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More Care Provided by RNs Can Reduce Hospital Restraint Usage

KANSAS CITY, MO – Many hospitals consider physical restraint an unnecessary evil. The problem is that these devices, such as belts, mittens, vests, bedrails, and geriatric chairs to restrict patients' freedom of movement to prevent them from hurting themselves or disrupting medical equipment and treatment, also can lead to agitation, confusion, adverse psychological effects, and pressure ulcers.

In the worst cases, the practice can even lead to strangulation and death.

Now, a new study appearing in the Journal of General Internal Medicine offers a solution: proper nurse staffing.

Researchers led by Vincent Staggs, PhD, of Children's Mercy Hospital and the University of Missouri-Kansas City, evaluated information collected on 869 hospitals providing care to more than 923,000 patients, as available in the National Database of Nursing Quality Indicators (NDNQI) between 2006 and 2010. Among information gathered by the NDNQI is quarterly data on restraints and monthly information on nurse staffing provided voluntarily by acute care hospitals.

Two nurse staffing variables were considered: staffing level (total nursing hours per patient day) and nursing skill mix (proportion of nursing hours provided by RNs). Outcomes were any use of restraint, regardless of reason, and use of restraint for fall prevention.

While use of restraints overall fell about 50% over the study period, results indicate that 1.6% of patients were restrained, about half of the time for the reported reason of preventing falls.

Researchers also were able to determine that the higher the average percentage of registered nurses on a shift, the less likely it was that restraint would be used. When a unit's percentage of registered nurses was low or very low relative to the unit's average, the odds of restraint were 11% and 18% higher, respectively, and the odds of fall prevention restraint were 9% and 16% higher.

Study authors suggest that the proportion of nursing care provided by the registered nurses rather than the total staffing level appears to be the more important predictor of restraint use.

"The findings suggest that patient care quality may suffer when unit staffing models cannot respond to changes in patient volume or registered nurse availability except by increasing the hours of staff who are not registered nurses," Staggs explained in a Springer press release. "This is further evidence that the type of nursing staff, not just the number of staff per patient, can be important for patient outcomes."

Having an adequate proportion of RNs, on the other hand, could reduce the likelihood of nursing staff requesting an order for restraint from a physician.

Staggs posits that the reason might be that registered nurses are better trained to find alternatives to restraint, adding, "In any case, restraint involves both nurses and physicians, and reduction in restraint use must be a collaborative effort.”

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