Mechanical restraint in acute health: identifying staff perceptions, alternatives and the sustainability of restraint reduction initiatives

© 2010 Catherine Elizabeth DanielAim: This research aimed to measure the impact of mechanical restraint reduction strategies in one acute hospital. Background: Restraint is used to prevent falls, treatment interference and to manage agitation. However, there is no evidence to support its use. A previous restraint policy was implemented at the study site in 2005 however there was no evaluation of practice and staff had limited awareness of the risks to patients who were restrained. Setting: The Royal Melbourne Hospital is an inner city 330 bed acute tertiary referral hospital including trauma, neurosciences and emergency services. Method: An action research approach was used to minimise the use of mechanical restraint and to improve the care provided to patients when mechanical restraint was used. The intervention phase included consultation with staff and implementing a structured education session to highlight the risks associated with restraint use, policy requirements to minimise the use of restraint and maintaining patient safety when restraint is used. Resources were developed to promote minimising restraint use including a poster of alternatives to restraint and a flowchart of policy requirements. Mechanical restraint use was measured by auditing at three time points to determine if changes in practice were sustainable. The use of bed rails was recorded when they had been raised in the previous 24 hours. The use of ankle/wrist restraint was included if it was used during the admission until the day of the audit. Staff completed a cross sectional survey (Perception of Restraint Use (PRUQ), Evans & Strumpf, 1990) before (n=248) and after (n=213) education to determine how important staff considered restraint was in managing different clinical situations such as falls, agitation and treatment interference. The convenience sample consisted of staff working in acute wards and included nursing, medical and allied health professionals. Results: The use of bed rails reduced from 58% (195/338) at baseline (T1) to 48% (159/329) post intervention (T2). A final audit conducted 9 months later (T3) found the use of bed rails had further reduced to 30.6% (102/333). There was a 60% (n=66) reduction in staff reporting falls prevention as the rationale for bed rail use. The use of ankle and wrist restraint was not reduced by restraint reduction initiatives. Ankle and wrist restraint was used for 2.6% (12/338) of patients at T1 and increased at T2 to 5.7% (19/329). A final audit (T3) found a reduction to 2.7% (9/333). Documentation was improved from the baseline audit when the restraint duration could not be determined due to restraint charts not being completed and limited nursing entries to indicate when restraints were applied and removed. The PRUQ (Evans & Strumpf, 1990) was completed by 248 staff before and 213 staff after the intervention phase. The baseline questionnaire was completed by 26% (n=191) of nurses in clinical roles and 24% (n=183) post intervention. The PRUQ identified a significant change in 2 items; that restraint was considered less important to prevent patients pulling out intravenous lines (p= 0.043) however, staff considered restraint more important as a substitute for staff observation (p= 0.036). Although staff considered restraint less important in 13 items they found restraint more important to manage falls, unsafe ambulation and provide rest for an overactive person. The qualitative comments provided by participants on the PRUQ represented a wide range of views. In particular, comments highlighted the complex nature of restraint reduction strategies. Responses included support for restraint minimisation strategies and also the challenges of providing increased observation while patients were restrained and nursing workload. Discussion: The use of mechanical restraint at the study site was reduced. The study demonstrated that the safety of patients who do require restraint can be improved through the use of policy, education initiatives and considering alternatives to restraint. Restraint minimisation in acute health depends on an individualised approach to patient care including the use of an evidence-based approach to preventing delirium and managing behavioural and psychological symptoms of dementia. The suitability of initiatives must to be considered to support long-term changes in practice