INTRODUCTION:

Nurses in Intensive Care Units (ICUs) face a crucial task: ensuring patient safety while managing critically ill patients with potentially risky behaviors^1-6. These patients, often connected to various machines and lines^7,8, can exhibit restlessness, confusion, or agitation, jeopardizing their well-being⁹.

Physical restraints (PR) are sometimes used as a last resort to maintain patient safety. However, PR use raises concerns. Studies report a high rate of PR use in ICUs, exceeding alternative methods¹⁰. This highlights the need for a balanced approach. While PR can prevent self-harm or equipment removal, it can also cause physical and psychological harm to patients, negatively impacting their recovery¹¹. Additionally, nurses experience moral distress when using PR⁵. PR is primarily used to protect medical instruments and ensure patient safety¹². PR involves any manual method that restricts a patient's movement¹³.

To manage PR appropriately, nurses must have adequate knowledge and a positive attitude towards its use, ensuring critical thinking and sound clinical judgment in its application¹. PR use in ICUs has been reported at 56%, significantly higher than the use of antipsychotic drugs^10,14. Various organizations have called for reduced PR use and increased monitoring of restrained patients.

The literature shows no consensus on how nurses' personal and work-related characteristics affect their PR knowledge, attitudes, or practices^1,2,12. Nurses' attitudes showed weak associations with age and experience but not with ICU work time or weekly hours¹².

Studies indicate that ICU nurses who improperly apply PR often lack knowledge and training¹⁵, and face inadequate guidelines on PR use¹⁶. Nurses' knowledge of PR is linked to their practices and related complications¹⁷.

In Jordan, the use of PR in ICUs is common, partly due to nurse-patient ratios below international standards, leading to overworked nurses¹⁸. Research shows that Jordanian nurses have low knowledge and attitudes towards PR^2,19. PR use in Jordanian ICUs is prevalent, especially in surgical ICUs²⁰.

This study aimed to examine the correlates of knowledge, attitudes, and working conditions with nurses’ PR practices in ICUs, focusing on demographic and personal characteristics as predictors. The findings are essential for understanding the high PR use rate in Jordan and for informing future healthcare programs and nursing curricula.

RESEARCH OBJECTIVES:

The specific research objectives of this study are: 1) to evaluate the knowledge, attitudes, and practices of critical care nurses regarding the use of physical restraints in ICUs, 2) to examine the correlations between demographic characteristics and nurses' PR practices, and 3) to identify the variables associated with the practice of physical restraints among nurses using multiple linear regression analysis.

METHODS:

Study Design:

This study employed a descriptive-predictive design, a method akin to correlational research, allowing researchers to forecast future outcomes by assessing the relationship between relevant variables. We conveniently sampled nurses working in ICUs for this study. Our aim was to investigate how knowledge, attitudes, as well as demographic and occupational factors relate to nurses' PR practice in ICUs. Specifically, we explored these variables as potential predictors of nurses' PR practice.

Sample and Settings:

The sample size for this study was determined using the G*Power 3.1.10 software. Employing multiple linear regression with 11 potential predictors (as outlined in the correlation table), the minimum sample size required was calculated to be 123 participants (power = 0.80, α = 0.05, medium effect size 0.15).

Participants were selected based on specific inclusion criteria, including: 1) being a registered nurse, 2) working full-time in an ICU within a hospital located in Jordan, and 3) possessing at least one year of experience in an ICU setting.

To recruit participants, a questionnaire was distributed to 200 registered nurses employed in the selected hospitals. Ultimately, 145 responses were received, yielding a response rate of 72.5%.

Ethical Approval:

Ethical approval for this study was secured from the Al-Zaytoonah University of Jordan Institutional Review Board (IRB) committee and the administrators of the designated hospitals, with approval number 12692. Additionally, permission to employ the PR questionnaire was acquired from its original author. Furthermore, consent forms were obtained from all participating nurses, ensuring their voluntary participation and adherence to ethical standards throughout the study.

Measures:

The survey utilized in this study consisted of three distinct sections. The first segment pertained to demographic information, encompassing six items including age, gender, years of experience, marital status, educational attainment, and the specific type of ICU where participants worked. The second portion captured work-related data through four items, focusing on aspects such as patient-to-nurse ratio, shift patterns, weekly working hours, and participation in in-service training courses. This section was developed by the researchers drawing upon existing literature.

The third segment assessed participants' knowledge, attitudes, and practices regarding PRs, comprising a total of 36 items. This section was adapted from a scale developed by Janelli et al. (1994). The scale consists of three subscales: knowledge, attitude, and practice.

In the knowledge subscale, comprising 11 items, each correct answer was awarded one point, with higher scores indicating superior levels of knowledge. The attitude subscale, consisting of 12 items, employed a Likert scale ranging from "I strongly agree" to "I strongly disagree," with responses scored from 4 to 1 respectively.

The practice subscale, comprising 14 items, also utilized a Likert scale format with responses ranging from "never" to "always," scored from 1 to 3 points respectively, resulting in a total possible score of 42. Higher scores on the practice subscale denoted more favorable PR practices (Gandhi et al., 2018).

The scale's reliability and validity have been established through extensive use in various global studies (Stinson, 2016). The original questionnaire demonstrated a content validity index (CVI) of 0.86, and test-retest reliability coefficients were established for each section (Janelli et al., 2006). In our study, the internal consistency reliabilities were as follows: knowledge subscale α = 0.70; attitudes subscale α = 0.65; and practices subscale α = 0.92, indicating satisfactory reliability across all subscales.

Data Collection Procedure:

To initiate the data collection process, the primary researcher liaised with nursing managers at the selected hospitals, elucidating the study's objectives. Hospitals consenting to participate were requested to furnish the research team with the email addresses of ICU nurses meeting the inclusion criteria. Subsequently, invitations to participate were extended to eligible nurses via email, prompting them to respond by completing a Google Form provided in the email.

Given the data collection period coincided with the onset of the COVID-19 pandemic, adopting an online data collection approach served multiple purposes. Primarily, it mitigated potential infection risks associated with in-person interactions, prioritizing the safety of both participants and researchers. Moreover, conducting data collection online facilitated the maintenance of confidentiality, as responses were directly submitted electronically. This method ensured the smooth progression of the study while adhering to ethical and safety considerations amidst the prevailing circumstances.

Data Analysis:

Data analysis was conducted using Statistical Package for Social Sciences (SPSS) version 25.0 (IBM Corp, 2017). Frequencies were employed to analyze categorical variables, providing insights into the distribution of responses within each category. Descriptive statistics were computed for continuous data, offering a summary of central tendency and dispersion.

To examine associations between variables, correlation coefficient analyses were conducted. This allowed for the exploration of relationships between different study variables, shedding light on potential patterns and connections. Furthermore, multiple linear regression analysis was performed to account for potential confounding factors when assessing the association of PR practice with the predictors under investigation. This analytical approach enabled the identification of significant predictors contributing to variations in PR practice, while controlling for other variables. By employing these statistical techniques, a comprehensive understanding of the relationships between variables and their predictive power in the context of PR practice was attained.

RESULTS:

Table 1 provides an overview of the demographic and clinical characteristics of the study participants (N=145). The mean age of the participants was 30.7 years, with a standard deviation of 5.2 years, ranging from 21 to 50 years. On average, participants reported 7.7 years of experience in their role as ICU nurses, with a standard deviation of 4.9 years, ranging from 1 to 30 years. Participants reported working an average of 39.9 hours per week, with a standard deviation of 8.5 hours, ranging from 20 to 96 hours. In terms of gender distribution, 51.0% of participants identified as male, while 49.0% identified as female. Regarding marital status, the majority of participants (62.8%) were married, while 37.2% were unmarried. Academic qualifications varied among participants, with 8.3% holding a diploma, 73.8% holding a bachelor's degree, and 17.9% having completed post-graduate studies. Regarding working shifts, 20.7% of participants reported working exclusively on day shifts, while the majority (79.3%) reported working on all shifts. Concerning nurse-to-patient ratios, the distribution varied, with 3.4% of participants reporting a 1:1 ratio, 26.2% reporting a 1:2 ratio, 39.3% reporting a 1:3 ratio, and 31.0% reporting a 1:4 ratio. These findings provide valuable insights into the characteristics of the study sample, offering a foundation for further analysis and interpretation of study outcomes.

Table 2 presents data on nurses' knowledge, attitude, and practice regarding physical restraints, as well as their participation in in-service training on this topic. Regarding in-service training, the majority of nurses (77.2%) reported having received training on physical restraints, while 22.8% indicated they had not undergone such training. When considering the frequency of using physical restraints, a minority of nurses (19.3%) reported always utilizing restraints, while the majority reported sometimes (76.6%) or never (4.1%) using them. The mean scores for nurses' knowledge, attitude, and practice regarding physical restraints were 3.3 (SD = 1.8), 29.4 (SD = 3.8), and 32.5 (SD = 7.2) respectively.

For the knowledge subscale, scores ranged from 0 to 10, indicating varying levels of understanding among participants. The mean score suggests a moderate level of knowledge among the nurses surveyed. In terms of attitude, scores ranged from 19 to 38, with higher scores reflecting more positive attitudes towards physical restraints. The mean score indicates a generally favorable attitude among the participants. For the practice subscale, scores ranged from 18 to 42, with higher scores indicating more frequent and appropriate use of physical restraints in clinical practice. The mean score suggests that, on average, participants reported engaging in positive practices related to physical restraint use. Overall, the findings from Table 2 suggest that while the majority of nurses have received in-service training on physical restraints and generally hold positive attitudes towards their use, there is room for improvement in terms of knowledge and practice. Further analysis and interpretation of these results may provide insights into factors influencing nurses' knowledge, attitudes, and practices regarding physical restraints in clinical settings.

Table 3 displays correlations between demographic and professional characteristics of nurses and their practice regarding physical restraint use. Age demonstrated a weak positive correlation with restraint practice (r = 0.079, p = 0.347), suggesting that older nurses tended to exhibit slightly higher levels of restraint practice, although this association was not statistically significant. Gender did not show a significant correlation with restraint practice (r = -0.076, p = 0.364), indicating that gender was not a significant predictor of restraint practice among nurses. Marital status also exhibited no significant correlation with restraint practice (r = 0.004, p = 0.963), suggesting that marital status did not influence nurses' practices regarding physical restraints. Years of experience showed a moderate positive correlation with restraint practice (r = 0.259, p = 0.002), indicating that nurses with more years of experience tended to have higher levels of restraint practice. Academic level did not exhibit a significant correlation with restraint practice (r = -0.072, p = 0.388), suggesting that educational attainment was not predictive of restraint practice among nurses. In-service training on physical restraints demonstrated no significant correlation with restraint practice (r = 0.018, p = 0.831), indicating that participation in such training did not influence nurses' practice regarding physical restraints. Working hours in the ICU per week showed a moderate positive correlation with restraint practice (r = 0.273, p = 0.001), suggesting that nurses working longer hours in the ICU tended to have higher levels of restraint practice. Nurse-to-patient ratio did not exhibit a significant correlation with restraint practice (r = -0.084, p = 0.314), indicating that the ratio of nurses to patients did not significantly influence restraint practice. Working shift demonstrated a strong positive correlation with restraint practice (r = 0.292, p < 0.001), suggesting that nurses working on all shifts tended to have higher levels of restraint practice compared to those working exclusively on day shifts. Furthermore, total scores of knowledge and attitudes showed significant negative correlations with restraint practice (r = -0.334, p < 0.001 and r = -0.285, p = 0.001 respectively), indicating that higher levels of knowledge and more positive attitudes were associated with lower levels of restraint practice among nurses.Overall, these results highlight several demographic and professional factors that may influence nurses' practice regarding physical restraints, with years of experience, working hours in the ICU per week, and working shift demonstrating notable associations with restraint practice.

Table 4 presents the results of the multiple linear regression analysis examining variables associated with restraint practice among nurses.Variables included in the analysis were knowledge, attitudes, years of experience, working shift, and working hours. The regression coefficients (b), standardized coefficients (Βeta), t-statistics, and p-values are reported for each predictor.The results indicate that knowledge (b = -0.85, Βeta = -0.21, p = 0.003), attitudes (b = -0.40, Βeta = -0.21, p = 0.004), experience (b = 0.41, Βeta = 0.28, p < 0.001), working shift (b = 2.71, Βeta = 0.31, p < 0.001), and working hours (b = 0.15, Βeta = 0.18, p = 0.018) were all significant predictors of restraint practice.The regression model accounted for 34% of the variance in restraint practices (R2 = 0.34, adjusted R2 = 0.32), indicating a moderate level of prediction accuracy. The F-statistic was significant (F = 14.4, p < 0.001), suggesting that the overall model was statistically significant.Among the predictors, working shift emerged as the strongest predictor of restraint practice, with a Beta coefficient of 0.31, indicating that nurses working night shifts tended to have higher levels of restraint practice. Overall, these findings highlight the importance of knowledge, attitudes, years of experience, working shift, and working hours in predicting restraint practice among nurses, with working shift being the most influential predictor in the model.

Table 1: Demographics and clinical characteristics of the participants (N=145)

Variable	n (%) or mean (SD)	Range
Age	30.7 (5.2)	21-50
Years of experience	7.7 (4.9)	1-30
Working hours/week	39.9 (8.5)	20-96
Gender Male Female	74 (51.0) 71 (49.0)
Marital status Married Unmarried	91 (62.8) 54 (37.2)
Academic level Diploma Baccalaureate degree Post graduate	12 (8.3) 107 (73.8) 26 (17.9)
Working shift Working on Day Shift only Working on all shifts	30 (20.7) 115 (79.3)
Nurse: Patient ratio 1:1 1:2 1:3 1:4	6 (3.4) 38 (26.2) 57 (39.3) 45 (31.0)

Table 2. Nurses' knowledge, attitude, and practice regarding physical restraints

Variable	n (%) or mean (SD)	Range
In-service training regarding physical restraints Yes No	112 (77.2) 33 (22.8)
Frequency of using physical restraints Always Sometimes Never	28 (19.3) 111 (76.6) 6 (4.1)
Nurses' knowledge, attitude, and practice regarding physical restraints
Knowledge	3.3 (1.8)	0-10
Attitude	29.4 (3.8)	19-38
Practice	32.5 (7.2)	18-42

Table 3: Correlations between demographic and nurses' characteristics with restraint practice

Demographic & professional characteristics	Practice Correlation (r)	P-value
Age	0.079	0.347
Gender	-0.076	0.364
Marital status	0.004	0.963
Years of experience	0.259	0.002
Academic level	-0.072	0.388
In-service training regarding physical restraints	0.018	0.831
Working hours in ICU per week	0.273	0.001
Nurse: Patient ratio	-0.084	0.314
Working shift	0.292	<0.001
Total score of knowledge	-0.334	<0.001
Total score of attitudes	-0.285	0.001

Table 4: Multiple linear regression analysis for variables associated with restraint practice

Item	b	Βeta	t-Statistics	P-value
Knowledge	-0.85	-0.21	-2.99	0.003
Attitudes	-0.40	-0.21	-2.95	0.004
Experience	0.041	0.28	3.69	<0.001
Working shift	2.71	0.31	4.08	<0.001
Working hours	0.15	0.18	2.40	0.018

*R² = 0.34 Adjusted R² = 0.32 F= 14.4 (P<0.001)

DISCUSSION:

This study explored the influential factors on nurses' physical restraint (PR) practices in ICUs, focusing on the relationships between nurses' knowledge, attitudes, working conditions, and PR practices. The findings provide valuable insights into the complexities surrounding PR use in critical care settings.

The results revealed a low level of knowledge about PR practices among the participants, which contrasts with several studies reporting high levels of knowledge among nurses ^{6,12,14,19,20}. This disparity might be due to the insufficient emphasis on PR in nursing curricula. Supporting this notion, two studies conducted in Jordan indicated that Jordanian nurses often rely on experiential learning rather than evidence-based knowledge².

The study also found that nurses had a positive attitude towards PR, with a mean score of 29.4 (SD=3.8), aligning with previous research^6,19,20. However, participants reported moderate to high levels of PR use. Notably, only 41% of the nurses would restrain patients strictly following a doctor’s instructions, suggesting non-adherence to international restraint guidelines, although some hospitals have internal restraint policies.

Nurses' knowledge and attitudes were negatively correlated with PR practice. Nurses with lower knowledge levels were more likely to use PR, whereas those with positive attitudes towards PR were less likely to use it, consistent with existing literature²¹. However, this relationship is controversial in Jordan. Almomani et al. (2021) found a strong positive relationship between knowledge and PR practice², while AbdElhameed and Elemam (2020) found a positive relationship between attitudes and PR practice⁶. In contrast, no such relationship was found among nurses in Egypt²².

Our regression model accounted for 34% of the variation in PR practices among nurses, suggesting its potential to predict factors influencing PR use. Interestingly, the results indicate that nurses with greater knowledge and more positive attitudes towards PR actually used PR less frequently. This finding contradicts existing literature, which presents mixed results regarding the relationship between knowledge, attitudes, and PR use in ICUs. For example, Kaya and Dogu (2018) found no significant correlation between these factors in their ICU study¹⁶. Nonetheless, our findings support prior research that positive attitudes towards PR positively affect nurses’ practices²³.

Furthermore, the study identified years of experience, working shifts, and working hours as significant factors influencing PR use, aligning with previous research^1,2,12. However, Birgili and İzan (2019) did not observe this association, highlighting the need for further investigation to reconcile these inconsistencies in the literature regarding PR practices among nurses¹⁴.

Implications for Practice and Future Research

These findings underscore the importance of targeted interventions to enhance nurses' knowledge and attitudes towards PR. Educational programs that emphasize evidence-based practices and the ethical implications of PR could potentially reduce its usage in ICUs. Furthermore, the study suggests that improving working conditions, such as adjusting shift patterns and reducing working hours, could positively influence PR practices.

Future research should aim to expand the sample size and include nurses from diverse healthcare settings to enhance the generalizability of the findings. Additionally, longitudinal studies could provide deeper insights into how changes in knowledge and attitudes over time affect PR practices. Addressing the identified gaps in knowledge and discrepancies in the literature will be crucial for developing effective strategies to optimize PR use in critical care settings.

Study Limitations:

While this study offers valuable insights into the factors influencing nurses' PR practices in ICUs, several limitations should be considered when interpreting the findings. The cross-sectional design restricts the ability to infer causality between knowledge, attitudes, working conditions, and PR practices, suggesting a need for longitudinal studies to establish causal relationships. The reliance on self-reported data introduces potential biases, as nurses may have inaccurately reported their knowledge, attitudes, and practices. The sample size, though adequate for analysis, may not be representative of all ICU nurses, limiting the generalizability of the findings beyond the Nigerian context. Additionally, the study did not account for specific hospital policies, which can significantly influence PR practices. Unmeasured confounding variables such as organizational culture and patient characteristics were also not considered. The study's assessment of PR knowledge may have been too broad, and the attitudinal measures might not fully capture the complexity of nurses' attitudes toward PR. Addressing these limitations in future research could enhance the understanding of factors influencing PR practices and lead to more effective interventions and policies.

CONCLUSION:

This study investigated the factors influencing physical restraint (PR) practices among ICU nurses. Our findings revealed a concerning gap in nurses' knowledge about proper PR use. Despite a moderately positive attitude towards restraints, nurses scored low on a knowledge assessment. Interestingly, self-reported PR use was relatively high.Several factors emerged as significant predictors of PR use. Nurses with more experience, longer workweeks in the ICU, and experience working different shifts reported using restraints more frequently. These findings suggest that factors beyond knowledge and attitude may influence restraint decisions.Our study highlights the crucial need for ongoing educational programs to equip ICU nurses with best practices for PR use. These programs should address not only the proper application of restraints but also explore alternative de-escalation techniques and strategies for preventing the need for restraints altogether. Additionally, further research is needed to explore the specific reasons behind the link between experience, workload, and shift work with higher PR use. By improving nurses' knowledge and skills, and addressing the underlying factors influencing restraint decisions, we can work towards minimizing the use of PR while ensuring the safety of both patients and staff in ICU settings.

CONFLICT OF INTEREST:

The Authors declare that there is no conflict of interest.

ACKNOWLEDGMENTS:

The authors would like to thank all participants who participated in this study. This study is supported via funding from Prince Sattam Bin Abdul Aziz University project number (PSAU/2023/R/1445).

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Received on 17.01.2024 Revised on 11.05.2024

Accepted on 05.07.2024 Published on 20.01.2025

Available online from January 27, 2025

Research J. Pharmacy and Technology. 2025;18(1):1-7.

DOI: 10.52711/0974-360X.2025.00001

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.