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Unwanted Immobilization:
The use of physical restraints in the pediatric population
Camille Diwata
Dominican University













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Introduction
There are many studies that attest to the detrimental effects of restraint use
(Nunno, Holden, & Tollar, 2006). Because of the physical, mental, and emotional
consequences, restraints are used as a last resort in all clinical settings (Nunno et al.,
2006). Despite their infrequency, restraints may be an unavoidable safety precaution,
especially if the safety of the patient or others is at risk (Minnick, Mion, Johnson,
Catrambone, & Leipzig, 2007). Considering the negative implications associated with
restraints, it is important for those involved in their application to understand the
indications for use, complications from use, and alternatives to use. Otherwise, the
ramifications on the patient could overshadow the therapeutic effects; thus, negatively
influencing the patients perspective and increasing the potential for harm.
The purpose of this paper is to explore the current literature surrounding the use
of physical restraints in the pediatric population. Because of the vulnerability of children
and adolescents, it is important for nurses to understand the purposes and potential
consequences of restraint use (Nunno et al., 2006). If the nurse were not confident in its
therapeutic value, or assesses the need for restraints inappropriately, the effects on the
child would not only be detrimental, but also long lasting. Therefore, it is important for
researchers to examine the prevalence and consequences of pediatric restraint in
pursuance of alternative methods to reduce or eliminate their use.
For the purpose of this paper, physical restraints will be defined as any
containment measure used to hold a patient against their will. Mechanical restraints, such
as straps to hold down the chest, wrists, or legs will be included in this review (Nunno et
al., 2006). Physical restraints, or the use of another person to restrict a child, will also be
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included (Nunno et al., 2006). Pediatric restraints used in non-clinical settings, such as
car seats, high chairs, or helmets will be excluded from the review.
This paper will use the current literature to explore the questions: What is the
prevalence of physical restraint in children? What are the complications associated with
restraint use? What are the current efforts to reduce physical restraint in children and how
effective are they?
Theoretical Framework
The research will be examined using Albert Banduras theory of self-efficacy.
This theory originated from Banduras social cognitive theory that discusses the way
humans learn and develop (Bandura, 1977). Bandura defines self-efficacy as a persons
perception of his or her own ability to accomplish a goal (Bandura, 1977). According to
Banduras theory, ones perceived self-efficacy influences his or her decisions and
actions (Bandura, 1997). This is important for the nurse determining a difficult childs
needs. The nurse needs to have an increased sense of self, along with a sufficient
knowledge base, in order to effectively communicate and respond in a situation where
restraint may be warranted.
Literature Review
All articles were found using CINAHL, Health Source: Nursing/Academic
Edition, and Science Direct. Search terms included restraint, children, nurses,
physical, and pediatric.
Minnick, Mion, Johnson, Catrambone, and Leipzig (2007) conducted a study in
the U.S. to address the prevalence of physical restraint use in acute care settings. The
authors approached the topic from a policy-making perspective with the intentions of
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analyzing the prevalence of physical restraint to improve the associated policies. Thus,
the aim of the study was two-fold: 1) to outline U.S. hospital restraint rates and patterns,
and 2) to investigate how to improve the related policy decisions based on their findings
(Minnick et al., 2007).
The study included forty randomly selected, acute-care hospitals allocated among
six major cities spread across the country (Minnick et al., 2007). Data were collected
between 2003-2005 on eighteen randomly selected days using observation and nurse
reports. Excluded units were post-anesthesia recovery, obstetrics, rehabilitation,
psychiatric, and emergency because of administrative differences that required alternative
research designs.
The results indicated about 27,100 patients are restrained each day with fifty-six
percent of restraint days occurring in the intensive care units compared to non-intensive
care units (Minnick et al., 2007). Prevention of therapy disruption was the highest
indication for restraint use with confusion listed as the second indication and fall
prevention as the third (Minnick et al., 2007).
The findings of this study underline the ever-present need to better address the
rate of restraint use. Without a baseline number of incidence, the effectiveness of
reduction strategies cannot be measured. Although the study by Minnick et al. (2007) was
not specific to children, it still paints a picture of restraint use in the U.S. The prevalence
in children is lower in acute settings, but this does not hold true in specialty units.
Additionally, because of the vulnerability of the population, the consequences can be
more severe.
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In 2006, Nunno, Holden, and Tollar explored the frequency and causes of death
surrounding restraint use in pediatric residential facilities across the country. In order to
gain more understanding about the safety and risks of restraint use, the authors conducted
a study uncovering the characteristics of children put in restraints and the clinical cause
of death.
The researchers used both mail-in surveys and Internet searches to uncover local,
state, and federally reported restraint deaths from 1993 to 2003 (Nunno et al., 2006).
Included in the study were male and females younger than 18 years of age receiving care
under public and private welfare, mental health, developmental disability, and
correctional facilities.
The results revealed forty-five pediatric deaths related to physical or mechanical
restraint use. Most of the fatalities occurred in psychiatric facilities. The most common
causes of death were asphyxia and cardiac arrest (Nunno et al., 2006). In thirty-eight
incidents, physical restraints where the child was placed in the prone position were used.
Out of the incidents, twenty-three fatalities documented a rationale for restraint. Restraint
use was indicated when the child showed combative behavior, refused to comply with
staff while in isolation, or exhibited aggressiveness towards other children (Nunno et al.,
2006).
The findings of Nunno et al. (2006) identify common causes of death related to
restraint use in children. Even though restraints are not implemented as frequently as they
are in other populations, the consequences can be highly detrimental and life threatening.
Their results also reflect a lack of knowledge among healthcare providers regarding
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appropriate times to initiate restraints, which puts children at risk for preventable injuries
and deaths.
Restraints are meant to promote a safe and therapeutic environment for those at
risk for harm to themselves or others, but their risks can easily outweigh their benefits if
misused. Based on previous literature, policy changes and educational models have been
pushed to further reduce the use of restraints across all populations, especially among the
pediatric population.
Martin, Krieg, Esposito, Stubbe, and Cardona (2008) conducted a study to
evaluate the effectiveness of a program intended to reduce the use of restraints in
children. The program was based on cognitive-behavioral principles to improve
collaborative communication skills. Improving these skills would help participants create
alternatives to restraint (Martin et al., 2008). The aim of the study was to analyze changes
before and after the implementation of the program in the pediatric psychiatric setting
(Martin et al., 2008).
The study was held from 2003 to 2007 in school-age children at the Yale-New
Haven Childrens Hospital. The program utilized problem solving, conflict resolution,
and anger management strategies to manage and prevent outbursts in children (Martin et
al., 2008). Twenty-five nurses participated in the training. Time and duration data were
collected before and after the implementation of the program (Martin et al., 2008).
Before the implementation of the program, 263 restraint interventions occurred
per year (Martin et al., 2008). After the completion of the program, seven events were
recorded per year. This marked a thirty-seven percent decrease in restraint use (Martin et
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al., 2008). The duration of restraints was also reduced from forty-one minutes to eighteen
minutes per episode, a forty-five percent decrease (Martin et al., 2008).
The findings of Martin et al. (2008) provide insight into foundational elements
that decrease the use of restraints. Some of these components include leadership support,
use of evidence-based practice, use of restraint prevention tools, participation of children
and families, and reviewing the restrictive event after it occurs (Martin et al., 2008). By
using collaborative, problem-solving skills, the nurses were more effective, not only in
communicating with the patient, but also with the healthcare team in order to maintain
safety on the unit.
In a more current study, Johnson, Lashley, Stonek, and Bonjour (2012) created an
education program to help staff prevent and manage challenging behaviors in children
with developmental disabilities. Based on Banduras theory of self-efficacy (1977), the
program concentrated on family-centered care and verbal communication skills. The
authors sought to answer two questions: 1) Do the nursing staff who participate in
training have more knowledge and less fear when working with children with
developmental disabilities? And, 2) Do the communication interventions in the program
lead to decreased staff injury or use of restraints (Johnson et al., 2012)?
Six hundred and four health care workers participated in the two-part program
(Johnson et al., 2012). The first portion was an online-based education with eight learning
objectives based on communication. The second portion was a one-hour, instructor-led
course to give professionals the opportunity to practice the skills learned in the online
portion. Based on a 10-point Likert Scale, staff knowledge increased from 5.5 to 8.7 (1 =
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no knowledge, 10 = much knowledge), while fear scores decreased from 3.2 to 2.7 (1 =
no fear, 10 = very fearful) after the program (Johnson et al., 2012).
Like the study by Martin et al. (2008), the study by Johnson et al. provides insight
on successful strategies nurses can implement when working in challenging situations.
Johnson et al. (2012) also provide successful teaching methods to create effective,
confident nurses. Johnson et al. (2012) furthers their program by including practice time
in which nurses can hone the skills taught to them through the videos. This type of
learning technique is especially beneficial when intervening with something as aggressive
as restraints. This way, the nurse has time in a safe environment to assess his or her own
feelings and discuss the possibilities of the situation with other healthcare team members.
Application to Nursing Practice
Restraint reduction programs target all health care workers working closely with
vulnerable children and their families (Martin et al., 2008; Johnson et al., 2012). Yet, it is
especially important for nurses to understand the indications of use because the
complications from using restraints can be long lasting and detrimental to both the child
and the family. Restraint-reduction programs are meant to empower health care
professionals, especially nurses, with additional tools and resources to avoid what should
be considered the final intervention when working with a difficult child (Martin et al.,
2008; Johnson et al., 2012). It is important to understand and participate in these types of
programs because it not only gives the nurse more tools to use with the pediatric
population, but with all populations of patients in difficult situations.


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Discussion
The current literature presents a dearth in knowledge regarding physical restraint
use in children. Because of the potential consequences associated with restraints, policies
were implemented to reduce their application in the healthcare setting. Although there
has been a reduction in the acute care units, the literature still reports routine use in
specific populations and specialty settings (acute psychiatric wards, residential facilities,
or developmentally delayed groups). Current research focuses on providing specialty unit
nurses with additional strategies to maintain a safe environment without jeopardizing the
independence of the patient.
In order to provide the best patient care and secure the best patient outcomes,
nurses in all settings need to be able to confidently assess a potential restraint situation
and exhaust all potential alternatives before considering restraints. Through education,
review, and practice, nurses can have the knowledge base and confidence when
participating in a difficult situation in order to make the safest decision for the patient. By
reviewing the risks, presenting additional strategies of intervention, and providing
support, nurses will be better equipped in various circumstances and in turn, reduce the
use of restraints.






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References
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavior change.
Psychological Review, 84, 191-215.
Johnson, N., L., Lashley, J., Stonek, A., V., & Bonjour, A. (2012). Children with
developmental disabilities at a pediatric hospital: Staff education to prevent and
manage challenging behaviors. Journal of Pediatric Nursing, 27(6), 742-749.
doi:10.1016/j.pedn.2012.02.009
Martin, A., Krieg, H., Esposito, F., Stubbe, D., & Cardona, L. (2008). Reduction of
restraint and seclusion through collaborative problem solving: A five-year
prospective inpatient study. Psychiatric Services, 59(12), 1406-1412.
Minnick, A. F., Mion, L. C., Johnson, M. E., Catrambone, C., & Leipzig, R. (2007).
Prevalence and variation of physical restraint use in acute care settings in the US.
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5069.2007.00140.x
Nunno, M. A., Holden, M. J., & Tollar, A. (2006). Learning from tragedy: A survey of
child and adolescent restraint fatalities. Child Abuse & Neglect: The International
Journal, 30(12), 1333-1342.