Physical restraining is an effective intervention in the care of the psychiatric patient to control them externally as well as internally to over their socially accepted behavior [2]. This Study focused on knowledge level, attitudes and practices regarding the aspect of physical restraining and specially regarding the patient care during retraining.
Physical restraining provides positive effect to the patient when it is applied in the correct way. Various studies have been conducted worldwide regarding physical restraining and its related areas have shown that improper application of restrain have been directly affected for the physical injuries and deaths. [4,5]. Mainly these failures occurred due to the lack of knowledge of nursing officers and their attitudes towards the use of restrain to the psychiatric patients and nonstandard restrain methods [5]. Improper application of physical restraining and restrain failures are the major causes for physical injuries and deaths. Dehydration, choking, circulatory and skin problems, loss of strength and mobility are the most common injuries associated with restrained failure.
Restrain or seclusion should be used as last option to prevent vulnerability and harm to self or others [6]. It should be used for a short time period and shouldn’t be used as a punishment [6]. This study showed a considerable proportion of nurses had satisfactory knowledge regarding physical restraining. Not only that most of them were aware of what is physically restrained, where physical restarting must be initiated and the time period that it should be continued. Present study identified that more than 90% of nursing officers were agreed with physical restraining must be initiated after trying all other less restrictive alternatives have been proven ineffective, which is similar to many studies reported that physical restraining applied when all other measures were failed [7-9]. This proves that the nursing officers have not felt guilty of physically restraining as they have tried every other means before the procedure with the patients and also the nurses have well balanced the ethical principles. A study in Hong Kong revealed that most of the nurses had little awareness regarding alternatives [10]. In addition, verbal therapy, verbal de- escalation, decreasing stimuli, offering support and communication were suggested as alternatives instead of physical restraining [7,9,11].
When considering basic needs of the patients while restraining, most of the nurses believed to provide basic needs such as foods, personal hygiene, bathroom facilities and exercises for restraining patients. A study in Turkey reported that the needs of the patient, such as nutrition and exertion were not met during the restraining period [12].
In the present study, the majority of respondents were aware that the restraining should be placed without harming the patient comfort and safety and were always checked for cyanotic appearance and cool temperature of the wrist while restraining. This is similar to the study in Iran reported that improper applying techniques may lead to violate the comfort and safety of the patient during restraining [2]. Similarly, a study in Portugal emphasized that all participants consider about the skin integrity in the application of physical restrain [7]. However, in the present study two third of nurses were unaware of the danger of restraining a patient while lying prone position and more than 80% of them were not believed that restraining can increase the risk of strangulation.
According to the American Psychiatric Nurses Association (APNA) standards, seclusion or restraint in a behavioral emergency was initiated by qualified staff and must be followed by an order- from a physician or Licensed Independent Practitioner (LIP). In the present study, almost half of the nurses mentioned that a request from a physician does not need to initiate restraining in a behavioral emergency always made the decision of restraining only with the physician order. A previous study revealed that small proportion of the respondent nurses (18%) used physical restrains only with a physician's order [11].
Physical restraining has harmful psychological effects for the patient as well as staff, mainly due to the staff behaviors and attitudes [9]. The present study showed positive attitudes of nurses regarding physical restraining and satisfactory level of awareness regarding psychological impact of restraint to the patient. These findings were supported by the study in Iran, which revealed that positive attitudes of the nurses may associated with positive effects of restraining [2]. More than half of the respondents agreed with that they felt guilty when placing a patient in restrain and they felt embarrassed when family members of the patient enters the room of a patient who was restraint. This might be due to the human perspective rooted in the Sri Lankan context. These findings were supported by a study in Turkey, which stated that 65.6% of nurses felt disappointed when they restrain or decided to restrain a patient [12].
According to the National Institute of health and Care Excellence (NICE) guidelines on the management of disturbed/violent behavior in inpatient psychiatric settings, the dignity of the patient must be respected throughout the physical restraining procedure [13]. In the present study, majority of the participants were explained reasons for family members and patients why physical restraining was applied. A similar study conducted by Okanil and others (2009) stated that patients were mostly not informed about the reason of applying restraining on them [14]. Majority of the Sri Lankan nurses are trained in a very disciplined environment where the nursing ethics are taught as a mandatory component. However, another study has published 56% of participants never inform family members and residents why the resident is being restrained and study also highlighted the need of increase awareness of patients’ rights and ethical issues related to physical restraining [11]. Physical retraining promotes human dignity if it is applied properly to promote the patient’s wellbeing [7].
With the agreement of this study, the major reason for initiating restrains was a shortage of staff [7,11,15]. Studies High number of staff showed shorter restrain duration and restraint were used more often when there was a shortage of staff [11,15].
There is a need for conducting in-service education programs regarding newly update policies and procedures regarding physical restraining in a hospital setting as more than half of respondents didn’t received in-service education reading this area. Conducting continuous in-service education programs based on best practice guidelines for nurses are essential to enhance their practice regarding use of restraints.
Many complications arising from restraining failures and danger of physical restraining can be avoided by continuing professional training, education and updating new policies and procedures. Specialized training and establishment, implementation and adhere to protocols and best practices are important to minimize danger and complications of physical and chemical restraining [2,7]. According to the current study, the majority of nursing officers were not participating in in-service education regarding physical restraining. There were a significant association of in-service education regarding physical restraining with knowledge, attitudes and practices of nursing officers and the majority of participants didn’t receive any in-service program regarding that aspect [10]. This study provided significant information which will be very useful in psychiatric nursing field to provide quality nursing care. This study benefits, health care professionals who are interested in this field and any other relevant parties who are interested in future research studies regarding this area of study.