prajsová J. Nurses’ opinions regarding patient safety in connection with the
use of restraints in patients in Czech hospitals. Kontakt. 2015;17(2):e73-e79.
11. Springer G. When and how to use restraints. Am
Nurse Today. 2015;10(1):26-32.
12. Registered Nurses’ Association of Ontario. Promoting Safety: Alternative Approaches to the Use of
Restraints. Toronto, Ontario, Canada: Registered
Nurses’ Association of Ontario; 2012.
13. Langley G, Schmollgruber S, Egan A. Restraints in intensive care units—a mixed method study. Intensive
Crit Care Nurs. 2011;27(2):67-75.
14. Knutzen M, Bjørkly S, Eidhammer G, et al. Mechanical
and pharmacological restraints in acute psychiatric
wards—why and how are they used? Psychiatry Res.
2013;209(1):91-97.
15. Hofsø K, Coyer FM. Part 2. Chemical and physical
restraints in the management of mechanically ventilated patients in the ICU: a patient perspective. Intensive Crit Care Nurs. 2007;23(6):316-322.
16. Kohen I, Preval H, Southard R, Francis A. Naturalistic study of intramuscular ziprasidone versus conventional agents in agitated elderly patients: retrospective findings from a psychiatric emergency
service. Am J Geriatr Pharmacother. 2005;3(4):
240-245.
17. Swickhamer C, Colvig C, Chan SB. Restraint use in
the elderly emergency department patient. J Emerg
Med. 2013;44(4):869-874.
18. Zun LS. A prospective study of the complication rate
of use of patient restraint in the emergency department. J Emerg Med. 2003;24(2):119-124.
19. Mion LC, Minnick AF, Leipzig RM, Catrambone CD,
Johnson ME. Patient-initiated device removal in intensive care units: a national prevalence study. Crit Care
Med. 2007;35(12):2714-2720.
20. De Jonghe B, Constantin J-M, Chanques G, et al. Physical restraint in mechanically ventilated ICU patients:
a survey of French practice. Intensive Care Med.
2013;39(1):31-37.
21. Burry L, Perreault M, Williamson D, et al. A Prospective evaluation of sedative, analgesic, anti-psychotic
and paralytic practices in Canadian mechanically ventilated adults. D23. ICU OUTCOMES. Am Thoracic
Soc. 2009:A5492.
22. Nurmohamadi A. The Rate of Physical Restraints
Use in Intensive Care Units and Its Related Factors
in View of Nurses at Hospitals. Tehran, Iran: Shahid
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
Beheshti University of Medical Sciences and Health
Services; 2011.
Yönt GH, Korhan EA, Dizer B, Gümüs F, Koyuncu
R. Examination of ethical dilemmas experienced by
adult intensive care unit nurses in physical restraint
practices. Holist Nurs Pract. 2014;28(2):85-90.
Cotter VT. Restraint free care in older adults with dementia. Keio J Med. 2005;54(2):80-84.
Tolson D, Morley JE. Physical Restraints: Abusive
and Harmful. J Am Med Dir Assoc. 2012;13(4):311313.
Evans D, Wood J, Lambert L. Patient injury and physical restraint devices: a systematic review. J Adv Nurs.
2003;41(3):274-282.
Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry.
2003;48(5):330-337.
Rubin BS, Dube AH, Mitchell EK. Asphyxial deaths
due to physical restraint. A case series. Arch Fam
Med. 1993;2(4):405-408.
Gastmans C, Milisen K. Use of physical restraint in
nursing homes: clinical-ethical considerations. J Med
Ethics. 2006;32(3):148-152.
Anonymous. Joint Commission Standards on
Restraint
and
Seclusion/Nonviolent
Crisis
R
Intervention
Training Program. Milwaukee,
WI; Crisis Prevention Institute, 2009.
Valiee S, Negarandeh R, Dehghan Nayeri N. Exploration of Iranian intensive care nurses’ experience of
end-of-life care: a qualitative study. Nurs Crit Care.
2012;17(6):309-315.
Hine K. The use of physical restraint in critical care.
Nurs Crit Care. 2007;12(1):6-11.
Mion LC, Sandhu SK, Khan RH, et al. Effect of situational and clinical variables on the likelihood of
physicians ordering physical restraints. J Am Geriatr
Soc. 2010;58(7):1279-1288.
Choi E, Song M. Physical restraint use in a Korean
ICU. J Clin Nurs. 2003;12(5):651-659.
Akansel N. Physical restraint practices among ICU
nurses in one university hospital in western Turkey.
Health Sci J. 2014;4(4):1-7.
Karlsson S, Bucht G, Eriksson S, Sandman PO. Factors
relating to the use of physical restraints in geriatric
care settings. J Am Geriatr Soc. 2001;49(12):17221728.
McCabe DE, Alvarez CD, McNulty SR, Fitzpatrick JJ.
Perceptions of physical restraints use in the elderly
among registered nurses and nurse assistants in a single acute care hospital. Geriatr Nurs. 2011;32(1):3945.
Moradimajd P, Noghabi AA, Zolfaghari M, Mehran A.
Physical restraint use in intensive care units. Iran J
Crit Care Nurs. 2015;8(3):173-178.
Agens J. Chemical and physical chemical and physical
restraint use in the older person restraint use in the
older person restraint use in the older person. Br J
Med Pract. 2010;3(1):302.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Restraint Use in ICU
40. Estévez-Guerra GJ, Fariña-López E, Núñez-González
E, Gandoy-Crego M, Calvo-Francés F, Capezuti EA.
The use of physical restraints in long-term care in
Spain: a multi-center cross-sectional study. BMC Geriatr. 2017;17(1):29.
41. Stinson KJ. Nurses’ attitudes, clinical experience, and
practice issues with use of physical restraints in critical care units. Am J Crit Care. 2016;25(1):21-26.
42. Yeh S-H, Hsiao C-Y, Ho T-H, et al. The effects
of continuing education in restraint reduction on
novice nurses in intensive care units. J Nurs Res.
2004;12(3):246-256.
43. Taha NM, Ali ZH. Physical restraints in critical care
units: impact of a training program on nurses’ knowledge and practice and on patients’ outcomes. J
Nurs Care. 2013;2(2):2167-1168. doi:10.4172/21671168.1000135.
44. Hooseinrezaee H, Nouhi E, Taherharikandee S. The
effect of education on trauma critical care nurses attitudes towards and knowledge and practices from
the viewpoint of their about application of physical
restraint. Journal of Nursing Education. 2015;4(1):
31-38.
45. Johnson K, Curry V, Steubing A, et al. A nonpharmacologic approach to decrease restraint use.
Intensive Crit Care Nurs. 2016;34:20-27.
46. Arai, F, Leibowitz, YS. Nurses’ perceptions of restraint. Yearbook J Japan Soc Nurs Res. 2014;24(5):
39-46.
47. Saeidi SZ, Khatiban M, Khazaei A, Soltanian AR,
Rahimi Bashar F. Assessment of intensive care unit
nurses’ knowledge, attitude, and practice of physical
restraint use. Sci J Hamadan Nurs Midwifery Fac.
2015;23(3):40-49.
48. Lau Y-y. Effect of treatment interference protocol
(TIP) on the use of physical restraints in ICU. Master’s
49.
50.
51.
52.
53.
54.
55.
56.
57.
115
degree dissertation in Nursing, University of Hong
Kong. 2008.
Mistraletti G, Pelosi P, Mantovani ES, Berardino M,
Gregoretti C. Delirium: clinical approach and prevention. Best Pract Res Clin Anaesthesiol. 2012;
26(3):311-326.
Van Rompaey B, Elseviers MM, Van Drom W,
Fromont V, Jorens PG. The effect of earplugs
during the night on the onset of delirium and
sleep perception: a randomized controlled trial
in intensive care patients. Crit Care. 2012;16(3):
R73.
Jones C, Dawson D. Eye masks and earplugs improve patient’s perception of sleep. Nurs Crit Care.
2012;17(5):247-254.
Karagozoglu S, Ozden D, Yildiz FT. Knowledge, attitudes, and practices of Turkish intern nurses regarding physical restraints. Clin Nurse Spec. 2013;
27(5):262-271.
Cheung PP, Yam B. Patient autonomy in physical restraint. J Clin Nurs. 2005;14(s1):34-40.
Kaya H, Aştı T, Acarog*lu R, Erol S, Savcı C. Nurses’
knowledge, attitudes and practices related to using
physical restraints. J Maltepe Univ Nurs Sci Art.
2008;1(2):21-29.
Janelli LM, Stamps D, Delles L. Physical restraint use:
a nursing perspective. Medsurg Nurs. 2006;15(3):
48-53.
Smith NH, Timms J, Parker VG, Reimels EM, Hamlin
A. The impact of education on the use of physical restraints in the acute care setting. J Contin Educ Nurs.
2003;34(1):26-33.
Choi K, Kim J. Effects of an educational program
for the reduction of physical restraint use by caregivers in geriatric hospitals. J Korean Acad Nurs.
2009;39(6):769-780.
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116
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2019
APPENDIX
Box 1. Educational Program
1
2
Types of restraints and their
definitions
Types of physical restraints
3
Legal and ethical issues
4
Patient’s rights
5
Application of physical
restraints
6
Contradictions to and
limitations for applications
of physical restraints
Determining and resolving the
reasons for using restraints
7
8
9
10
Complications caused by the
use of physical restraints and
how to prevent them
Accurate care for and
controlling the patient
Methods for controlling
patient’s behavior
Presenting different types of restraints and their
categorizations
Explaining different types of physical restraints
using images and pictures and explaining the
mechanism for their application
Presenting the consequences and negative
outcomes of applying restraints regarding social
issues and the outcomes that would involve
nurses for applying physical restraints to
patients
Overviewing and explaining patient’s rights.
Reviewing patients’ rights charter
Explaining the cases for application and
indications for using physical restraints for
patients
Presenting the cases of contraindication for using
physical restraints
Describing the conditions and reasons that would
encourage nurses to apply physical restraints
and recommending to avoid these conditions
Presenting the chronic and acute physical and
mental complications caused by the use of
restraints
Explaining accurate care for patients, constantly
monitoring them, spending as much time as
possible by the patients, not leaving the patient,
and providing mental support if needed
Reducing environmental stimuli, using familiar
articles in patient’s room, using audio and visual
aid devices and other facilities for relaxing the
environment such as music therapy, and
putting images of nature in patient’s room
Providing visual and hearing aids, frequent
communication and reorientation with patient,
familiar objects from patient’s home in the
room, consistent nurse staff, allow television
during the day with daily news, and nonverbal
music.
Environmental approaches included sleep quiet
time, lights on during the day and off at night,
control excess noise, and ambulate patient
early and often.
Providing and using therapeutic alternative device
included pictures, based on a patient or family’s
preference; cognitive capacity and physical
abilities; providing mental, sensory, auditory, or
tactile stimulation; range of motion; and eye
and hand coordination.
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