Preventing the use of physical restraints on residents
newly admitted to psycho-geriatric nursing home wards:
A cluster-randomized trial
Anna R. Huizinga, Jan P.H. Hamersa,*, Math J.M. Gulpersb,
Martijn P.F. Bergerc
aDepartment of Health Care Studies, Section of Nursing Science, Maastricht University, The Netherlands
bVerpleeghuis Lu ¨ckerheide (Nursing Home), MeanderGroep Zuid-Limburg, The Netherlands
cDepartment of Methodology and Statistics, Maastricht University, The Netherlands
Received 5 April 2007; received in revised form 25 March 2008; accepted 28 March 2008
Background: Although there is an urgent need for restraint-free care, the number of randomized clinical trials on preventing or
reducing physical restraints has been limited.
Objectives: To investigate the effectiveness of an educational intervention to prevent the use of physical restraints on residents
newly admitted to psycho-geriatric nursing home wards.
Design: Cluster-randomized trial.
Setting: Fourteen Dutch psycho-geriatric nursing home wards.
Participants: 138 residents admitted to 14 psycho-geriatric nursing home wards after baseline measurement of the trial were
selected, out of which 33 residents died or informed consent had not been obtained. A total of 105 residents were included in the
Methods: The nursing homewards were randomly assigned to either educational interventionor control status. The educational
intervention consisted of an educational programme for nurses combined with a nurse specialist’s consultation. The data were
collected at 1, 4 and 8 months post-intervention. The use of physical restraints was measured by blinded, trained observers on
regarding restraint status, restraint intensity, multiple restraints and types of restraints were found. One month post-
intervention, 38% of the residents newly admitted to the experimental wards were restrained. Bilateral bedrails were the
most frequently used restraints at Post-test 1 (24%), Post-test 2 (23%) and Post-test 3 (28%), followed by the use of infrared
systems at Post-tests 2 and 3.
Conclusion: An educational programme combined with the consultation of a nurse specialist does not prevent the use of
physical restraints on residents newly admitted to psycho-geriatric nursing home wards. Although other studies have shown
Available online at www.sciencedirect.com
International Journal of Nursing Studies 46 (2009) 459–469
* Corresponding author at: Department of Health Care Studies, Section of Nursing Science, Maastricht University, P.O. Box 616, 6200 MD
Maastricht, The Netherlands. Tel.: +31 43 3881549; fax: +31 43 3884162.
E-mail address: email@example.com (J.P.H. Hamers).
0020-7489/$ – see front matter # 2008 Elsevier Ltd. All rights reserved.
promising results with the effectiveness of these types of intervention on restraint reduction, the development of additional
interventions to prevent restraint usage is recommended.
# 2008 Elsevier Ltd. All rights reserved.
Keywords: Cluster-randomized trial; Consultation; Education; Resident admission; Psycho-geriatrics; Physical restraint
What is already known about the topic?
? Physical restraints are commonly used with psycho-ger-
iatric nursing home residents and restraints are used as a
routine procedure in most cases.
? Several studies have shown a need for restraint-free care
in nursing homes.
? The number of randomized controlled trails (RCTs)
investigating the effect of restraint reduction programmes
is limited and has shown varying results.
What this paper adds
? An educational programme for nurses combined with the
consultation of a nurse specialist cannot prevent the use of
bilateral bedrails and other restraint types on residents
newly admitted to psycho-geriatric nursing home wards.
? This study confirms the general assumptions concerning a
routine usage of physical restrains on psycho-geriatric
nursing home residents.
? In order to achieve restraint-free care for psycho-geriatric
nursing home residents, more effort and interventions, in
addition to education and consultation, are needed, such
as analysing the attitudes and knowledge of the (nursing)
staff population, the residents and their representatives,
and stimulating the mobilization of residents.
Physical restraints are defined as any limitation on an
individual’s freedom of movement by using measures or
equipments such as belts tied to a chair or bed, bilateral
bedrails andchairswithtables (Hantikainen, 1998). Physical
restraints are commonly used on psycho-geriatric nursing
home residents. High prevalence values have been reported
in several studies, ranging from 15% to 66% (Capezuti et al.,
2007; Hamers et al., 2004; Huizing et al., 2006). In nursing
homes, physical restraints are in most cases used for more
than 3 months and as a routine measure (Hamers et al.,
2004). The use of physical restraints is based mainly on the
assumption that restraints prevent falls and fall-related
injuries (Evans and FitzGerald, 2002; Evans and Strumpf,
1990; Hamers et al., 2004). Furthermore, residents’ char-
acteristics, such as impairment in mobility and cognitive
status, are highly associated with restraint use with nursing
home residents (Hamers et al., 2004; Sullivan-Marx et al.,
1999). There are also indications that nurses’ attitude influ-
ences the use of physical restraints (Karlsson et al., 2001;
Suen et al., 2006; Werner and Mendelsson, 2001). Various
studies, however, conclude that the use of physical restraints
is ineffective in preventing falls and fall-related injuries and
may also lead to negative physical, psychological and social
consequences, suchaspressure ulcersanddepression (Cape-
zuti et al., 2007; Evans et al., 2003; Hamers and Huizing,
2005). The need to reduce physical restraint use in nursing
homes has, therefore, often been recommended in the lit-
erature (Hamers and Huizing, 2005; Strumpf et al., 1998).
The transition to restraint-free care involves a process of
change from viewing behaviourof residents, such as fall risk
and wandering, as a problem to be controlled with physical
restraints to viewing behaviour of residents as a commu-
nication of health-state change or unmet need (Strumpf
et al., 1998). This process of change can be complex and
slow (Strumpf et al., 1998), just like other processes of
change in healthcare (Grol et al., 2005; Rogers, 2003). So
far, a limited number of RCT investigations has examined
theeffectiveness of programmes onthe reduction of restraint
use (Evans et al., 1997; Huizing et al., 2006; Testad et al.,
2005). Comparable interventions, mostly consisting of edu-
cation and consultation, were tested in these studies.
Restraint education for (nursing) staff, usually combined
with support and advice in practice, was an important
component in these interventions. Although Huizing et al.
(2006) showed no effect on restraint reduction, two of the
RCT studies reported positive effects in reducing the use of
physical restraints (Evans et al., 1997; Testad et al., 2005).
Testad et al. (2005) have shown that an education program
nursing homes. Furthermore, Evanset al. (1997)have shown
that restraint education combined with specialist nurse
consultation is effective in safely reducing the use of phy-
sical restraints. However, it is unclear whether education and
consultation prevent the use of physical restraints on newly
admitted nursing home residents. Preventing the use of
restraints on these residents may be a first step in the
transition to restraint-free care, given the new situation
where nurses can implement individualized care and break
with routines concerning restraint use. Research on this
specific population is therefore needed to further understand
the transition process to restraint-free care.
The aim of this study was to determine whether an
educational intervention, consisting of an educational pro-
specialist, has a preventive effect on the use of physical
restraints with residents newly admitted to psycho-geriatric
nursing home wards.
A.R. Huizing et al./International Journal of Nursing Studies 46 (2009) 459–469460
Morris, J.N., Fries, B.E., Morris, S.A., 1999. Scaling ADLs
within the MDS. J. Gerontol.: Med. Sci. A 54 (11), M546–
Neufeld, R.R., Libow, L.S., Foley, W.J., Dunbar, J.M., Cohen, C.,
Breuer, B., 1999. Restraint reduction reduces serious injuries
among nursing home residents. J. Am. Geriatr. Soc. 47 (10),
Strumpf, N.E., Robinson, J.P., Wagner, J.S., Evans, L.K., 1998.
Restraint-free Care; Individualized Approaches for Frail Elders.
Springer Publishing Company, Inc., New York.
Suen, L.K.P., Lai, C.K.Y., Wong, T.K.S., Chow, S.K.Y., Kong,
S.K.F., Ho, J.Y.L., Kong, T.K., Leung, J.S.C., Wong, I.Y.C.,
2006. Use of physical restraints in rehabilitation settings: staff
knowledge, attitudes and predictors. J. Adv. Nurs. 55 (1),
Sullivan-Marx, E.M., Strumpf, N.E., Evans, L.K., Baumgarten, M.,
Maislin, G., 1999. Predictors of continued physical restraint use
Am. Geriatr. Soc. 47 (3), 342–348.
Testad, I., Aasland, A.M., Aarsland, D., 2005. The effect of staff
training on the use of restraint in dementia: a single-blind
randomised controlled trial. Int. J. Geriatr. Psychiatry 20 (6),
Van der Windt, W., Calsbeek, H., Talma, H., Hingstman, L., 2003.
Feiten over verpleegkundige enverzorgende beroepen in Neder-
land 2003 (Facts about nursing professions in the Netherlands
2003). The Netherlands Centre for Excellence in Nursing
to use physical restraints with older people: testing the theory of
reasoned action. J. Adv. Nurs. 35 (5), 784–791.
A.R. Huizing et al./International Journal of Nursing Studies 46 (2009) 459–469 469