Question

what are the 9 mental effects of restraints use

Answer 1

Risks and Side Effects of Restraint Use

Psychological/Emotional Effects

• Feelings of humiliation, loss of dignity

• Diminished quality of life; increased stress, confusion, fear

• Depression, withdrawal, isolation, desolation; loss of hope and internal motivation

• Anger, frustration, demoralization

• Increased agitation, hostility, and aggression; learned dependence

• Diminished staff opinion of the

Physical Effects

• Pressure ulcers and skin irritation

• Bone loss from decreased weight bearing activity

• Stiffness and muscle atrophy from lack of use

• Increased risk of respiratory infection

• Reduced functional capacity, decreased ambulation

• Increased risk of contractures

• Decreased mobility • Deconditioning

• Physical discomfort, increased pain

• Serious injuries from falls

• Increased morbidity and mortality

• Increased risk of death from struggling to get free

Increased stress on the heart

• Increased risk of death due to strangulation or asphyxiation

• Risk of burns if trying to burn the restraint off

• Risk of injury from restraint friction on the skin

• Nerve injuries

• Increased constipation, increased risk of fecal impaction

• Increased incontinence

• Increased risk of urinary tract infection due to urinary stasis

• Sleep disturbances

• Restricted circulation

• Decreased appetite

The problem with the use of physical restraints is not limited to the ethical dilemma of impinging on a person's autonomy. Previous studies show that the use of physical restraints is associated with an increased risk of mortality [9–11] and morbidity, such as due to increased instances of falling [12], greater cognitive decline, increases in the occurrences of nonsocial behavior, increases in bladder and bowel incontinence, increases in new pressure sores and nosocomial infections, a rise in dependency for undergoing activities of daily living and walking, and increases in agitation [13].

Despite numerous reports on the side effects of physical restraints, unfortunately, only a few local scholars and health professionals have paid attention to the phenomenon of restraint use. Besides studies showing the relatively high prevalence rate of restraint use in local nursing homes and long-term care facilities, clinical observations by many health professionals also attest to the fact that the use of physical restraints is widespread. To ensure good quality care, the issue of restraint use, therefore, deserves better attention.

As mentioned by many healthcare workers, the major justifications for the use of physical restraints are patient-oriented. They include the maintenance of patients' safety, management of their agitation and aggression, control of their behavior, preventing patients from wandering, and extension of physical support. However, as observed in many nursing homes or hospitals, physical restraints may also be used for the convenience of healthcare workers, for the attainment of organizational goals (such as to complete work schedules), to maintain a comfortable social environment (such as by stopping residents from bothering others), and to facilitate treatment (such as by preventing patients from tampering with medical devices or from removing clothing or dressings and catheters) [14].

Though restraint rates were high prior to intervention, research findings show that reducing rates of restraint to 5% or below is achievable [15]. In a comprehensive review by Guttman and colleagues, several prospective randomized trials were noted to have attained impressive outcomes, such as reducing the prevalence of restraint use by 20% [15]. Previous studies demonstrate that carefully orchestrated programming can greatly reduce the use of physical restraining devices [16–19].

Education programs, consisting of a full-day seminar and a one-hour guidance session per month over six months, focused on the decision-making process in the use of restraints and alternatives to restraints consistent with professional practice and quality care, can reduce the number of restraint cases by 54% [20]. In addition, a six-month educational program combined with unit-based, resident-centered consultation can effectively and safely reduce the use of physical restraint in nursing homes by 56% [21].

As a summary of the overseas studies mentioned above, a reduction of the prevalence rate of physical restraint use to 5% or lower is achievable through implementation of well-structured programs that involve both education and advance administration-committee consultation. However, to what extent the same could be applied to local settings is still unknown. This study is a prospective quasi-experimental clinical trial aimed at reducing the use of physical restraint on patients in rehabilitation settings. Some local studies that explore the physical restraint rate, knowledge, and practice of nurses can be found. In Hong Kong, the rate of bedrail use was about 62.5% in local nursing homes, while the rate of use of other physical restraints was about 25% [22]. Another local study mentioned that 69% of nursing staff reported that they had used at least one form of physical restraint in the previous three months [23]. The paucity of local interest illustrates the immediacy of the need for attention to restraint education for health professionals and other health workers. Through the investigation of this important yet neglected phenomenon, health-service providers would be able to reflect on their manner of delivery of health services.

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2. Methods

2.1. Setting and Sampling

This project was a collaborative effort between two rehabilitation hospitals and a school of nursing (SN). Two rehabilitation centers serving fairly similar patient groups were recruited into the study. One was designated as the intervention site (hereafter refer to as the study site for ease of discussion), while the other served as the control site. The adult psychiatry units in the control site were excluded because restraint use in these units was mainly for the management of possibly violent behaviors. There were no other exclusion criteria during the selection of subjects, as this study aimed to be a facility-wide endeavor for a change of practice. All patients in both settings were approached and invited to join the study.

Approval for the study was obtained from the ethics committee of both rehabilitation hospitals and the university. Informed written consent was obtained from the patients or their proxies prior to the collection of data.

2.2. Intervention

The study site underwent the restraint reduction program, while the control site did not. The restraint reduction program consisted of two components—staff education and the setup of a restraint reduction committee (RRC) and was implemented after a period of baseline observation.

2.2.1. Staff Education

All staff members were educated using the staff education package (both in Chinese and in English) developed based on (i) literature search, (ii) the research team's clinical experiences, and (iii) our analysis of the pre-intervention staff attitudes, beliefs, and behavior on the use of restraints. The content of the education package include is myths and misconceptions about restraint use, the facts and evidence of restraint use, what is restraint and understanding why we are using them, how to deal with the fear of patients' falls, are restraint alternatives available, caring for special patient populations and preventing them from being restrained. Discussions, simulation exercises, and case studies were used as much as possible to render the content more relevant to real life practice.

Similar contents, but with different levels of detail, were provided for health professionals and unregulated healthcare workers. The period of staff education lasted one year, from October 2002 to November 2003. Twelve repeating one-hour sessions were conducted. Members of the team attended staff meetings, case conferences, and unit meetings to facilitate the mastery of knowledge and skills development of the participants in the workplace. Staff could consult with the project team for uncertainties and on an individual basis during, for instance, RRC meetings, ward rounds, and personal encounters between the staff and members of the project team.

2.2.2. Restraint Reduction Committee

After the staff education program was completed, the RRC meetings commenced. The RRC was formed by an interdisciplinary committee, whose members included doctors, nurses, occupational therapists, physical therapists, and social workers. It was formed with the aim of changing the behaviors of nursing staff. The existing physical restraint policy in the rehabilitation center was compared with that proposed in the literature. We found that they were similar, and no revisions were needed before the study could begin. In fact, both facilities are under the Hospital Authority of Hong Kong (a government-funded independent body) and are expected to comply with the Hospital Authority's guidelines in the use of physical restraints. A nurse specialist in the center's RRC provided consultation to staff, and the team conducted further in-service sessions for reinforcement or for the orientation of new staff. Alternatives to the use of restraints were introduced to the staff during this period. Patients who were restrained were reviewed by the RRC. The RRC meeting was incorporated into the weekly case conferences in the medical and geriatric units. The multidisciplinary team would identify the circumstances leading to the use of restraints, the presence and the feasibility of alternatives to restraints, and possible solutions during the case conferences.

The same protocol was used in both hospitals during data collection. Subject data of individual patients were collected when they gave their consent to participate. Subjects who were restrained were reviewed by the RRC during the case meeting at the study site.

2.3. Data Collection

There was a monthly baseline observation for five months in all centers. The outcome variables (restraint, risk of fall, and functional level) were collected (before intervention). After obtaining the baseline data, there was a two-month period of staff education. Each staff education period lasted for one hour, and 12 sessions were given during the two-month period. After the conduct of staff education, the RRC reviewed the cases of restraint for another four months. Data were again collected (after intervention). This post intervention data-collection period lasted for five months.

The prevalence of restraint was calculated as the “number of patient-restraint days/total number of patient days ×100”. The patient-restraint day is equal to one patient being restrained for any amount of time within a 24-hour period.

Since most patients would be discharged before the end of the study, the mean scores on key variables (e.g., restraint, risk of fall, and functional level) were used as the unit of analysis. Data on the clinical and demographic characteristics of patients who were and those who were not being restrained in both the pre- and postintervention periods and the prevalence of restraint use were obtained.

All data were collected by research assistants who were trained by members of the team. Use of staff in the facilities could introduce bias. Training was provided for all research assistants until at least the conventional interrater agreement of 0.8 or more could be achieved. Assessment tools (e.g., MMSE) were administered by the RAs, while other data (e.g., restrained status) were collected through direct observations and examination of charts. Staff and patient interviews were conducted if there were discrepancies in the data.

2.4. Instruments

Demographic data and medical and health-related information were collected once subjects were enrolled in the study. These included gender, consumption of psychoactive drugs, vision and hearing ability, restraint status, type of restraint used, and fall experience in hospital. The Cantonese version of the Mini-Mental State Examination (MMSE), the Morse Fall Scale (MFS), and the Modified Barthel Index (MBI) were used to assess the cognitive status, risk of fall, and functional level of the subjects.

The Cantonese version of the MMSE was validated by Chiu et al. and found to have a Cronbach's alpha of 0.86 [24]. In this version, 19/20 (out of a total score of 30) was found to be the appropriate cut-off point for cognitive impairment in the local population, with a reliability rate of 97.5% and a validity rate of 97.3%. The interrater correlation was 0.99. The MFS was validated in Chinese hospital populations by Chow et al. and had a sensitivity rate of 31% and a specificity rate of 83% when the cut-off point was determined at 45 [25]. The field test demonstrated excellent interrater reliability with an ICC value of 0.97 (95% CI 0.94–0.98) [25]. For the MBI, the test-retest reliability of the Chinese version at the item level was comparable with that of the original version, with kappa statistics ranging from 0.63 to 1.00 (P < 0.001). Factor analyses revealed a two-factor structure that explained 75.7% of the total variance. Factor 1 was found to consist of eight items relating to the functional performance of patients. Factor 2 consisted of the two items that focused on patients' physiological needs [26].

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3. Results

The samples in the two hospitals were first compared in terms of their demographic and clinical characteristics. The pre intervention sample at the intervention facility was considerably older—mean age 75.4 (SD 10.7) versus 59.1 (SD 17.4) of the control facility (P < 0.001). The two samples were different in terms of the number of medical diagnosis, with the study site having a mean of 3.1 diagnoses (SD 1.5) versus the control site's mean of 1.8 diagnoses (SD 1.2) (P < 0.001); the mean MMSE score of the study site was 16.7 (SD 7.0) versus control site's 25.4 (SD 5.3) (P < 0.001); the mean MBI score was 12.7 (SD 5.5) in the study site versus control site's mean 15.1 score (SD 3.2) (P < 0.001). There were no significant differences found in all the other clinical and demographic variables.

The post intervention sample at the study site remained considerably older, with a mean age of 74.8 (SD 10.6) versus 62.9 (SD 17.7) in the control site (P < 0.001). Again, the two samples were different in terms of the number of medical diagnosis, with the study site having a mean of 3.2 diagnoses (SD 1.5) versus control site's mean of 1.9 diagnoses (SD 1.2) (P < 0.001); the mean MMSE score of the study site was 16.4 (SD 7.2) versus control site's 24.4 (SD 6.5) (P < 0.001); the mean MBI score of the study site was 12.0 (SD 5.1) versus control site's mean 15.1 (SD 3.4) (P < 0.001). The two facilities were also significantly different in terms of their gender composition—49.0% males in the study site versus 34.8% males in the control site. No other significant differences were found in clinical and demographic variables between the two hospital samples in the post-intervention period.

Then the baseline sample profile of the patients before the intervention in the study and control site were compared (Tables ​(a) and ​and.1(b)). The control site had a significantly younger patient group than the study site (P < 0.001) in the nonrestrained patient group. This younger patient group probably resulted in the higher cognitive status as reflected in the significantly higher mean MMSE total score (P < 0.001) and the lower risk of fall as reflected in the lower Morse Fall Scale score (P < 0.001) . Restrained patients had a similar sample profile in both the study and control sites. However, significant differences were found in age (P < 0.01) in both the nonrestrained and restrained groups of patients between the study and control sites. A significant difference in the experiences of falling in hospital (P < 0.01) was also found in the nonrestrained patients