身体约束不良影响及减少约束的策略

本文通过对身体约束的不良影响和各国减少约束的措施进行综述,提出应营造减少约束的环境,制定并有效实施基于循证的指南,加强对约束执行人员的教育培训,通过影响其知识、态度和行为改进约束实践。     

The movement of physical restraint‐free care for the elderly in Japan and Japanese culture

Abstract For a long time in Japan, there was no legal control or guidelines in the use of physical restraints at both acute and long‐term care facilities. Keeping the elderly in bed or binding them in beds, wheel chairs or geriatric‐chairs was commonly done. This seems to be related to a chief characteristic of the Japanese.     

Physical restraint reduction in the acute rehabilitation setting: a quality improvement study.

A prospective, continuous quality improvement study was implemented at a hospital on two rehabilitation units: stroke and brain injury. The purpose of the study was to decrease restraint use by 25% and to maintain fall rates no greater than 10% over baseline. A multi-component restraint reduction program was implemented that focused on administrative support, education, consultation, and feedback. Monthly restraint rates and fall rates were monitored and compared to the previous year's rates. Both units reduced restraint use. Importantly, this reduction was accomplished at the same time as a decline in fall rates.     

临床护士对患者身体约束的认知、态度及行为的调查

目的旨在调查临床护士对患者身体约束的认知水平、所持态度及行为表现,探讨其相关性和分析其影响因素。方法2015年1-6月,便利抽样法选取3所三级医院186名护士为研究对象,采用一般资料问卷和患者身体约束知识、态度、行为问卷进行问卷调查。结果护士对患者身体约束的认知评分为(8.67±1.54)分,其中"患者身体约束的护理原则"的答对率最高(76.60%),"身体约束适用情况"的答对率最低(48.17%)。护士对患者身体约束持中立态度,为(26.51±3.31)分;身体约束行为表现较为恰当,为(38.53±3.22)分。在对患者身体约束的认知、态度及行为上,近3年是否参加过身体约束继续教育的护士的得分差异均有统计学意义(均P0.05)。护士对患者身体约束的认知与态度、态度与行为之间呈正相关(r=0.343,P0.01;r=0.196,P0.05)。结论护士应提升自身对患者身体约束的认知水平,积极寻找替代措施;医院的护理管理者应规范身体约束的使用,并提供针对患者身体约束的继续教育。     

An exploratory account of registered nurses'' experience of patient aggression in both mental health and general nursing settings

Until relatively recently, aggression and violence in nursing has been an area of little discussion (Poster & Ryan 1993). Today, concerns are rising about escalating levels of violence towards nurses (Wykes 1994, Whittington 1997). In response, this paper explores registered nurses' experiences of patient aggression encountered in the acute inpatient general and mental health settings. Critical incidents from registered nurses in both areas are examined and analyzed in relation to existing literature. The aim of the research is to ascertain if differences exist or similarities prevail. Findings reveal that the two areas have similar problems in terms of types of aggression. Verbal and 'minor' types of aggression are the most problematic. Also, the 'biomedical model' of care is evident in both settings and possibly underpins chosen approaches to aggression management. The repeated use of chemical and physical restraint is apparent. The main comparison identified between the two groups relates to nursing control over situations involving violent patients. Mental health nurses seem to consistently take control of aggressive situations whilst general nurses tend to rely more heavily upon the input of others (medical staff, mental health teams and the police) when intervening. These two nursing specialties therefore have much to learn from each other in terms of nursing experience and possible future approaches to the management of aggressive patients.     

精神科患者保护性约束中知情同意的相关问题及对策

本文分析了精神科患者保护性约束中知情同意存在的问题和原因,并对我院实践方法进行了介绍,提出在保护性约束中只有遵循患者充分知情、理解、同意的原则,才能保证知情同意的实现。     

Medicate,restrain or seclude? Strategies for dealing with violent and threatening behaviour in a Norwegian university psychiatric hospital

The aim of this study was to examine staff strategies for applying emergency procedures with patients who were violent or threatening. The study addressed those situations where verbal intervention, voluntary medication, and other interventions had been tried unsuccessfully and where staff found it necessary to apply emergency procedures in the shape of forced emergency medication (pharmacological restraint), physical restraint, and seclusion. The study was conducted in a 100-bed Norwegian university psychiatric hospital. By retrospectively examining hospital records we found there were 797 episodes of physical restraint, 384 episodes of pharmacological restraint, and 88 episodes of seclusion during a five and a half year period. The preferred emergency procedures varied significantly with patients' sex, age, and diagnoses. Physical restraint was preferred more often with male, younger, and nonpsychotic patients. Pharmacological restraint was preferred more often with female patients and older patients with a nonorganic psychotic disorder. Seclusion was preferred more often with older male patients with an organic psychotic disorder.     

Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities

This study seeks to identify some of the explanatory factors associated with the use of intrusive measures among children with mental health and developmental disabilities in psychiatric facilities. Intrusive intervention data were collected using an organizational database that was developed internally at a tertiary care facility. The sample was composed of 338 children/youth aged between 6 and 18 years (mean = 12.33, standard deviation = 2.70) admitted within a 2‐year period. Logistic regression was used to examine the relationship between chemical restraint, physical restraint and secure isolation, and programme type after controlling for demographic and other relevant client characteristics. The study found that the number of chemical restraints and secure isolations was higher for clients with developmental disabilities than for clients with mental health, whereas the number of physical restraints was lower for clients with developmental disabilities than clients with mental health issues. Demographic variables also predicted specific types of intrusive measures. The results of this study outline the differential factors associated with specific types of intrusive measures to control aggressive and self‐harm behaviours. The paper also outlines cultural change initiatives, organizational interventions, and policy implications for best practice services for children/youth in psychiatric facilities to further reduce intrusive measures.     

Perspectives on the experience of being physically restrained: an integrative review of the qualitative literature

Publications providing information on the safe use of physical restraints, guidelines for restraint use, and journal articles on the care of mental health patients are frequently devoid of information regarding patients' perspectives on physical restraint. As physical restraint is a common procedure in many settings, the purpose of this review is to examine and summarize the qualitative literature on patients' perspectives on being physically restrained, from 1966 through to 2009. A formal integrative review of existing qualitative literature on patients' perspectives of physical restraint was conducted. Studies were critiqued, evaluated for their strength, and analysed for key themes and meanings. Twelve studies were ultimately identified and included in the review. Four themes emerged from the review, including negative psychological impact, retraumatization, perceptions of unethical practices, and the broken spirit. While little qualitative research on patients' perceptions of physical restraint exists, findings within the current literature reveal serious implications for patients and nurses alike. Additional research into physical restraint implications for the patient-nurse dyad is needed, and nurses should approach the use of physical restraint with caution and awareness of their potential psychological impact.     

ICU住院病人身体约束实施的现况调查

[目的]调查ICU住院病人身体约束的实施现况,为制定ICU身体约束实践指南提供依据。[方法]采用便利抽样法抽取国内12个省/直辖市的3055名ICU护士,采用自行编制的"临床护士对住院患者身体约束现状调查问卷"进行调查。[结果]24.3%的护士约束前不使用约束评估工具,16.0%的护士告知时未使用知情同意书,43.1%的护士实施约束后导致投诉或其他不良后果,24.9%的护士不知道具体的约束替代措施,62.5%的护士遇见被约束的病人发生过约束相关并发症,10.3%的护士实施身体约束后未进行护理记录。[结论]ICU病人身体约束评估、约束告知、约束器具使用、约束记录等存在不规范,需制定统一的身体约束标准以规范指导临床实践。     

重症监护室护士对身体约束相关知识、态度和行为的调查分析

目的了解重症监护室护士对患者身体约束相关知识、态度、行为的状况。方法对北京市某三级甲等医院4个重症监护室的121名护士进行患者身体约束相关知识、态度、行为的调查。结果重症监护室护士身体约束知识得分为(12.69±1.84)分,答对率为79.29%,态度得分为(33.46±3.05)分,行为得分为(49.33±6.46)分。不同性别、科室及监护室工作年限的护士在身体约束知识、态度、行为得分差异具有统计学意义(P0.01或P0.05)。结论重症监护室护士身体约束知识整体呈中等偏上水平,但身体约束适应知识存在不足;对身体约束呈中性态度,且有较恰当的身体约束行为。     

Dilemmas facing Japanese nurses regarding the physical restraint of elderly patients

Aim: The purpose of this study was to clarify the meaning of “dilemma” regarding the use of physical restraint on elderly persons as described by nurses in general wards at community hospitals. The questions asked included: to what extent has the dilemma of nurses regarding the restraint of elderly persons in the general ward been clarified?, which factor/s compose the dilemma?, what are the psychometric properties of the factors?, and how should nurses deal with the dilemma with regard to restraining elderly persons? Methods: The participants were 1477 nurses (12 male, 1463 female, and two: no answer) at 54 wards (excluding the emergency wards of psychiatry, pediatrics, obstetrics, outpatients, operating rooms, and intensive care units). The dilemma was measured by using a questionnaire consisting of 20 items previously developed by the author. Results: An explanatory factor analysis revealed four dilemma factors among 17 items investigated. These were “execution of treatment and security”, “characteristics in nursing of elderly patients”, “a cooperative relationship”, and “priorities in nursing”. The cumulative contribution ratio was 68.3%. In respect to the dilemma where nurses are faced with the physical restraint of elderly persons, four factors in the clarification of the dilemma were extracted: “execution of treatment and security”, “characteristic features in nursing”, “a cooperative relationship in nursing”, and “priorities in nursing”. Conclusions: Based on the psychometric properties, the Dilemma scale is a valid and reliable tool. The construction of four systems to cope with these dilemmas is suggested. These systems would enable practising nurses to communicate with comedical workers in order to reach a consensus about the elderly’s care, avoid restraining the elderly by allocating care specialists to the elderly, establish institutional policies and safety standards that establish the nurses’ responsibilities for patients’ decision‐making, and receive continuous and timely ethical education.     

住院患者身体约束方法的研究进展

本文对身体约束的分类、器械约束装置的改良、患者活动监管装置以及约束的辅助方法进行综述,以期为身体约束的合理使用提供参考,从而降低住院患者身体约束的使用率和使用时间,减少伤害的发生。     

ICU患者身体约束使用现状调查与分析

目的：了解重症监护室（ICU）患者身体约束使用现状。方法：采用自行设计的《ICU患者身体约束调查表》回顾性调查102例ICU使用约束的成人患者资料,内容包括一般资料、疾病与治疗状况、身体约束特征、护理记录等。结果：ICU患者身体约束的使用率为45.7%,其中65岁及以上老年人占41.5%,精神心理状况异常者占13.2%,认知状况受损者占12.1%,镇静剂使用者占17.2%,机械通气者占75.2%;约束工具以手腕棉布约束带为主,部位以肢体约束为主;存在约束护理不规范、使用指征不明确、护理记录不全等问题。结论：应逐步明确患者身体约束的使用指征及护理内容,构建信息化管理系统,最终形成适用于我国临床护理工作的规范。     

An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings

In Western society, policy and legislation seeks to minimize restrictive interventions, including physical restraint; yet research suggests the use of such practices continues to raise concerns. Whilst international agreement has sought to define physical restraint, diversity in the way in which countries use restraint remains disparate. Research to date has reported on statistics regarding restraint, how and why it is used, and staff and service user perspectives about its use. However, there is limited evidence directly exploring the physical and psychological harm restraint may cause to people being cared for within mental health inpatient settings. This study reports on an integrative review of the literature exploring available evidence regarding the physical and psychological impact of restraint. The review included both experimental and nonexperimental research papers, using Cooper's (1998) five‐stage approach to synthesize the findings. Eight themes emerged: Trauma/retraumatization; Distress; Fear; Feeling ignored; Control; Power; Calm; and Dehumanizing conditions. In conclusion, whilst further research is required regarding the physical and psychological implications of physical restraint in mental health settings, mental health nurses are in a prime position to use their skills and knowledge to address the issues identified to eradicate the use of restraint and better meet the needs of those experiencing mental illness.     

Views of nursing staff on the use of physical restraint

A postal questionnaire survey was employed in regional secure and psychiatric intensive care units in England and Wales, in respect of mental health nurses' training in the use of physical restraint. The nurses' views were sought relating to their last experience of implementing the procedure. Whilst most nurses (n = 259, 96.3%) reported positive outcomes in so far that the incident was brought under control, the views of the aftereffects of the procedure were of concern and ambivalence. The literature suggests that service users did not necessarily hold the same positive views. A range of alternatives, which were consistent with the literature, was made by staff to improve intervention in the management of violence. Negative aspects relating to the use of physical restraint were also highlighted. They included procedural, injury, clinical and management issues. Some respondents also expressed concerns about the negative attitudes of their colleagues. The findings of this aspect of the survey highlights that the therapeutic value of physical restraint can only be achieved with appropriate monitoring and with emphasis on psychological intervention in the prevention and management of violence.