Due to the continued concern regarding the safety of both patients and staff in hospitals and long term facilities, the use of restraints continues to be part of common clinical practice; however their use remains controversial. Following an ABI the incidence and prevalence of agitation or aggressive behaviours ranges from 10% to 96%. Studies have found as many as 13%-32% of survivors may be restrained while undergoing care in either an acute or rehabilitative hospital (Gregory & Bonfiglio 1995; McNett et al. 2012; Morrison et al. 1987; Stubbs & Alderman 2008). Due to the broad definition of agitation, the reported numbers of agitated patients may be misleading; consequently, questions are being raised about how many individuals actually need to be restrained (Eisenberg et al. 2009).
The term “restraint” includes the use of either chemical (medications) or physical (mechanical) restraints or a combination of both (Marks 1992). Chemical restraints used to assist in controlling behaviours that occur during agitated states include many pharmaceutical agents with primary or secondary psychotropic effects, including: beta blockers, anti-depressants, psychostimulants, anti-Parkinson’s agents and anticonvulsants (Gregory & Bonfiglio 1995; McNett et al. 2012). Medication treatments used in non-emergent situations to reduce the need for physical restraints include propranolol, atypical neuroleptics and valproic acid (Busch & Shore 2000). Physical restraints have been defined as any manual method that immobilizes or reduces the ability of individuals to move their arms, legs, body, or head freely (Busch & Shore 2000; Stevens 2012). Typically they are not meant to be a part of the standard practice of care (Amato et al. 2006). Physical restraints include the use of bed rails, feeding trays, mittens (tying of hands), chest straps (seat belts), ankle and wrist restraints, and jacket restraints (Busch & Shore 2000; Gregory & Bonfiglio 1995; Marks 1992; Morrison et al. 1987).
Policies related to the application of restraints often state that the use of restraints should meet the following criteria: (1) be individualized and offer as much dignity to the individual as the situation allows; (2) be humanely and professionally administered; (3) have safety protocols in place; (4) patient must be monitored; (5) careful documentation of the type of restraint, the reason for it, and the means for observation while in the restraint; (6) the method or choice of restraint must be the least restrictive option available (American Nurses Association 2012; College of Nurses of Ontario 2009; Ministry of Health and Long Term Care for the Province of Ontario 2001; St. Joseph’s Health Care 2012). In accordance with the province’s legislation, the College of Nurses for Ontario suggests that the following information is to be recorded when using restraints: significant patient behaviours, alternative considered and used, date and time of application, reason given to patient, type used, reason for choice and patient’s response.
The decision to use restraints whether mechanical or chemical is generally made by physicians or nurses on the unit. In a recent survey, hospital physicians were asked to review a series of vignettes and to comment on the likelihood of ordering restraints (Sandhu et al. 2010). Those most likely to order restraints were family physicians and surgeons while geriatricians were least likely. Further, male doctors were more likely to order restraints than female doctors and they were more likely to order them for male patients. The use of restraints must be accompanied by a consent form signed by the family or caregiver indicating they are in agreement; in emergency situations, this form may not be required. Whether or not individuals were restrained, a study by Schleenbaker and colleagues (1994) found restraint orders, written as “restrain as needed”, were in that charts of more than 75% of individuals admitted for rehabilitation. Of those who were admitted for a TBI approximately 90% had restraint orders appearing on their chart.
Despite guidelines and policies around restraint use, the literature suggests that there is need for improvement around the documentation and use of restraints in clinical practice. In a retrospective audit conducted in a Canadian hospital, Kow and Hogan (2000) found either chemical or physical restraints were used in 11.5% of patients. Of concern, despite hospital policy, “orders” approving the use of restraints were missing from some charts and the nursing documentation pertaining to the use of restraints was often vague and questionable. The lack of documentation or an “order” to use a restraint has been echoed by others in the literature (Macpherson et al. 1990; McNett et al. 2012; Minnick et al. 2007; Mion et al. 1996; Morrison et al. 1987; Schleenbaker et al. 1994), with one study noting nursing and physicians found getting a physician’s order and properly documenting were not always necessary (Mion et al. 1996).
Reasons Cited for their Use
A great deal of research has been conducted looking at the use of physical restraints in nursing homes or in acute care hospitals (Evans & FitzGerald 2002; Ludwick et al. 2008). Nursing literature indicates that the use of restraints is influenced by the values, education, and beliefs of the nurses themselves, as well as the behaviours and demographic characteristics of the patients (Ludwick et al. 2008). Results from a recent study indicate impulsiveness, pulling at devices or removing endotracheal tubes, central venous lines and other life support measures, and decreased attention span are often cited as reasons for the use of a restraint (McNett et al. 2012). Additional reasons were controlling agitation or acts of aggression, behaviour control related to altered mental status and confusion, prevention of wandering, patient safety related to impaired mobility, supporting patient's posture or sitting balance and preventing disruption of therapy (Evans & FitzGerald 2002; Minnick et al. 2007; Sandhu et al. 2010). Finally, many care professionals indicate the use of restraints prevents the individual from falling and further injuring themselves (Kow & Hogan 2000; Minnick et al. 2007; Mion et al. 1996; Sandhu et al. 2010; Schleenbaker et al. 1994; Suen et al. 2006) and protects the safety of family and staff (Kow & Hogan 2000; Mion et al. 1996). Despite the use of restraints to prevent falls there is no evidence to suggest this procedure is effective; on the contrary there is some evidence to suggest it puts patients at a greater risk of injury (Busch & Shore 2000; Evans & FitzGerald 2002; Mion et al. 1996; Sandhu et al. 2010). Unfortunately, despite there being many legitimate reasons for using restraints, some reasons are not justified; one study found over 70% of nurses felt restraints enabled them to spend less time on nursing care (Suen et al. 2006). Alternative strategies to restraint use (e.g. manipulating the environment, supervision, companionship, reviewing prescribed medications) were not known to many nurses (Suen et al. 2006).
Patients in physical restraints have been found to have higher rates of clinical agitation, as did patients who require constant supervision (McNett et al. 2012; Minnick et al. 2007; Morrison et al. 1987; Visscher et al. 2011). A higher level of aggression was also related to an increase length of stay, lower Functional Independence Measure scores and Mini Mental State Examination (Visscher et al. 2011). Recently McNett et al. (2012) noted reorientation, redirection, constant supervision, the administration of benzodiazepines, restraints, and/or modifying the patient’s environment as common ways to manage agitation post TBI. Visscher and colleagues (2011) found 42% of the study population, which included patients with ABI, had engaged in one or more aggressive acts prior to the patients being restrained; three or more aggressive acts were dealt with daily. Using the Staff Observation Aggression Scale-Revised, 67% of the aggressive incidents were judged to be mild in severity and 33% were severe. Often these incidences were triggered by asking the individual to engage in an activity or take medications, or the individual required help with his or her activities of daily living (Visscher et al. 2011).
Effectiveness of physical restraints
Many hospitals use physical restraints to ensure the safety of patients, staff and family members. No clinical evidence supports their use with individuals who have sustained an ABI (Marks 1992). The use of restraints is considered acceptable if the restraint is used to ensure the patient’s safety, if less restrictive interventions have been ineffective in preventing harm to the patient or others, the restraint is implemented safely, and appropriate techniques are used as determined by hospital or organizational policy (Recupero et al. 2011). The risk of harm to the patient must be taken into consideration when using physical restraints, thus all restraints must be discontinued at the earliest possible time, and patients must be monitored to ensure their safety (Busch & Shore 2000). Currently there is not enough data available to determine the efficacy of using physical restraints to reduce agitated or aggressive behaviour post ABI (Duxbury & Wright 2011).
Despite their use, there is no evidence to support the use of restraints in those who have sustained an acquired brain injury/traumatic brain injury.
Reducing the Use of Physical Restraints (PR)
In many facilities the number one reason cited for the use of physical restraints is the prevention of falls. Several studies have looked at a variety of education programs aimed at staff to reduce the use of physical restraints; however no studies were found that investigated the effectiveness of these programs on an ABI/TBI unit.
Three studies investigating the effectiveness of education programs designed to reduce the use of physical restraints on individuals in nursing homes were examined. All three programs were education based (Gulpers et al. 2011; Huizing et al. 2009; Rask et al. 2007); however, two studies included more substantial changes. Rask et al. (2007) included staff buy-in and the creation of a falls coordinator to increase accountability. Gulpers et al. (2011) make reference to policy changes. Although Huizing et al. (2009) did not find education alone was effective in reducing the use of restraints, the two studies that included multiple components in their interventions and took a more active approach had more favourable outcomes (Gulpers et al. 2011; Rask et al. 2007).
Staff education programs to reduce the use of physical restraints, without increasing the risk of falls, have been shown to be somewhat successful with staff in nursing homes. Further research needs to be completed looking at the impact these education programs would have on those staff working in rehabilitation hospitals.
Restraint policies are often prefaced with the hospital’s philosophy regarding the use of restraints. They have been defined as an unusual and temporary measure, either physical or pharmacological, to limit the activity or control the behaviour of an individual. In the earlier study conducted by Mion and colleagues (1996) they state “reducing the use of physical restraints is a challenge” and almost twenty years later despite current hospital policies and the risk of patient injury it continues to be a challenge. It appears as though the clinicians’ perceptions of the benefits of physical restraints is without any empirical data to support the purported benefit (Mion et al. 1996). The use of restraints to meet the needs of staff striving to maintain order, routines and rules is no longer considered acceptable.