ORIGINAL ARTICLE
The Journal of Nursing Research h VOL. 24, NO. 1, MARCH 2016
The Efficacy of an In-Service Education Program Designed to Enhance the Effectiveness of Physical Restraints Yin-Yin Chang1 & Hsiu-Hui Yu2 & El-Wui Loh3 & Li-Yin Chang4* 1
MSN, RN, Supervisor, Department of Nursing, Taichung Veterans General Hospital & 2MSN, RN, Department of Nursing, Taichung Veterans General Hospital & 3PhD, Senior Consultant, Science and English Editing Department, Herbace´e International Company, Ltd. & 4PhD, RN, Deputy Director, Department of Nursing, Taichung Veterans General Hospital.
KEY WORDS:
ABSTRACT Background: Physical restraints are used to enhance the safety of patients and to avoid injury. However, physical restraints may cause injuries if improperly used or if they are used in the absence of continuous monitoring. Nursing staff who use physical restraints often lack sufficient related knowledge, which may increase the risk to patient safety. Purpose: This study investigates the impact of an in-service education program for nursing staff that is designed to improve physicalrestraint-related knowledge, attitudes, behaviors, and techniques. Methods: A pretestYposttest design and a quasi-experimental method were employed to evaluate the effectiveness of the inservice education program. One hundred thirty-six nursing staff from four adult intensive care units (ICUs), including two medical ICUs and two surgical ICUs, in a medical center in central Taiwan were enrolled as participants. The experimental group (EG) and the control group (CG) were composed of patients from one randomly assigned medical ICU and one randomly assigned surgical ICU each. The pretest data on physical-restraint-related knowledge, attitudes, behaviors, and techniques were collected before the in-service education program. The EG received 2 hours of classroom education on guidelines and techniques related to physical restraints. The posttest data for the two groups were collected a month after implementation of the in-service education program. General Estimation Equation was used to measure and analyze the data repeatedly. Results: The posttest scores of the EG for knowledge and technique were significantly higher than the pretest scores (p G .0001). However, the posttest scores of the EG for attitudes and behaviors did not significantly differ from the pretest scores. Conclusions/Implications for Practice: In-service education for physical restraints enhances relevant knowledge and techniques but does not significantly affect attitudes or behaviors. Correct implementation of physical restraints not only promotes the quality of nursing care for patients in the ICU but also reduces the risk of physical-restraint-related complications. This study highlights the importance of changing the thoughts and concepts related to the use of physical restraints within the overall caring strategy of hospitals.
physical restraint, in-service education, intensive care unit (ICU).
Introduction Physical restraints are intended to keep patients safe by preventing the removal of infusion tubes, controlling patient restlessness, avoiding injuries, and other measures. Physical restraints may cause injuries if improperly used or if implemented without continuous monitoring. Some studies have pointed out that restraints do not reduce the number of accidental events. On the contrary, their use has been implicated in increased physical and psychological injuries, and restraint bands have been implicated in a number of patient deaths (Berzlanovich, Schopfer, & Keil, 2012; Mion & O’Connell, 2003). A previous systematic review (Evans, Wood, & Lambert, 2003) of the literature indicated that there are few statistics on physical-restraint-related injuries but that case reports on injuries caused by physical restraint (e.g., nerve injuries caused by armpits restricted by restraint bands or restraint clothes) are not uncommon. Some articles have cited restraint clothes, bed rails, and wrist restraints as causes of patient death. Furthermore, it has been reported that patients who were physically restrained to prevent unexpected extubation had a higher rate of falling than their Accepted for publication: October 1, 2014 *Address correspondence to: Li-Yin Chang, No.1650, Sec. 4, Taiwan Boulevard, Xitun District, Taichung City 40705, Taiwan, ROC. Tel: +886 (4) 2359-2525 ext. 6002; Fax: +886 (4) 2374-1367; E-mail: [email protected] The authors declare no conflicts of interest. Cite this article as: Chang, Y. Y., Yu, H. H., Loh, E. W., & Chang, L. Y. (2016). The efficacy of an in-service education program designed to enhance the effectiveness of physical restraints. The Journal of Nursing Research, 24(1), 79Y86. doi:10.1097/jnr.0000000000000092
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unrestrained peers and that restrained patients faced a higher risk of contracting nosocomial infections (Chang, Wang, & Chao, 2008; Evans et al., 2003). Although restraint is generally used to prevent unexpected extubation, various studies have reported self-extubation rates for restrained patients of 44%Y87% (Birkett, Southerland, & Leslie, 2005; Chang et al., 2008; Curry, Cobb, Kutash, & Diggs, 2008). Therefore, nonrestraint nursing has been strongly advocated in Europe and the United States in recent years (Berzlanovich et al., 2012; Endrikat, 2012; Mion, 2008; Park & Tang, 2007). Non-restraint nursing has also been promoted in Taiwan (Taiwan Joint Commission on Hospital Accreditation, 2014). However, the long-term, chronic shortage of nursing staff in Taiwan has made implementing non-restraint nursing difficult, especially in acute care units. The efficacy of reducing physical restraint has been widely discussed in the nursing community in Taiwan. In recent years, most hospitals in Taiwan have attached considerable importance to topics related to physical restraint, and inservice education has enhanced related knowledge, attitudes, and behaviors and reduced restraint use. Yeh et al. (2004) developed a 4-hour in-service education program for new staff that promoted the reduced use of physical restraints in the ICU. This program included instructions, guidelines for physical restraints, and alternative approaches. The lecture was videotaped for night-shift nurses who could not attend the program. They found that the program influenced new staff knowledge and attitudes about physical restraints and that the usage of alternative measures increased. Chyan, Chen, Guo, and Lee (2004) developed a 3-hour-and-10-minute inservice education program that addressed physical-restraint indicators and skills; alternative approaches; and hands-on practice with physical restraints, communication, and relaxation techniques. Huang, Chuang, and Chiang (2009) developed a 90-minute physical-restraint education program. The program included a 70-minute session focused on important concepts and scenarios followed by a 20-minute discussion and questions session. The studies of Chyan et al. and Huang et al. reached a similar conclusion: Physical-restraint usage in the adult ICU diminished after administration of the in-service education program. Furthermore, Evans, Wood, and Lambert (2002) reviewed physical restraints minimization in three acute care and 13 residential care settings. The duration of this restraint education varied from around 1 hour to 12 weeks or longer. The content of this restraint education addressed the impact of physical restraints and alternative approaches. Common topics addressed included ethical and legal issues and the dangers and adverse outcomes of physical restraints. Specific behavioral problems for which restraints are commonly used include agitation, risk of falling, and positioning problems. In addition, scales have been developed to measure the competency of healthcare staff in using physical restraints. Karlsson, Bucht, and Sandman (1998) pointed out that nursing staff who lacked sufficient restraint knowledge tended to use restraints more often than their more knowledgeable peers. Evan et al. (2003) pointed out in a systemic review of a
Yin-Yin Chang et al.
physical restraint reduction program that an education policy on reducing bed rails reduced serious injuries but had no impact on minor injuries. There is currently limited evidence for restraint reduction education programs decreasing patient injury rates in ICUs. In addition, the evidence regarding whether this type of program may be conducted effectively over an extended period remains inconclusive. Huang, Ma, and Chen (2003) investigated the nursing staff of hospitalbased internal medicine and surgical wards as well as ICUs at three medical centers and found positive correlations among physical-restraint-related knowledge, attitudes, and behaviors. Huang et al. (2009) suggested that, based on cost-benefit considerations, short-term in-service education programs could improve nurses’ knowledge and behavior in acute care settings. They pointed to the need for more two-group intervention designs to examine the effectiveness of these short-term programs in enhancing physical-restraint-related efficacy. The Taiwan Joint Commission on Hospital Accreditation (2014) emphasizes respect for the safety and human rights of patients. A standard operation procedure for physical restraints is required for accreditation. Before implementing restraints, the procedures and purposes must be clearly explained to patients or their family members, and a consent form must be signed. A routine visit every 30 minutes is required to ensure a humane and safe care. However, the potential of the standard operation procedure to reduce harm and accidents may fail if procedures are not properly followed or are conducted without proper knowledge and/or skills.
Purpose The purpose of this study was to evaluate the effectiveness of in-service education on knowledge, attitudes, behaviors, and technical change among nursing staff in the ICU with regard to physical restraints.
Methods Experimental Design A time-series pretestYposttest design using a quasi-experimental method was used to evaluate the effectiveness of in-service education. The subjects were the nurses of four adult ICUs of a medical center, which included two internal care units (Critical unit 1 and respiratory intensive care unit) and two surgical ICUs (Critical unit 2 and surgical ICU). The four ICUs maintained 73 beds. The four units employ the same nursing care model and the same nurse-to-patient ratio. To minimize the differences between groups, the four ICUs were clustered into two pairs, each including one surgical and one internal care ICU. The two pairs were then randomly assigned by the researchers as the experimental group (EG) and the control group (CG). The researchers then described research methods and purposes to all of the nurses in the four units, with willing participants completing the consent form. The pretest data of knowledge, attitudes, behaviors, and technology status related
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Physical Restraint In-Service Education Program
to physical restraints were collected before in-service education. The EG received the in-service education program. Posttest data for the two groups were collected 1 month after completion of the intervention.
Education Contents The 2-hour in-service education was a multicomponent intervention program that was developed based on relevant articles in the evidence-based literature (Chyan et al., 2004; Cosper, Morelock, & Provine, 2015; Evans et al., 2002; Huang et al., 2009; Yeh et al., 2004). The program included narration, question-and-answer, technical demonstration, and open discussion. Two registered nurses with a master’s degree and at least 3 years of work experience in the ICU delivered the education program. Each had completed a year of evidence-based medical study training on physical restraints at our hospital and took charge of monitoring the physicalrestraint indicators. Furthermore, one of two registered nurses was a Ministry of Education-certified instructor. Four program schedules covering all nurse shifts were opened to all participants. The contents of the narrations were (a) types of physical restraints and tools, (b) how to choose restraint tools and precautions when using physical restraints, (c) user instructions and guidelines, and (d) alternative approaches and ethical and legal issues. The technical demonstration for each kind of restraint tool included a clear explanation on the purpose of the tools, suitable-use situations, standard techniques, and applications with hemiparalyzed patients.
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Questionnaire for behavior related to physical restraints This questionnaire was modified from the Restraint Behavior Questionnaire developed by Huang et al. (2003). There were 16 questions in this scale, and a 3-point Liker scale was used for scoring. Questions 11, 13, and 16 addressed inappropriate restraint behaviors and thus used reversed scoring. The range of total possible scores was from 16 to 48. The response frequently (3) means that the frequency of implementing physical restraint in response to the occurrence of a restraint condition or incident is over 50%, the response sometimes (2) means that the frequency is less than half (1%Y49%) but greater than zero, and never (1) means that the respondent never implements physical restraints. A higher score implies closer compliance to the restraint protocol. Expert validation using a 5-point Likert scale was greater than 4.85, and the Cronbach’s " of the scale was .90. Scoring items for technical operation of physical restraints The operation protocol for physical restraints was shown, and then, participants received 1 point for each procedure they carried out correctly.
Ethical Considerations Ethical approval was obtained from the ethics committee of the Taichung Veterans Hospital, Taiwan (C05093). Informed consent was obtained from participants before data collection. One month after completing data collection, the same in-service physical-restraint education program was administered to the participants in the CG.
Pretest and Posttest Instruments Questionnaire for knowledge about physical restraints There are 10 multiple-choice objective questions on the questionnaire for knowledge about physical restraints, including one question asking if the restraint was ordered by an appropriate physician, four questions on technical principles and guidelines, three questions regarding indexes to be monitored for restrained patients, and two questions on the criteria for releasing the restraints. Expert validity, as assessed by using a 5-point Likert scale, was greater than 4.63, and the KuderRichardson Formula 20 (KR-20) value was .73. Questionnaire for attitudes about physical restraints This questionnaire was modified from the restraint attitude questionnaire developed by Huang et al. (2003). Eight of the 10 questions on the questionnaire for attitudes about physical restraints were scored from strongly agree (5 marks) to strongly disagree (1 mark). The 4th and 10th questions used reversing scoring. The total score ranged from 10 to 50, with higher scores associated with a lower tendency to use restraints. Expert validity using a 5-point Likert scale was greater than 4.8, and the Cronbach’s " of the scale was .82.
Data Analysis Excel was used to enter and manipulate the basic data, SPSS 13.0 was used to conduct differential analysis on the basic data, and the General Estimation Equation of SAS was used to conduct repeated measuring analysis.
Results The sample included 136 participants, with 76 in the EG and 60 in the CG. Almost three quarters (72.8%) of the participants had never participated in in-service education related to physical restraints. There were no significant differences between the EG and CG in terms of job title, educational level, or prior training on physical restraints; there were no differences between the groups in terms of years of nursing experience, years of ICU experience, age, or training hours for physical restraint (Table 1). The General Estimation Equation revealed no pretest effects between the EG and CG; there were no differences between the groups after the inservice education intervention (Tables 2 and 3). Furthermore, there were no significant differences between pretest 81
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Yin-Yin Chang et al.
TABLE 1.
Comparison of Control Variables for the Two Groups Using Categorical Variables (N = 136) EG (n = 76)
CG (n = 60)
M
SD
M
SD
F
p
Age
33.72
6.04
33.20
4.88
0.31
.58
Years of nursing experience
11.86
6.13
11.02
4.80
0.80
.37
Years of ICU experience
5.97
4.49
6.11
5.79
0.03
.87
Training hours
0.38
0.73
0.35
0.68
0.07
.80
n
%
n
%
22
Job title Above NP Below NP
23 53
30.3 69.7
17 43
28.3 71.7
Educational level Above Bachelor Below Bachelor
39 37
51.3 48.7
39 21
65.0 35.0
Prior training Yes No
22 54
28.9 71.1
15 45
25.0 75.0
Variable
0.06
.85
2.57
.12
0.26
.70
Note. EG = experimental group; CG = control group.
TABLE 2.
Comparison of Knowledge Scoring Index Between the Two Groups Variable
Regression Coefficient
SE
Z Value
p Value
6.97
0.19
36.39
G.0001
Pretest groups (EG/CG)
j0.10
0.26
j0.38
.70
CG time (pretestYposttest)
j0.17
0.23
j0.73
1.37
0.30
4.54
Intercept
Interaction between pretest group and CG time
.47 G.0001
Note. EG = experimental group; CG = control group. Regression model: knowledge score = 6.97 j 0.10 (group) j 0.17 (time) + 1.37 (Group Time).
TABLE 3.
Comparison of the Technique Correctness Index of the Two Groups Variable
Regression Coefficient
Intercept Pretest groups (EG/CG)
SE
Z Value
p Value
6.64
0.14
48.49
G.0001
j0.02
0.20
j0.09
.93
CG time (pretestYposttest)
0.22
0.15
1.42
.16
Interaction between pretest group and CG time
1.61
0.22
7.26
G.0001
Note. EG = experimental group; CG = control group. Regression model: technique score = 6.64 j 0.02 (group) + 0.22 (time) + 1.61 (Group Time).
and posttest scores for the CG in terms of knowledge, techniques, or attitudes. After taking pretest and growth effects into consideration for the EG, significant changes appeared in
knowledge and technical scores after the intervention but not in scores for attitudes or behaviors (p G .0001; Tables 2 and 3, Figures 1 and 2).
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Physical Restraint In-Service Education Program
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Discussion In-service education for physical restraints is insufficient in Taiwan. Nearly 73% of the participants in this study had never participated in in-service education related to physical restraints. Lee (2005) also found that 68% of their subjects had not taken any in-service education for physical restraints within the most recent 3-year period. Yeh et al. (2004) indicated that physical restraint had been addressed in the in-service education of only one third of nursing staff. Therefore, it is clear that in-service education on physical restraints has been neglected, which may lead to the improper use of restraints on patients in the ICU (Chiang, Hsu, Chen, & Kao, 1999; Kontio et al., 2009; Morris, 2007; Yeh et al., 2004). According to Yeh et al. (2004), although an in-service education intervention had a marked impact on new nursing staff in terms of knowledge and attitudes regarding physical restraints, it did not impact the skill of new nursing staff in terms of implementing the technique. This was attributed mainly to the short duration of time (3 days) between pretest and posttest. The subjects in this study had an average of more than 11 years of professional nursing experience, including 5Y6 years of experience in the ICU. Therefore, it is reasonable that the intervention would result in significant progress in terms of physical-restraint-related techniques and knowledge. The lack of impact of in-service education on attitudes and behaviors in this study is similar to the findings of Huang et al. (2009). Further research may examine the potential of short-term in-service education to affect long-term changes in attitudes and behavior. Evans et al. (2002) found that the restraint rate declined during the first 6 months of an in-service education program but that this trend reversed 12 months later because of the need to prevent patient falling and self-extubation. The finding indicated that 72% of critical care clinicians consider the absence of physical restraints to be a risk factor for accidental extubation in the ICU (Tanios, Epstein, Livelo, & Teresd, 2010). Therefore, ‘‘minimizing restraint use in patients with medical devices always carries a risk of deliberate or accidental device removal’’ (White, Purcell, Urquhart, Joseph,
Figure 1. Change of knowledge scoring index in EG and CG as evaluated by GEE. The average knowledge scores for the CG were 6.97 for pretest and 6.80 for posttest. The average knowledge scores for the EG were 6.87 for pretest and 8.07 for posttest.
Figure 2. Change of technique correctness index in EG and CG as assessed by GEE. The average technique scores for the CG were 6.64 for pretest and 6.86 for posttest. The average technique scores for the EG were 6.63 for pretest and 8.46 for posttest.
& O’Connor, 2012). Martin and Mathisen (2005) pointed out that, whereas Norwegian ICUs implemented 100% nonrestraint, 39% of ICU patients in the United States were restrained. Norway’s low nurseYpatient ratio (0.5Y1.5 patients/ nurse) and higher dosage and frequency of sedative drug administration are likely two important reasons supporting the high level of nonrestraint achieved in Norwegian ICUs. In Taiwan, the nursing staff in ICUs care for two-to-four patients, with one nursing staff responsible to the total care of one patient. Although increasing the nursing staff in the ICU may be an effective alternative to using restraints to prevent device removal, this option would incur significant extra manpower costs. In addition, because most physicians in Taiwan tend to use light rather than heavy sedation, patient incidents such as removing infusion tubes and falling are not uncommon. To prevent these events, most ICU nursing staff tend to support the use of physical restraints (Chiang et al., 1999). Martin and Mathisen (2005) suggested that using physical restraints was not only an implementation of healthcare measures but also the expression of ethical and cultural values and related healthcare authority policies. Cosper et al. (2015) pointed out that policy makers focused their attention on the needs of the entire organization rather than a single unit or ward. Changing restraint policy would thus require the involvement of a committee and a multidisciplinary team. Lee (2005) found that nursing standard operating protocols were the strongest predictor of physical restraint, accounting for 10% of restraint behaviors. Thus, this is worth further research focus and attention. Thus, the ability of in-service education to improve the use of patient restraints in the ICU with proper guidelines is worth further examination and exploration. However, changing the attitudes and behaviors of ICU nurses to reduce the use of restraints will require the Taiwan Joint Commission on Hospital Accreditation to coordinate an effective oversight program on physical restraint. The care team must also collaborate more closely to improve the sedation of restless patients, lower the nurseYpatient ratio, 83
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and offer ongoing in-service education for nurses to be able to reduce the use of restraints and to enhance patient care quality through the proper use of restraints.
Conclusions In-service education for physical restraints enhances the related knowledge and techniques of nursing staff but not the related attitudes and behaviors. This article found the use of demonstrations, the use of the teachYreply mode in conjunction with discussions on restraint techniques, and the use of standards to guide the correct choice of materials to be particularly effective tools. In-service education further significantly enhances the proper implementation of restraints by nursing staff. Future curriculum designs for physical restraint in-service education should take this mode into consideration. Furthermore, incorporating into in-service education materials data on restraint cases that use alternative measures and information on relevant ethical issues will help improve the reflection and learning of nurses and thus enhance their attitudes and behaviors with regard to the use of physical restraints. In summary, the implementation of physical restraint requires not only professional knowledge but also correct technique. Therefore, in-service education should combine classroom learning and hands-on technical practice to achieve improvement objective. The optimal clinical physical restraint in-service education curriculum design combines restraint techniques with judgment on ethical issues and the execution of alternative measures. We believe this design will effectively improve the curriculum in all the four aspects of physical-restraint-related knowledge, skills, attitudes, and behaviors; substantively reduce the use of physical restraints; and improve the use of alternative measures.
Limitations of the Study The major limitation of this study was the relatively short (1-month) follow-up period. Therefore, the long-term impact of the in-service education program and the correctness of the restraint technique over the long term were not evaluated.
Acknowledgments The authors wish to thank the Taichung Veterans General Hospital for funding this research (Project number TCVGH-951409A), Professor Sheng-liang Wu for statistical assistance, and the several experts who assisted with the validity test. The authors also gratefully acknowledge the assistance of the participating nurses.
References Berzlanovich, A. M., Schopfer, J., & Keil, W. (2012). Deaths due to physical restraint. Deutsches Arzteblatt International, 109(3), 27Y32. doi:10.3238/arztebl.2012.0027
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Birkett, K. M., Southerland, K. A., & Leslie, G. D. (2005). Reporting unplanned extubation. Intensive and Critical Care Nursing, 21(2), 65Y75. doi:10.1016/j.iccn.2004.07.012 Chang, L. Y., Wang, K. W. K., & Chao, Y. F. (2008). Influence of physical restraint on unplanned extubation of adult intensive care patients: A case-control study. American Journal of Critical Care, 17(5), 408Y415; quiz 416. Chiang, M. C., Hsu, L. N., Chen, T. O., & Kao, M. L. (1999). An exploration of the nurses’ knowledge and attitudes of physical restraints. Chang Gung Nursing, 10(1), 42Y50. (Original work published in Chinese) Chyan, M. R., Chen, Y. C., Guo, R. M., & Lee, Y. W. (2004). The effect of education intervention on nurses’ knowledge, attitude, and behavior of restrains in the intensive care units. Chang Gung Nursing, 15(3), 248Y257. (Original work published in Chinese) Cosper, P., Morelock, V., & Provine, B. (2015). Please release me: Restraint reduction initiative in a health care system. Journal of Nursing Care Quality, 30(1), 16Y23. doi:10.1097/ncq .0000000000000074 Curry, K., Cobb, S., Kutash, M., & Diggs, C. (2008). Characteristics associated with unplanned extubations in a surgical intensive care unit. American Journal Critical Care, 17(1), 45Y51; quiz 52. Endrikat, W. (2012). Almost free from restraints. Deutsches Arzteblatt International, 109(20), 376. doi:10.3238/arztebl.2012.0376a Evans, D., Wood, J., & Lambert, L. (2002). A review of physical restraint minimization in the acute and residential care settings. Journal of Advanced Nursing, 40(6), 616Y625. doi:10.1046/j.13652648.2002.02422.x Evans, D., Wood, J., & Lambert, L. (2003). Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing, 41(3), 274Y282. doi:10.1046/j.1365-2648.2003.02501.x Huang, H. T., Chuang, Y. H., & Chiang, K. F. (2009). Nurses’ physical restraint knowledge, attitudes, and practices: The effectiveness of an in-service education program. The Journal of Nursing Research, 17(4), 241Y248. doi:10.1097/JNR.0b013e3181c1215d Huang, H. T., Ma, F. C., & Chen, C. H. (2003). A correlation study among nurses’ knowledge, attitudes and practice toward physical restraints. Tzu Chi Nursing Journal, 2(2), 32Y41. (Original work published in Chinese) Karlsson, S., Bucht, G., & Sandman, P. O. (1998). Physical restraints in geriatric care. Knowledge, attitudes and use. Scandinavian Journal of Caring Sciences, 12(1), 48Y56. doi:10.1080/02839319850163138 Kontio, R., Va¨lima¨ki, M., Putkonen, H., Cocoman, A., Turpeinen, S., Kuosmanen, L., & Joffe, G. (2009). Nurses’ and physicians’ educational needs in seclusion and restraint practices. Perspective in Psychiatric Care, 45(3), 198Y207. doi:10.1111/ j.1744-6163.2009.00222.x Lee, H. J. (2005). A correlational study among nurses’ knowledge, attitudes, and practice toward physical restraints in intensive care units (Unpublished doctoral dissertation). Fooyin University, Kaohsiung, Taiwan, ROC. (Original work published in Chinese) Martin, B., & Mathisen, L. (2005). Use of physical restraints in adult critical care: A bicultural study. American Journal of Critical Care, 14(2), 133Y142. Mion, L. C. (2008). Physical restraint in critical care settings: Will they go away? Geriatric Nursing, 29(6), 421Y423. doi:10.1016/j .gerinurse.2008.09.006 Mion, L. C., & O’Connell, A. (2003). Parenteral hydration and nutrition in
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the geriatric patient clinical and ethical issues. Journal of Infusion Nursing, 26(3), 144Y152. doi:10.1097/00129804-200305000-00005 Morris, K. (2007). Issues and answers: Restraint use. Ohio Nurses Review, 82(4), 14Y15.
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Tanios, M. A., Epstein, S. K., Livelo, J., & Teres, D. (2010). Can we identify patients at high risk for unplanned extubation? A largescale multidisciplinary survey. Respiratory Care, 55(5), 561Y568.
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身體約束在職教育
VOL. 24, NO. 1, MARCH 2016
身體約束在職教育之效果評價 張瑛瑛1 尤琇慧2 羅爾維3 張麗銀4* 1
臺中榮民總醫院護理部督導長 2臺中榮民總醫院護理師 3禾八國際有限公司科學與英文 編譯部資深顧問 4臺中榮民總醫院護理部副主任
背 景
身體約束旨在維持病人安全 、預防受傷 ，但是如果使用不當 、未密切監測病人 ，或護 理人員執行身體約束的知能不足 ，則身體約束反而會造成病人的傷害。
目 的
主要在評價在職教育的介入對提升護理人員身體約束的知識 、態度 、行為及技術之效 果。
方 法
採類實驗法之二組前後測研究設計 ，以評價在職教育之效果。研究對象為中部某醫學 中心 4 個成人加護病房之護理人員 ，共 136 位 ，4 個加護病房內外科各為二 ，以隨機分 派內外科各一個加護病房為實驗組 ，另外則為對照組。先收集二組身體約束知識 、態 度 、行為及技術之前測資料 ，然後予實驗組2 小時以實證為基礎的身體約束臨床指引 ， 及身體約束技術之在職教育為介入方案 ，在職教育介入後一個月 ，收集二組之後測資 料。以 SAS 統計軟體之 GEE 進行重複測量分析。
結 果
護理人員身體約束之知識及技術在介入在職教育後有顯著的進步（p < .0001）；但態度 和行為則無顯著性改變。
結 論 在職教育可以提升護理人員身體約束的知識及技術 ，而藉由正確身體約束方法的執行 實務應用 不僅可以促進加護病房病人照顧的品質 ，亦可減少身體約束所造成的合併症。
關鍵詞：身體約束、在職教育、加護病房。
接受刊載：103年10月1日 *通訊作者地址：張麗銀 40705臺中市西屯區台灣大道四段1650號 電話：（04）23592525－6002 E-mail: [email protected]
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The Journal of Nursing Research h VOL. 24, NO. 1, MARCH 2016
The Efficacy of an In-Service Education Program Designed to Enhance the Effectiveness of Physical Restraints Yin-Yin Chang1 & Hsiu-Hui Yu2 & El-Wui Loh3 & Li-Yin Chang4* 1
MSN, RN, Supervisor, Department of Nursing, Taichung Veterans General Hospital & 2MSN, RN, Department of Nursing, Taichung Veterans General Hospital & 3PhD, Senior Consultant, Science and English Editing Department, Herbace´e International Company, Ltd. & 4PhD, RN, Deputy Director, Department of Nursing, Taichung Veterans General Hospital.
KEY WORDS:
ABSTRACT Background: Physical restraints are used to enhance the safety of patients and to avoid injury. However, physical restraints may cause injuries if improperly used or if they are used in the absence of continuous monitoring. Nursing staff who use physical restraints often lack sufficient related knowledge, which may increase the risk to patient safety. Purpose: This study investigates the impact of an in-service education program for nursing staff that is designed to improve physicalrestraint-related knowledge, attitudes, behaviors, and techniques. Methods: A pretestYposttest design and a quasi-experimental method were employed to evaluate the effectiveness of the inservice education program. One hundred thirty-six nursing staff from four adult intensive care units (ICUs), including two medical ICUs and two surgical ICUs, in a medical center in central Taiwan were enrolled as participants. The experimental group (EG) and the control group (CG) were composed of patients from one randomly assigned medical ICU and one randomly assigned surgical ICU each. The pretest data on physical-restraint-related knowledge, attitudes, behaviors, and techniques were collected before the in-service education program. The EG received 2 hours of classroom education on guidelines and techniques related to physical restraints. The posttest data for the two groups were collected a month after implementation of the in-service education program. General Estimation Equation was used to measure and analyze the data repeatedly. Results: The posttest scores of the EG for knowledge and technique were significantly higher than the pretest scores (p G .0001). However, the posttest scores of the EG for attitudes and behaviors did not significantly differ from the pretest scores. Conclusions/Implications for Practice: In-service education for physical restraints enhances relevant knowledge and techniques but does not significantly affect attitudes or behaviors. Correct implementation of physical restraints not only promotes the quality of nursing care for patients in the ICU but also reduces the risk of physical-restraint-related complications. This study highlights the importance of changing the thoughts and concepts related to the use of physical restraints within the overall caring strategy of hospitals.
physical restraint, in-service education, intensive care unit (ICU).
Introduction Physical restraints are intended to keep patients safe by preventing the removal of infusion tubes, controlling patient restlessness, avoiding injuries, and other measures. Physical restraints may cause injuries if improperly used or if implemented without continuous monitoring. Some studies have pointed out that restraints do not reduce the number of accidental events. On the contrary, their use has been implicated in increased physical and psychological injuries, and restraint bands have been implicated in a number of patient deaths (Berzlanovich, Schopfer, & Keil, 2012; Mion & O’Connell, 2003). A previous systematic review (Evans, Wood, & Lambert, 2003) of the literature indicated that there are few statistics on physical-restraint-related injuries but that case reports on injuries caused by physical restraint (e.g., nerve injuries caused by armpits restricted by restraint bands or restraint clothes) are not uncommon. Some articles have cited restraint clothes, bed rails, and wrist restraints as causes of patient death. Furthermore, it has been reported that patients who were physically restrained to prevent unexpected extubation had a higher rate of falling than their Accepted for publication: October 1, 2014 *Address correspondence to: Li-Yin Chang, No.1650, Sec. 4, Taiwan Boulevard, Xitun District, Taichung City 40705, Taiwan, ROC. Tel: +886 (4) 2359-2525 ext. 6002; Fax: +886 (4) 2374-1367; E-mail: [email protected] The authors declare no conflicts of interest. Cite this article as: Chang, Y. Y., Yu, H. H., Loh, E. W., & Chang, L. Y. (2016). The efficacy of an in-service education program designed to enhance the effectiveness of physical restraints. The Journal of Nursing Research, 24(1), 79Y86. doi:10.1097/jnr.0000000000000092
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unrestrained peers and that restrained patients faced a higher risk of contracting nosocomial infections (Chang, Wang, & Chao, 2008; Evans et al., 2003). Although restraint is generally used to prevent unexpected extubation, various studies have reported self-extubation rates for restrained patients of 44%Y87% (Birkett, Southerland, & Leslie, 2005; Chang et al., 2008; Curry, Cobb, Kutash, & Diggs, 2008). Therefore, nonrestraint nursing has been strongly advocated in Europe and the United States in recent years (Berzlanovich et al., 2012; Endrikat, 2012; Mion, 2008; Park & Tang, 2007). Non-restraint nursing has also been promoted in Taiwan (Taiwan Joint Commission on Hospital Accreditation, 2014). However, the long-term, chronic shortage of nursing staff in Taiwan has made implementing non-restraint nursing difficult, especially in acute care units. The efficacy of reducing physical restraint has been widely discussed in the nursing community in Taiwan. In recent years, most hospitals in Taiwan have attached considerable importance to topics related to physical restraint, and inservice education has enhanced related knowledge, attitudes, and behaviors and reduced restraint use. Yeh et al. (2004) developed a 4-hour in-service education program for new staff that promoted the reduced use of physical restraints in the ICU. This program included instructions, guidelines for physical restraints, and alternative approaches. The lecture was videotaped for night-shift nurses who could not attend the program. They found that the program influenced new staff knowledge and attitudes about physical restraints and that the usage of alternative measures increased. Chyan, Chen, Guo, and Lee (2004) developed a 3-hour-and-10-minute inservice education program that addressed physical-restraint indicators and skills; alternative approaches; and hands-on practice with physical restraints, communication, and relaxation techniques. Huang, Chuang, and Chiang (2009) developed a 90-minute physical-restraint education program. The program included a 70-minute session focused on important concepts and scenarios followed by a 20-minute discussion and questions session. The studies of Chyan et al. and Huang et al. reached a similar conclusion: Physical-restraint usage in the adult ICU diminished after administration of the in-service education program. Furthermore, Evans, Wood, and Lambert (2002) reviewed physical restraints minimization in three acute care and 13 residential care settings. The duration of this restraint education varied from around 1 hour to 12 weeks or longer. The content of this restraint education addressed the impact of physical restraints and alternative approaches. Common topics addressed included ethical and legal issues and the dangers and adverse outcomes of physical restraints. Specific behavioral problems for which restraints are commonly used include agitation, risk of falling, and positioning problems. In addition, scales have been developed to measure the competency of healthcare staff in using physical restraints. Karlsson, Bucht, and Sandman (1998) pointed out that nursing staff who lacked sufficient restraint knowledge tended to use restraints more often than their more knowledgeable peers. Evan et al. (2003) pointed out in a systemic review of a
Yin-Yin Chang et al.
physical restraint reduction program that an education policy on reducing bed rails reduced serious injuries but had no impact on minor injuries. There is currently limited evidence for restraint reduction education programs decreasing patient injury rates in ICUs. In addition, the evidence regarding whether this type of program may be conducted effectively over an extended period remains inconclusive. Huang, Ma, and Chen (2003) investigated the nursing staff of hospitalbased internal medicine and surgical wards as well as ICUs at three medical centers and found positive correlations among physical-restraint-related knowledge, attitudes, and behaviors. Huang et al. (2009) suggested that, based on cost-benefit considerations, short-term in-service education programs could improve nurses’ knowledge and behavior in acute care settings. They pointed to the need for more two-group intervention designs to examine the effectiveness of these short-term programs in enhancing physical-restraint-related efficacy. The Taiwan Joint Commission on Hospital Accreditation (2014) emphasizes respect for the safety and human rights of patients. A standard operation procedure for physical restraints is required for accreditation. Before implementing restraints, the procedures and purposes must be clearly explained to patients or their family members, and a consent form must be signed. A routine visit every 30 minutes is required to ensure a humane and safe care. However, the potential of the standard operation procedure to reduce harm and accidents may fail if procedures are not properly followed or are conducted without proper knowledge and/or skills.
Purpose The purpose of this study was to evaluate the effectiveness of in-service education on knowledge, attitudes, behaviors, and technical change among nursing staff in the ICU with regard to physical restraints.
Methods Experimental Design A time-series pretestYposttest design using a quasi-experimental method was used to evaluate the effectiveness of in-service education. The subjects were the nurses of four adult ICUs of a medical center, which included two internal care units (Critical unit 1 and respiratory intensive care unit) and two surgical ICUs (Critical unit 2 and surgical ICU). The four ICUs maintained 73 beds. The four units employ the same nursing care model and the same nurse-to-patient ratio. To minimize the differences between groups, the four ICUs were clustered into two pairs, each including one surgical and one internal care ICU. The two pairs were then randomly assigned by the researchers as the experimental group (EG) and the control group (CG). The researchers then described research methods and purposes to all of the nurses in the four units, with willing participants completing the consent form. The pretest data of knowledge, attitudes, behaviors, and technology status related
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Physical Restraint In-Service Education Program
to physical restraints were collected before in-service education. The EG received the in-service education program. Posttest data for the two groups were collected 1 month after completion of the intervention.
Education Contents The 2-hour in-service education was a multicomponent intervention program that was developed based on relevant articles in the evidence-based literature (Chyan et al., 2004; Cosper, Morelock, & Provine, 2015; Evans et al., 2002; Huang et al., 2009; Yeh et al., 2004). The program included narration, question-and-answer, technical demonstration, and open discussion. Two registered nurses with a master’s degree and at least 3 years of work experience in the ICU delivered the education program. Each had completed a year of evidence-based medical study training on physical restraints at our hospital and took charge of monitoring the physicalrestraint indicators. Furthermore, one of two registered nurses was a Ministry of Education-certified instructor. Four program schedules covering all nurse shifts were opened to all participants. The contents of the narrations were (a) types of physical restraints and tools, (b) how to choose restraint tools and precautions when using physical restraints, (c) user instructions and guidelines, and (d) alternative approaches and ethical and legal issues. The technical demonstration for each kind of restraint tool included a clear explanation on the purpose of the tools, suitable-use situations, standard techniques, and applications with hemiparalyzed patients.
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Questionnaire for behavior related to physical restraints This questionnaire was modified from the Restraint Behavior Questionnaire developed by Huang et al. (2003). There were 16 questions in this scale, and a 3-point Liker scale was used for scoring. Questions 11, 13, and 16 addressed inappropriate restraint behaviors and thus used reversed scoring. The range of total possible scores was from 16 to 48. The response frequently (3) means that the frequency of implementing physical restraint in response to the occurrence of a restraint condition or incident is over 50%, the response sometimes (2) means that the frequency is less than half (1%Y49%) but greater than zero, and never (1) means that the respondent never implements physical restraints. A higher score implies closer compliance to the restraint protocol. Expert validation using a 5-point Likert scale was greater than 4.85, and the Cronbach’s " of the scale was .90. Scoring items for technical operation of physical restraints The operation protocol for physical restraints was shown, and then, participants received 1 point for each procedure they carried out correctly.
Ethical Considerations Ethical approval was obtained from the ethics committee of the Taichung Veterans Hospital, Taiwan (C05093). Informed consent was obtained from participants before data collection. One month after completing data collection, the same in-service physical-restraint education program was administered to the participants in the CG.
Pretest and Posttest Instruments Questionnaire for knowledge about physical restraints There are 10 multiple-choice objective questions on the questionnaire for knowledge about physical restraints, including one question asking if the restraint was ordered by an appropriate physician, four questions on technical principles and guidelines, three questions regarding indexes to be monitored for restrained patients, and two questions on the criteria for releasing the restraints. Expert validity, as assessed by using a 5-point Likert scale, was greater than 4.63, and the KuderRichardson Formula 20 (KR-20) value was .73. Questionnaire for attitudes about physical restraints This questionnaire was modified from the restraint attitude questionnaire developed by Huang et al. (2003). Eight of the 10 questions on the questionnaire for attitudes about physical restraints were scored from strongly agree (5 marks) to strongly disagree (1 mark). The 4th and 10th questions used reversing scoring. The total score ranged from 10 to 50, with higher scores associated with a lower tendency to use restraints. Expert validity using a 5-point Likert scale was greater than 4.8, and the Cronbach’s " of the scale was .82.
Data Analysis Excel was used to enter and manipulate the basic data, SPSS 13.0 was used to conduct differential analysis on the basic data, and the General Estimation Equation of SAS was used to conduct repeated measuring analysis.
Results The sample included 136 participants, with 76 in the EG and 60 in the CG. Almost three quarters (72.8%) of the participants had never participated in in-service education related to physical restraints. There were no significant differences between the EG and CG in terms of job title, educational level, or prior training on physical restraints; there were no differences between the groups in terms of years of nursing experience, years of ICU experience, age, or training hours for physical restraint (Table 1). The General Estimation Equation revealed no pretest effects between the EG and CG; there were no differences between the groups after the inservice education intervention (Tables 2 and 3). Furthermore, there were no significant differences between pretest 81
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Yin-Yin Chang et al.
TABLE 1.
Comparison of Control Variables for the Two Groups Using Categorical Variables (N = 136) EG (n = 76)
CG (n = 60)
M
SD
M
SD
F
p
Age
33.72
6.04
33.20
4.88
0.31
.58
Years of nursing experience
11.86
6.13
11.02
4.80
0.80
.37
Years of ICU experience
5.97
4.49
6.11
5.79
0.03
.87
Training hours
0.38
0.73
0.35
0.68
0.07
.80
n
%
n
%
22
Job title Above NP Below NP
23 53
30.3 69.7
17 43
28.3 71.7
Educational level Above Bachelor Below Bachelor
39 37
51.3 48.7
39 21
65.0 35.0
Prior training Yes No
22 54
28.9 71.1
15 45
25.0 75.0
Variable
0.06
.85
2.57
.12
0.26
.70
Note. EG = experimental group; CG = control group.
TABLE 2.
Comparison of Knowledge Scoring Index Between the Two Groups Variable
Regression Coefficient
SE
Z Value
p Value
6.97
0.19
36.39
G.0001
Pretest groups (EG/CG)
j0.10
0.26
j0.38
.70
CG time (pretestYposttest)
j0.17
0.23
j0.73
1.37
0.30
4.54
Intercept
Interaction between pretest group and CG time
.47 G.0001
Note. EG = experimental group; CG = control group. Regression model: knowledge score = 6.97 j 0.10 (group) j 0.17 (time) + 1.37 (Group Time).
TABLE 3.
Comparison of the Technique Correctness Index of the Two Groups Variable
Regression Coefficient
Intercept Pretest groups (EG/CG)
SE
Z Value
p Value
6.64
0.14
48.49
G.0001
j0.02
0.20
j0.09
.93
CG time (pretestYposttest)
0.22
0.15
1.42
.16
Interaction between pretest group and CG time
1.61
0.22
7.26
G.0001
Note. EG = experimental group; CG = control group. Regression model: technique score = 6.64 j 0.02 (group) + 0.22 (time) + 1.61 (Group Time).
and posttest scores for the CG in terms of knowledge, techniques, or attitudes. After taking pretest and growth effects into consideration for the EG, significant changes appeared in
knowledge and technical scores after the intervention but not in scores for attitudes or behaviors (p G .0001; Tables 2 and 3, Figures 1 and 2).
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Physical Restraint In-Service Education Program
VOL. 24, NO. 1, MARCH 2016
Discussion In-service education for physical restraints is insufficient in Taiwan. Nearly 73% of the participants in this study had never participated in in-service education related to physical restraints. Lee (2005) also found that 68% of their subjects had not taken any in-service education for physical restraints within the most recent 3-year period. Yeh et al. (2004) indicated that physical restraint had been addressed in the in-service education of only one third of nursing staff. Therefore, it is clear that in-service education on physical restraints has been neglected, which may lead to the improper use of restraints on patients in the ICU (Chiang, Hsu, Chen, & Kao, 1999; Kontio et al., 2009; Morris, 2007; Yeh et al., 2004). According to Yeh et al. (2004), although an in-service education intervention had a marked impact on new nursing staff in terms of knowledge and attitudes regarding physical restraints, it did not impact the skill of new nursing staff in terms of implementing the technique. This was attributed mainly to the short duration of time (3 days) between pretest and posttest. The subjects in this study had an average of more than 11 years of professional nursing experience, including 5Y6 years of experience in the ICU. Therefore, it is reasonable that the intervention would result in significant progress in terms of physical-restraint-related techniques and knowledge. The lack of impact of in-service education on attitudes and behaviors in this study is similar to the findings of Huang et al. (2009). Further research may examine the potential of short-term in-service education to affect long-term changes in attitudes and behavior. Evans et al. (2002) found that the restraint rate declined during the first 6 months of an in-service education program but that this trend reversed 12 months later because of the need to prevent patient falling and self-extubation. The finding indicated that 72% of critical care clinicians consider the absence of physical restraints to be a risk factor for accidental extubation in the ICU (Tanios, Epstein, Livelo, & Teresd, 2010). Therefore, ‘‘minimizing restraint use in patients with medical devices always carries a risk of deliberate or accidental device removal’’ (White, Purcell, Urquhart, Joseph,
Figure 1. Change of knowledge scoring index in EG and CG as evaluated by GEE. The average knowledge scores for the CG were 6.97 for pretest and 6.80 for posttest. The average knowledge scores for the EG were 6.87 for pretest and 8.07 for posttest.
Figure 2. Change of technique correctness index in EG and CG as assessed by GEE. The average technique scores for the CG were 6.64 for pretest and 6.86 for posttest. The average technique scores for the EG were 6.63 for pretest and 8.46 for posttest.
& O’Connor, 2012). Martin and Mathisen (2005) pointed out that, whereas Norwegian ICUs implemented 100% nonrestraint, 39% of ICU patients in the United States were restrained. Norway’s low nurseYpatient ratio (0.5Y1.5 patients/ nurse) and higher dosage and frequency of sedative drug administration are likely two important reasons supporting the high level of nonrestraint achieved in Norwegian ICUs. In Taiwan, the nursing staff in ICUs care for two-to-four patients, with one nursing staff responsible to the total care of one patient. Although increasing the nursing staff in the ICU may be an effective alternative to using restraints to prevent device removal, this option would incur significant extra manpower costs. In addition, because most physicians in Taiwan tend to use light rather than heavy sedation, patient incidents such as removing infusion tubes and falling are not uncommon. To prevent these events, most ICU nursing staff tend to support the use of physical restraints (Chiang et al., 1999). Martin and Mathisen (2005) suggested that using physical restraints was not only an implementation of healthcare measures but also the expression of ethical and cultural values and related healthcare authority policies. Cosper et al. (2015) pointed out that policy makers focused their attention on the needs of the entire organization rather than a single unit or ward. Changing restraint policy would thus require the involvement of a committee and a multidisciplinary team. Lee (2005) found that nursing standard operating protocols were the strongest predictor of physical restraint, accounting for 10% of restraint behaviors. Thus, this is worth further research focus and attention. Thus, the ability of in-service education to improve the use of patient restraints in the ICU with proper guidelines is worth further examination and exploration. However, changing the attitudes and behaviors of ICU nurses to reduce the use of restraints will require the Taiwan Joint Commission on Hospital Accreditation to coordinate an effective oversight program on physical restraint. The care team must also collaborate more closely to improve the sedation of restless patients, lower the nurseYpatient ratio, 83
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and offer ongoing in-service education for nurses to be able to reduce the use of restraints and to enhance patient care quality through the proper use of restraints.
Conclusions In-service education for physical restraints enhances the related knowledge and techniques of nursing staff but not the related attitudes and behaviors. This article found the use of demonstrations, the use of the teachYreply mode in conjunction with discussions on restraint techniques, and the use of standards to guide the correct choice of materials to be particularly effective tools. In-service education further significantly enhances the proper implementation of restraints by nursing staff. Future curriculum designs for physical restraint in-service education should take this mode into consideration. Furthermore, incorporating into in-service education materials data on restraint cases that use alternative measures and information on relevant ethical issues will help improve the reflection and learning of nurses and thus enhance their attitudes and behaviors with regard to the use of physical restraints. In summary, the implementation of physical restraint requires not only professional knowledge but also correct technique. Therefore, in-service education should combine classroom learning and hands-on technical practice to achieve improvement objective. The optimal clinical physical restraint in-service education curriculum design combines restraint techniques with judgment on ethical issues and the execution of alternative measures. We believe this design will effectively improve the curriculum in all the four aspects of physical-restraint-related knowledge, skills, attitudes, and behaviors; substantively reduce the use of physical restraints; and improve the use of alternative measures.
Limitations of the Study The major limitation of this study was the relatively short (1-month) follow-up period. Therefore, the long-term impact of the in-service education program and the correctness of the restraint technique over the long term were not evaluated.
Acknowledgments The authors wish to thank the Taichung Veterans General Hospital for funding this research (Project number TCVGH-951409A), Professor Sheng-liang Wu for statistical assistance, and the several experts who assisted with the validity test. The authors also gratefully acknowledge the assistance of the participating nurses.
References Berzlanovich, A. M., Schopfer, J., & Keil, W. (2012). Deaths due to physical restraint. Deutsches Arzteblatt International, 109(3), 27Y32. doi:10.3238/arztebl.2012.0027
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Birkett, K. M., Southerland, K. A., & Leslie, G. D. (2005). Reporting unplanned extubation. Intensive and Critical Care Nursing, 21(2), 65Y75. doi:10.1016/j.iccn.2004.07.012 Chang, L. Y., Wang, K. W. K., & Chao, Y. F. (2008). Influence of physical restraint on unplanned extubation of adult intensive care patients: A case-control study. American Journal of Critical Care, 17(5), 408Y415; quiz 416. Chiang, M. C., Hsu, L. N., Chen, T. O., & Kao, M. L. (1999). An exploration of the nurses’ knowledge and attitudes of physical restraints. Chang Gung Nursing, 10(1), 42Y50. (Original work published in Chinese) Chyan, M. R., Chen, Y. C., Guo, R. M., & Lee, Y. W. (2004). The effect of education intervention on nurses’ knowledge, attitude, and behavior of restrains in the intensive care units. Chang Gung Nursing, 15(3), 248Y257. (Original work published in Chinese) Cosper, P., Morelock, V., & Provine, B. (2015). Please release me: Restraint reduction initiative in a health care system. Journal of Nursing Care Quality, 30(1), 16Y23. doi:10.1097/ncq .0000000000000074 Curry, K., Cobb, S., Kutash, M., & Diggs, C. (2008). Characteristics associated with unplanned extubations in a surgical intensive care unit. American Journal Critical Care, 17(1), 45Y51; quiz 52. Endrikat, W. (2012). Almost free from restraints. Deutsches Arzteblatt International, 109(20), 376. doi:10.3238/arztebl.2012.0376a Evans, D., Wood, J., & Lambert, L. (2002). A review of physical restraint minimization in the acute and residential care settings. Journal of Advanced Nursing, 40(6), 616Y625. doi:10.1046/j.13652648.2002.02422.x Evans, D., Wood, J., & Lambert, L. (2003). Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing, 41(3), 274Y282. doi:10.1046/j.1365-2648.2003.02501.x Huang, H. T., Chuang, Y. H., & Chiang, K. F. (2009). Nurses’ physical restraint knowledge, attitudes, and practices: The effectiveness of an in-service education program. The Journal of Nursing Research, 17(4), 241Y248. doi:10.1097/JNR.0b013e3181c1215d Huang, H. T., Ma, F. C., & Chen, C. H. (2003). A correlation study among nurses’ knowledge, attitudes and practice toward physical restraints. Tzu Chi Nursing Journal, 2(2), 32Y41. (Original work published in Chinese) Karlsson, S., Bucht, G., & Sandman, P. O. (1998). Physical restraints in geriatric care. Knowledge, attitudes and use. Scandinavian Journal of Caring Sciences, 12(1), 48Y56. doi:10.1080/02839319850163138 Kontio, R., Va¨lima¨ki, M., Putkonen, H., Cocoman, A., Turpeinen, S., Kuosmanen, L., & Joffe, G. (2009). Nurses’ and physicians’ educational needs in seclusion and restraint practices. Perspective in Psychiatric Care, 45(3), 198Y207. doi:10.1111/ j.1744-6163.2009.00222.x Lee, H. J. (2005). A correlational study among nurses’ knowledge, attitudes, and practice toward physical restraints in intensive care units (Unpublished doctoral dissertation). Fooyin University, Kaohsiung, Taiwan, ROC. (Original work published in Chinese) Martin, B., & Mathisen, L. (2005). Use of physical restraints in adult critical care: A bicultural study. American Journal of Critical Care, 14(2), 133Y142. Mion, L. C. (2008). Physical restraint in critical care settings: Will they go away? Geriatric Nursing, 29(6), 421Y423. doi:10.1016/j .gerinurse.2008.09.006 Mion, L. C., & O’Connell, A. (2003). Parenteral hydration and nutrition in
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the geriatric patient clinical and ethical issues. Journal of Infusion Nursing, 26(3), 144Y152. doi:10.1097/00129804-200305000-00005 Morris, K. (2007). Issues and answers: Restraint use. Ohio Nurses Review, 82(4), 14Y15.
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Tanios, M. A., Epstein, S. K., Livelo, J., & Teres, D. (2010). Can we identify patients at high risk for unplanned extubation? A largescale multidisciplinary survey. Respiratory Care, 55(5), 561Y568.
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身體約束在職教育
VOL. 24, NO. 1, MARCH 2016
身體約束在職教育之效果評價 張瑛瑛1 尤琇慧2 羅爾維3 張麗銀4* 1
臺中榮民總醫院護理部督導長 2臺中榮民總醫院護理師 3禾八國際有限公司科學與英文 編譯部資深顧問 4臺中榮民總醫院護理部副主任
背 景
身體約束旨在維持病人安全 、預防受傷 ，但是如果使用不當 、未密切監測病人 ，或護 理人員執行身體約束的知能不足 ，則身體約束反而會造成病人的傷害。
目 的
主要在評價在職教育的介入對提升護理人員身體約束的知識 、態度 、行為及技術之效 果。
方 法
採類實驗法之二組前後測研究設計 ，以評價在職教育之效果。研究對象為中部某醫學 中心 4 個成人加護病房之護理人員 ，共 136 位 ，4 個加護病房內外科各為二 ，以隨機分 派內外科各一個加護病房為實驗組 ，另外則為對照組。先收集二組身體約束知識 、態 度 、行為及技術之前測資料 ，然後予實驗組2 小時以實證為基礎的身體約束臨床指引 ， 及身體約束技術之在職教育為介入方案 ，在職教育介入後一個月 ，收集二組之後測資 料。以 SAS 統計軟體之 GEE 進行重複測量分析。
結 果
護理人員身體約束之知識及技術在介入在職教育後有顯著的進步（p < .0001）；但態度 和行為則無顯著性改變。
結 論 在職教育可以提升護理人員身體約束的知識及技術 ，而藉由正確身體約束方法的執行 實務應用 不僅可以促進加護病房病人照顧的品質 ，亦可減少身體約束所造成的合併症。
關鍵詞：身體約束、在職教育、加護病房。
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