Authors
- Annamalai, Jancirani RN, RMN, BSc (Nursing) (Hons)
- San, Gan Thiam RN, BSc (Nursing) (Hons)
- Huiting, Xie RN, RMN, BHSc, PhD (Nursing)
Abstract
Review question/objective: The objective of this review is to synthesize the best available evidence on the use of non-pharmacological interventions to reduce the use of physical restraint in mental health settings in adults aged 21 to 65 years with acute or chronic mental illness including dementia.
Background: Physical restraint (PR) is defined as, "any device, material, or equipment attached to or near a person's body that could not be controlled or easily removed by a patient and deliberately prevents or is intended to prevent free body movement to a position of choice."1 (p.367) Restraint is considered as 'an emergency measure to prevent imminent harm to the patient or other persons when other means of control are not effective or appropriate''.2(p.418) Physical restraint was used to prevent falls and related injuries in long-term care settings.3,4 Some psychiatric hospitals considered it acceptable practice to use PR for agitated and violent persons.5,6
The use of PR in hospitals varies between countries.7 In some European (Dutch, German, Swiss) psycho-geriatric nursing homes, PR was used as a fall preventive measure with the prevalence ranging from 26% to 56%.8 It was most frequently used in the care of older people with the prevalence ranging from 41% to 64% in Dutch nursing homes.4 Similarly, PR is still used in Singaporean psychiatric hospitals and nursing homes. Our local study in Singapore showed that 22% of residents were restrained to prevent dislodgement of a feeding tube, 18.7% were restrained to prevent falls, and 8.8% were restrained for agitation.9
There has been increasing attention placed on the use of PR in psychiatric settings.5 The use of PR in psychiatric settings has become a common practice among nurses to control challenging behavior and to prevent falls, despite many injuries and deaths having been reported to have resulted from the use of physical restraint.10, 11 Although PR is commonly used to prevent falls and fall-related injuries, it has been found to be ineffective in preventing falls.12, 13 The use of restraint can result in falls and problems with balance and coordination14, 15 and can even cause death.16 The risk of suffering serious fall-related injuries and fractures was found to be higher among those who were continuously restrained compared to those who were intermittently restrained.17, 18 Kron, Loy and Strumpf stated that applying PR increases the level of agitation rather than controlling it.15 In addition, use of PR has been associated with adverse outcomes including hospital acquired infections, increased length of hospital stay and poor cognitive functioning.17, 19 PR was also linked to higher medical costs involving significant legal risks,20 and litigation and criminal prosecution for hospitals.21 Physically restraining a patient may also lead to injury of staff members who are involved in the act.22, 23 PR intervention should be avoided if other therapeutic approaches can be successful in de-escalating a patient's aggression.
There is a worldwide move towards the reduction or elimination of restraints.22 In current practice, there are recommendations to reduce the use of PR for older people.4 Singapore's population is aging rapidly. It is estimated that the proportion of older people aged 65 and above will rise from 7.2% of the total population in the year 2000 to 18.2% in 2030. Mamun and Lim stated that there was a high rate of restraint use in nursing homes in Singapore with a statistically significant association between dementia and restraint use (p = 0.0004).9 In most acute psychiatric hospitals, PR was used for the management of behavioral problems in disturbed, aggressive, and violent patients and safety-related problems like high risk for falls.24 The use of PRs should only be used as a last resort when all other interventions have failed to prevent patients from harming themselves or others. However, staff members have been observed carrying out this procedure against the patients' will, which violate the patients' rights and autonomy.25, 26
The misuse of PR can be seen as an organizational problem that reflects failure in leadership, communication, or in the therapeutic capacity to manage aggressive patients.26 Healthcare professionals could employ evidenced-based practice (EBP) strategies to identify non-pharmacological interventions such as structured framework or restraint minimization programs that include an educational program for nursing staff, policy or guideline change, restraint alternatives and behavioral strategies to manage agitated, aggressive and violent psychiatric patients without using PR. Through EBP, the quality of clinical judgment can be strengthened when rational inferences are made based on all the available information.27 A preliminary search was conducted in the Joanna Briggs Library, PubMed, CINAHL and Cochrane Library for any existing systematic reviews on this topic. Although a few systematic reviews on the evaluation of interventions for preventing and reducing the use of physical restraints were found, these studies were focused on long-term geriatric settings. No recent systematic reviews on the effectiveness of non-pharmacological interventions to reduce physical restraint in psychiatric settings were identified from the preliminary search. Therefore, this systematic review will critically review the literature to synthesize the best available evidence to consider the effectiveness of non-pharmacological interventions for reducing the use of physical restraint in psychiatric settings.
Article Content
Inclusion criteria
Types of participants
This review will consider studies that include male and female residents aged from 21 to 65 years with acute or chronic mental illness (including dementia) residing in mental health settings (such as acute and long stay inpatient settings, residential care, and nursing homes with patients with mental health conditions). Patients with learning disabilities and drug, alcohol or substance abuse will be excluded.
Types of interventions
This review will consider studies that evaluate any non-pharmacological approaches. Non-pharmacological approaches are interventions with no direct effects on a specific biological target. Examples of non-pharmacological interventions may include structured frameworks or programs that aim to reduce or prevent the use of PR such as behavioral, crisis, early or educational interventions or a combination of various interventions and programs. The effectiveness of non-pharmacological interventions to reduce PR will be compared to usual care.
Types of outcome measures
This review will consider studies that include one or more outcome measures of physical restraint. This may include, but will not be limited to, the number of times PR was applied, the duration of PR or the rate that PR was applied.
Types of studies
This review will consider randomized controlled trials (RCTs) that examine the effectiveness of interventions to reduce PR in psychiatric settings.
In the absence of RCTs, other quantitative research designs, such as non-randomized controlled trials, before and after studies, cohort studies, and case control studies will be considered for inclusion to enable the identification of current best evidence regarding the effectiveness of interventions to reduce PR in psychiatric settings.
Search strategy
The search strategy aims to find both published and unpublished studies over the last 10 years in order to retrieve studies that are in line with the topic; only in recent times has there been a worldwide move towards restraint free nursing care and various research studies have focused on the use for PR. The search strategy will aim to find articles published in the English only due to translational restriction. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies.
The databases to be searched:
CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed and Web of Knowledge.
The search for unpublished studies will include ProQuest Dissertations and Theses.
Keywords to be used:
Medical Subject Headings (MeSH) will be used to make the search more relevant and consistent.27 The keywords chosen from the MeSH Tree are "interventions, non-pharmacological intervention, reduction of physical restraints and psychiatric settings". The alternative key words found for non-pharmacological interventions from MeSH are "crisis interventions", "early interventions", "intervention studies". Keywords such as "education" and "behavioral interventions" will also be used in the search. In addition, the keyword "physical restraints" and alternative keywords from MeSH such as "physical immobilization" and "seclusion" will also be used. Keywords for psychiatric settings are "mental health settings", "psychiatric units".
Boolean operators (OR, AND, NOT) will be used to link concepts and keywords together.
Assessment of methodological quality
Studies selected will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the JBI-MAStARI (Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data extraction
Data will be extracted by the two independent reviewers using data extraction tools developed by JBI. Quantitative data will be extracted from papers using standardized data extraction tools from the JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Where possible, quantitative research study results will be pooled using JBI-MAStARI. All results will be double entered. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square.
Ordinal and measurement scale outcomes will be meta-analysed as continuous data. Two summary statistics used for meta-analysis of continuous data include the weighted mean difference (WMD) and the standardized mean difference (SMD). WMD will be used if studies all report the outcome using the same scale while SMD will be used if the studies report the outcome using the different scales.
Nominal outcomes will be meta-analysed as dichotomous data using event rate (number that had the outcome/number that received the specific intervention). Where statistical pooling is not possible, the findings will be presented in narrative form.
Conflicts of interest
There are no conflicts of interest regarding this systematic review.
Acknowledgments
The reviewers acknowledge the Institute of Mental Health, Singapore for its support in this review.
References
1. Demir A. The use of physical restraints on children: practices and attitudes of paediatric nurses in Turkey. International Nursing Review 2007; 54 : 367-374.
2. Metzner JL, Tardiff K, Lion J. Resource document on the use of restraint and seclusion in correctional mental health care. Journal of the American Academy of Psychiatry and the Law 2007; 35: 417-425.
3. Evans D, FitzGerald M. Reasons for physically restraining patients and residents : A systematic review and content analysis. International Journal of Nursing Studies 2002; 39, 735-743. [Context Link]
4. Hamers JP, Huizing AR. Why do we use physical restraints in the elderly? Zeitschrift fur Gerontologie Geriatric 2005; 38: 19-25. [Context Link]
5. Migon MN, Coutinho ES, Huf G, Adams CE, Cunha GM, Allen MH. Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms. General Hospital Psychiatry 2008; 30: 263-268. [Context Link]
6. Keski-Valkama A, Sailas E, Eronen M, Koivisto AM, Lonnqvist J, Kaltiala-Heino R. Who are the restrained and secluded patients: A 15-year nationwide study. Social Psychiatry and Psychiatric Epidemiology 2009; 45: 1087-1093. [Context Link]
7. Bowers L, van der Werf B, Vokkolainen A, Muir-Cochrane E, Allan T, Alexander J. International variation incontainment measures for disturbed psychiatric inpatients: A. International Journal of Nursing Studies 2007; 44: 357-364. [Context Link]
8. Huizing AR, Hamers JPH, de Jonge J, Candel M, et al. Organisational determinants of the use of physical restraints: a multilevel approach. Social Science and Medicine 2007; 65: 924-33. [Context Link]
9. Mamun K, Lim J. Use of Physical Restraints in Nursing Homes: Current Practice in Singapore. Annals of the Academy Medicine Singapore 2005; 34: 158-162. [Context Link]
10. Kontio R, Joffe G, Putkonen H, Kuosmanen L, Hane K, Holi M, Valimaki M. Seclusion and Restraint in Psychiatry: Patients' Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives. Perspective in Psychiatric Care 2012; 48: 16-24. [Context Link]
11. Write S. Control and Restraint technique in the management of violence in inpatient psychiatry: A critical review, Medical Science Law 2003; 43(1):31-38. [Context Link]
12. Sze TW, Leng CY, Lin SKS. The effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes: a systematic review. JBISRIR 2012; 10 (5): 307-351. [Context Link]
13. Kopke S, Muhlhauser I, Gerlach A, Haastert B, Mohler R, Meyer G. Effect of a Guideline- Based Multicomponent Intervention on Use of Physical Restraints in Nursing Homes. A Randomized Controlled Trial. Journal Of American Medical Association, 2012, 307(20): 2177-2184. [Context Link]
14. Capezuti E, Maislin G, Strumpf NE, Evans, LK. Side rail use and bed-related fall outcomes among nursing home residents. Journal of the American Geriatrics Society 2002; 50: 90-96. [Context Link]
15. Kron M, Loy S, Strumpf E. Risk indicators for fall in institutionalized frail elderly. American Journal of Epidemiology 2003; 158: 645-653. [Context Link]
16. Berzlanovich AM, Schopfer J, Kell W. Deaths Due to Physical Restraint. Deutsches Arzteblatt International 2012; 109(3): 27-32. [Context Link]
17. Evans D, Wood J, Lambert L. Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing 2003; 41(3): 274-282. [Context Link]
18. Castle NG, Engberg J. The Health Consequences of Using Physical Restraints in Nursing Homes. Medical Care 2009; 47(11): 1164-1173. [Context Link]
19. Engberg J, Castle N, McCaffrey D. Physical restraint initiation in nursing homes and subsequent resident health. The Gerontologist 2008; 48 : 442-452. [Context Link]
20. Cecchi R, Lazzaro A, Cataneses M, Mandarelli G, Ferracuti S. Fatal thromboembolism following physical restraint in a patient with schizophrenia. International Journal of Legal Medicine, 2012; 126 : 477-482. [Context Link]
21. Lancastewitz S, Urff J. Legal consequences of seclusion and restraint. Psychiatric Services 2006; 57: 1516. [Context Link]
22. Lancaster GA, Whittington R, Lane S, Riley D, Meehan C. Does the position of restraint of disturbed psychiatric patients have any association with staff and patient injuries? Journal of Psychiatric and Mental Health Nursing 2008; 15: 306-312. [Context Link]
23. Stubbs B. The manual handling of the aggressive patient: A review of the risk of injury to nurses. Journal of Psychiatric and Mental Health Nursing 2009; 16: 395-400. [Context Link]
24. Keski-Valkama A, Sailas E, Eronen M, Koivisto A.-M, Lonnqvist J, Kaltiala-Heino R. The reasons for using restraint and seclusion in psychiatric inpatient care: A nationwide 15-year study. Nordic Journal of Psychiatry 2010; 64(2): 136-144. [Context Link]
25. Clark MA. Involuntary admission and the medical inpatient: Judicious use of physical restraint. MEDSURG Nursing 2005; 14(4): 213-219. [Context Link]
26. Cleary M, Hunt GE, Robertson M, Escott P. Mental Health Research Through Clinical Innovation or Quality Improvement-A Reflection on the Ethical Aspects. Journal of Ethics in Mental Health 2009; 4(2): 1-3. [Context Link]
27. Lorenzo RD, Baraldi S, Ferrara M, Mimmi S. Physical Restraint in an Italian Psychiatric Ward: Clinical Reason and Staff Organization Problems. Perspectives in Psychiatric Care 2012; 48: 95-107. [Context Link]
Appendix I: Appraisal instruments[Context Link]
Appendix II: Data extraction instruments[Context Link]
Keywords: restraint; mental health; nursing