Journal of Integrative Nursing

: 2020  |  Volume : 2  |  Issue : 1  |  Page : 11--17

Evaluation and analysis of the effect of continuing education on nurses' physical restraint knowledge, attitude, and behavior

Luo Yang1, Ling Tang2, Hong Guo1, Yan-Ling Shen3, Li Li4, Qing-Xia Liu5, Hai-Yan Wang6, Yan-Juan Liu3,  
1 School of Nursing, Beijing University of Chinese Medicine, Beijing, China
2 Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China
3 Surgical Intensive Care Unit, China-Japan Friendship Hospital, Beijing, China
4 Geriatric Ward, China-Japan Friendship Hospital, Beijing, China
5 Department of Nursing, China-Japan Friendship Hospital, Beijing, China
6 National Geriatric Center, Beijing Hospital, Beijing, China

Correspondence Address:
Hong Guo
School of Nursing, Beijing University of Chinese Medicine, East Sanhuan Road, Chaoyang District, Beijing 100029
Yan-Ling Shen
China-Japan Friendship Hospital, Cherry Garden East Street, Beijing 100029


Objective: The objective of the study is to construct a training course for physical restraint (PR) evidence-based practice project and apply it to verify its effect. Methods: A total of 162 nurses from five departments of a general hospital in Beijing were trained to compare the PR knowledge, attitudes, and behaviors of nurses before and after training. Results: The nurses were satisfied with the overall curriculum; the total scores of PR' knowledge, attitude and behavior of nurses after training were higher than before, and the difference was statistically significant (P < 0.05); the total scores of nurses who received evidence-related training before this training were higher than those of nurses who did not receive relevant training, and the difference was statistically significant (P < 0.05). Conclusion: Continuing education can effectively improve nurses' knowledge, attitude, and behavior level of PR, ensure patient safety, and promote physical and psychological rehabilitation of patients.

How to cite this article:
Yang L, Tang L, Guo H, Shen YL, Li L, Liu QX, Wang HY, Liu YJ. Evaluation and analysis of the effect of continuing education on nurses' physical restraint knowledge, attitude, and behavior.J Integr Nurs 2020;2:11-17

How to cite this URL:
Yang L, Tang L, Guo H, Shen YL, Li L, Liu QX, Wang HY, Liu YJ. Evaluation and analysis of the effect of continuing education on nurses' physical restraint knowledge, attitude, and behavior. J Integr Nurs [serial online] 2020 [cited 2022 Aug 18 ];2:11-17
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Full Text


Physical restraint is a safety measure taken to avoid self-harm, unplanned extubation, and bed crash of intensive care unit (ICU) patients.[1] There is still a lack of national large-scale data support in China in terms of physical restraint (PR) rate. The PR rate of ICU patients in some areas of China is 39.04%–45.7%,[2],[3] which is much higher than the institutional restraint rate of hospital inpatients indicated by the Australian Evidence-Based Nursing Center at 4%–21% (average 10%) standard.[4] In addition, PR protects patients' safety and guarantees patient compliance for medical treatment, but at the same time, it inevitably hurts patients' dignity and even causes some complications, resulting in damage to physiology[5],[6] and psychology.[7],[8] As the medical model shifts from the traditional biomedical model to the biopsychosocial model, the ethical issues brought about by PR have become the focus of researchers.[9] In 2016, the Nursing Center of the Hospital Management Research Institute of the National Health and Family Planning Commission of China issued the Practical Handbook of Nursing Sensitive Quality Indicators, and the “Physical Restraint Rate of Inpatients” was included to reduce the PR rate of inpatients in China. However, China still lacks uniform standards and procedures for the use of patients' PR, and PR has not yet been incorporated into nursing education. A number of surveys on the use of ICU PR have shown that ICU-related education and training should be strengthened. Intensive nursing staff training can improve the level of theoretical knowledge and clinical practice of PR, reduce the use of PR, reduce the length of restraint, and thus reduce the damage of restraint.[10],[11] Therefore, this study intends to provide education for nurses in a 3-A general hospital in Beijing. The purpose is to improve nurses' knowledge, attitude, and behavior level of PR, correct use of PR, improve clinical nursing level, and provide effective and high-quality nursing care for inpatients.


Research design and participants

This study used a pretest-posttest design with self-control to clarity the effect of the education on nurses' knowledge, attitude, and behavior regarding the PR.

The study participants were 175 nurses from the surgical ICU, the medical ICU, the cardiology ICU, the emergency ICU, and neurology unit in a 3-A general hospital of Beijing. No nursing staff flows before and after the education program.

Research tools

General questionnaire

The general questionnaire is a self-designed questionnaire that includes age, gender, education, marital status, professional title, department of work, length of work, position in the department, research experience, work stress, knowledge of evidence-based care degree, participation in evidence-based practice activities, and participation in evidence-based nursing training.

Physical restraint knowledge, attitude, and behavior questionnaire

The questionnaire consists of three parts: the PR knowledge questionnaire, the PR attitude questionnaire, and the PR behavior questionnaire. The questionnaire was prepared by Xia Chunhong and Li Zheng from the School of Nursing, Peking Union Medical College, by reference to the questionnaires used in studies of Suen et al.[12] and Huang et al.[13] and other related literature,[14],[15] based on China's national conditions. The content validity index was 0.85, 0.85, and 1, respectively, and the Cronbach's α coefficients were 0.63, 0.57, and 0.81, respectively.[16]

The PR knowledge questionnaire has a total of 16 items, including knowledge of PR applicability (4 items), knowledge of PR care (6 items), and knowledge of the effects of PR on the subject (6 items). The questionnaire adopts a single choice form, including “Yes”, “No”, and “Uncertainty”. The answer is “Yes” for 1 point, the answer for “No” or “Uncertainty” is 0 points, and the total score is 16 points. Items 1, 2, 4, and 5 are reverse scores. The higher the score, the higher the level of physical knowledge.

The PR attitude questionnaire has 13 items, including ethical and legal aspects of using PR (4 items), feelings using PR (4 items), and behavioral tendency using PR (5 items). The questionnaire was graded by Likert 4, which was divided into four levels: strongly disagree, disagree, agree and strongly agree, which were recorded as 1, 2, 3, and 4 points, respectively. The total score is a minimum of 13 points and a maximum of 52 points. Items 1, 5, 9, 10, 11, 12, and 13 are reversed points. A higher score indicates a more correct attitude toward PR.

The PR behavior questionnaire consists of 15 items, which are divided into five levels, namely, never, sometimes, often, and always, using the Likert 4 rating. They are rated as 1, 2, 3, and 4 points, respectively. The total score is a minimum of 15 points and a maximum of 60 points. Items 6 and 7 are reversed points.

Educational course satisfaction questionnaire

The self-designed course satisfaction questionnaire was used to conduct a survey after each training and scored 0–5 points to investigate the satisfaction of the participants. At the same time, the questionnaire sets up open-ended questions to understand the trainees' suggestions for the course.

Research procedures

Education program formation process

In the early stage, guided by the knowledge-to-action model,[17] after searching and screening the clinical practice guidelines related to PR, we selected the high-quality guidelines after the quality evaluation of the guidelines, and integrate the recommendations with the latest evidence to form a pool of recommendations for PR. The clinical applicability of the recommendations for best practice of PR is finally determined through the expert argumentation, practitioner survey, and physical-restraint patient interviews, and the recommendations for the current clinical scenarios are clearly defined [Table 1].[18]{Table 1}

Moreover, the recommendations are transformed into a PR care program. Based on the evidence-based PR care program, the results of the PR knowledge, attitude, and behavior questionnaire survey, and the interview results of nurses, the first draft of the training program was determined. Finally, the final draft of the education program was determined through experts panel discussion.

Education program content

Education methods include special lectures, setting up exhibition boards, online learning, and on-site guidance. Each department's monthly department will conduct a lecture on PR-related knowledge, and randomly select nurses to ask questions after the lecture; and give lectures to nurses who have not participated; the training duration is 60 min. A PR knowledge board is setup in the ward and in the nurse, rest area to remind the nurse of the standardized use of PR. Establish an e-learning platform for PR, upload-related knowledge, nurses can learn without the time and place limitation, and conduct exchange discussions on the network platform. Each department conducted two bedside guidances in the morning shift, with a tutor to select a patient with PR, and on-site guidance of the nurses' PR.

The education mainly includes the outline of PR (the definition of PR, the use situation, the problems reflected by the Chinese domestic PR nursing process, the harm of PR), the formation process of the evidence-based care program of PR (evidence retrieval process, evidence integration process, evidence transformation process), PR care process (stakeholder collaboration, assessment process, recorded content, use of PR alternatives, selection, and use of restraint tools).

Data collection methods

The study data collection was conducted from May to July 2019 with data analysis. On the basis of obtaining the consent of the relevant departments of the hospital, the researchers conducted a baseline survey of all nurses to understand the PR knowledge, attitude, and behavior of the nurses at the current stage. After the education program is completed, the nursing staff who participated in the training will once again conduct a survey of the PR. Before the questionnaire is issued, the researcher will explain the purpose and significance of the research and the test content in the form of a group. After obtaining the informed consent of the respondent, the questionnaire will be issued and filled out independently. The unclear explanation will be explained by the researchers. Invalid questionnaire standard: (1) the answer presents the same answer, (2) select multiple answers for the same entry, and (3) missing items.

Ethical considerations

Written informed consent was secured from participants with an assurance of confidentiality.

Statistical analysis

The collected data were analyzed using the SAS 9.2 program (SAS, version 9.2, SAS Institute). The data were checked by two people. The scores of each item were described by (x̄±s). The t-test was used for comparison between the two groups. One-way analysis of variance was used for comparison among groups. The total score of the questionnaire was analyzed by single factor analysis. P < 0.05 was considered statistically significant.


Characteristics of research participants

A total of 175 questionnaires were distributed, all of which were collected, and 162 valid questionnaires, with an effective rate of 92.57%. Among the respondents, 150 were women, accounting for 92.59%, and 12 were men, accounting for 7.41%; the average working life was 9.01 years. [Table 2] shows the general information.{Table 2}

Baseline and posteducation comparisons of each characteristic [Table 2]

Education program effect analysis

Compare the total scores before and after education in each characteristic, and use independent t-test or variance test. The results are shown in [Table 2].

Comparison of the scores of physical restraint knowledge, attitude and behavior scale

Before the education program, all the scores of the scales were (119.35 ± 20.3) points. After the training, all the scores of the scales were (99.43 ± 8.35) points. The comparison of the scores before and after the program is shown in [Table 3].{Table 3}

Education program evaluation feedback

After the program, the overall satisfaction score was (4.30 ± 0.20), and there was no significant difference in the satisfaction of each department (P > 0.05). The feedback suggestions from the members are as follows: (1) increase the provision of preeducation materials to ensure that the participants preview the follow-up courses in advance and have sufficient preeducation preparation; (2) record videos related to the PR care process, and carry out standardized follow-up and continuous education for departmental rotation nurses and intern nurses; and (3) select 1–2 best practice advocates in each department to guide the PR practice.


Physically restrained education program is recognized by nurses

Knowing the level of satisfaction of the nurses with the education helps to identify problems in the education and continually improve the program. Through the establishment of evidence-based research group, this study completed the summary and transformation of the best evidence, and finally formed the education program. After the application, the nurses expressed satisfaction with the program, which is beneficial to improve the enthusiasm of the nurses to participate in the program and ensure the effect of the program. At the same time, some nurses put forward suggestions for improvement, which will help to adjust the education in the future. For example, nurses suggest increasing the provision of preeducation materials. It may be that nurses have poor knowledge about PR and evidence-based knowledge, and the curriculum is rich in content. There may be situations in which the content of the class cannot be understood in time. Therefore, some basic concepts and course profiles will be issued before the class to help understand the content of the class. For the video recording of the PR care process, on the one hand, because there are more mobile staff in the department (including rotation nurses, training nurses, and internship students), in order to ensure the standardization and unification of the quality of care, more related practices can be recorded by the form of video. A number of studies[19],[20],[21] have shown that video teaching methods can improve the enthusiasm, initiative, and acceptance of knowledge of the educated. In the information age, this method also makes the dissemination of knowledge more convenient. On the other hand, the content of the lectures is mostly to text specific actions. For clinical nurses, the visualization method is more acceptable and convenient for review after class. This is also in line with the interpretation of evidence dissemination in evidence-based nursing practice: the evidence and information are transmitted to others in an easy-to-understand and accepted manner for use in the decision-making process.[22] In addition, some nurses suggested that 1-2 best practice champions should be trained in each department to more effectively guide the evidence-based practice of follow-up PR in the department. The implementation of evidence-based practice projects is closely related to the configuration of evidence-based personnel. The establishment of a PR evidence-based practice group to train and incorporate a group of clinical nursing professionals with evidence-based knowledge from the evidence application department plays an important role in the implementation and quality control of the evidence-based practice program.

Actively carrying out evidence-based nursing education is conducive to the dissemination and implementation of evidence

The results of this study showed that the scores of PR knowledge, attitude, and behavior of nurses after training were higher than those before training, and the differences were statistically significant (P < 0.05). The scores of each sub-questionnaire were higher than those before the training, and the differences in the scores of the knowledge dimension sub-questionnaire and the behavioral dimension sub-questionnaire were statistically significant. The effect analysis of nurses with different characteristics found that the nurses who had participated in evidence-based education and training had higher scores than those who had not participated in relevant training, and the difference was statistically significant (P < 0.05). Evidence-based nursing practice requires nursing workers to have a positive attitude, rich theoretical knowledge, and basic skills of practice,[23] which is the basic quality of evidence-based nursing practice, such as evidence-based nursing knowledge, evidence-based skills, evidence-based attitudes, and evidence-based behavior. Studies[24],[25] have shown that the development of evidence-based nursing needs to create a lot of external conditions, but the comprehensive ability of clinical nursing staff (i.e. “quality”) is the key to whether evidence-based nursing ideas can be implemented, is the “internal factor” that affects the development of evidence-based care. The difficulties encountered in the clinical implementation of evidence-based practice are largely due to the lack of knowledge in nurses.[26] A number of surveys on the use of ICU restraint have shown that ICU-related education and training should be strengthened. Gu et al.[27] found that the current situation of PR in ICU, the lack of understanding of PR by nurses, the lack of relevant knowledge and skills is the reason for the high rate of PR, and suggested strengthening the countermeasures for nurses' education and training. Gordon et al.[28] significantly improved nurse PR-related knowledge, reduced PR usage rate, reduced use time and related adverse events by training nurses with PR knowledge, skills, and alternative methods. Intensive nursing staff training can improve the level of theoretical knowledge and clinical practice of PR, reduce the use of PR, the length of restraint, and the damage of restraint.[10],[29]

Continuous education drives evidence implementation

The implementation of evidence to the clinic is a dynamic process that requires constant assessment of barrier factors and appropriate measures for barrier factors to promote evidence-based practices. From evidence to program, from program to care practice, from care practice to nurses behavior, managers, practitioners, and researchers need to closely reflect, act, and evaluate. Continuous education is one of the driving forces of evidence implementation.[30] We need to sum up experience from each training and practice, continuously improve the training content, and provide assistance to the evidence implementation process through education to narrow the gap between evidence and practice.


First, the limitation of this study was that the effect evaluation was only tested on paper and not in clinical practice. An assumption in this study was that an increase in knowledge would carry over into the care and management of PR- and patient-related indicators can be reduced, such as PR rate, PR duration, and so on; however, this assumption was not tested in practice. Second, there was no time laps between the end of the education and the posttest to determine whether the knowledge gained from the program persisted overtime. Further research is needed to explore the results of the relevant outcome indicators and how they will continue over time as the education ends.


In summary, after the PR evidence-based education program, the nurses have improved the knowledge, attitude, and behavior of PR, which laid the foundation for the subsequent application of evidence. Subsequent research will further assess the level of evidence application through the measurement of patient-related indicators and continuously improve the content of education and training.


All members of the research team sincerely thank all the nursing workers involved in the research. We would like to thank Professor Jing ZHAO, Director of the Nursing Department of the China-Japan Friendship Hospital for her help in the coordination of the whole study and thank the head nurse Yu-Hong SUN of the China-Japan Friendship Hospital for her help.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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