Attitudes of nurses towards the use of physical restraints in geriatric care: A systematic review of qualitative and quantitative studies

Abstract

Objectives

To examine nurses’ attitudes towards the use of physical restraints in geriatric care.

Design

Systematic review and synthesis of qualitative and quantitative studies.

Data sources

The following databases were searched: Medline, CINAHL, EMBASE, Psyndex, PsychInfo, Social SciSearch, SciSearch, Forum Qualitative Social Research (1/1990 to 8/2013). We performed backward and forward citation tracking to all of the included studies.

Review methods

We included in the present review all qualitative and quantitative studies in English and German that investigated nurses’ attitudes towards the use of physical restraints in geriatric care. Two independent reviewers selected the studies for inclusion and assessed the study quality. We performed a thematic synthesis for the qualitative studies and a content analysis of the questionnaires’ items as well as a narrative synthesis for the quantitative surveys.

Results

We included 31 publications in the review: 20 quantitative surveys, 10 qualitative and 1 mixed-method study. In the qualitative studies, nurses’ attitudes towards the use of physical restraints in geriatric care were predominately characterised by negative feelings towards the use of restraints; however, the nurses also described a perceived need for using restraints in clinical practice. This discrepancy led to moral conflicts, and nurses described several strategies for coping with these conflicts when restraints were used. When nurses were in doubt regarding the use of restraints, they decided predominantly in favour of using restraints. The results of the quantitative surveys were inconsistent regarding nurses’ feelings towards the use of restraints in geriatric care. Prevention of falls was identified as a primary reason for using restraints. However, the items of the questionnaires focussed primarily on the reasons for the use of restraints rather than on the attitudes of nurses.

Conclusions

Despite the lack of evidence regarding the benefits of restraints and the evidence on the adverse effects, nurses often decided in favour of using restraints when in doubt and they used strategies to cope with negative feelings when they used restraints. A clear policy change in geriatric care institutions towards restraint-free care seems to be warranted to change clinical practice. The results of this review should also be considered in the development of interventions aimed at reducing the use of restraints.

Introduction

Physical restraints are commonly used in geriatric care in many countries (De Vries et al., 2004, Feng et al., 2009, Meyer et al., 2009). Studies have revealed pronounced centre variation in the prevalence of physical restraints use, which could not be explained by the case-mix or organisational characteristics, e.g., staffing levels (Feng et al., 2009, Minnick et al., 2007, Meyer et al., 2009). Other factors, such as the “philosophy of care” in the facilities or the nurses’ attitudes and beliefs towards the use of physical restraints, are likely to be powerful determinants of physical restraints use in geriatric care (Hamers and Huizing, 2005, Meyer et al., 2009). A change in the “philosophy of care” was called for to improve nursing practice and to reduce the use of physical restraints (Flaherty, 2004).

Several educational interventions have been evaluated in different countries, which aimed to reduce the use of physical restraints in geriatric long-term care (Gulpers et al., 2011; Köpke et al., 2012; Möhler et al., 2012). These interventions were designed to change nursing practice and reduce the use of physical restraints by addressing nurses’ knowledge and attitudes towards physical restraints use. The results of these trials were inconsistent; several small trials showed a reduction of physical restraints use, whereas others with a lower risk of bias showed little or no effect (Möhler et al., 2012). Our recently published study, which investigated a guideline-based intervention programme, found that the intervention reduced the use of physical restraints effectively and safely in nursing homes (Köpke et al., 2012). In the majority of the studies, a clear description of nurses’ attitudes was missing, although a change of clinical practice was intended by explicitly addressing nurses’ attitudes. Therefore, a systematic description of nurses’ attitudes and of the link between nurses’ attitudes and their practical use of physical restraints is a necessary basis to develop theoretically well-grounded interventions aimed at reducing the use of physical restraints.

Studies that explore attitudes towards physical restraints use in geriatric care settings have been conducted in many countries, using either qualitative or quantitative study designs. The qualitative studies aimed at describing the attitudes from the nurses’ perspective. In these studies, nurses’ attitudes towards physical restraints were described as ambivalent, characterised by respect for a person's dignity and by anxiety and the responsibility for the resident's safety (Hantikainen and Käppeli, 2000). Nurses described feelings of frustration and guilt when they used physical restraints against the will of a resident (Hennessy et al., 1997; Karlsson, 2000, Michello et al., 1993). The quantitative surveys aimed at describing nurses’ attitudes by using different questionnaires and by investigating the associations between nurses’ attitudes and other factors, e.g., use of physical restraints, the educational level of nurses, and characteristics of facilities or countries (Karlsson et al., 2001, Matthiesen et al., 1996, Myers et al., 2001). The results of these studies were inconsistent; no clear associations have been identified. A comparative survey in three countries suggested that nurses’ attitudes differed depending on the nurses’ definition of physical restraints and their national and cultural affiliations (Hamers et al., 2009).

To gain a deeper understanding of the themes and emotions that characterise nurses’ attitudes towards the use of physical restraints in geriatric care and to explore the connection between their attitudes and nursing practice, a systematic analysis of qualitative and quantitative studies investigating nurses’ attitudes is required.