ASSESSMENT OF NURSES MANAGEMENT SKILLS
FOR CRITICALLY ILL PATIENTS
*ALI S1, GILLANI SA2, AFZAL M1,
PERVEEN K1
1Lahore
School of Nursing, The University of Lahore, Lahore,
Pakistan
2Allied
Health Sciences, The University of Lahore, Lahore,
Pakistan
*Corresponding author email: pbsn02183050@student.uol.edu.pk
Abstract
The
Nurses usually use physical restraints for maintaining patients’ therapies and
devices in a critical ill setting like ICU, like central lines, endotracheal tubes and the arterial lines. It has been
found that about up to 78% among the critical ill patients who have been admitted
into various types of ICUs and may have a need for applying a physical self-possession
due to the alterations found among their levels of the awareness while during their
stay at ICU ward. The nurses' attitude, knowledge and their practice for
physical self-control played a vital role for nursing care which has to be provided
for restrained patients to prevent form complications in ICU. We have conducted
our research to assess nurse's attitudes, knowledge and practice regarding their
physical self-control among the most critically ill patients in ICU. We have
used a descriptive type of design for our study. The number of nurses used for
our study was 66 in total who are working at Lahore School of Nursing, The
University of Lahore, Lahore, Pakistan. From our study
most of the samples were female, who had a bachelor degree in nursing, with
experience of more than 5 years, the aged was ranged between 21-30 years old, along
with not attended any of the previous degree or equivalent educational program related
with self-control or restraints were under consideration. It was found from our
study that majority of samples under study were with reasonable level of nursing
knowledge, offensive type of attitude however, around 90.8% out of all nurses showed
a satisfactory and moderate type of practice for applications of the physical self-control
or restraints for critical ill patients in ICU. It was frond from correlation
among the socio-demograhpic characters and nurses`
knowledge, the practice and attitude, no significant type of correlation was
recorded while among the nurses' age vs knowledge, the
practice and attitude, a significant and positive correlation was found while
among the nurses’ knowledge, gander and practice was also found a significant
correlation along with nurse’s practice and qualification, a significant positive
correlation was also among the nurses’ practice score, attitude and experience.
It was concluded from our study that, a reasonable level of nurses' improper
attitude, knowledge and a satisfactory practice for physical self-control or restraints
was found among the critically ill patients in ICU. From our study we have
suggested that there must be some proper training programs to teach nurses to
develop their knowledge and physical restraints while working in ICU for proper
care of patients.
Keywords: ICU, critical ill patients, nurses' knowledge, physical
restraints, attitude, practice, consciousness alteration
Introduction
Special
care with constant nursing monitoring is necessary for critically ill patients
to help them recover from life threatening conditions or injuries (Kandeel
and Attia, 2013) additionally,
these patients are prone to develop altered consciousness level i.e confusion, thus can try to get rid of connected life
support and monitoring devices including nasogastric
tube, endotracheal tubes, arterial line, and central
lines which can harm themselves (Azab
and Abu Negm, 2013). About 80% of
severely ill patients that admitted to a variety of ICUs require application of
physical restraints because of change in their consciousness level during ICU
stay (Phillips,
2013). Use of
physical restraint within surgical ICU patients was much lower (14.5 to 34%)
than medical ICU patients (12.6 to 50.1%) (Martin
and Mathisen, 2005). Physical
restraint refers to “any device ,substance or equipment that is used to
restrict any physical activity or free movement of patient including usual
access to his/her own body (Elsatar
and El-latief, 2015). The prevalence
of physical restraints application is 62% and 65% in confused patient in order
to avoid falling risk. Though this is a difficult decision and depends on
patient characters, the practitioner, and the environment. There are a variety
of restraints including mitts and wrist restraints, elbow immobilizers, vests,
belts, leg restraints as well as bed side barriers (Ang et al., 2015; Taha and Ali, 2013). Maintaining
patient safety is the main indication in use of physical or chemical restraint
during the change in her or his level of consciousness. The limitation of
chemical restraint is increased risk of sedation. Thus, Application of physical
restraint in confused patients limits interference while providing nursing care
(Younis
and Sayed Ahmed, 2017). Use of
physical restraint is contraindicated in patient with edema, aspiration,
breathing problems, contractures, fractures, paralysis and pressure ulcers .An informed consent must be
taken from patient or his/her family as ethical consideration (Elsatar
and El-latief, 2015). As it effects
patient and family reactions such as low patient’s self-esteem, increased
anxiety, fear, loneliness and detention. It also has effect on nurse’s feelings
including guilt, disappointment, and embarrassment when they apply physical
restraint to their patients (De
Jonghe et al., 2013). Critically ill patients develop some
complications due to physical restraint application such as limb edema,
restricted circulation, pressure sore, and also skin laceration at restraint
site (Strout,
2010). Close
monitoring and alteration in nursing care plan can preclude theses
complications. Given that, nursing care plan should consists of regular and
frequent change of patient’s position with sufficient range of movement (Elsatar
and El-latief, 2015), removal of
restraints for every two hours, assessment of the patient’s response hourly and
also skin care (Kandeel
and Attia, 2013). Application of
physical restraints can be affected by numerous factors such as number of
nurses, their attitude, experience, qualification and knowledge about the use
of physical restraint. These factors accounts for their major role in providing
nursing care to restrained patients and prevent its complications. The KAP
study outlines the correlation of restraint effect with nursing care and
identification of the strengths and weakness (Nasrate
et al., 2017). Thus, the
study was aimed to assess nurse's knowledge, attitude and practice, concerning
physical restraints in critically ill patients.
Significance of
the study
The
food and drug administration (FDA) reported the death rate of at least 100
individuals per year in USA due to lack of practice in application of physical
restraints (Elsatar
and El-latief, 2015). Rate of
application of physical restraints is higher in ICU patients than other ward
patients; 33% - 68% and 30% respectively (Goethals
et al., 2013). Physical
restraint is among the most conventional practice in ICU patients. Though there
is insufficient data regarding the evaluation of nurses' knowledge, attitude
and practice for physical restraint application in critically ill patients.
This assessment is very significant because it identifies the need of nursing
education and training, which is necessary in training competent nurses with
good practice for physical restraint patients.
The aim of the
study
To assess nurse's knowledge, attitudes,
and practice about physical restraints in critically ill patients.
Research
question
Q1:
What are the nurses' knowledge, attitudes, and practice regarding physical
restraints?
Q2-Is
there a relationship between nurse's knowledge, attitudes, and practice and
their socio-demographic features?
Materials and
methods
A descriptive
type of hospital based study design was used for this study. The present study
was carried out in the ICU, Intermediate A, and B, at The Lahore University Teaching
Hospital, The University of Lahore, Lahore. The targeted
population of our study was consisted of 66 nurses who are working at The
Lahore University Teaching Hospital during our current study period. Our study
inclusion criteria were nurses willing for participation and the nurses who
were on vocation. The data were collected through using the structured
questionnaire interviews. The demographic data which was related to the nurses for
our study was included following of the characteristics: nurses' sex, age,
qualification, a number of years' experience, previous education on physical
restraint, and type of ICU. The tools were tested for their content by three
experts in the field of Medical-Surgical Nursing and Pediatric Nursing to
ascertain relevance and completeness.
Results
The
results from table 1 showed that the higher number of nurses was from age
ranged 21-30 years old with 56.061% from total 66 nurses who were kept under
study. The females were 49 with 74.242% along with bachelor education with same
number and percentage. The experience was found higher for more than 5 years
59.091%. The higher number of nurses was from ICU (39.394%).
Table
1.
Socio-demographic characteristics of nurses
|
Socio-demographic characteristics |
Study group (n=60) |
||
|
No. |
% |
||
|
|
21-30 years old |
37 |
56.061 |
|
Age (years) |
31-40 years old |
19 |
28.788 |
|
|
41 -50 years old |
10 |
15.152 |
|
|
Male |
17 |
25.758 |
|
Gender |
Female |
49 |
74.242 |
|
|
Diploma |
4 |
6.061 |
|
Qualification |
Bachelor |
49 |
74.242 |
|
|
Master |
13 |
19.697 |
|
|
Less than 5 years |
27 |
40.909 |
|
Experience years |
More than 5 years |
39 |
59.091 |
|
|
Yes |
23 |
34.848 |
|
Previous education program on physical
restraint |
No |
43 |
65.152 |
|
|
Intermediate A(CCU 1) |
17 |
25.758 |
|
Type of CC Nurses |
Intermediate B(CCU 2) |
23 |
34.848 |
|
|
ICU |
26 |
39.394 |
Table 2: Assessment of nurses` knowledge regarding physical restraints among
critical ill patients (n=66)
|
Question statements |
Agree No (%) |
Disagree No (%) |
Mean ± SD |
||
|
Physical
restraints designed to prevent patient’s injury and their application was
safety. |
54 |
81.818 |
12 |
18.182 |
0.516±0.237 |
|
A restraint is legal only if
it is necessary from patient harm. |
41 |
62.121 |
25 |
37.879 |
0.358±0.249 |
|
From patients' rights are
refusing the application of a restraint. |
28 |
42.424 |
38 |
57.576 |
0.403±0.150 |
|
Its application requires a
doctor’s order. |
31 |
46.970 |
35 |
53.030 |
0.428±0.251 |
|
The disturbance in the patient’s level of
consciousness disturbance requires application of a restraint. |
24 |
36.364 |
42 |
63.636 |
0.312±0.147 |
|
The
nurse should be released a restraint every 2 hours. |
37 |
56.061 |
29 |
43.939 |
0.058±0.149 |
|
Restraints
should be applied not tightly, with pad between the restraint and patient’s
skin. |
12 |
18.182 |
54 |
81.818 |
0.112±0.232 |
|
If a patient restrained while
lying flat in bed, maybe incidence of choking. |
41 |
62.121 |
25 |
37.879 |
0.067±0.147 |
|
There is many patients'
complication due to physical restraints as skin breaks up or restlessness. |
58 |
87.879 |
8 |
12.121 |
0.288±0.232 |
|
Never attached the restraint
to the side rails after restrained patient. |
27 |
40.909 |
39 |
59.091 |
0.243±0.250 |
|
Assessment and record for the
restrained patient are important every shift. |
51 |
77.273 |
15 |
22.727 |
0.808±0.132 |
|
A
nurse can be charged with assault if he/she applies restraints when they are
not needed. |
37 |
56.061 |
29 |
43.939 |
0.502±0.050 |
|
In an emergency situation, it
is legally a nurse can restrain a patient without a physician’s order. |
11 |
16.667 |
55 |
83.333 |
0.123±0.334 |
|
May
be presence of effective alternatives to restraints. |
34 |
51.515 |
32 |
48.485 |
0.408±0.250 |
|
May
be the presence of a relationship between the deaths and the use of vest
restraints. |
37 |
56.061 |
29 |
43.939 |
0.423±0.250 |
|
Total
nurses` knowledge mean score regarding Physical Restraints among Critical Ill
Patients |
|
8.355±2.926 |
|||
The results from table 2
indicated that the nurses` knowledge mean score regarding physical restraints
among Critical Ill Patients was found as 8.355±2.926. The results from table 3
indicated that nurses`
attitude mean score regarding physical restraints among critical ill patients
was found as 19.37±2.23.
Table 3: Assessment of nurses` attitude
regarding physical restraints among critical ill patients (n=66)
|
Statement |
Agree No (%) |
Disagree No (%) |
Non decided No (%) |
Mean ± SD |
|
I think that
patient’s family members have the right to refuse the use of restraints. |
23(34.85) |
10(15.15) |
33(50.00) |
0.57±0.54 |
|
I think that the nurses have the right
to refuse the application of patient restraints. |
12(18.18) |
14(21.21) |
34(51.52) |
0.43±0.69 |
|
If, i am a patient, I should have the right to refuse/oppose
when restraints apply to me. |
45(68.18) |
17(25.76) |
4(6.06) |
1.54±0.64 |
|
I believe that
placing a patient in restraints is wrong. |
11(16.67) |
23(34.85) |
32(48.48) |
0.23±0.44 |
|
I think that
the main cause of restraints application in the hospital is limited staff
number. |
36(54.55) |
17(25.76) |
13(19.70) |
1.14±0.57 |
|
I feel with uncomfortable senses when the family enters the patient’s
room, and they see him/ her
restrained. |
39(59.09) |
19(28.79) |
8(12.12) |
1.26±0.81 |
|
The hospital administration is legally
responsible for using restraints to keep the patient safe. |
35(53.03) |
26(39.39) |
5(7.58) |
1.34±0.22 |
|
It makes me feel terrible if the
patient gets more upset after restraints are applied. |
25(37.88) |
28(42.42) |
13(19.70) |
1.27±0.54 |
|
I think that it is more important to
let the patients with agitation or disturbed consciousness levels in restraints
during I provide care for them. |
23(34.85) |
33(50.00) |
10(15.15) |
0.76±1.2 |
|
I think that a patient suffers a loss
of dignity when placed in restraints. |
17(25.76) |
28(42.42) |
21(31.82) |
1.17±0.34 |
|
In general, I
think that I have all knowledge needed for caring for a restrained patient. |
19(28.79) |
26(39.39) |
21(31.82) |
1.29±0.23 |
|
Total nurses`
attitude mean score regarding Physical Restraints among critical ill patients |
19.37±2.23 |
|||
The
results from table 4 showed relationship among socio-demograhpic
characters and nurses` knowledge, attitude and practice regarding their physical
restraints among the critical ill patients. The results showed that there was no
significant correlation among the nurses’ age with knowledge, the attitude with
practice regarding the physical restraints faced by them. It was found that
here was significant and positive correlation among the nurses’ knowledge,
gander and the practice. In sense of the nurses’ qualification, a significant
and positive correlation was reported for nurse's practice and qualification. With
reference to the nurses' ICU experience a significant positive correlation was
found for nurses’ attitude, experience and practice scores.
Table 4: Relationship among socio-demograhpic characters and nurses` knowledge, attitude and
practice regarding physical restraints among critical ill patients
|
Socio-demographic
characteristics |
NO. |
Knowledge score Mean ± SD |
Attitude scores Mean ± SD |
Practice score Mean ± SD |
|
|
Age (years) |
21-30 years old |
37 |
8.32±2.15 |
14.19±2.0 |
13.13±0.72 |
|
31-40 years old |
19 |
7.67±0.80 |
11.125±1.124 |
14.27±3.12 |
|
|
41 -50 years old |
10 |
7.87±0.43 |
13.212±1.02 |
15.0±2.32 |
|
|
Test of significance |
F=1.03 |
F=0.261 |
F=1.21 |
||
|
P
value |
0.205 NS |
0.051 NS |
0.221 NS |
||
|
Gender |
Male |
17 |
10.15±2.41 |
14.18±0.127 |
17.16±0.32 |
|
Female |
49 |
9.13±1.13 |
13.06±2.23 |
17.61±2.32 |
|
|
Test
of significance |
t=3.109 |
t=0.128 |
t=3.112 |
||
|
P
value |
0.002 S |
0.106 NS |
~0.001 HS |
||
|
Qualification |
Diploma |
4 |
9.10±0.053 |
12.321±1.09 |
17.0±2.122 |
|
Bachelor |
49 |
8.027±2.15 |
13.22±1.04 |
15.97±0.145 |
|
|
Master |
13 |
9.135±0.152 |
14.31±1.102 |
13.55±3.521 |
|
|
Test
of significance |
F=0.95 |
F=2.820 |
F=2.125 |
||
|
P
value |
0.143 NS |
0.03 NS |
0.03 S |
||
|
Experience
years |
Less than 5 years |
27 |
9.19±1.94 |
14.210±1.124 |
15.68±0.147 |
|
More than 5 years |
39 |
8.21±1.21 |
13.25±1.231 |
14.73±0.322 |
|
|
Test
of significance |
t=0.43 |
t=3.973 |
t=2.11 |
||
|
P
value |
0.214 NS |
~0.002 HS |
0.03 S |
||
|
Previous education program on
physical restraint |
Yes |
23 |
9.21±0.51 |
13.02±0.10 |
15.36±3.20 |
|
No |
43 |
8.210±2.05 |
12.52±1.23 |
14.18±1.19 |
|
|
Test
of significance |
t=2.87 |
t=3.019 |
t=2.144 |
||
|
P
value |
0.27 S |
0.01 S |
0.003 S |
||
|
Type of CC nurses |
Intermediate A (CCU 1) |
17 |
9.104±1.205 |
13.35±1.43 |
16.43±1.48 |
|
Intermediate B(CCU 2) |
23 |
9.30±1.012 |
11.40±1.15 |
16.113±1.39 |
|
|
ICU |
26 |
6.20±1.203 |
10.07±1.38 |
18.16±2.31 |
|
|
Test
of significance |
F=0.021 |
F=0.212 |
F=0.09 |
||
|
P
value |
0.030 NS |
0.91 NS |
0.812 NS |
||
Discussion
Sick
patients may have many problems, or other diagnoses may lead to changes in
consciousness such as confusion and disturbance, causing a behavioral disorder.
Therefore the use of physical restraints is helpful in the intervention of
patients who resist during treatment. Physical restraint may create numerous
adverse responses, so prevented patients need to prepare nurses with enough
information and good training that gives them the right attitude and enables
nurses to transform their care plan to avert issues of physical restraint (Rose
et al., 2016). Evaluation of
nurse’s knowledge, attitudes, and practices regarding physical restraint are
critical in collecting information about current and future nursing care to determine
the quality of care provided to the patient and identify their weaknesses and
strengths. The purpose of the current study was to evaluate nurse information,
attitudes, and exercises regarding immune function among critically ill
patients. Regarding the demographic features of the study sample the present study
noted that, most of the evaluated nurses were women, their ages between 21-30
years old, and did not receive any previous education or training on physical
restraint (Younis
and Sayed Ahmed, 2017); which observed
that the majority of the sample was female and aged between 20-30 years and did
not attend any previous training or education program about physical restraint.As afar as the academic
qualification is concerned the majority of nurses had graduate degrees with
over 5 years of experience in nursing occupation inside ICU situations (Dolan
and Dolan Looby, 2017); who stated
that, Most of the nurses involved in their study practiced for many years in
the ICU as a registered nurse in the attention of intensely sick patients; and
they were nursing science graduates. The level of nurses`
knowledge about application of physical restraints. The mean score of
knowledge amongst nurse’s was 8.352±2.92 that reflected
that they were fairly informed about the usage of physical restraints in
seriously sick patients. This was not in agreement to the study results whom
established that, the knowledge of nurses about using physical restraints was
not appropriate (Gunawardena
and Smithard, 2019; Kısacık et
al., 2020). The
application of physical restraints in critically ill patients was found through
the attitude mean score in regards to use of physical restraints was 19.37±2.23.
This reflects that majority of nurses were having inadequate attitude associated
with the practice of applying physical restraints to seriously sick patients (Al-Khaled
et al., 2011; Luk et al., 2015; Unoki et al., 2020). Those studies
claimed that the attitude of most nurses was negative in their exercise of
applying physical restraints to the highly dependent patients. When the
practice parameter of nurses with reference to physical restraints was studied,
it was seen that the mean score was 17.08±2.09. Approximately 91.7% of the
nurses under study showed a good level of practice related to usage of physical
restraints on severely sick subjects (Kısacık et al., 2020). They
established that a fairly good number of their sample had adequate practice
about application of physical restraints.
Evaluating the association
of socio- demographic feature with & nurses` knowledge, attitude &
practice about physical restraints in severely ailing patients. The
current study failed to establish any significant correlation between academic
qualification and familiarity with physical restraints (Azab
and Abu Negm, 2013; Chien and Lee, 2007; Suliman et al., 2017). They
established that the knowledge of nurses having a graduate degree was not
significantly different from diploma holder nurses. However the difference in
practice parameter was statistically significant between academic degree and
diploma holder nurses (McHugh
and Lake, 2010; Oyesanya et al.,
2016). They
recognized that graduates (BSN) nurses were better than diploma holder nurses concerning
expert practices. It was elaborated by these researchers that baccalaureate
nurses accomplished extensive exercise on restraining during their enriched
curricular scheme of studies during graduation. The present study succeeded to
establish a positive relationship between gender and KAP of nurses (Kandeel
and Attia, 2013; Taha and Ali, 2013). In their study
no association was found between gender and KAP of nurses in physical
restraints usage. We found a statistically significant association between the
KAP score and the years of experience of nurses. These were similar to the
findings by various researchers who agreed that with increase in experience
time; the KAP score of nurses improves connected to physical restraints as
compared to inexperienced or low experienced nurses (Hamers
et al., 2009; Hofmann et al., 2015; Huang et al., 2009; Köpke et al., 2012).
Conclusion
In
the current study it was concluded that level of nurses' knowledge was good,
attitude was inadequate and practice was appropriate about physical restraints amongst
serious patients. Furthermore, no significant relation was found between nurses'
age and knowledge, attitude & practice. However, correlation was positive
between gender of the nurses but with practice and knowledge components only. Nurses’
qualification had a positive correlation with practice parameter only. Lastly, the
experience years of nurses were associated significantly only with practice and
attitude scores.
Recommendation
In
light of findings of our study, the investigators suggest that professional instructive
and academic curricula should be designed and workshops shall be arranged for
nurses employed in entire critical care locations like ICUs to enrich them with
sufficing training about physical restraint usage and their substitutes.The
healthcare systems must adopt evidence-based procedures transcribed formally
aimed at strategies or plans on physical restraint to be accessible to all
nurses and doctors to ensure compliance.
Conflict of
interest
The
authors declared absence of any type of conflict of interest for manuscript
publication.
References
Suliman, M., Aloush,
S., and Al‐Awamreh, K. (2017). Knowledge, attitude and practice of
intensive care unit nurses about physical restraint. Nursing in critical care 22,
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