The data showed that the use of physical restraints in the centers studied was higher than other studies using direct observation (84.9%). The highest usages reported in the literature were in Northern Ireland, Canada and Taiwan, with values between 62 and 68% [1, 26, 32], and the lowest in Germany with 26.2% . The Netherlands was situated between them, with a prevalence of around 50% [24, 25].
When the use of full-enclosure side rails was excluded, the prevalence dropped to 36.6%. Compared with other studies using a similar methodology, this rate was higher than those recorded in Canada (33.7%) and Singapore (23.3%) [26, 33], although it was far higher than that recorded in Germany, where belts and other restraints are very rare .
There are several possible explanations for these differences. The attitude of nursing staff towards the use of physical restraint is an important contributing factor since it will influence the process of decision-making . While nurses often have negative feelings towards this procedure, in practice they use it whenever they consider it necessary, especially to address patient safety concerns [3, 34–36]. This finding was confirmed by reviewing clinical records and interviewing staff: the risk of falls was the most common justification for the use of restraint, as also found in studies from other countries [1, 2]. However, there is insufficient evidence to support this reasoning and, in fact, it has been found that patients continue to fall despite the restraint [37, 38] and, moreover, their use may increase the risk of serious injury or even death [6, 7, 39].
Another aspect that could be related to the high prevalence is that there is very little training in fall prevention or the management of behavioral and psychological problems for professionals [34, 36, 40], leading them to see restraint as one of the few alternatives available. Previous studies also detected a lack of awareness of the potential complications [34, 36, 40], so that staff may erroneously overestimate the benefits of these devices. Teaching programs addressing these issues, supported by other measures, such as the implementation of technical assistance, changes in institutional culture, or support from a specialist consultant, have been found effective in reducing their usage [16, 41, 42].
The absence of effective national legislation regulating the use of physical restraint in long-term care in Spain  could be another factor. In countries where the law significantly limits the use of these devices, Germany for example, the prevalence is much lower than in Spain, and belts are little used [12, 15]. In the USA, the introduction of the Nursing Home Reform Act (OBRA, 1987), and subsequent regulations, reduced the use of restraints, excluding side rails, from more than 30% to less than 10% [43, 44]. At present, some Spanish regions have begun to develop a legal framework to limit the use of restraint, both physical and chemical .
In addition to the high prevalence found in this study, the level of restraint use variability among the centers investigated was striking. This result has been observed in other studies [12, 13, 25]. Given that many have similar characteristics, we cannot explain the source of this variability.
It was observed that full-enclosure side rails were the most commonly used restraints, as reported in other studies [1, 2, 12, 13, 15]. Professionals often believe they are essential in the prevention of accidents and in the reduction of potential legal liability . However, there is growing evidence to suggest that these devices may not be so beneficial, especially since they have been associated with fatal injuries . Another important observation made in this study is that their use is not routinely recorded in the patient’s history; this suggests that nursing staff do not consider them as a form of restraint , which may help to explain their frequent use. However, full-enclosure side rails, when limiting the freedom of movement of the person, should be considered as a restraint. In other countries with more stringent regulations, documentation, including the rationale for their usage, is mandated .
Therefore, we believe that decisions about the use of physical restraint should be based on an individualized assessment that takes into account the benefits and risks, as well as possible damage to the dignity and autonomy of the person [4, 38]. Furthermore, their implementation should be agreed between professionals, residents and family members, documented and regularly reviewed .
Regarding the relationship between the variables and the application of physical restraint, the multivariate analysis showed that low functional and cognitive status was associated with the use of restraint; these results are consistent with those reported in the literature [1, 12, 13, 25]. This loss of capacity may mean nurses see residents as fragile and dependent, to be protected from all risk, a perception that would lead to a pro-restraint attitude [36, 46]. But it might also demonstrate that they do not have alternatives to the use of restraint in the care of this group of residents, and have to sacrifice the autonomy of these people for their own security . However, it must be remembered that the limitation of movement that characterizes physical restraint is, in effect, increasing a patient’s disability [37, 48]. For this reason, it is important to provide support and training to nurses when caring for residents with these characteristics, especially those aspects of training that could contribute to reducing the use of these procedures.
The sample size of this study could be considered a limitation as it may have reduced the accuracy of the confidence interval. The data regarding some of the variables was obtained from the clinical records; given that studies in nursing homes have highlighted that not all events are recorded in patient notes [49, 50], it is possible that in some cases information might be missing such as the recording of falls. Other data, such as the cognitive impairment evaluation, must be treated with caution as these did not figure in a large number of patient records.
The decision not to include residents without voluntary movement may also have influenced the results, especially their comparability to other studies that did not follow the same criteria; however, we felt this provided a more representative sample of those in which bilateral full-enclosure side rails, and other devices, would be considered a restraint.
Finally, the data were collected uniquely in the Canary Islands, but it is probable that the results would be similar throughout Spain, given that these types of public institution have similar characteristics and operate under similar legislation regarding the use of physical restraint.