Skip to main content

Table 3 Overview of the six clinical questions, ten recommendations, quality of the evidence and strength of the recommendations according to GRADE

From: Reducing physical restraints by older adults in home care: development of an evidence-based guideline

Clinical Practice Question

No.

Recommendations

GRADE

1. What is meant by physical restraint use in home care?

1.

A definition of physical restraint should be used in home care. The following definition is suggested: as ‘Physical restraint is any device, material or equipment, attached to or near a person’s body and which cannot be controlled or easily removed by the person and which (is) deliberately (intended to) prevent(s) a person’s free body movement to a position of choice and\or a person’s normal access to their body’ (Retsas, 1998). (e.g. bedrails, bed-against-the-wall (positioned in a way that the person will not fall out of bed), locked room or house doors, deep chair that prevents rising and restrictive clotting and belts).

1 C

2.

Healthcare providers should be aware that the application of any measure that limits free movement of the patient, regardless of its purpose, is a form of restraints.

1 C

2. What factors affect the probability of physical restraint use in home care?

3.

Healthcare providers should take the complex set of risk factors into account that affect the probability of physical restraint use in home care:

1 B

 - personal (e.g., poor mobility) and contextual factors

 - knowledge and attitudes of healthcare providers

 - culture of home care organisation

 - legislation

3. What are the consequences and the impact of physical restraint use in home care?

4.

The use of physical restraints should be avoided as much as possible due to the negative physical and psychosocial consequences for the patient.

1 A

5.

Healthcare providers should be aware of the negative impact of physical restraints on the informal caregiver and should pay attention to support them.

1 C

6.

Healthcare organizations should be aware of the impact of using physical restraints on the involved healthcare providers.

1 B

4. What ethical and legal framework can support healthcare providers in decisions about the use of physical restraint in home care?

7.

Consider carefully the different values, norms and reasons in the context of humane care.

1 C

8.

Physical restraints may only be used as a last resort and exception. A clear reporting of the careful decision-making process in the patient record is necessary.

1 *

* No strength of evidence because it is based on legal texts

5. How can healthcare workers reduce physical restraint use in home care?

9.

Healthcare providers should reduce restraint use in home care. The following elements should be considered:

1 B

 1. Gain insight into personal and contextual factors: thorough assessment

 2, Collaborate with interdisciplinary team (including patient and family) and take personal responsibility.

 3. Communicatie proactively and transparently with all involved persons.

 4. Develop a care plan with the involved persons (formal and informal caregivers) to determine the aims and preventive actions.

6. What steps and persons need to be involved in the decision-making process regarding and the application of physical restraints in home care? (see flowchart Fig. 1)

10.

A successful decision-making process to reduce physical restraints in home care should consists of the following components:

1 C

 - carefully and consciously dealing with situations where means of physical restraints are considered, requested or already used;

 - taking the preferences of the patient into account;

 - involving the patient and the family and all other involved healthcare providers from the beginning of the process.

Physical restraint is a last resort and should only be used after first considering alternatives, over a short period of time, with careful supervision and with materials that are in proportion to the patient’s behaviour.

  1. GRADE: The strength of the recommendation is based on the GRADE methodology expressed in a number (1 = strong; 2 = weak). The quality of the evidence is classified into high (A), moderate (B) or low (C) (Van Royen et al., 2008 [34])