A Descriptive Cross-Sectional Study to Assess the Perception and Knowledge of Staff Nurses regarding Physical Restrains

Purpose: The purpose of this study was to examine the perceptions and knowledge regarding physical restraint used among registered nurses (RNs) and nursing assistants (NAs). Method and Sample: A descriptive cross-sectional design was used. A convenient sample was recruited from nursing staff from Palestinian and Saudi Hospitals. Perceptions of Restraint Use Questionnaire (PRUQ) were used [1]. Results: A total of 144 nursing staffs were included. Physical restraint use was perceived as more important in some circumstances than others. In the critical care unit/ICU, the most important perceived reason for physical restraint use was protecting from falling out of bed and preventing removing dressing. There were significant differences of overall score for the PRUQ among all nursing staff according to hospital, t (142) = 8.74, P = 0.001. The mean of Saudi Arabia hospitals group (M = 4.56) was higher than the mean of Palestinian hospital group (M = 3.67). At the same time, there were significant differences of overall score for the PRUQ among all nursing staff according to specialized education in geriatrics, t (40) = 3.60, P = 0.001. The mean of no specialized education in geriatrics group (M = 4.13) was higher than the mean of yes specialized education in geriatrics group (M = 3.69). Conclusion and Implications: Nursing staff showed positive attitudes towards restrains application with difference between Palestinian and Saudi Arabian nurses. Proper implementation and good awareness of the complications are prerequisite for application of physical restrains for patients.


Introduction
Physical restraints is using any method or equipment attached to the body of a person to limit his movement or restrict it [2]; the most common equipment or devices are dressing and gauze, side rails, upper and lower limbs restraints, wrist restraints, or multi of them [3] [4] [5]. The Center for Medicare and Medicaid Services (CMS) defines a restraint as any manual method, physical or mechanical device, material or equipment immobilizing or decreasing the ability of a patient to move arms, legs, body or head freely in all hospital settings [6].
Nurses as well-known are usually the primary care givers for patients; they are usually the ones who take the decision of the need to apply physical restraints or not. Their perception, knowledge, practice, and attitude about physical restraints can affect the health of their restrained patients, and reduce the percentage of complications among them [7].
Prevention of falling of self-harm and removal of medical devices may be reasons for restraint [8]. But at the same time strangulation, muscle loss, pressure ulcers, incontinence, contractures, cognitive and functional impairment, agitated behaviors, psychological distress and death have been reported in hospital settings from physical restraint use [9].
Nurses perceived physical restraints purposes in different ways: the majority of 785 Spanish nurses perceived them as a method for patients safety like preventing fall from bed or chair or avoiding medical devices interference, while only some of them perceived them as a way to prevent patients from taking things from others, preventing them bothering others, or as substituting for staff observation [10].
Nurses in ICU perceived physical restraints as a method to prevent tubes disconnection. Preventing falling from bed could manage confusion, agitation, or impaired psychology, while the lowest reported was prevent falling from chair.
They didn't think that nurses needed to stop using of physical restraints [4].
One systematic review concluded that fallings were prevented as the major rational for using physical restraints [10]. But some nurses feel gilt when using restrains [11].
Nurses' knowledge of physical restraints and how to apply them were found to be poor. 100% of nurses reported had inadequate knowledge of wrist and legs restraints [7]. Another study reported lack of knowledge regarding alternatives of physical restraints. 71% of the nurses agree that there are no alternatives for physical restraint, and [12].
Physical restrains still one of important topics discussed in health care setting specially hospitals. More and more debates arise in the literature regarding using circumstances that allow nurses to use restraints especially in acute care units [13].
Some deaths caused by restraints were results from nurses' lack of continuous observation for those patients who died from strangulation, chest compression, or dangling in head down position [14].

Study Purpose
The purpose of this study is to examine perception and knowledge of nurses regarding the use of physical restraints.

Study Design
A cross-sectional descriptive design was used in this study. Data collection takes about two months from May to July 2017.

Sample and Setting
A convenience sample of (N = 144) nurses was selected from 3 hospitals in Pa-  Evans and Strumpf.

Data Collection and Instruments
The questionnaire was distributed by hand by the researchers to the participants and collected the second day during working shifts.
The questionnaire is already tested for its validity and reliability by the authors.

Ethical Concerns
Participants in the study were informed to insure consent form, and not to write their personal information and names. Possible harms, benefits, and the right to

Data Analysis
SPSS version 20.0 was used to analyze data, descriptive analysis was used to analyze demographic data, and t test statistics were used to assess nurse's perception and knowledge of physical restraints.

Results
There were 144 participants out of a total possible number of 200; thus the response rate was 72%. Fifty percent of the sample was staff nurses, the practical nurses sample composed 41%, and nurse managers were 9% of the total population. The subjects had been in their nursing role between 1 and 36 years with average 6.53 years; 56.3% were female. Thirty-nine percent work in ICU or critical care unit. Around fourteen percent reported being enrolled in previous education program see in Table 1. Previous education about restrains: • Yes  Perception of restraint: The mean overall score for the PRUQ among all nursing staff was 4.1out of a possible 5.0. The mean score among Practical Nurses were 3.68; the mean score for staff nurses were 4.44; and the mean score for nurse managers were 3.78.
Examining of the scores indicates that physical restraint use was perceived as more important in some circumstances than others. The mean ranking order for item area is given in Table 2.     To assess whether overall score for the PRUQ among all nursing staff was affected by sex, experience, specialized education in geriatrics, and hospital. An independent sample t test was performed. There were significant differences of overall score for the PRUQ among all nursing staff according to hospital, t (142)  Table 4. Table 5 showed that a Pearson's correlation coefficient was performed to assess the relationship between PRUQ among all nursing staff and age, and with experience. There was a small positive correlation between PRUQ among all nursing staff and age (r = 0.04, n = 144, P = 0.631). At the same time, there was a small positive correlation between PRUQ among all nursing staff and experience (r = 0.06, n = 144, P = 0.476).

Discussion
A majority of the sample were staff nurses (50%) while 9% of the participants were nursing managers (9%). Compatible sample characteristics were in one study in Dutch hospitals. A majority of the sample were nurses (81%), while managers were about 5% [5], and in the study of [3]. Results of this study showed that 56% of the participants were females and 44% were males, while in another study females represented almost all the sample. In the study of [4] 99% of the sample were females, while in another study in Malaysia 95% of the participants were females [12], and 90% in one study in Spain [10]. In Germany, 81% of one study sample were females [5]. The sample was balanced between male and female which might reflect more represented results.
The mean of years of experiences among participants was 6.53 years close to the results of one study conducted in China m = 6.29 [4], while in one study in Malaysia it was 4 years or less [12]. Even in Egypt the majority (64%) of one study' participants' experiences were less than 5 years [3]. In contrast it was about 18.6 years in another study in Germany [5].
Results of this study showed that the mean overall score for the PRUQ among all nursing staff was (m = 4.1) out of a possible 5.0. It was (m = 4.44) for staff nurses, and (m = 3.68) for assistant nurses. In contrast the results of one study in Spain used the same questionnaire which showed total score (m = 3.47). The mean score of staff nurses was (m = 3.0), while nursing assistant score was (m = 3.59) [10]. This means that Spanish nurses have better perception and knowledge of physical restrains than our nurses.
Regarding general wards nurses perception of the purpose of using physical restraints, "prevent patients removing dressing" was perceived as the most important purpose for using restraints (m = 4.51), and "protecting from falling out of bed" (m = 4.41) was perceived as the second important purpose. In one study in Taiwan (China) 59% of the patients were restrained to prevent falls, and in Spain the highest mean for restraints purpose was for preventing falls out of bed (m = 4.36) which was close to the results of the current study, while preventing removing dressing mean (m = 3.61) was less than mean of this study (m = 4.51) [15].
In contrast, in another study different purposes were perceived to be more important. In one study in china nurses perceived "preventing pulling out the feeding tubes" as the main purpose for using physical restraints; its use was higher among agitated patients (m = 4.19), while falling out of bed mean was only 2.95 [3].
ICU unit nurses in this study perceived "prevent patients removing dressing" and "protecting from falling out of bed" (m = 4.30) as the most important rational for using physical restraints compatible with the results of general wards in this study. ICU nurses in another studies perceived another rationales. In china the most important reason was to prevent accidental extubation and higher used to manage agitation (m = 4. 53) followed by "prevent pulling out an endotracheal tube" (m = 4.32) [4]. Canadian ICU nurses at two ICUs reported that 43% out of 141 patients were restrained to prevent agitation, 17% because of restlessness, and 17% as a precautionary measure. In contrast alternative methods prior restraints were used with only 33% of the patients [16] [17].
Preventing taking from others was perceived as least important (m = 3.32); it

Recommendation and Implication
The difference in mean between Saudi and Palestine hospitals need more studies to explain the factors affect total score of PRUQ. Nurses needs to be more aware of the importance of assessment and follow up when apply physical restraints.