1. Forrester, David Anthony (Tony) PhD, RN
  2. McCabe-Bender, Jean MPA, RN, CNA
  3. Walsh, Noreen RN
  4. Bell-Bowe, Jacqueline MSN, RN, CNS, C


During the winter of 1998 the management of 118 (N = 118) physically restrained adult patients in a 238-bed urban acute care hospital were assessed by 26 registered nurse (RN) data collectors. In the spring of 1999, following a comprehensive hospital-wide staff development program and revised physical restraint protocol, 10 RN data collectors conducted a follow-up study of 53 (N = 53) restrained adults in the same institution. In both studies, data regarding restraints management were gathered using a Restraint Management Improvement Indicator. Following a program of restraint management education, substantial improvements were found for virtually all of the physical restraint indices studied. The findings suggest that future educational efforts should be undertaken to further improve the documentation in hospital medical records regarding medical orders and ongoing observation, assessment, and interventions for physically restrained patients. Future research should further document and study interventions to reduce or eliminate the use of physical restraints.


In the United States, approximately 500,000 hospital and nursing home patients are placed in physical restraints each day (Blakeslee, 1988; Stratman, Vinson, Magee, & Hardin, 1997). The use of physical restraints in general hospitals ranges from 6% to 17% (Frengley & Mion, 1986; Mion, Minnick, Palmer, Kapp, & Lamb, 1996). For patients older than 65 years, the rate increases to 18% to 20% (Mion, Frengley, & Adams, 1986; Mion et al., 1996). Approximately one in ten adults and one in five older adults are physically restrained at some point during their hospitalization. Physical restraints refer to "... any manual method or physical or mechanical device, material, or equipment attached or adjacent to the individual's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body" (Health Care Financing Administration, 1992, p. 76).


Even though patient safety is cited as the primary reason for applying physical restraints, the devices may actually increase the potential for harm to patients (Coyle, 1979; Tinetti, Liu, & Ginter, 1992). Frequent serious injuries, even death, as a direct result of physical restraints have been reported (Miles, 1993; Miles & Irvine, 1992; Mion et al., 1996).


In 1996, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised its standards for seclusion and restraint management (JCAHO, 1996). The new standards required a major change on the part of acute care hospital staff nurses from system-centered to patient-centered care and from routine task first to patient first. In response, the hospital revised its restraint management policy, physician order set, and nursing documentation tools.


Staff development regarding the revisions was carried out in a 1.5 hour program on safety and risk management focusing on restraint management and fall prevention. The program was part of a day-long continuing education program provided to all staff nurses during the summer of 1998. Educational efforts focused on patients' rights and differentiating physical restraint from medical immobilization and postural/safety supports. Emphasis was placed on identifying patients at risk, selection and use of the least restrictive devices, alternatives to restraints, and documentation requirements.