Authors' objectives

To summarise the empirical evidence regarding the effectiveness of interventions or programmes to reduce physical restraint use in long-term facilities.

Searching

A computer search of online databases (i.e. CINAHL, MEDLINE, HealthSTAR, PsycINFO and Current Contents), abstracting services (i.e. Cambridge Scientific Abstracts-Health and Safety Sciences and Dissertation Abstracts International) and registries and indexes (i.e. the Cochrane Collaboration, Agency for Health Care Policy and Research, Canadian Research Index, and Government Publication Office Monthly) was conducted for the time period from January 1985 to April 1997. Keywords used to identify articles were 'physical restraint'; 'long-term care', 'residential care', and/or 'residential facility'; 'aged'; and/or 'research'. In addition, handsearches of pertinent journals (i.e. Contemporary Longterm Care, The Gerontologist, Journal of the American Geriatrics Society, and Journal of Gerontological Nursing) were conducted; reference lists of retrieved articles were reviewed; and several key informants were contacted.

Study selection

Assessment of study quality

The quality of each study was assessed using criteria in five categories:

1. Research design and method of subject allocation to study groups.

2. Sample size, representativeness of the sample and rate of attrition.

3. Control of potentially confounding variables.

4. Methods of data collection.

5. Appropriateness of statistical analyses and conclusions drawn.

Each category was rated as weak, moderate or strong. The first author rated the validity of all 32 relevant studies. The second author independently rated a subset of the studies (24/32). The level of agreement between the two reviewers was high (kappa=0.80). A consensus approach was used to determine the overall rating when discrepancies arose.

Data extraction

The authors do not state how many of the reviewers performed the data extraction. An instrument to extract data was developed, pretested and modified. Five outcome categories were identified: frequency of restraint use, physical and cognitive status of residents, knowledge and attitudes of nursing staff, knowledge and attitudes of family members and residents, and health care utilisation.

Methods of synthesis

Results of the review

Fifteen studies that met the inclusion criteria and received a moderate or strong validity rating were included. The studies included over 2891 residents, 900 nursing staff, 373 all staff, and 153 family members.

Frequency of restraint use. All but one of the studies reported the prevalence of restraint use as an outcome. Twelve studies reported a decrease in restraint use following implementation of a restraint reduction programme. Two studies found no significant change in restraint use following restraint reduction programmes.

Physical and cognitive status of residents. Ten studies examined residents' physical status. Generally, physical status was measured using behavioural symptoms, incidence of injuries and falls, or functional status. The outcomes of individual studies are discussed, without presenting a summary.

Knowledge and attitudes of nursing staff. Four studies assessed nursing staffs' knowledge about restraint use following an educational programme. Several studies noted a significant change; two studies reported more knowledge towards alternatives to restraints and in one study nursing staff identified fewer alternatives. Six studies assessed nursing staffs' attitudes concerning restraint use, morale, stress, and burnout. Three studies noted a reduction in the perceived importance of restraint use with increased exposure to educational sessions.

Knowledge and attitudes of family members and residents. One study examined residents' and family members' knowledge and attitudes about restraint use. Family members viewed the use of restraints as significantly less acceptable over time. Overall, however, family members agreed with significantly more reasons for using restraints than staff. Family members' perceptions of the benefits of restraint reduction did not change following an information session and a discussion of individual care plans.

Health care utilisation. Eight studies examined outcomes related to health care utilization, such as nursing staff patterns, hospitalization rates, cost of supplies, and chemical restraints. The outcomes of individual studies are discussed, without presenting a summary.

Cost information

None, although the authors do mention that further research is needed on the cost-effectiveness of restraint reduction programmes and the impact of restraint reduction programmes on residents' quality of life.

Authors' conclusions

Research findings indicate that physical restraint reduction programmes which included an educational component, restraint removal, and interventions individualised to residents' specific needs were successful in decreasing restraint use. There were no significant negative consequences for residents or staff associated with implementation of restraint reduction programmes or interventions. Educational programmes had a positive impact on nurses' knowledge, attitudes and practices regarding restraint use. Findings, however, must be considered in light of the methodological weaknesses noted in the studies.

CRD commentary

This is a well performed systematic review on interventions to reduce physical restraint use in long-term care settings.

The search strategy was comprehensive and there were no restrictions with respect to language. A clear validity assessment was performed on the included studies. Assessment of primary studies and validity was performed independently by two reviewers.

The only methodological shortcoming was that it is not reported how many researchers were involved in the data extraction.

The main critique to this study is the research question. The authors include a wide range of interventions, which makes the synthesis of results hard to read.

Overall the conclusions seem to follow from the results presented.

Implications of the review for practice and research

Practice: According to the authors, the practice goal of achieving least-restraint or restraint-free long-term care facilities is an appropriate and achievable one. This objective can be facilitated through ongoing mandatory educational programmes for staff, individualised assessment and implementation of appropriate interventions for residents, and adequate administrative support.

Research: According to the authors, well-designed research studies investigating the efficacy of specific interventions, cross-cultural issues and longitudinal outcomes would all contribute to the further development of evidence-based practice regarding restraint use in long-term care facilities.

Funding

Alberta Heritage Foundation for Medical Research; College of Licensed Practical Nurses of Alberta; Faculty of Nursing, University of Alberta

Bibliographic details

Godkin M D, Onyskiw J E. A systematic overview of interventions to reduce physical restraint use in long-term care settings. Online Journal of Knowledge Synthesis for Nursing 1999; 6(6) [PubMed: 12870094]

Indexing Status

Subject indexing assigned by NLM

AccessionNumber

11999005545

Database entry date

30/04/2001

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.