In this secondary data analysis of cross-sectional data on restraint use in Swiss and Austrian hospitals, we analysed the impact of organisational factors on the use of restraints in the somatic acute care hospital setting, as well as the practice variation among hospitals. Overall, the restraint prevalence rate was 8.7%. We found that the availability of guidelines regarding restraint use on the institutional level and refresher courses for at least 80% of ward nursing staff in the last two years are associated with less restraint use. On the contrary, no association was found for the availability of a multi-disciplinary expert committee regrading restraint use within the institution and regular audits on the ward level to ensure compliance with the guidelines regarding restraint use. Furthermore, the findings show that a relevant part of the variance in restraint use is explained at the hospital level (random effect), suggesting that a hospital effect exists regarding restraint use. The difference between hospitals also appears to be greater than that between countries, as might have been expected given the much higher restraint prevalence rate in Switzerland (the country variable was not selected for the model). Thus, there is evidence that, in similar patient situations, restraints are used more frequently in some hospitals than in others. This finding supports assumptions from the literature that, regarding restraint use, local habits, routine and institutional culture seem to play an important role (18–21, 42). Such routine or habitual restraint use, independent of an objective and evidence-based evaluation, violates professional values and fundamental human rights. Therefore, critical interprofessional reflections on the current restrictive practice within hospitals are needed to minimise non-professional, non-legal and non-ethical restraint use. However, based on well-known safety models, like the Swiss cheese model, we know that patient safety is not only influenced by health professionals involved in direct patient care (micro level) (43). The conditions within an institution (meso level) and on a national level (macro level) also have a significant impact on patient safety. For this reason, critical reflection on current restraint practices should take place on micro, meso and macro level.
On the micro level, a critical interprofessional reflection of practice is only possible with appropriate knowledge about the topic of interest. Regarding restraint use, it is widely discussed that health professionals in the hospital setting do not have sufficient knowledge and expertise (21). As a result, restraints are often applied in situations that are not appropriate (14, 19, 22, 44). For example, restraints are used for fall prevention, even though there is growing evidence that restraints are ineffective in preventing falls (16, 17). Also, in this study, indications could be found that knowledge influences the use of restraints, since attending a refresher course is associated with less restraint use. Thus, in line with the recommendations of a Cochrane review regarding restraint reduction in general hospitals (45), education of health professionals seems to be a relevant component for restraint reduction. In this regard, it seems important that an interprofessional approach is taken, as this is the only way to change the institutional culture, the perception of risk-taking and the work ethic (42). In particular, the results of this study show how important these institution-specific aspects seem to be (hospital effect).
However, changes in these institution-specific aspects also require a strong commitment from the meso level. First of all, there is a need for open discussion within an institution, for example to clarify responsibilities for safety (42). Especially in the care of elderly people, the assessment of security issues needs different perspectives (46). For example, functional needs must also be weighed in the decision-making process in terms of using or not using restraints. This is even more important as, like the findings show, older and more care-dependent patients have an increased risk of being restrained during their hospital stay, and as restraint use is associated with functional decline. In addition, mental and behavioural disorders are associated with a higher use of restraints. This means that a very vulnerable patient group is most affected, i.e. patients who often cannot stand up for themselves; therefore, ethical considerations are even more important. In this regard, the management has the responsibility to support front-line staff by influencing the structural conditions for example, as also shown in this study, by providing policies/ guidelines that support decision-making or at least restraint management in line with legal and ethical requirements (18, 20–22, 24, 45). In addition, they can adapt the infrastructural conditions, for example by removing restraint equipment from the wards, as it is known that the availability of restraint equipment influences its use (23). It seems interesting that, in this study, regular audits and the availability of an expert committee were not found to be associated with restraint use. A possible explanation might be that, for both tasks, the individual person (who conducts the audit or is a member of the expert committee) must be able to critically reflect on the situation in which restraints are used and, in particular, to take an outside perspective in order to identify restraint use due to the institutional culture or attitudes. However, as discussed above, the knowledge and expertise of the individual person might be insufficient and therefore no effect of these two organisational factors could be measured.
To support critical reflection on the micro and meso level and thus to support the change in restrictive practice in order to protect human rights of personal freedom and to ensure professional restraint use, interventions should also be taken on the national (macro) level (43, 47, 48). For example, in both included countries (Switzerland and Austria), clear legal regulations regarding restraint use in the hospital setting are lacking (15). However, clear regulations, professional statements of nurses or medical associations and national guidelines would help institutions to clarify their policies, would support the uniform education of health professionals and would provide a basis for national quality improvement programs in the hospital setting. Such programs often lead to more uniform monitoring of restraint use within institutions and thus enable comparison, which are both important aspects in restraint reduction (24, 49).
As restraint use is a very sensitive issue, in this respect, a national quality measurement with a risk-adjusted comparison should be considered. This is the only way to guarantee that the different patient mix of institutions is taken into account and that a fair statistical comparison can be made (43). Moreover, there is otherwise a risk that institutions with a higher restraint prevalence rate will only see their patient mix (e.g. older, more care-dependent) as the reason for the higher rate and will then reflect on the institution-specific aspects insufficiently. However, as described, this critical reflection seems to be essential for less restrictive practice. In addition, such efforts on the national level could stimulate a more open information policy regarding restraint use in hospitals, more critical thinking about restrictive practice in general and open discussions both within institutions but also in society. These aspects are well-known from similar approaches in the mental health or long-term care setting (50, 51).
Limitations
Beside its relevant findings, this study has some limitations. First of all, some organisational factors expected to be associated with restraint use (e.g. nurse to patient ratio) and health professional-related factors were not assessed with LPZ 2.0. It is, therefore, possible that the impact of the included organisational factors is over- or underestimated as is the relevance of the hospital effect. Secondly, it is possible that a selection bias exists. Patients who could not give informed consent and had no legal representative available had to be excluded. It could be that these patients were at high risk for restraint use and, therefore, the prevalence rate might be underestimated. Also, the impact of the predictors might be slightly different when including these patients in the analysis. Similar consequences could also be caused by a potential recall or documentation bias because restraint use was assessed over a period of 30 days. However, it is known that, regarding restraint use, the documentation is often incomplete (5, 15). Thirdly, the cross-sectional design has its limitations; on the one hand, the patient situations under investigation can fluctuate strongly within institutions on the measurement day and, on the other hand, no causal correlations can be identified using a cross-section design. For example, greater care dependency could lead to restraint use, but could also be a consequence of restraint use.
Despite these limitations, the results are expected to be generalisable due to the sample size and the methodological accuracy. They provide important indications for future quality development efforts. In this context, it seems to be of interest to investigate explanations for the additional 31% of explained variance on the hospital level. The inclusion of further structural characteristics in data collection and a subsequent analysis or a qualitative approach, for example by observing the (interprofessional) processes surrounding restraint use, could be helpful in this regard.