This study carried out to reveal the level of nurses' practice and influencing factors regarding PR in the ICUs. Even though PR is used to prevent removal of life support tubes and falling injure of agitated patients in the critical care, complications such as skin edema and laceration at the restrained site, respiratory distress, worsening of agitation or delirium are encountered (8, 27, 28). Usually, this caused by the nurses’ improper clinical practice on restraining. Due to this, alternative strategies such as lowering bed height, raising bed rails, settling a family with patients, early detection of delirium risk factors, and using medications are important to reduce the application of PR in the ICUs (17-19). If it is used, the nurses should practice it by considering ethical issues based on policies & guidelines of restraining to reduce the adverse events and enhancing the quality of ICU care services.
This study reflected that majority of the nurses’ had a satisfactory practice regarding PR use in which greater than 71% of the participants had a certain important good clinical practice and application of restraints. This result is agreed with the studies held in Jordan and India (14, 37); but the mean score of this study is higher than other studies done in Sudan, Egypt and Malaysia (22-24). The possible reason for the variation might be attributed to the difference in sample size and participants' characteristics. In those studies, most of the participants were diploma in their educational qualification and small in number (below 100) but 89.5% of the nurses from the total (237) in this study were bachelors and masters in their educational qualification. So this finding supposed to increase the mean score of practice regarding PR use as the nurses' educational level was higher.
On the other hand, the level of nurses’ practice in this study is lower than those of other studies done in Sakarya and Konya, Turkey, and the United States (25, 26, 41). The reason for the variation might be the participants in those studies were got ongoing in-service training and the hospitals have guideline regarding restraining; on the opposite in our setting, there are insufficient policies and guidelines on restraint use, and no one has received in-service training that results in a certain improper clinical practice. This shortage of in-service training and guidelines causes a lower level of nurses' knowledge, frequent and improper application, and extending of misperception/ poor attitude on restraining (23, 25, 35). Again it may lead to a negative impact on nursing care of patients; complications to the patients, and legal problems to the nurse providing the care. However, educational training can improve nurses’ knowledge, attitude, and practice through changing their perceptions on the preference of alternative methods and reduction PR use to prevent the complications and ethical problems associated with restraining (16, 24, 36, 42).
Half of the nurses (49.8%) responded “sometimes” to the question “When physical restraint is applied, I record on the nursing charts the type of restraint used, the reason for adopting it, the time when the application commences, and the related nursing care required”; and (34.2%) of the nurses responded “never” to the question “I explain to the patient why the restraint is being applied”. These results indicated that the nurses had a poor practice of restraining. Because recording nursing activities on the charts and informing the reason why patients are restrained are important to avoid legal and ethical issues associated with PR (25, 43). This may be due to ICUs staff and resource restrictions, insufficient policy, and management issues, nurses’ insufficient information about restraints use related ethical or legal issues.
Skin edema, bruising, and pain around the restrained part were the most frequent complications of PR application as observed by the participant nurses. This finding is in agreement with the study done in Egypt as reported that skin complications are the most frequent (22). This may be due to faulty technique, prolonged use of restraining or unsuitable equipment since the usually used devices for restraining in the hospitals are ropes, chains, bed belts, gauzes, and patient’s cloth. Furthermore, fatigue, agitation, and respiratory distress are the other types of complications reported by the nurses in this study. This may be due to prolonged use of restraining, insufficient monitoring patients, insufficient range of motion, and position changing (19). This indicates the need for integration of standard protocol for application of PR in ICU with sufficient training of nursing staff.
Regarding predictor variables: ≤2 years’ work experience at ICU was significantly associated with poor practice regarding PR use. This finding was consistent with another previous study (24) that found fewer years of work experiences correlated with poor practice on restraint use. The possible reason might be when the nurses had short years of experience; they challenged a difficulty to apply the best nursing activities properly regarding physical restraints than long years of experienced nurses (42, 44). Received educational training about PR during graduate class was significantly associated with good nurses’ practice regarding PR use. This finding was consistent with those of other studies (22, 23) that showed nurses who had got training in their graduate class had a proper practice regarding PR use. Because training is the process of transforming information and skills through learning regarding the restraining of patients that influences the nurses to have better awareness, attitude, and clinical practice (16, 35, 36). This emphasizes developing guidelines, and providing effective educational training is necessary for nurses concerning PR use on agitated and delirious patients to maximizing the good clinical practice on the aspects of restraining (22, 42).
Nurses with a higher level of knowledge score were significantly associated with better nurses' practice score regarding PR use. This result is in agreement with other previous studies (22, 23, 30), those found that adequate nurses' knowledge had a positive effect on good staff practice regarding restraint use. The possible reason might be: based on the theory of planned behavior (45, 46), adequate knowledge is essential for the basis of nurses’ behavior to affect their subjective feelings regarding restraint use on critically ill patients, and to perform appropriate nursing activities during constraints.
Additionally, our study revealed that a higher attitude score was significantly associated with better nurses’ practice regarding restraining. This result is consistent with the findings of other studies (22, 23, 30); those reported that better nurse’s attitude has a positive effect on the nurses' practice regarding PR. This might be due to nurses with better subjective feelings and beliefs about restraint use put themselves in place of patients and their families on the use of PR. This feeling and thought can guide nurses to prefer alternative methods and performs them appropriately when used (23). Whereas our finding was not in agreement with the finding of another study (47), it reported that attitude has no effect on nurses' practice regarding restraining.
The participants were nurses’ who were motivated by their willingness to participate in the study, which limits the external generalizability of the result. Practices regarding PR use were assessed via a self-report questionnaire, which might not reflect the actual behavior of nurses. Besides, since the study design was cross-sectional, as a result of its nature; it is difficult to show the cause-effect relationship between predictors and nurses' practice regarding PR use.