Physical restraint use is an ongoing challenge in all healthcare settings. The use of restraints comes with strict orders and time frames as well as specific documentation requirements. These obstacles should prompt clinicians to explore alternatives to their use; however, this is not always the case. The American Nurses Association strongly supports RN participation in reducing patient restraints in healthcare settings. Restraining patients either directly or indirectly is contrary to the fundamental goals and ethical traditions of the nursing profession that uphold the autonomy and inherent dignity of each patient.1 It is critical to study physical restraint use in healthcare settings and focus on the attitudes, perceptions, and behaviors of nursing staff in relation to restraining patients. This project took place in a 21-bed medical ICU of a 700-bed acute care facility located in central Pennsylvania. The patient population included patients with ventilator-dependent respiratory failure, sepsis, gastrointestinal bleeding, acute myocardial infarction, heart failure, and complex comorbid conditions. It was conducted by a process improvement (PI) team composed of clinical nurses, critical care intensivists, and nursing leadership. The clinical nurses were representative of all shifts and various experience levels. In order to reduce physical restraint use, this project was conceived and conducted September 2014 to February 2015 and included a review of the evidence-based practice literature, a survey of clinical nurses' perceptions and attitudes, and the development of a job aid focused on implementing alternatives to physical restraints. Literature A literature search was conducted prior to the start of the trial period. Databases included the Joanna Briggs Institute, CINAHL, Nursing Reference Center, and MEDLINE. Keywords included physical restraints, critical care, nurses, and alternatives. The literature selected to guide the project had to be published within 10 years of the trial period. The review included a total of 16 quality A and B studies, three Level I, three Level II, four Level III, five Level IV, and one Level V study. The John Hopkins Nursing Evidence-Based Practice Model was used to synthesize and translate the evidence.2 This model is a problem-solving approach to clinical decision-making, and it is designed explicitly to meet the needs of the practicing nurse with a three-step process: practice question, evidence, and translation. The goal of the model is to ensure that the latest research findings and best practices are promptly identified and incorporated into patient care.2 The results of the review were as follows. Physical restraints are more likely to be used in CCUs than other hospital units because of the increased risk of tube dislodgement related to greater frequency of invasive lines and mechanical ventilation. Studies have revealed that physical restraints are not effective at preventing unplanned endotracheal extubation. Patients who are physically restrained have a higher rate of unplanned endotracheal extubation than those who are not restrained.3-5 A possible explanation for this finding is that staff apply physical restraints in response to increased agitation or lack of cooperation with treatment and/or devices; however, physical restraints may actually increase patient agitation.6 Continuing education can improve nurses' knowledge and attitudes toward physical restraint use and may enhance quality of care provided to ICU patients. In one study, the ICU nurses' attitudes toward physical restraint use changed significantly posteducational intervention, in that nurses reported more concern over patient and family feelings toward the use of physical restraints.7 In a descriptive-correlational study, where responses to a survey were solicited from all members of the American Association of Critical-Care Nurses in a weekly e-newsletter, there were no strong correlations among attitudes toward physical restraints in critical care, clinical experience, and nursing practice issues with the use of physical restraints. Nurses reported a lack of content addressing the use of physical restraints in today's nursing curricula.8 Strumpf and Evans utilized the Perceptions of Restraint Use Questionnaire (PRUQ) to measure nurse attitudes toward physical restraint use in the acute care setting.9,10 The PRUQ was designed to determine the relative importance caregivers attribute to reasons for using physical restraints for older adult patients. Results indicated that the use of physical restraints is not a benign practice, and alternatives need to be developed consistent with professional practice and quality care.9 Survey After the literature review was concluded, a modified PRUQ survey of existing staff at the authors' facility was conducted; no Institutional Review Board approval was required for this nursing practice survey. It included a detailed questionnaire regarding attitudes, perceptions, and current practices for physical restraints (see Survey tool). The survey was offered to all RNs and patient-care attendants. The survey was administered electronically and only allowed users a one-time opportunity to participate. A total of 92 staff members responded to the survey. Results were compiled and reviewed by the PI team members. Results indicated that 98% of the respondents of the survey would utilize physical restraints to prevent a patient from disrupting a medical treatment, wound contamination, and/or pulling out an I.V. catheter or central line; 57% of the respondents would utilize physical restraints to provide safety when patient judgment is impaired or the patient is agitated. A smaller portion, 14% of the respondents, said they would utilize physical restraints as a substitution for direct observation by staff. Common themes identified by respondents in the subjective feedback section included: physical restraints are utilized to maintain the safety of patients and staff, a feeling of “pressure” from peers and management to decrease or eliminate their use, the “fear” of retribution if a patient is injured, and the belief that physical restraints are necessary in some situations and cannot be avoided. Problem description The medical ICU was experiencing an incredibly high volume of episodes of restraint as well as overall restraint hours. Reports from the organization's electronic medical record as well as the National Database for Nursing Quality Indicators revealed that the unit's restraint use was higher than the national average (14.88 compared with 10.69), with a baseline data point of 1,308 hours in a single month.11 The challenge was to create a strategy to reduce physical restraint use that addressed the misperceptions that many RNs had about the efficacy of physical restraints. Based on survey results and the evidence-based practice literature review, the PI team identified a primary goal of physical restraint use reduction through changing attitudes and behaviors of RNs. The focus was on education and support for the clinical staff so they could feel confident in changing their practice. Documentation audits were conducted by the PI team to determine physical restraint need, whether alternatives were initiated prior to application, and for appropriateness of application. The audits were performed from Q2 2014 and continued throughout implementation of all of the interventions. Intervention Based on the survey results, the team focused on three primary areas: Providing staff education to increase understanding of evidence-based best practices and alternatives to physical restraint use via online slide lectures offered through the hospital's learning management system. The evidence-based practices included: – Reorient the patient as needed. – Provide a calm, reassuring environment. – Provide explanations of healthcare-related actions in advance. – Investigate for possible causes of behavior (changes in medications, electrolyte imbalances, lack of sleep, substance withdrawal). – Encourage the use of eye glasses and hearing aids while patient is awake. – Assess for pain, elimination needs, hunger, position for comfort. – Employ frequent observation (every-15-minute checks, direct 1:1 observation). – Utilize the familiar: Encourage family members and friends to sit with the patient when available. – Assess for the immediate removal of invasive lines and tubes. Promoting peer-to-peer accountability during bedside shift report and daily interdisciplinary rounds. Physical restraint reduction in the intensive care environment on a daily basis is a team effort; team collaboration is essential to minimize the use of physical restraints. Implementing a dislodgement tool developed by the PI team to track any unexpected dislodgement events, such as endotracheal extubations, line removals, or treatment interference during the project and pinpoint commonalities related to tube dislodgement (see Dislodgement tool). The tool was used for all dislodgement events during the trial period to isolate types of dislodgements, and to explore strategies for restraint reduction. Survey findings and data analysis results were communicated to staff via meetings and huddles. Subjective strategies generated by respondents from the survey were shared with the staff. The following statement is an example of a staff suggestion: “Patients are scared and unfamiliar with the environment. Therefore, having family members present and more involved in the patient care and decision making may improve the overall patient experience.” Based on this suggestion, the PI team encouraged nurses to allow family members to be present during care to provide patient support, reorientation to situation, and help prevent restraint application. Another strategy suggested in the survey results was to take the extra time and “reorient the patient, figure out why they are agitated, provide patient education, provide diversion or activity to distract, and make sure toileting occurs every 2 hours. The greatest barrier to reducing restraint use is the peace of mind restraints give staff.” In lieu of restraints, staff were encouraged to provide a calm and comforting environment, ongoing patient education and distraction, and 1:1 observation; review medications; and frequently assess hunger, pain, and elimination needs. Results Physical restraint use was monitored following implementation of the interventions. Data were collected on the number of physical restraint use episodes as well as the overall physical restraint hours. In addition, data were collected from the dislodgement tool to assist in communicating to staff that physical restraint use did not have an impact on the dislodgement of medical devices. The results following implementation showed a reduction in overall hours of physical restraint use. Baseline data showed 1,308 hours per month of physical restraint use. Following implementation, physical restraint hours trended down to less than 800 hours per month (see Project results). Summary Each instance of physical restraint use poses an inherent danger, both physically and psychologically, to the patient and to the staff who are involved in implementing physical restraints. Leaders should continually monitor performance data and trends in physical restraint use and related safety concerns. When the data indicate an opportunity for improvement, the organization should respond accordingly.12Figure: Project resultsResearch suggests that tube dislodgement occurs regardless of physical restraint use.3-6 Educational programs should focus on eliminating misperceptions related to physical restraint application and support the use of alternatives. Efforts should be embedded in an extensive physical restraint reduction approach incorporating administrative support, interdisciplinary collaboration, and staff education. Evidence supports physical restraint reduction, and with a change in nursing practice, attitudes and perceptions will improve. Nursing rounds need to include communication related to alternatives, coaching, and peer-to-peer accountability, supporting an environment of physical restraint reduction and improving optimal patient outcomes. Survey tool Section 1: Attitudes/beliefs/perceptions (Nurses were asked to score the necessity of restraint use in each of the following situations on a 1-5 point Likert-type rating scale, where 1=not at all necessary, 3=somewhat necessary, and 5=most necessary) Protecting a patient from falling out of bed Protecting a patient from getting out of a chair Preventing a patient from pulling out a catheter Preventing a patient from pulling out a tube Preventing a patient from pulling out an I.V. Preventing a patient from pulling out a central line Preventing a patient from removing a dressing Preventing a patient from contaminating a wound Preventing a patient from disrupting medical treatment Providing quiet time or rest for an overactive patient Providing safety when patient judgment is impaired As a substitution for staff observation Protecting staff or other patients from physical abusiveness/combativeness Managing agitation Section 2: Open-ended questions Please identify measures that could be used instead of physical restraints. What do you believe to be the greatest barrier to reducing the use of restraints? How would you feel about working on a unit that discourages the use of restraints? Identify several physiologic and psychological/emotional states that patients may experience while receiving care in this unit. Dislodgement tool Was the patient's mental status altered? Was the patient weaning from the ventilator? Was the patient restrained? What type of restraint was present? Was the patient high-risk for dislodgement without restraints? What time did the dislodgement happen? What was the nurse-to-patient ratio when this happened? In your own words, why do you think this happened?