INTRODUCTION:

“The Nature has desired the provision that infants be fed upon their mother’s milk. They find their food and mother, at the same time. It is complete nourishment for them, both for their body and soul…”

Rabindranath Tagore

All infants and children have physiologic and psychological needs, children needs to be mobile. Just as in the adult, prolonged immobility of children may result in physiologic loss of muscular strength and flexibility. It may also affect the physiologic functioning of the body in other ways, such as influencing respiratory volume and peripheral circulation, psychologically; long period of restraint may result in the child’s inability to develop motor and psychosocial skills owing to a lack of motor sensory contacts with the surrounding environment.¹

Restraints are devices used for partially or completely immobilizing infants for various medical and nursing procedures. The common types of restraints include Jacket restraint, Mummy restraint, Extremity restraint, Abdominal restraint, Elbow restraint and Crib with Dome. The main purpose of restraints include to immobilize the infant, to quieten the child, to examine the specific body parts and to perform medical and nursing procedures.²

A simple pediatric restraint for restraining movement makes procedure with pediatric patient much easier. The method uses a standard, readily available bed sheet, which is easy to learn, can be modified for use on various body areas, and makes short procedures possible with minimal nursing assistance. Procedures are made more safe by keeping children still, without sedatives. Because wrapping in a bed sheet is less threatening to a young child than a standard Velcro restraint system, the entire procedure proceeds more smoothly than with commercially available restraints.³

In extreme cases, a client who is at risk for injury need to be restrained. A restraint is any one of numerous devices used to immobilize a client. Physical restraints are any manual method or mechanical device, material or equipment attached or adjacent to a client’s body that the client cannot easily remove and that restricts freedom of movement or normal access to one’s body. The use of restraints must be part of the client’s medical treatment, all less restrictive interventions must be tried first, other discipline must be used and supporting documentation must be provided.⁴

Body restraints are usually used as a final measure. Providing nursing care is difficult. There is often a need to completely restrain children for special procedure. This can be done in several ways. Nurse’s judgment is critical in the implementation of restraint that is sufficient to protect the individual without violating the person’s right. Using restraints is an emotion –laden experience; nurse must be aware of the feelings that may cause error of over restraining or under restraining.⁵

By using nursing process, nurses can help reduce the risk of injury and in the patient’s immediate environment. Specific interventions can help ensure a safe environment by removing potential treats to safety is treated; guidelines are available to handle the situation.

NEED FOR THE STUDY:

The use of restraints is common and this use may be hazardous, it is important that the education of health-care providers include acquiring knowledge, skills, and attitudes related to restraint use. Teaching method includes lectures, demonstrations, case study, simulation, interactive videos, films, discussion, debate, clinical assignment and examination.⁶

The use of restraints is widespread in the North America. From 7% to 10% of the hospital population is restrained approximately 50% of the time. Most of the health care facilities have specific policies and procedures related to the use of restraints. Most facilities require a specific order from a physician. The nurse should be familiar with the policies regarding the application of restraints. If any question arises, the nurse should consult the supervisor.⁶

Nurses frequently have ambivalent feelings about using restraints or protective devices. Despite of all efforts, restraints may be the only solution in some situations. It is important to explain the client and his/her family that the restraints are being applied as a protective device, not as a punishment measure. Documentation should include alternative strategies that are ineffective, the reason for restraining the client, the type of restraint, pertinent nursing assessments and the regular intervals when the restraints were removed.⁷

To meet the need of nursing education related to the current use of restraints, model education programs need to be developed, implemented and evaluated .The health care financing administration defines physical restraints as “any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body”. Restraints have the potential to produce serious outcomes, including physical or psychological harm, loss of dignity, violation of patient’s rights and possibility death. Health care providers need to identify opportunities to decrease the risks associated with the use of restraints through preventive strategies, innovative alternatives and process improvements to help focus on the pediatric patients overall well-being, health and safety.⁸

Crisis situation of the youth in the treatment setting may require restraints. Restraints should only be used in situations where there is imminent danger to the child and when there is a no alternative. Restraints are meant to maintain child’s safety, but there is risk for respiratory compromise. The nursing care of children in restraints must include respiratory assessment and when indicated, immediate intervention to prevent disastrous outcomes. The clinical assessment and awareness of risks in physical restraints is essential for the safety and well-being of the child.⁹

Nurses need to assess whether or not, restraints are needed. The nurses need to take into account the child’s development, mental status, potential threat to others or self and safety. In some health care institutions the decision to apply a restraint is a nursing decision, whereas in others, a physician’s order is required before or within 1 to 2 hours of application. Parental consent may be required for reasons other than procedures.¹⁰

A study was conducted in Korea, to verify the effects of an education program of restraints use on nurse’s knowledge, attitude and nursing performance related to restraints use. It was a Quasi-Experimental design and the subjects were nurses. Twenty nurses in ‘A’ hospital were designated as the experimental group and twenty nurses in ‘B’ hospital as the control group. The results revealed that, experimental group had higher scores of knowledge than the control group. Finally, the study had concluded that, an education program for nurses on the use of restraints needs to be introduced to decrease inappropriate use of restraints.¹¹

A study was conducted to examines 45 children and adolescent fatalities related to restraints in residential (institutional) placements in the United States from 1993 to 2003.The study team used common Internet search engines as its primary case discovery strategy to determine the frequency and the nature of the fatalities, as well as the characteristics of the children and the adolescents involved. The result shows that, Male children and adolescents were over-represented in the study sample. Thirty-eight of the fatalities occurred during or after a physical restraint and 7 fatalities occurred during the use of mechanical restraints, twenty-eight of the deaths occurred in a prone restraint in 25 of the fatalities, asphyxia was the cause of death. The study concludes that, in the 23 cases in this study where information is available, none of the child behaviors or conditions that prompted the restraint would meet the standard of danger to self or others, the commonly accepted criteria for the use of a restraint.¹²

TITLE OF THE STUDY:

“A study to assess the effectiveness of information booklet on knowledge and skill of the 3^rd year B.Sc. nursing students regarding restraints and its use for children admitted in pediatric unit at S.C. Hospital, Hassan, Karnataka.”

AIM OF THE STUDY:

The aim of the study was to identify the effectiveness of the information booklet in the improvement of knowledge and skill of the 3^rd year B.Sc. nursing students regarding restraints and its use for children.

OBJECTIVES OF THE STUDY:

1. Identify the knowledge and skill of the 3^rd year B.Sc. nursing students regarding restraints and its use for children during the pre-test.

2. Assess the knowledge and skill of 3^rd year B.Sc. nursing students regarding restraints and its use for children after the administration of information booklet and demonstration and the post-test.

3. Compare the knowledge and skill score of 3^rd year B.Sc. nursing students regarding restraints and its use for children after the post-test.

4. Associate the knowledge gain and skill of 3^rd year B.Sc nursing students regarding restraints and its use for children with selected socio- demographic data.

OPERATIONAL DEFINITIONS:-

1. Assess: - An activity to estimate the outcome of the knowledge and skill related to the information booklet and demonstration of restraints and its use for the children.

2. Effectiveness: - It is a process, which produces an intended result on knowledge and skills among 3^rd year B.Sc. nursing students regarding restraints and its use for children.

3. Information booklet: - It is a pre-planned explanatory document, which helps in the learning process for 3^rd year B.Sc. nursing students about restraints and its use for children. The information booklet will be prepared by the investigator.

4. Restraint: - A device, which limits or prevents freedom of movement. The main types of restraints include Mummy restraint, Jacket restraint, Elbow restraint, Extremity restraint, Abdominal restraint and Crib with dome.

5. Children: - A young human being below the age of full physical development, (0 to 18 years,)

6. Knowledge: - It refers to the understanding and awareness regarding restraints and its use.

7. 3^rd year B.Sc. nursing students: - The students of N.D.R.K College of nursing , Hassan, those who have completed 2^nd year B.Sc. nursing and are presently studying in the 3^rd year B. Sc. nursing and are posted in the pediatric unit for clinical experience.

8. Skill: It refers to respondent’s physical ability to do the procedure regarding restraints and its use for children among 3^rd year B. Sc. nursing students.

9. Pediatric unit: - It is a unit, where the children get admitted for the illness presented by the child.

10. S.C. Hospital Hassan: It is a district government 1000-bedded multi – Specialty Hospital that is located in the heart of the Hassan city, attached with a Medical College and Nursing College.

RESEARCH HYPOTHESIS:

There is a significant difference in the knowledge and skill of the 3^rd year B.Sc. nursing students on restraints and its use for children who have attended the information booklet and demonstration.

Inclusion Criteria:

1. Male and Female students studying in the 3^rd year B.Sc. nursing at N.D.R.K College of nursing, Hassan, Karnataka.

2. 3^rdyear B.Sc. nursing students who know to speak, read and write in Kannada and English

3. 3^rdyear B.Sc. nursing students who are willing to participate in the study.

4. Exclusion criteria

5. 3^rd year B. Sc nursing students who are not willing to participate.

Delimitations:

This study is limited to: -

1) The children admitted in the pediatric unit at S.C. Hospital, Hassan, and Karnataka.

2) A Period of 4 – 6 weeks.

3) A sample size of 72, 3^rdyear B. Sc. nursing students

Conceptual framework:

The conceptual framework for this study is derived from “Core, Care, and Cure Theory.” The theory was developed by the LYDIA.E. HALL. (Fig-1)

The review of literature:

A study was conducted at Turkey University, Finland, the aim of the study was to analyze the use of holding, restraints, seclusion and time-out in children and adolescent psychiatric in-patient treatment in Finland. The samples were 504 children and adolescent psychiatric in-patients in the year 2000. Time-out had been used for 28 %, holding for 26 %, seclusion for 8 % and mechanical restraints for 4 % of the in-patients. The study concluded that, high prevalence of restraint techniques used indicated a need for guidelines of restraint and seclusion which takes into account the child's need for protection from his/her own impulses and the legal rights of the child.¹³

A study was conducted, to examine the variations and complexities in nurse’s decision making about the initiation, maintenance and termination of physical restraints. The study was a qualitative research used a semi-structured interview of registered nurses on medical-surgical units at a mid-sized hospital in the Mid-west. The result shows that, all the nurse respondents easily re-called caring for a patient in restraints and detailed in their accounts a complex trajectory of care that centered on safety. The findings revealed a forceful interplay of patient, nurse, family, healthcare worker and organizational factors that influence nurse’s decision making about restraint use. The study had concluded that, how a deeper understanding of the intricacies of the decision-making processes related to restraints can help clinical nurse specialists tailor education, impact policy and serve as role models to reduce the use of restraints in hospitals.¹⁴

A study was conducted at Ankara University Cebeci School of Health Turkey, to determine pediatric nurse’s ideas and attitudes towards physical restraint in Turkey, by using descriptive, analytical and cross-sectional methods with 121 pediatric nurses working in four hospitals. The questionnaire consisted of open-ended questions and was applied via face-to-face interviews. The results revealed that, 66.9% of the nurses reported that nurse shortages were the main reason for increased physical restraint applications, 58.7% tried alternative methods and 71.1% indicated no need of written orders for physical restraint use. Physical restraint decreased while the mother accompanied her child and increased while inexperienced clinical nurses were in charge. Wrist, ankle and whole body restraints were used. The researcher concluded the study that, Physical restraint could be reduced by a wiser combination of education and expert consultation in the pediatric unit.¹⁵

METHODOLOGY:

Research approach and Research design:

The quasi - experimental design and one group pre -test and post -test with experimental group design was used in the study.

Setting:

The present study was conducted at the district general Government Hospital called as Shri.Chamarajendra Hospital, which is situated in the heart of Hassan city between the Government High school and court.

Population:

In this present study the population comprised of 3^rd year B Sc nursing students, studying at NDRK college of nursing Hassan,

Independent variable:

The independent variable of the study refers to the information booklet regarding restraints and its use for children.

Dependent variables:

The dependent variable of the study refers to the knowledge and skill regarding restraints and its use for children.

Sample and sample size:

The present study was conducted among 72 3^rdyear B.Sc. nursing students of N.D.R.K. college of Nursing, Hassan,

Sampling technique:

The sampling technique used for the present study is Probability sampling .In which simple random sampling is used for the selection of the subjects will be followed by lottery method.

Description of the instrument:

The tool consists of self-administered questionnaire and observation check -list. It consists of two parts.

Part–I: It consists of socio-demographic profile of the subjects.

Part–II: It consists two sections, section-A and section-B.

Section A: Consists of 24 multiple-choice questions about student nurses knowledge regarding restraints and its use for children

Section B: Consists of an observation check - list to assess the skill of student nurses regarding restraints and its use for children. Which consists of three sections?

Pre-procedure – 6

During procedure – 4

After the procedure – 6

Ethical clearance:

Ethical clearance was obtained.

Reliability:

· The reliability of the tool was estimated by the Karl – Pearson's Correlation of co-efficient.

· Test-Retest method was used to find out the reliability of the Information booklet.

RESULTS:

Major findings of the study: With regard to their age majority of them were in the age group between 22 to 23 years with 65% (Fig-2).Considering the sex of the students majority were (n=37) female students 57.8% (Fig-3). Considering their area of residence majority of the students were belongs to urban area (n=44) (Fig-4) with 68.8% and majority of the samples belongs to (n=54) Christians with 84.4% (Fig-5). The family income of the 3^rd year B.Sc. nursing students (n= 28) have a monthly family income between rupees 5,001-10,000, with 43.8% (Fig-6). These students (n=38) represent a nuclear family with 59.4% (Fig-7).Regarding language all the 3rd year B.Sc. nursing students (n=64) have got 100% in the English language proficiency (to read, write and speak English) (Fig-8).Majority of the 3^rd year B Sc N students had no knowledge on restraints about 70.3% and had no skill in application of restraints in children about 71.9% (Fig-9).

Fig 4 Pie diagram showing the place of residence of 3^rd year B.Sc. nursing students.

Fig 5 Pyramid diagram showing the Family monthly income of 3^rd year B.Sc. Nursing students.

Fig 6.Doughnut diagram showing the religion of 3^rd year B.Sc. nursing students

Fig 7 Simple bar diagram showing the type of family of 3^rd year B.Sc. nursing students

Fig 8 Conical diagram showing the idea about restraints of 3^rd year B.Sc. nursing students

Fig 9 cylindrical diagram showing the previous skill exposure of 3^rd year B.Sc. nursing students.

Table 1: OVERALL PRE-TEST KNOWLEDGE

Questions

No. of questions

Mean ± SD

% of

pre-test knowledge

Overall knowledge on Restraints

14.07±1.42

58.6 %

Overall pre-test percentage of knowledge was 58.6%

Table 2: PRE-TEST LEVEL OF KNOWLEDGE

Level of knowledge	No. of students	%
Inadequate knowledge	20	31.3%
Moderately adequate	44	68.7%
Adequate knowledge	0	0.0%
Total	64	100.0%

Fig 10 simple bar diagram showing the pre-test level of knowledge of 3^rd year B.Sc. nursing students

As per (Fig-10), the pre-test, 31.3% of the (n=20) 3^rd year B.Sc. nursing students are having inadequate knowledge and 68.7% of the (n=44) 3^rd year B.Sc. nursing students are having moderately adequate knowledge on restraints. None of the students are having adequate knowledge.

< 50% = Inadequate

51-75% = Moderate

>75% = Adequate

Table 3: Overall post-test knowledge

Questions

No. of questions

Mean ±SD

% of post-test

knowledge

Overall knowledge on restraints

20.29±1.56

84.6 %

Overall post-test percentage of knowledge is 84.6%

Table 4: Post-test level of knowledge

Level of knowledge	No. of students	%
Inadequate knowledge	0	0.0%
Moderately adequate	11	17.2%
Adequate knowledge	53	82.8%
Total	64	100.0%

Fig 11 simple bar diagram showing the post-test level of knowledge of 3^rd year B.Sc. Nursing students

In post-test, none of the 3^rd year B. Sc. nursing students are having inadequate knowledge and the 3^rd year B.Sc. nursing students(n=11) are having moderately adequate knowledge on restraints ,with 17.2% and the 3^rd year B. Sc. nursing students are having adequate knowledge with 82.8% (Fig-11).

Table 5: POST-TEST LEVEL OF SKILL

Skill assessment	No. of students	%
Inadequate skill	0	0.0%
Moderately skill	16	25.0%
Adequate skill	48	75.0%

Fig 12 Pyramidal diagram showing the post-test level of skill of 3^rd year B. Sc. nursing students

Above (Fig-12) shows, level of skill in each aspect of restraints after the administration of the information booklet and demonstration. (n=16) 3^rd year B.Sc. nursing students are having Moderate skill with 25% and (n=48) nursing students are having adequate skill with 75%.

Fig 13: Multiple bar diagram showing the comparison of pre-test and post-test knowledge of 3^rd year B. Sc. nursing students

In the pre-test 3^rd year B.Sc. nursing students have scored 60% of knowledge regarding restraints and its use for children. After the administration of Information Booklet and demonstration, the 3^rd year B.Sc. nursing students have scored 85% of knowledge in the post-test. And it is a large difference in the knowledge gain of 3^rd year B.Sc. nursing students, which indicates the effectiveness of the information booklet (Fig-13).

DISCUSSION:

Based on the objective of the study the findings of the pre-test knowledge score of the third year B.Sc. nursing student’s regarding restraints and its use for children shows that they were able to answer the questions to some extent. The study shows that students have responded 58.6% answers correctly of questions related to knowledge “related to restraints and its use in children”. The students responded 61.0% answers correctly the questions related to knowledge “related to the use of restraints”. The students responded 60.7% answers correctly the questions related to knowledge “related to the application and complications of restraints in children.” The students have responded 52.8% answers correctly the questions related to knowledge “related to prevention of complications in the use of restraints”. In the pre-test the third year B.Sc. nursing students are having an average of 58.6% of overall knowledge of restraints use for children. The study finding shows that on an average, in the pre-test, in all aspects of restraints use for children. The third year B.Sc. nursing students are having inadequate knowledge.

The above study findings were supported by the study was conducted in Italy, to fill the knowledge gap on the extension and quality of physical restraints in acute care hospitals a survey aiming at evaluating knowledge, opinions and behaviors of nurses in this area of care was performed. A questionnaire has administered to the nurses of a large Italian hospital obtained a response rate of 66.2% (227 nurses) and the situation of 77 patients (15.8% of admitted patients) hospitalized and constrained in the target wards was reported. Fifty-two per cent of nurse’s felt uneasy in constraining patients because of the relational implications with relatives. The study had concluded that, different forms of constriction and on alternative strategies warrant an educational intervention to control and improve the implementation of physical measures of containment.³⁴

Association between socio-demographic variables and skill score after the information booklet and demonstration the findings shows irrespective of the demographic variables all the students have scored adequate score. Only the two demographic variables influencing the skill score are –

(1) Place of residence of the student.

(2) Idea about restraints of the students.

(3) Experience of the student.

CONCLUSION:

From the findings of the present study, it is concluded that the score gained on restraints and its use for children by the third year B.Sc. nursing students was inadequate (58.6 %) during the pre-test. However, the findings of the post-test knowledge score regarding restraints and its use for children among third year B.Sc. nursing student’s has improved and the score has indicated that the score gained during post-test was more (84.6 %)than the pre-test (58.6%). The difference between pre-test and post-test overall knowledge score is 28% (84.6 -58.6 %). The overall skill score of the third year B.Sc. nursing students on each aspects of observation check-list regarding restraints and its use for children was 82.5%. This improvement was due to the implementation of the information booklet and demonstration on restraints and its use for children. Therefore knowledge and skill of the third year B.Sc. nursing students can be further improved by providing the health education and training program with demonstration on restraints and its use for children. The knowledge and skill gained score of the third year B.Sc. nursing students were associated with the selected socio-demographic variables like age, residence, type of family, experience about restraints and its use for children.

IMPLICATION OF THE STUDY:

The findings of the study has important implications to the nursing education, nursing practice, nursing administration and nursing research which provides the way towards better improvement in knowledge and skill of student nurses regarding restraints and its use for children.

Nursing education:

The present study emphasizes on the enhancement of knowledge and skill of nurse’s regarding restraints and its use for children through nursing education. Therefore, the nurse’s must have the adequate knowledge and skill regarding all aspects of restraints and its use for children for providing better care to the ill children. The nurse’s should take active participation in the health education and training program regarding the restraints and its use for children. They can assess the general condition of the sick child; they should understand the use of restraint device, purposes and complications of the restraints use, cleaning and maintenance of the restraint devices. The nurse’s should provide the education regarding restraints and its use for children to the parents and sick children while using, restraints for children

Nursing practice:

An implication for nursing practice from the study is to improve the knowledge and skill regarding restraints and its use for children among the 3^rd year B.Sc. Nursing students. Educate the student nurse’s about the use of restraints by conducting the seminar, training program with demonstration. The students are the staff nurses of tomorrow. Once student nurses have good knowledge and skill, they can perform well in applying restraints for treating the sick children. Nurses can provide the health education and training to the family members and sick children regarding restraints and its use for children.

Nursing Administration:

Nursing administrators should take interest in motivating the nursing personnel’s especially pediatric nurse’s to improve their professional knowledge and skill by attending the health conferences, workshops, seminars and training program on restraints and its use for children. The nursing administrator should arrange regular in-service education program on restraints and its use for children, purposes of restraints use and the care of the children who are under restraint therapy.

Nursing research:

The findings of the present study is helpful for the nursing professionals and nursing students to conduct further research studies and to find out the effectiveness of the various methods of providing health education and training on the restraints and its use for children among student nurse’s. It will further strengthen the nursing research program related to restraints and its use for children by the nurse’s.

REFERENCE:

1. Dorothy. R. Marlow, “Test book of pediatric nursing” Edition – 6th, Elsevier, page no 280-282.

2. Vivian Rose Ramsden, “Nursing principles and practice manual”, Edited by Sivagami Natesan and Susan Jacob, edition – 1st, 1999, page no- 388-391.

3. Raskin BI, “A simple pediatric restraint”, Cutis 2000 NOV; 66(5): 335-6.

4. Potter Perry, “Fundamentals of Nursing” 4th edition, Publication – Mosby, Page number 882-889.

5. Verolyn Rae Bolander, “Sorensen and Luckmanns basic Nursing, A psychophysiological Approach” edition – 3rd, Publication– W. B. Saunders Company Page number- 882-889.

6. Grace Cole, “Basic Nursing Skills and concepts” edition- 1991, Publication – Mosby, Page number – 223-225.

7. Carol taylor, Carol Lillis, Priscilla LeMone” Fundamentals of Nursing” edition – 2nd, Publication- Lippincott Company, Page number – 489-499.

8. Saufl NM,” Restraints use and falls prevention”, J Perianaesth Nurs: 2004Dec; 19(6) 433-6.

9. Johnson TD, “Respiratory assessment in child and adolescent residential treatment Setting: reducing restraint-associated risks”, J child Adolesc Psychiatr Nurs, 2007 Aug; 20(3): 176-83.

10. Donna L Wong, “Nursing care of infants and children: Edition-6th, page no- 1246-1248.

11. Castle NG. “Nursing homes with persistent deficiency citations for physical restraint use.” Med Care. 2002 Oct;40(10):851-2.

12. Nunno MA, Holden MJ, Tollar A. “Learning from tragedy: a survey of child and adolescent restraint fatalities.” Child Abuse Negl. 2006 Dec;30(12):1329- 31.

13. Sourander A, Ellila H, Valimaki M, Piha J,, “Use of holding, restraints, seclusion and time-out in child and adolescent psychiatric in-patient treatment.” Eur child adolesc Psychiatry, 2002 Aug; 11(4):162-7.

14. Ludwick R, Meehan A, Zeller R, O'Toole R. “Safety work: initiating, maintaining, and terminating restraints” Clin Nurse Spec. 2008 Mar-Apr;22(2):81-7

15. Demir A. “The use of physical restraints on children: practices and attitudes of paediatric nurses in Turkey”. Int Nurs Rev, 2007 Dec; 54(4):367-74.

Received on 28.05.2014 Modified on 09.08.2014

Asian J. Nur. Edu. and Research 4(4): Oct.- Dec., 2014; Page 472-480

Restraints and Its Use for Children

Mr. Mahesh M. Rebinal

Assistant Professor, P.D. Bharatesh College of Nursing, Halaga, Belgaum Karnataka

OBJECTIVES OF THE STUDY:

Conceptual framework:

METHODOLOGY:

Nursing practice:

Nursing research: