Nurses’ Knowledge and Performance Toward Physical Restraint at Critical Care Units

Kamil, Abbas Hamid; Ali Hattab, Wafaa Abed

doi:10.33899/mjn.2023.180102

Journals List

Nurses’ Knowledge and Performance Toward Physical Restraint at Critical Care Units

Mosul Journal of Nursing (Print ISSN: 2311-8784 Online ISSN: 2663-0311)

Article 4, Volume 11, Issue 2, July 2023, Pages 308-315 PDF (841.46 K)

Document Type: Original Articles

DOI: 10.33899/mjn.2023.180102

Authors

Abbas Hamid Kamil¹; Wafaa Abed Ali Hattab²

¹Ministry of Health, Diyala Health Directorate, Iraq

²Department of adult nursing, College of Nursing, University of Baghdad, City of Baghdad, Iraq

Abstract

To preserve the patients' equipment and therapy, such as endotracheal tubes, central lines, and arterial lines, nurses in critical illness settings typically use physical restraints. Due to changes in their level of awareness while a patient in a critical care unit, a high percent of critically ill patients admitted to various types of critical care units may require the use of physical restraints. The nursing care offered to constrained patients and the prevention of its problems depend heavily on the knowledge and practice of nurses about physical restraints. The study was done to evaluate nurses’ knowledge and practices toward physical restraint at critical care unit and to identify the relationships between demographic characteristic and nurses’ knowledge and practices toward physical restraint at critical care unit. Fifty nurses, who were selected by a non-probability (convenient) sampling method, participated in this descriptive study. The instrument of the study was knowledge parts of the questionnaire were initially developed by Janelli et al., (1991) in the U.S.A for nursing homes; in 2006 they were adopted for all hospital units by the original developers (Janelli et al., 2006). The knowledge section of the questionnaire consisted of 20 items, which were used to measure knowledge of nurses towards the definition, indications and contraindications, proper application and legal and ethical considerations of physical restraint use. A three- point ordinal scale (Agree, Uncertain and Disagree) was applied to determine nurses’ responses to the items; it contained negative and positive sentences. Positive items, if answered with “agree,” were considered correct; if answered with “disagree,” items were considered incorrect. To evaluate the nurse's practices with respect to physical restraint, the researcher observes and checks for correct or incorrect performance. The practices checklist for nurses is composed of (94) items divided into six content domains. The result of this research showed that 90% of nurses had low knowledge about physical restraint, and 80 % of the participants had unsatisfactory performance. The study recommended Development of local policies for physical restraint use including detailed descriptions of conditions requiring its use is mandatory.

Keywords

Knowledge; Performance; Physical Restraint; Critical Care Units

Full Text

Nurses’ Knowledge and Performance Toward Physical Restraint at Critical Care Units

Abbas Hamid Kamil ¹, Wafaa Abed Ali Hattab ² *

Ministry of Health, Diyala Health Directorate, Iraq;
Department of adult nursing, College of Nursing, University of Baghdad, City of Baghdad, Iraq.

Corresponding author: Abbas Hamid Kamil

Email: abbasnurse1992@gmail.com

ORCID

ABSTRACT

Keywords: Knowledge, Performance, Physical Restraint, Critical Care Units

INTRODUCTION

The definition of physical restraint (PR) is any action or practices that prohibit a person's free bodily mobility to a position of choice and/or normal access to his or her body by the use of any means, attached or adjacent to a person's body that he or she cannot control or remove easily. (Bleijlevens et al., 2016).

The physical constraint is now often used in clinical settings both domestically and internationally, particularly in critical care units. Patients frequently feel anxious and restless due to the unfamiliar treatment environment, the suffering of the disease, and the particular nature of the treatment; as a result, they may unintentionally remove some vital tubes for life support, such as the tracheal intubation, a central venous catheter (CVC), and other various drainage tubes (Gu et al., 2019).

Kaya and Dogu (2018) stated these behaviors not only result in bodily harm to the patient but also present numerous dangers and treatment difficulties. Therefore, nurses in critical care units frequently restrain patients physically during nursing procedures to temporarily restrict their activities in order to maintain patient safety and the efficient delivery of care, making this practice more prevalent than it is in general hospital departments.

Applying physical restriction to critically sick patients is a difficult choice that is influenced by the patient's personality, the practitioner, and the surrounding circumstances. Numerous restraints, including wrist restraints, mitts, elbow immobilizers, belts, vests, leg restraints, and bedside rails, can be used. (Pan et al., 2018)

Eskandari et al. (2018) reported the major purpose of physical and chemical restraint is to keep the patient safe when their level of consciousness changes, although chemical restraint comes with a risk of sedation. Accordingly, the use of physical restraint is practiced in a critical care setting to stop confused patients from interfering with the delivery of nursing care.

A study was conducted that revealed 75% of ICU patients were placed in restraints during their ICU stay for a median duration of 3 days. Even in the presence of opioid use, when ventilated, a patient’s chances of ending up physically restrained were increased by eight times (Hamilton et al., 2017). While nurses continue to cite prevention of extubation as a reason to apply physical restraints, patients who are physically restrained experience an increased incidence of self-extubating of endotracheal tubes (Hall et al., 2018).

METHOD

AIMS OF THE STUDY

The study aims to

Evaluate nurses’ knowledge, and performance toward physical restraint.

The Study Design: A quantitative (descriptive design) study design was used in this research to accomplish the objectives of the study.

Study Setting: The research was carried out by nurses working in critical care units in Baqubah Teaching Hospital.

Study Sample: The sampling of this study is a nonprobability (convenient) sampling method. The minimum sample size is 50 according to the population of 62 nursing staff and 95% level of confidence with a margin of error of 5

Instrumentation: To evaluate nurses’ knowledge and performance toward physical restraint in critical care units, this tool was developed by the researcher. Two tools were utilized to collect data in this study includes:

Part One: Demographic and professional characteristics this portion is with the collection of basic socio- concerned demographic data gained from the nurses from interview questionnaire sheet such as (age, gender, nurses' qualification, years of experience in the nursing, years of experience at the critical care units).

Part two: It includes questions to assess nurse’s basic knowledge regarding physical restraining. The knowledge parts of the questionnaire were initially developed by Janelli et al., (1991) in the U.S.A for nursing homes; in 2006 they were adopted for all hospital units by the original developers (Janelli et al., 2006). The knowledge section of the questionnaire consisted of 20 items, which were used to measure knowledge of nurses towards the definition, indications and contraindications, proper application and legal and ethical considerations of physical restraint use. A three- point ordinal scale (Agree, Uncertain and Disagree) was applied to determine nurses’ responses to the items; it contained negative and positive sentences. Positive items, if answered with “agree,” were considered correct; if answered with “disagree,” items were considered incorrect.

Part three: performance checklist to evaluate the nurse's practices with respect to physical restraint, the researcher observes and checks for correct or incorrect performance. The practices checklist for nurses is composed of (82) items divided into six content domains.

First domain: (19) items related to Environmental Modifications and Alternatives Before Physical Restraint

Second domain: (3) items related to Monitor Altered Level of Consciousness and Delirium.

Third domain: (48) items related to Restraint Phase.

Fourth domain: (10) items related to Prevent Complication of Physical Restraint.

Fifth domain: (4) items related to After Restraint

Validity of the Study: Validity of tools was done by a group of experts to check the relevancy, clarity, comprehensiveness, and applicability of the questions.

Pilot study and reliability of questionnaire: The pilot study aimed to determine the suitability of the language of the questionnaire and whether it was understandable for participants and to test the reliability (test re-test reliability and internal consistency) of the knowledge and performance questionnaire.

Rating and Scoring: The responses for knowledge questions are scored and rated on three levels dichotomous scale; (2) points for correct choice, (1) point for uncertain choice and (0) incorrect choice. The response performance checklist (2) points for done correctly and completely, (1) points for done correctly but incompletely and (0) not done or done incorrectly.

Data Analysis: The data of the present study is analyzed through using the Statistical Package of Social Sciences (SPSS), version (23). The researchers used descriptive and inferential data analysis to analyze the results.

Implication of the study

One of the values of this study is the adoption and validation of the knowledge and performance of nurses towards physical restraint (KAIP) questionnaire in Iraq. Thus, it is appropriate for application by educators, administrators, policymakers, and researchers to improve the quality of care provided to patients who may need to be restrained. Based on the level of knowledge and performance of nurses, a program to minimize physical restraint can be appropriately planned, implemented, and evaluated.

RESULTS

The findings in Table 1 presented the distribution of the study sample according to their demographic characteristics. Results in this table revealed that (28.22 years) mean age of study sample. Males were constituted the higher percentage (68%) of the study sample, and the remaining were females. Nurses' qualification among nurses presented (68%) were Bachelor, followed by (20%) of them Diploma, and only (12%) of them were prepared. Years of experience in the nursing showed (60 %) of them were working through the range of years less than 5 years in the hospital, also 40 % of nurses have more than 5 years of experience. The study presented that 70% of nurses have less than 5 years’ experience at critical care units and 30% have more than 5 years’ experience.

Table (2) Show that most of nurse’s had low level of knowledge toward physical restraint in most answers for 20 questions regarding.

Table (3) Show that most of nurse’s had unsatisfactory performance toward physical restraint in all domain.

Table 1. Participants’ sociodemographic characteristics (N = 50)

Characteristics	Frequency	Percent
Age M±SD= 28. 22±6. 10 Total	50	100
Gender
Male	34	68
Female	16	32
Total	50	100
Nurses' Qualification
Preparatory	6	12
Diploma	10	20
Bachelor	34	68
Total	50	100
Years of Experience in The Nursing
Less Than 5 Years of Experience	30	60
More Than 5 Years of Experience	20	40
Total	50	100
Years of Experience at Critical Care Units
Less Than 5 Years of Experience	35	70
More Than 5 Years of Experience	15	30
Total	50	100

Table 2. Nurses' Knowledge Toward Physical Restraint

No.	Items	Mean	SD	Ass
1	Physical restraint is a vest or safety attire used to prevent injuries.	1.5	0.6	L
2	Physical restraint is only allowed if it is required to protect patients or other people from injuries.	1.60	0.7	L
3	Physical restraint must be used when a nurse is not capable of supervising a patient intensively.	2.13	0.9	M
4	The use of physical restraint is the first option to prevent self-removal of endotracheal tube (F)	1.77	0.6	M
5	Patients have right to refuse to be restrained.	1.50	0.6	L
6	Families can refuse to allow the use of physical restraint (T)	1.37	0.6	L
7	Confusions or disorientation are good reasons for the use of physical restraint.	1.63	0.8	L
8	Physical restraint requires a medical prescription (T)	1.77	0.6	M
9	Hyperactive delirium is the main reason for the use of physical restraint (F)	1.57	0.7	L
10	The occurrence of complications associated with physical restraint should be assessed every 6h (F)	1.37	0.6	L
11	The use of physical restraint is associated with the development of post-traumatic stress after discharge (T)	1.37	0.6	L
12	The need to remove physical restraint must be assessed every 8h (T)	1.50	0.7	L
13	Patients are not to be restrained while lying down facing up on the bed for fear of spluttering choking.	1.60	0.7	L
14	There have been deaths related to the use of vest physical restraint.	1.37	0.6	L
15	Restraints should be put on snugly so that there is no space between the restraint and patient’s skin	1.37	0.6	L
16	A patient should never be restrained while lying flat in bed because of the danger of choking	1.5	0.6	L
17	When a patient is restrained, skin can break up or restlessness can increase	2.0	0.7	M
18	When a patient is restrained in bed, the restraint should not be attached to the side rails	1.37	0.6	L
19	A record should be kept on every shift of patients in restraints	1.5	0.6	L
20	In an emergency, a nurse can legally restrain a patient without a physician’s order	2.13	0.7	M

(M.s) mean of score, (SD) stander deviation Ass. = Assessment; H. = High (2.34 – 3.0); M. = Moderate (1.67 – 2.33); L. = Low (1 – 1.66)

Table3. Nurses Performance Related to Physical Restraint

Performance Related to	Weighted	Freq.	%	Ms. ± SD
Promoting Rest and Sleep for the Critically Ill Patient	Unsatisfactory	28	56	1.02± 0.069
	Need Improvement	16	32
	Satisfactory	6	12
	Total	50	100
Monitor Altered Level of Consciousness and Delirium	Unsatisfactory	39	88.0	1.2 ± 0.3.3
	Need Improvement	11	12.0
	Satisfactory	0	0.0
	Total	50	100
Environmental Modifications Before Physical Restraint by nurses	Unsatisfactory	41	82	1.10± 305
	Need Improvement	8	16
	Satisfactory	1	2
	Total	50	100
Restraint Phase	Unsatisfactory	46	92	1.06± 0.254
	Need Improvement	4	8
	Satisfactory	0	0
	Tota1	50	100
Assess and Prevent Complication of Physical Restraint	Unsatisfactory	37	74	1.23± 0.430
	Need Improvement	11	22
	Satisfactory	2	4
	Tota1	50	100
Termination Restraint Phase	Unsatisfactory	44	88	1.13± 0.346
	Need Improvement	6	12
	Satisfactory	0	0
	Tota1	50	100

DISCUSSION

The finding of data analysis that were shown in Table 1 Distribution of the Sample according to demographic characteristics presented the distribution of the study sample revealed mean age 28.22 years old. This finding was consistent with a study Fawzy Zaki et al. (2021) conducted to evaluate the effectiveness of an educational program on critical care nurses` performance and patients’ outcomes regarding physical restraints in Intensive Care Unit in Benha University Hospital which found that the majority of the study population was mean the ages of 28.89 years. According to the researcher opinion, the presence of a large proportion of nurses whose age is less than 30 years as a result of the hospital administration’s endeavour to provide a young group capable of bearing the pressures and workloads in critical care units. Another reason is the large number of appointments that occurred on the staff of the Ministry of Health according to conversation that has took place between the researcher and the health care providers in the hospital.

In the current study, male nurses were 68 percent of the participants, with 32 females accounting for the remaining participants. in contrast to a study in Guilan University of Medical Sciences by Gheidari et al. (2019) to determine the knowledge, attitude and performance of nurses in intensive care units regarding the application of physical restraint of patients and their related factors, all 179 (92.7% %) nurses were female. According to the researcher opinion , the advent of the percentage of males more than females is due to several reasons, including that working in critical care units requires high endurance and courageous, females’ shying away from nursing work and going to administrative work, as well as the influence of society and some societal traditions, even though the education system in Iraq gives a larger percentage to women for admission to nursing study and direct appointment after the end of the academic study.

The nurses’ qualifications among nursers in this research were bachelor (68%), followed by 20% of them diploma, (12%) of them were Preparatory and only (0 %) postgraduate certifiable. Awad (2019) this study was conducted in the three ICUs affiliated to Mansoura Emergency Hospital to evaluate the effect of a designed physical restraint protocol on critical care nurses' knowledge and practices. The result of the study was the majority of nurses (51.7) holding a bachelor degree.

Also result this research about years of experience in nursing among nurses showed 60% were less than 5 years of experience and 40 % of them were more than 5 years of experience. Similarly, a study conducted by AL-gabri et al. (2015) to assess nurses' knowledge and performance about physical restraints in critical ill patients found as a result, overall, the survey group had a median career experience less than 5 years in their current job.

Another research conducted in Jordan by Nasrate al. (2020) to evaluate the impact of a training program on nurses’ knowledge, attitude and H. practice regarding PR use in ICUs found that 31 (77.5%) of nurses had less than 5 years of experience, while 9 (22.5%) had more than 5 years. According to the researcher’s interpretation, the more the years of experience, nurses is more knowledgeable about the physical restraint, complications, its impact, and ways to reduce it.

Years of experiences at critical care units in this study showed the distribution of among nurses the finding revealed that more than half 70% had less than 5 years and other 30% had more than 5 years. This finding similar to study conducted in conducted at Intensive Care Unit in Benha University Hospital by Fawzy Zaki et al. (2021) reported that from 36 samples (60.0%) were had 1-5 years experiences and (40.0%) were had more than 5 years at critical care units.

Table 2 showed that low level of knowledge in most items scale about physical restraints at pre-test except items (3,4,8,17,20) moderate level of knowledge. The results of this research reflected the results of a research conducted by Taha NM and Ali ZH (2013), in view of the foregoing, it was quite expected to find very low levels of knowledge among the nurses in the present study before implementation of the guidelines. This was noticed in all the tested areas of knowledge. This lack of knowledge would have a negative impact on the nursing care provided to these patients. Additionally, it might lead to complications among the patients that may lead to legal problems to the nurse providing the care. The significant improvements demonstrated at the post-guidelines phase indicate that these nurses were in real need for such information.

Table 3 shows that high percentage of nurses at critical care unit had unsatisfactory performance related to promoting rest and sleep for the critically ill patient, monitor altered level of consciousness and delirium, environmental modifications before physical restraint by nurses, restraint phase, assess and prevent complication of physical restraint & termination restraint phase at the pre-test period of measurement before application of instructional program. Younis & Sayed Ahmed, (2017), also added that, their study results demonstrated that the nurses' total mean practice score were unsatisfactory and inadequate before applying clinical guidelines. And explained that, such low standard of performance in physical restraints practice, is due to some factors such as; no physician’s order that the nurse can follow, lack of cooperation between nurse and physician or lack of physicians’ knowledge regarding their role in participating in the decision of restraining a patient.

CONCLUSIONS

The study concluded that the nurse's knowledge toward physical restraint in critical care units is low. This study shows unsatsfactory nurses performance toward physical restraint, also no statistical association between the nurses' knowledge and their socio-demographic characteristics.

Administrative Arrangements and Ethical Consideration: The Institutional Review Board (IRB) at University of Baghdad, college of nursing approved the study to be conducted. The Medical Surgical Nursing Science Committee first reviewed and accepted the study protocol. The researcher received the consent of the Health Care Professionals representatives through the informed consent. In addition to review the study specifics with them after obtaining College of Nursing approval for the study. The researcher explained the study's overall purpose and how to complete the questionnaire to the study participants. The researcher told participants that their data would be kept private and safe during and after their participation in the analysis. The researcher also told study participants that their names will be kept anonymous in the study's introduction, publishing, and/or subsequent publication.

FUNDING
This research did not receive any grant from

funding agencies in the public, commercial, or

non-profit sectors.

AUTHOR’S CONTRIBUTIONS

Study concept, Writing, Reviewing the final

edition by all authors.

DISCLOSURE STATEMENT:

The authors report no conflict of interest.

ACKNOWLEDGEMENTS

We thank the anonymous referees for their useful suggestions.

REFERENCES

AL-gabri, M. M., Mohammed, O. A., Mehany, M. M., & Mohammed, M. A. (2015). Nurses' Knowledge And Performance About Physical Restraints For Critical Ill Patients. Assiut Scientific Nursing Journal, 3(5), 207-217.‏

https://doi.org/10.21608/asnj.2015.59027

Awad, S. A. (2019). The effect of Designed Protocol about Physical Restraint on Critical Care Nurses' Performance.‏ International Journal of Novel Research in Healthcare and Nursing Vol. 6, Issue 2, pp: (1324-1330)

Bleijlevens, M.H., Wagner, L.M., Capezuti, E., Hamers, J.P., 2016. Physical restraints: consensus of a research definition using a modified Delphi technique. J. Am. Geriatr. Soc. 64, 2307-2310.

https://doi.org/10.1111/jgs.14435

Eskandari, F., Abdullah, K. L., Zainal, N. Z., & Wong, L. P. (2018). The effect of educational intervention on nurses' knowledge, attitude, intention, practice and incidence rate of physical restraint use. Nurse education in practice, 32, 52-57.‏

https://doi.org/10.1016/j.nepr.2018.07.007

Fawzy Zaki, A., Said Taha, A., & El Sayed Ghonaem, S. (2021). Effectiveness of An Educational program on Critical Care NursesPerformance and Patients Outcomes Regarding Physical Restraint. Journal of Nursing Science Benha University, 2(2), 370-383.‏

https://doi.org/10.21608/jnsbu.2021.186502

Gheidari, Z., Adib, M., Mohamadii, T. K., & Kazemnejad, E. (2019). Knowledge, attitude and performance of nurses in intensive care units in the field of patients' physical restraint use and their related factors. Journal of Advanced Pharmacy Education & Research| Apr-Jun 9(S2).‏

Gu, T., Wang, X., Deng, N., & Weng, W. (2019). Investigating influencing factors of physical restraint use in China intensive care units: a prospective, cross-sectional, observational study. Australian critical care, 32(3), 193-198.‏

https://doi.org/10.1016/j.aucc.2018.05.002

Hall, D. K., Zimbro, K. S., Maduro, R. S., Petrovitch, D., Ver Schneider, P., & Morgan, M. (2018). Impact of a restraint management bundle on restraint use in an intensive care unit. Journal of Nursing Care Quality, 33(2), 143-148.

https://doi.org/10.1097/NCQ.0000000000000273

Hamilton, D., Griesdale, D., & Mion, L. C. (2017). The prevalence and incidence of restraint use in a Canadian adult intensive care unit: A prospective cohort study. Canadian Journal of Critical Care Nursing, 28(3), 25-33.

Kaya, H., & Dogu, O. (2018). Intensive care unit nurses' knowledge, attitudes and practices related to using physical restraints. International Journal of Caring Sciences, 11(1), 61-70.‏

Nasrate, H., Shamlawi, A., & Darawad, M. W. (2017). Improving ICU nurses' practices of physical restraints in Jordan: Effect of an educational program. Health, 9(12), 1632.‏

https://doi.org/10.4236/health.2017.912120

Taha NM, Ali ZH (2013) Physical Restraints in Critical Care Units: Impact of a Training Program on Nurses' Knowledge and Practice and on Patients' Outcomes. J Nurs Care 2: 135.

https://doi.org/10.4172/2167-1168.1000135

Pan, Y., Jiang, Z., Yuan, C., Wang, L., Zhang, J., Zhou, J., ... & Wu, Q. (2018). Influence of physical restraint on delirium of adult patients in ICU: A nested case-control study. Journal of clinical nursing, 27(9-10), 1950-1957.‏

https://doi.org/10.1111/jocn.14334

Younis,G.,A& Sayed Ahmed,S.,E(2017). Physical Restraint and Maintenance of critically ill patient's safety in Intensive Care Unit: Effect of Clinical practice guidelines on nurse's practice and attitude. IOSR Journal of Nursing and Health Science: Volume 6, Issue 4 Ver , PP 06-21.

References