Yearbook on Journal of the Japan Society of Nursing Research 2014

Nurses’ Perceptions of Restraint
Fujimi Arai1), Yoshiko S. Leibowitz2)
Key Words :restraint
perception
standard

ABSTRACT
Background: Restraint had been a taboo for a long time in Japan, and it is difficult to describe the nurses’
perceptions of restraint. We do not have enough research in restraint usage.
Objectives: The purpose of this study is to identify nurses’ perceptions of restraint.
Methods: The subjects consisted of 827 nurses who worked at hospitals in 3 prefectures of the Kyushu
district in Japan. This study utilized the Perception of Restraint Use Questionnaire (PRUQ) scale.
Results:
1) 50% of the nurses recognized that verbalization and medication may be used as restraint, but lacked
knowledge about the dangers associated with restraint use.
2) Nurses’ perceptions of restraint were influenced by education, the practice setting, and organization
policy.
3) 58% of the nurses considered a standard of restraint to be necessary, however, most of the hospitals
did not have a standard policy of restraint and lacked education concerning the ethical issues inherent
in the use of restraint.
Conclusions: Nurses were confused about the usage of restraint because of the many types for restraints.
These findings suggest that it is essential for hospitals and health care facilities to establish their restraint
policies for safety and human rights. Educations related to the dangers of restraint, protocols for proper
restraint use, research the development of strategies and effective alternatives to restraint as well as
management is essential.

I. Introduction
Patient restraint is currently used for safety and medical
necessity, according to the nurse’s judgment1-3). Only the
Mental Health Act, implemented in 1988, regulates physicalrestraint and isolation. There is no legal regulation for the
restraint of patients without psychiatric disorders. Restraint
became a social problem after a death from suffocation due tovomitus in 1998 revealed the fact that patient restraint was
being implemented, which led to the consideration of patients’human rights and questions about the medical management
structure. Some nursing directors and physicians called forthe abolition of the use of restraint in what is known as the“Fukuoka declaration on abolition of restraint”4-6). Meanwhile
the Ministry of Health, Labour and Welfare determined that
restraint would be prohibited in principle in medical facilities
where the long-term care insurance system, created in 2000,
is applied, which includes geriatric hospitals and healthcenters for the elderly that have nursing home-type units7).
For many years in the U.S., it has been recognized that
“restraint was necessary.” However, since adverse effects
of restraint were found, it is said that the perception ofnursing staff changed to thinking “restraint is not necessarily
necessary but rather a danger”8-11). It is recognized that
restraint includes not only restraint with drugs, but also
includes isolation and environments in which one side of abed is attached to a wall. In addition, legislation on restraint
was enacted and there is a tendency to give patients’ humanrights more respect12, 13). Currently, the term “restraint” hasbeen replaced with “protective device” and nursing staff in the
U.S. provide nursing care according to standards of restraint
to prevent the unreasonable violation of patient’s rights14).
They constantly evaluate the use of restraint and continuously

1) Kyushu University of Nursing and Social Welfare2) Former Oita Medical University School of Nursing, Adult Nursing,
Professor

Corresponding author. Tel.: +81 4 7094 5626; Fax: +81 4 7094 5635.
E-mail address: farai@kameda.ac.jp (F. Arai)

39

review problematic aspects to improve quality.
In Japan, most studies on restraint focus on the innovationof restraint techniques and physical restraining devices.
Therefore, the actual state of restraint is unknown. Thereis only an awareness survey by Nagahama stating that
75% of nursing staff consider restraint to be necessary15).
Furthermore, there is still a strong image of restraint asbinding patients’ limbs with a restraining band2), 12), 16), 37). In
clinical nursing, restraint is seen as equal to restriction35),
restraining clothing, and jumpsuits41), and thus, restriction is
generally used as if it is almost synonymous with restraint41).
Furthermore, there is nothing in the literature to clearly
define the difference between restriction and restraint.
However, considering that one study described restraint as
forcing a patient to maintain a certain posture or position
with restraining bands in order to avoid various risks41),
it can be regarded that restraint is a means to accomplish
something. On the other hand, another study describes
restriction as restricting freedom of actions in a certain place,or for a certain time period42). It is thought that restriction
can be considered as a wider concept than restraint, and theresult of using a means of restraint is restriction. There seems
to be some differences between restraint and restriction.
In the current conditions, what nursing staff regard as
restraint, other than binding, is not yet clear, nor is theirawareness of the importance of restraint. It is predicted thatthe enforcement of the law to prohibit restraint in principle
in April 2000 may have confused the nurses’ judgment in
the implementation of restraint. In addition, research on
restraint has lagged and there is a need to establish standardsof restraint as a basis for judging its use16-17), 12). At present,
amid changes in medical trends regarding restraint, analyzing
and discussing the perceptions of nursing staff who care forpatients directly may be significant to establish standards ofrestraint that will be introduced in the future.
This study aims to determine the perception of nursing
staff regarding patient restraint according to the following
two questions, and to identify issues that may be required
when standards of restraint are introduced.

This paper was published at “the Japan Society of Nursing Research” Vol.24 No.5 in 2001.

Yearbook on Journal of the Japan Society of Nursing Research 2014

1. What do nursing staff regard as restraint other thanbinding?
2. What factors influence the perception of nursing staff
regarding the importance of restraint?
For the items mentioned above, the terminology was
operationally defined as follows:
Restraint: restriction of patient’s actions to inhibit
movement using a cord, belt, bed sheet, or restraining band.
Perception regarding the importance of restraint: thenursing staff considers restraint to be effective and important.
Abolition of restraint: the policy of abolishing restraint by
the nursing profession based on the “Fukuoka declaration on
abolition of restraint,”18) proposed in October 1998.
The Fukuoka declaration on the abolition of restraint
consists of the following five clauses: 1. Decide and implement
the termination of binding and restraint; 2. Consider what
restraint is; 3. Implement hospital transparency to facilitate
the abolition of restraint; 4. Bring the frequency of restraint
close to zero; 5. Expand the campaign to abolish restraint
throughout the whole country.
Standard of restraint: assessment of the judgments or basis
used when restraint is implemented, through continuous
observation methods, instructions by the physician, andlimitations, which are clearly documented.
Geriatric ward: wards for the elderly and patients withdementia. A ward in a geriatric hospital in which certain
standards are established according to the regulations
published by the Ministry of Health, Labour and Welfare38).

Evans.21) The question items were partially revised to adapt
them to actual nursing care in Japan based on the results ofthe pre-interview and the preliminary survey.
(1) Reliability and validity of the PRUQ

The PRUQ is a questionnaire consisting of nine items tomeasure the perception of nursing staff regarding restraint.
Responses are given on a three-point rating scale ranging
from 1 (not important) to 3 (most important). High scoresindicate that the nursing staff held a high level of belief in thesafety and effectiveness of using physical restraint. Strumpf
demonstrated that the reliability of the questionnaire was
0.809). Later, the rating scale of the PRUQ was revised to a
five-point scale ranging from 1 (not important at all) to 5
(most important) and the number of questions was revised
to 17 items. According to Kolanowski, the reliability of therevised PRUQ was 0.9422). Thomas verified the face validity
and content validity of the PRUQ20). The reliability and validityof the PRUQ were verified as described above.
(2) Process of using the PRUQ in this study

A semi-structured interview regarding restraint was
conducted with the nursing staff to understand whether the
17 items of the existing PRUQ scale were actually suitable
for nursing care in Japan. In comparing the results of thesemi-structured interview with the 17 items of the PRUQ,
all the nursing staff responded that for items related tostealing, entering into dangerous places, being restless andnot following instructions, causing trouble, and unstable gaitthat “when a patient performed only the action describedin that item, we have never implemented restraint; it isinappropriate for nursing care in Japan.” Therefore, these
items were excluded. In our study, the questionnaire
consisted of 11 items with a 5-point rating scale ranging from1 (not important at all) to 5 (most important). The score range
was 11 to 55 points. High scores indicate that the nursing
staff held a high level of belief in the safety and effectivenessof restraint.

II. Methods

1. Study design

Research study using a self-report questionnaire

2. Study Subjects

The subjects were nursing staff (nurses and assistantnurses, hereinafter referred to as nursing staff) who workin a hospital with at least the mean bed capacity of all the
hospitals in Japan19). The Kyushu district, where abolitionof restraint was first implemented with local cooperationin Japan, was chosen for this research study. Finally, 827
nursing staff who worked in one of 12 hospitals within threeprefectures in Kyushu were included in this study.

4. Preliminary survey

A preliminary survey was conducted with 20 nursing staff
over six days from June 26 to July 1, 1999. Cronbach’s α for
the PRUQ was 0.92 in this study. In the preliminary survey,
difficult aspects in the text of the questions were revealed. For
these questions, the questionnaire was revised by describing
the sentences concretely and adding explanatory notes.
Cronbach’s α after revision was 0.89.

3. Measurement tools

A questionnaire was used to measure the following items
besides attributes: education about restraint, standardsof restraint, presence or absence of abolition of restraint,
restraint other than binding (open ended question),measurement of nursing staff’s perception regarding patient
restraint. To measure the nursing staff’s perception ofpatient restraint, we used the Perception of Restraint Use
Questionnaire (PRUQ), which was developed by Strumpf
and Evans in the U.S. in 1988 to determine the perceptionof nursing staff regarding the use of physical restraining
devices. The questionnaire by Strumpf and Evans includes
items related to medical procedures such as catheter removal.
Thomas used it to describe restraint in acute nursing care20).
In our study, we used the PRUQ scale used by Bradley, which
was based on the questionnaire developed by Strumpf and

5. Procedure and method of the survey(1) Study period

July 19, 1999 to August 12, 1999.

(2) Data collection procedure

From the beginning of June to the end of July 1999, we
mailed a document including the purpose and intention ofthis study to each senior nursing officer in the 12 selected
hospitals. The questionnaires were collected as bundles or
40This paper was published at “the Japan Society of Nursing Research” Vol.24 No.5 in 2001.

Yearbook on Journal of the Japan Society of Nursing Research 2014

Table 1. Subject backgroundby mail.

(3) Ethical considerations

The purpose of the study and the way that the results
would be used were described in the questionnaire. It wasan anonymous survey. An explanation was given indicatingthat the results would be used only for statistical processing
so subjects’ privacy would be protected. The subjects who
returned the completed questionnaire were considered tohave provided consent for participation in this study.

Frequency Mean age ± SD(%)
(range) Years

Nurse

514
(73.0)
190(27.0)
704(100)

Assistant nurse
Total

32.5 ± 9.5(20-67)36.5 ± 11.4
(19-62)33.6 ± 10.2
(19-67)

Mean years of clinicalexperience ± SD
(range) Years
10.1 ± 8.1(10.2-40.0)
13.2 ± 10.3
(0.2-43.0)
11.0 ± 8.8(0.2-43.0)*Two incomplete response sheets were excluded; SD: Standard
Deviation

6. Data analysis method

Whether restraint is abolished or not

The SPSS version 9.0 was used for the data analysis. The
level of significance of the statistical test was set at p ≤ .05.
(1) The means of restraint other than binding, and opinions
on restraint were classified by content.
(2) For perception of the importance of restraint, a t test
was performed on the presence or absence of education
on abolition of restraint, or on the presence of absenceof restraint. One-way analyses of variance and multiple
comparisons were conducted according to workplace towhich the subjects belonged.
(3) A chi-square test was conducted between the following
items: necessity of standards of restraint; department towhich each subject belonged; and job type.

Restraint isabolished
17%

Restraint is notabolished
83%

Figure 1-1. Subject background (N = 706)

III. Results

Job types

1. Collection rate of the questionnaire

Assistant nurse
27%

We distributed 827 questionnaires and collected 730(collection rate of 88.2%). Valid responses were obtained
from 706 respondents (valid response rate of 96.7%). For
the 24 questionnaires that were considered to be invalid, 10
were completed by someone besides the subject, 10 were
blank, and four had at least one incomplete page.

Nurse
73%

2. Subject background

The mean age and mean years of clinical experience of thesubjects are presented in Table 1. The highest percentage,according to the department to which each subject belonged,
was internal medicine (28%), followed by geriatrics (24%),and surgical medicine (23%); no nursing staff working
in psychiatry departments was included. In four out of 12
hospitals, restraint had been abolished. Of the 706 nursing
staff, 120 (17%) belonged to a hospital where restraint has
been abolished [Figure 1-1 to Figure 1-3].

Figure 1-2. Subject background (N = 704)

Workplace of subjects
Others4%

ICU/CCU
2%

Mixed ward
19%

3. Actual state of restraint(1) Implementation of restraint

The number of nursing staff who responded that theyexperienced the implementation of restraint was 667(94.5%). Thirty-seven nursing staff had never experienced
the implementation of restraint (5.2%). Of the 189 assistantnurses, nine had not experienced the implementation of
restraint.

Surgical medicine
23%

Internal medicine
28%

Geriatric ward
(Ward for theelderly or paentswith demena)24%

Figure 1-3. Subject background (N = 706)

41
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Yearbook on Journal of the Japan Society of Nursing Research 2014

Necessity of standards of restraint(2) Postgraduate education regarding restraint

Not
necessary㻝㻠㻑Postgraduate education regarding restraint was provided
to 256 nursing staff (36.3%) in a clinical setting, lecture, ortraining, while 447 nursing staff (63.3%) did not receive thistype of education.

Necessary㻡㻤㻑(3) Presence and necessity of standards of restraint

There were no standards of restraint in 12 hospitals(including four hospitals where restraint had been abolished).
The number of nursing staff who recognized that standardsof restraint were required was 401 (58%); 194 nursing
staff (28%) responded that they did not know; 100 nursing
staff (14%) thought that standards of restraint were notrequired [Figure 2]. Concerning the presence or absence ofabolition of restraint, 110 nursing staff (72%) who worked
in a hospital where restraint had been abolished recognizedthat standards of restraint were required; 291 nursing staff(53%) who worked in a hospital where restraint had notbeen abolished recognized that standards of restraint wererequired. The nursing staff who worked in a hospital whereabolition of restraint was implemented tended to recognizethat standards of restraint were required.
χ2 = 48.456; d.f. = 2; p < 0.05

Don't Know㻞㻤㻑

Figure 2. Necessity of standards of restraint (N = 706)

Whether there are means of restraint other than "binding"Don't Know
41%

There is50%

(4) Association between necessity of standards of restraint
and department to which each subject belonged

There is not
9%

Of the 164 nursing staff working in geriatric wards, 122
nursing staff (74%) responded that standards of restraint
were required. There was an association between thenecessity of standards of restraint and the department towhich each subject belonged. The nursing staff who worked ingeriatric wards were more likely to recognize that standardsof restraint were required.
χ2 = 30.7; d.f. = 6; p < 0.05

Figure 3. Presence or absence of restraint other thanbinding (N = 706)

Means of restraint other than "binding"
Words
Sedave/sleeping pill
Isolaon in a single room(5) Association between necessity of standards of restraint
and job type

Bed rest level/regulaons
Jumpsuits
Bed guard rails
All the acts without thepaent's consent
Mien

Of the 507 nurses, 277 recognized that standards ofrestraint were required (55%); 156 nurses (30%) responded
that they did not know; and 74 nurses (15%) thought thatstandards of restraint were not required. Of the 186 assistantnurses, 123 recognized that standards of restraint wererequired (66%); 37 assistant nurses (20%) responded
that they did not know; and 26 nurses (14%) thought thatstandards of restraint were not required. The assistantnurses were more likely than nurses to think that standardsof restraint were required. There was an association between
job type and the necessity of standards of restraint.
χ2 = 8.93; d.f. = 2; p < 0.05

Hospitalizaon itself

㻜

㻞㻜

㻠㻜

㻢㻜

Frequency (person)

㻤㻜

㻝㻜㻜

㻝㻞㻜

*Mulple answers allowed

Figure 4. Detailed means of restraint other than "binding"quantity, and isolation in a single room, were mentioned by
103 (29.0%), 54 (16.0%), and 40 staff (12.0%), respectively[Figure 4].
5. Perception of the importance of restraint

4. Means of restraint other than binding

Of the 11 PRUQ items (measuring the perception of theimportance of restraint), the items indicating the mostcommon reasons that nursing staff considered restraint tobe important were those concerning the prevention of selfremoval of intubation tubes, feeding tubes, and infusion tubes.
There were differences in the nursing staff’s perception of
the importance of restraint according to the presence orabsence of abolition of restraint, the presence or absenceof postgraduate education concerning restraint, and theOf all the nursing staff, 346 (50%) responded that there
were means of restraint other than binding [Figure 3]. In
the hospitals where abolition of restraint had not been
implemented, 27 nursing staff (32%) responded that they
did not know whether there were means of restraint otherthan binding. The means of restraint other than binding:verbal reprimand sedative/sleeping pill beyond the necessary
42This paper was published at “the Japan Society of Nursing Research” Vol.24 No.5 in 2001.

Yearbook on Journal of the Japan Society of Nursing Research 2014

department to which each subject belonged.

6. Opinions on restraint(1) Abolition of restraint and the PRUQ

Opinions were obtained from 74 of the 706 subjects(completion rate of 14%; multiple answers allowed).
First, the most frequent opinion (13 subjects) concerned ashortage of nursing staff, based on the opinion that restraint
was unavoidable due to understaffing; however, they did
not perform restraint when a family or staff member was
there. Second, the next most common opinion revealed
the increased stress of nursing staff caused by restraint(six subjects); in particular, patients exhibited resistancewhen restraint was implemented; there was anxiety
regarding whether an accident could be prevented without
restraint; there were many cases where restraint had been
implemented without careful consideration; and the nursing
staff would be held responsible for patients if there was anaccident. Third, the opinions indicated that restraint was
associated with increased nursing duties (four subjects); in
particular, in some cases restraint was implemented because
the quantity of nursing duties had increased, not as a resultof concern for patient safety; restraint was indispensable
to complete duties during the night shift; and nursing staff
tended to use restraint easily because they could attend only
to one patient. Fourth, it was demonstrated that there weredifferences among the nursing staff’s perception of restraint(four subjects); in particular, there were many cases whererestraint was implemented for nurse-centered reasons; andrestraint varied according to each nurse’s judgment. Fifth,
defects in the environment and facilities were indicated (foursubjects); in particular, insufficient ward space and facilities.
In most of the responses, one of the purposes of restraint wasfor “patient security.” In addition, there was an opinion that“there was anxiety whether an accident could be prevented
without restraint; and there were many cases that restraint
has been implemented without careful consideration.” There
were also comments focusing on education: “education
related to ethical aspects is necessary for health care
professionals; and education to put oneself in the positionof the patient or the patient’s family is important.” There
were some comments regarding the abolition of restraint
as follows: “a large work environment, a sufficient numberof staff, and an understanding of family and physicians
are required conditions. When restraint is implemented
without consideration for accident and risk, securing able
personnel, or maintenance of the ward environment, nurses
can suffer from neurosis.” As stated in another opinion,“through abolishing restraint, I noticed that restraint was
not necessarily important and that restraint might be avoided
with ingenuity.”

The mean PRUQ score for nursing staff at hospitals thatabolished restraint was 28.6 (±6.8), while the mean score
for nursing staff at hospitals that did not abolish restraint
was 36.4 (±7.8). Thus, when compared with the scores ofnursing staff at hospitals that abolished restraint, the PRUQ
score of the nursing staff at hospitals that did not abolishrestraint was significantly higher. In other words, the nursing
staff’s perception of the importance of restraint tended to belower in hospitals in which restraint has not been abolishedorganizationally.
t value = 13.83; p < .5
(2) Region and the PRUQ

The mean PRUQ score for the nursing staff in the region
where restraint had been abolished was 27.8 (±7.5) while
the score for the nursing staff in the region where restraint
had not been abolished was 34.9 (±7.3). Compared with thenursing staff in the region where restraint has been abolished,
the PRUQ score was significantly higher for the nursing staff
in the region where restraint has not been abolished. In
other words, nursing staff’s perception of the importance ofrestraint tended to be lower than the region where restraint
had not been abolished.
t value = -9.27; p < 0.05
(3) Postgraduate education concerning restraint and the
PRUQ

The mean PRUQ score for nursing staff who received
postgraduate education concerning restraint was 31.2 (±8.1)
while the score for nursing staff who did not receive any
postgraduate education about restraint was 35.1 (±7.2). When
compared with nursing staff who received postgraduate
education about restraint, the PRUQ score was significantly
higher for nursing staff who did not receive postgraduate
education about restraint. In other words, the nursing staff’s
perception of the importance of restraint tended to be lower
for nursing staff who did not receive postgraduate education
about restraint.
t value = 6.199; p < 0.05
(4) Subjects’ department and the PRUQ

According to each subject’s department, the PRUQ score
for those who worked in the ICU/CCU was high at 40.1(±5.1), while the score for those who worked in geriatricwards tended to be low at 29.6 (±7.1). There were significant
differences in the PRUQ scores by the department to which
each subject belonged. In other words, the nursing staff’s
perception of the importance of restraint varied dependingon their department.
f value = 23.6; d.f. = 5; p < 0.05
There were differences between scores for those who
worked in geriatric wards and those who worked in all theother departments.

IV. Discussion

1. Factors that influence the nursing staff’s perception of
the importance of restraint: Management, education, anddepartment

Abolition of restraint was initiated in cooperation withsome regions of the Kyushu district when the nursing
staff’s distress or desire to reconsider the use of restraint inclinical practice for geriatric medicine, such as caring for theelderly with dementia, coincided with the leaders’ decisionthat a hospital administrator would take responsibility
for issues resulting from the abolition of restraint. In the
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Yearbook on Journal of the Japan Society of Nursing Research 2014

background, there seemed to be an aim that a reconsiderationof the conventional perception of restraint may lead to an
improvement in the quality of care. External evaluation was
introduced as a part of information disclosure for users whochoose a hospital or institution, and improvement in thequality of continuous care was targeted. These efforts seemed
to be an approach to the future practice of medicine. Since thispractice is spreading to various places, the Kyushu district
was chosen as the target area of this study. The collection
rate was high at 88%, which seemed to demonstrate a highlevel of nursing staff interest, as restraint has attracted theattention of society. Though the targeted hospitals included
general hospitals with a psychiatry department, there wasno response from any nursing staff working in a psychiatry
department. These results seem to indicate that restraint has
attracted the public’s attention, but may still be consideredtaboo in some areas of medical care. In this situation, thenursing staff’s perception of restraint was compared froma managerial perspective between regions that have aframework to abolish restraint and regions where restraint
had not been abolished. Regions where restraint had beenabolished tended to regard restraint as less important thanregions where restraint had not been abolished. Nursing
staff who had abolished restraint had a higher perception of
the importance of restraint than nursing staff who had not
abolished restraint. One opinion expressed that “I noticed
that restraint might be avoidable with ingenuity.” Thus,
abolition of restraint results in an opportunity to promote
the acquisition of knowledge regarding behavior modificationand the definition of restraint. In addition, by considering
alternative methods to restraint, the subjects have learned
that restraint alone might not always be effective. The
importance of supervisors, such as hospital directors andsenior nursing officers, deciding to abolish restraint has
also been reported30). This study revealed that nursing
staff experienced stress in situations where the abolitionof restraint was implemented, but where the hospitalenvironment was not improved and there was no increase in
the number of nursing staff.
The policy of abolition of restraint can be regarded more
highly in situations where the hospital organization itself
has no policy or measures for restraint. However, it seems
that top-down abolition of restraint is not the only means tochange the perception of nursing staff. Participation of all staff
in workshops facilitated educational effects on restraint31).
Moreover, multiple conditions are required to abolishrestraint, including cooperation of hospital administration,clarification of policy, and enforcement of continuing
education32). Although the effort to abolish restraint, as asingle policy, is an opportunity to change the perceptionof nursing staff, it is also thought to be a managerial
problem, considering labor, institutional, and educational
environments.
Our study indicated that the nursing staff who received
postgraduate education regarding restraint have more
knowledge and a higher perception of the importance ofrestraint than nursing staff who did not receive postgraduate
education. However, in this study, it is not clear whether
the content of the postgraduate course included restraint
methods or the risks of restraint. Therefore, we could not
discuss the association between the perception of theimportance of restraint and the educational contents. On
the other hand, the opinion that education related to ethicalaspects is necessary for health care professionals suggests
much about the present conditions of nursing staff, inthat they recognize the importance of ethical aspects bothin nursing and in the medical field as a whole, and they
complain about the lack of ethical education. As previously
mentioned, postgraduate education is necessary for nursing
staff to form an attitude based on human rights2); restraint
could serve as an opportunity to assure human rights are
considered in various aspects in educational initiatives. In
addition, in nursing staff’s perception of restraint, anxiety
and fear that safety cannot be maintained without restraint
take precedence25, 26); and studies have shown that education
about restraint is delayed27, 28). In this study, subjects thoughtthat the purpose of restraint is patient safety and there was an
opinion indicating that the subjects experienced anxiety overwhether accidents could be prevented without restraint. In
both cases, the risk of restraint was not recognized. However,these results may not necessarily signify that nursing staff’s
perception of restraint is insufficient. It seems that an analysis
is necessary for various situations: for example, where noalternative method is available or a patient is experiencing alife-threatening risk. An association was indicated between
the perception regarding the necessity of standards ofrestraint and job type: the percentage of subjects who
required standards of restraint was 11 percentage points
higher for the assistant nurses than the nurses. In the preinterview, both nurses and assistant nurses reported that they
had performed the same duties regarding restraint. Of 189
assistant nurses, only nine assistant nurses had no experiencein the implementation of restraint. This seems to suggest acharacteristic of nursing care in Japan, in that the differencein duties related to restraint between nurses and assistantnurses is vague, despite the fact that legally, there are distinct
differences in duties between both job types. Some topics
for future study include targeting study subjects based on
differences in the contents and scope of work, educational
background, or chain of command to determine the risks ofrestraint, the educational content regarding restraint, and its
effects.
In Japan, informed consent and the rights of patientsbegan to be discussed since approximately 1990. However,the percentage of the public who understand the meaningof these terms was 19%29). This seems to indicate that theawareness of human rights has not been thoroughly rooted
in Japan. In addition, it has been said that Japan is a society
with an extremely poor concept of personal human rights ascompared with the U.S.2). It has been speculated that the lackof nursing staff’s perception of the importance of restraint
has been influenced by not only education for nursing staff
but also cultural factors such as national character.
In terms of department, there was a difference of perception between intensive care/critical care units (ICU/CCU), in
which restraint is generally thought to be implemented for
medical treatment for more urgent and life-threatening cases,
and internal medicine departments, such as geriatric wards,
which work to achieve independent living during a chronic
life stage. In ICU/CCU, there was a tendency for restraint tobe considered an important means, as compared with geriatric and internal medicine wards. In other words, restraint isused similarly in both ICU/CCU and internal medicine departments, but the purposes for its use seem to differ greatly. In
critical care, nursing staff seem to recognize that restraint isimportant and that it has been implemented more frequently
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Yearbook on Journal of the Japan Society of Nursing Research 2014

in those units than in internal medicine departments20). There
have also been differences found between restraint for theelderly and restraint for emergency medical treatment in the
degree of patients’ confusion, patients’ characteristics, andthe level of emergency34).
Since the necessity of restraint can be predicted basedon department, restraint should be used only when all thefollowing conditions are met: it is confirmed that there are
no alternative means other than restraint; restraint is not
used continuously; and there is an emergency situation forthe patient that is life threatening. Therefore, standards ofrestraint may be required. In this study, the percentage ofnursing staff who have ever implemented restraint was
94.5%, while no hospital had actual, established standardsof restraint. It can be speculated that whether restraint was
implemented and continued was at the discretion of individual nursing staff. In the results of this study, 58% of all
the nursing staff recognized that standards of restraint wererequired, and 71% of the nursing staff employed in hospitals
where restraint had been abolished, recognized the necessityof standards of restraint. In the past, restraint was unavoidably used in chaotic situations. However, currently it has
been suggested that nursing staff are demanding guidelines
so they can use restraint after having assessed each caseappropriately. Previous studies have reported that introducing standards of restraint reduced unnecessary and excessive
restraint, and have confirmed the existence of situations inwhich restraint was the only choice26), 33). Thus, restraint
would be implemented only as needed when standards ofrestraint are used, which may lead to a decrease in unnecessary and preventive restraint. For medical institutions
besides those institutions covered by Japan’s long-term-careinsurance system, restraint is not prohibited at present. It
is desirable to propose a system in which the human rightsof patients are assured in all medical facilities. Standards ofrestraint for hospitals or institutions, that consider the special
characteristics of workplace as well as nursing care, need to
be clarified promptly.

patients’ actions using words, the result was restraining thepatient. Other various means of restraint included in the
responses were bed guard rails and actions disliked by thepatient, while only 37 nursing staff included clothing suchas jumpsuits with a lock in their responses. According to thedefinition of restraint by the Ministry of Health, Labour andWelfare, “clothing” is considered a physical restraint. However,in general, the definition of physical restraint seems to have
yet been fully understood by nursing staff. Given the vagueness of this definition, its interpretation by nurses and physicians has been varied24). Thus, there are various viewpoints ofrestraint. When standards of restraint are introduced, a process of considering what restraint is and discussing whether
the standards of restraint are based on the current state ofsociety and medical care will be important.
3．Future issues and limitations of this study

It cannot always be said that restraint is safe because ofvarious adverse effects. Even if such adverse effects are sufficiently known, professional judgment will be required when
it is necessary to restrain patients. The results of this study
revealed the following issues in introducing standards ofrestraint:
1. Each nursing staff must know and recognize that restraint
is not necessarily safe.
2. Hospitals and institutions should clarify standards ofrestraint.
3. The method of nursing education regarding restraint
should be reconsidered and staff should be reeducatedThough there are already standards of restraint, the standards have been revised again in the U.S.36), and the qualityof restraint has been evaluated consistently to continuously
review and address problems. In the future, the continuous
evaluation of the quality of restraint will also become an
important issue in Japan.
In this study, the validity of the items in a measurement tool
developed abroad was examined for Japanese nursing staff.
However, to generalize the use of the scale, the reliability andvalidity need to be examined in a larger number of nursing
staff. In addition, the generalization of the findings is difficult
because the subjects were limited to one region.
Inpatients from the whole country were classified into twogroups: patients aged ≥65 years and patients aged ≤65 years.
Nationwide, patients aged ≥65 years accounted for 52.1% of
the total number of patients. The average life span in Japan ishigh in the west and low in the east. The acceptance rates oftreatment in each prefecture in the Kyushu district are higher
than the national average of 1,176 (per 100000 Population)39,
40). Thus, the age of inpatients in the regions selected for thisstudy is higher, and it is difficult to make judgments on analyses only by department. In addition, there was no response
from nursing staff working in psychiatry departments and wecannot deny that a bias could have existed.

2. Nursing staff’s perception of restraint other than binding

Fifty percent of the nursing staff recognized that there
were means of restraint other than binding. According to thepresence or absence of the abolition of restraint, many nursing staff who work where restraint had not been abolishedresponded that they did not know whether there were meansof restraint other than binding. As previously noted, 94.5%of the nursing staff have experienced the implementation of
restraint and many of them believed that restraint had been
implemented without careful consideration. Therefore, it canbe assumed that restraint by binding was routinely implemented. It has been indicated that the awareness of using
restraining bands may come to be chronic and unconscious
when restraining bands are used continuously23). Nursing staff
may become accustomed to restraint while implementing it.
On the other hand, 50% of the nursing staff recognized that
there were means of restraint other than binding. In their
responses, physical restraint, such as isolation, and chemical
restraint, such as sedatives and sleeping pills, were included.
The nursing staff most commonly recognized “restraint bywords,” such as words for prohibition (do not...) or for commands (do...). The nursing staff discerned the influence ofwords on restraint since they noticed that when they limited

V. Conclusion

1. Fifty percent of the nursing staff recognized that there
were means of restraint other than binding. The means ofrestraint other than binding obtained from the responses
included the use of words for a prohibition or command, andthe use of drugs, such as sleeping pills, beyond the necessary
quantity.
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This paper was published at “the Japan Society of Nursing Research” Vol.24 No.5 in 2001.

Yearbook on Journal of the Japan Society of Nursing Research 2014

2. The nursing staff’s perception of the importance ofrestraint was influenced by the presence or absence of education, management, and the department to which each subject belonged. However, there was no association found witheducational content.
3. Fifty-eight percent of the nursing staff recognized thatstandards of restraint were necessary and required evidencebased information on restraint.
This study was supported by a grant of the Sasakawa
Memorial Health Foundation.

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This paper was published at “the Japan Society of Nursing Research” Vol.24 No.5 in 2001.