nursing kontakt 17 (2015) e73e79

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Original research article

Nurses' opinions regarding patient safety in

connection with the use of restraints in patients in
Czech hospitals

Sylva Brtlov a,*, Hana Hajduchov a, Jitka Prajsov b

a
University of South Bohemia in esk Budjovice, Faculty of Health and Social Studies, Department of Nursing and
Midwifery, Czech Republic
b
National Institute of Mental Health/NIMH, Czech Republic

article info abstract

Article history: This research survey was aimed at identifying the opinions of nurses regarding the issue of
Received 21 November 2014 patient safety in the use of restraints on patients in hospitals in the Czech Republic. The
Received in revised form research was designed as a sociological study and was accomplished through the technique
11 February 2015 of a questionnaire survey using an interviewer. The sample group of nurses included nurses
Accepted 2 April 2015 working in shifts on the hospital wards and was based on the needs of the project and the
Available online 18 April 2015 methodology of the Institute of Health Information and Statistics of the Czech Republic. The
entire sample consisted of 772 nurses. Most nurses considered the likelihood of an injury to
Keywords: the patient in the use of means of restraint (specically when strapping the patient) to be
Patient safety negligible (48%) and low (36.9%). Nurses working in surgical and medical wards reported a
Hospitals higher likelihood of patient injuries during restriction while bedridden than nurses working
Restraints in other departments. The existence of a standard or regulation that would regulate the
Nursing care procedure for the use of restraints, if a patient is restless, aggressive or at risk of self-harm
Nurse was conrmed by 91.3% of nurses. Immobilization and restraint in justiable cases in
surgeries are carried out by 65.5% of nurses. To prevent complications connected with
the use of restraints, we consider continual training sessions and education of medical
personnel important in connection with the use of restraints and auditing in maintaining
standards of nursing care and the prevention of complications associated with the use of
restrictive procedures, and then using these measures only in necessary and justied cases.
# 2015 Faculty of Health and Social Studies of University of South Bohemia in esk
Budjovice. Published by Elsevier Sp. z o.o. All rights reserved.

* Corresponding author at: University of South Bohemia in esk Budjovice, Faculty of Health and Social Studies, Department of Nursing
and Midwifery, U Vstavit 26, 370 04 esk Budjovice, Czech Republic.
E-mail address: sbartlova@zsf.jcu.cz (S. Brtlov).
http://dx.doi.org/10.1016/j.kontakt.2015.04.001
1212-4117/# 2015 Faculty of Health and Social Studies of University of South Bohemia in esk Budjovice. Published by Elsevier Sp. z o.
o. All rights reserved.
e74 kontakt 17 (2015) e73e79

Introduction Material and methods

The issue regarding the use of restraints applies to all sectors The aim of the research was to determine nurses' opinions on
of health care, not just psychiatric wards, but also medical the issue of patient safety in connection with the use of
institutions for long term patients, social care institutions, restraints in hospitals in the Czech Republic.
acute hospital wards, as well as home care. Indicators
regarding the use of restraints, however, vary depending on Design
what devices or which departments they are applied at. The
topic of restrictive measures is (and probably always will be) Sociological research under the project Improving the Safety
discussed, both among laymen and public experts [1]. The use of Care, designed between 2013 and 2015, was composed as
restraints are seen as a restriction of personal freedom. The quantitative, using research instruments provided by the
issue of their use is logically associated with a wide variety of Faculty of Health and Social Studies of University of South
both ethical [24], and legal context. Using them creates an Bohemia in esk Budjovice. The main aim of the research
extremely stressful situation for both the patient and medical was to map risk management from the point of view of the
personnel who do the restraining. Attention should be paid not nursing staff with a focus on identication of high-risk nursing
only to thorough monitoring, but also a regular evaluation of processes and the prevention of events that threaten the
their use. Caring for patients whose condition requires special safety of patients, their relatives and staff.
attention is often provided at small and inadequately
technically equipped workplaces. Regular training sessions Sample group
of medical personnel in the issue of the use of restraints is also
important [5]. A eld survey was carried out in the Czech Republic from
While using restraints, the staff must always act in September 15 to 30, 2013. The selected sample group included
accordance with the operative law and standards of the nurses working in shifts in hospital departments. The selected
medical institution. The nursing staff must keep in mind that sample group consisted of 772 nurses.
when using restraints, injuries to the personnel or patients In designing the group, the number of nurses in individual
may occur. The aim is to avoid safety, health or life threatening Czech regions was taken as a fundamental indicator of
situations to the patient or other persons when using such representativeness. The regions were dened on the basis of
restraints that will lead to the fulllment of the purpose of its administrative division, which has been in force since January
use with the smallest risk possible, and all that while 1, 2001. As a part of the research, nurses from all regions of the
maintaining privacy, respect and dignity of the patient, during Czech Republic were addressed, where their representation
the period of their use. Throughout the procedure, it is corresponds to the structure of the population.
mandated that at least one of the members of a care team, who We can note that the deviation from the basic sample group
would be in a permanent visual and verbal contact with the does not go over 0.3% in division by region. Research ndings
patient, be present. It is imperative to take precautions that are representative for Czech nurses in terms of individual
will allow sufcient nursing staff, including ensuring the night regions (Table 1).
shifts [6]. Overuse of restraints may also indicate a lack of Another feature of socio-demographic character that has
erudition of medical personnel or it can also indicate that the been designated as representative was the age of nurses; 54.7%
institution has an insufcient number of workers [7]. A of nurses were between 30 and 49 years old, from 50 years of
restraint must not, under any circumstances, be used as a
punishment or in order to ease the provision of care [8]. The
benet of this measure should be greater than its potential risk
[9]. The terms of the use of restraints is regulated by Act no.
372/2011 Coll. on health services [10]. To restrict free Table 1 Composition of the sample of nurses by region.
movement of a patient in the provision of health services Region N % Deviation from
there may be used: a healthcare staff member's or another the basic set (in %)
authorized person's grip, restriction of a patient's movement Prague 139 18.0 0.0
with safety bands or courts, placing a patient in a net bed, Central Bohemia 62 8.0 0.3
placing a patient in a room to create safe movements, and a South Bohemia 42 5.4 +0.1
safety jacket or vest to prevent movement of the upper limbs of Pilsen Region 45 5.8 +0.1
the patient. Psychotropic drugs can also be used, or other Karlovy Vary 24 3.1 +0.1
st nad Labem 54 7.0 0.1
medical products given parenterally, which are suitable for the
Liberec 28 3.6 +0.1
restriction of free movement of a patient in the provision of Hradec Krlov 43 5.6 +0.2
health services, unless the treatment is a patient's request or a Pardubice 34 4.4 +0.2
systematic treatment of psychiatric disorders or a combina- Vysoina 36 4.7 0.0
tion of the restrictions mentioned above [10]. South Moravia 94 12.2 +0.2
According to the amendment to the Act no. 372/2011 Coll. Olomouc 46 6.0 0.2
Zln 38 4.9 0.1
on health services, effective since 14 March, 2013, the grip has
Moravian-Silesian 87 11.3 0.1
been removed from the list of restrictive measures, whose use
Source: [12].
must be reported [11].
 kontakt 17 (2015) e73e79 e75

age and over were 27.7% of nurses; 17.6% of nurses were from Table 3 Composition of the sample of nurses according
18 to 29 years of age. to the type of separation.
The structure by age shows that the deviation from the Type of department N %
basic sample group does not exceed individual age categories
The anesthetic-resuscitation department 23 3.0
by 0.5%. Research ndings are representative for Czech nurses
Department of obstetrics and gynecology 61 7.9
in terms of age. Surgery 137 17.7
Other observed signs were not intended as representative, Department of infectious diseases 7 0.9
because in Czech information systems there is no other data Department of internal medicine 195 25.3
on nurses. Nevertheless, there are characteristics of the Cardiac surgery 15 1.9
sample group in the following text because they allow a Department of dermatology 16 2.1
Neurosurgery 11 1.4
better description. Statistically signicant connections that
Neurology 29 3.8
were found in the testing of these characteristics, however,
Department of ophthalmology 11 1.4
need to be interpreted as tendencies. Department of intensive care 45 5.8
Among the basic demographic characteristics of the group Department of aftercare/LDN 53 6.9
found in the framework of the research is, together with age, Oncology 11 1.4
also the gender of the respondents. In terms of gender there ENT department 15 1.9
were 3.6% of men and 96.4% of women. The vast majority of Orthopedics 31 4.0
Pediatrics and neonatal departments 31 4.0
women in this profession in the Czech Republic are evident.
Psychiatry 12 1.6
A great deal of attention in the research was paid to the Rehabilitation 10 1.3
professional characteristics of the sample group. The subjects Traumatology 15 1.9
of the research were also the education of nurses, the length of Urology 30 3.9
experience in their profession, the length of their experience at Other departments 14 1.8
their current workplace, and the type of hospital and the
department nurses work at.
More than a half of the surveyed nurses reported vocational in university or regional hospitals. Approximately 1/3 of
high school education as their highest. Higher vocational nurses work in provincial or municipal hospitals, and less
education was reached by 27.5% of respondents, a bachelor's than 1/5 of the remaining nurses stated that they were
degree was reached by 16.3% of nurses. The remaining 5.1% employed in the private sector.
graduated from university a master's degree. Specialized In the sample group, there are nurses working in shifts at all
extension studies were researched with a special question. departments. The biggest part of them work at departments of
The research showed that specialized education was achieved internal medicine and surgeries (Table 3).
by 36.5% of nurses.
An indicator of a professional stabilization and the level of Data collection
experience is the amount of experience in the profession of a
nurse. Its structure is shown in the following Table 2. It is The eld research was carried out through a questionnaire
understandable that the length of experience in the profession survey with an inquirer. The respondents were informed
of a nurse is strongly related to age. beforehand about the objectives of the research and they were
Another indicator of the stability and also the degree of acquainted with the interview sheet. The participation of
uctuation tendencies within the eld, is the amount of respondents in the research was voluntary and based on their
experience at the current workplace. Almost 1/3 of the nurses consent. The actual survey did not contain any controversial
working at a current workplace have had more than ten years ethical issues. The data were collected through INRES network.
of experience. This group can be regarded as the most The survey covered 216 interviewers from the Czech Republic
stabilized. Others have worked at the current workplace for who were given detailed instructions before the commence-
less than ten years. This character again, of course, is related to ment of the research. All questionnaires were coded, under-
the age and the amount of experience of a nurse. went optical and logic checks and the data was entered into
An important characteristic is the type of the medical the computer, as well as the basic tabulation and interpreta-
facility where the nurses work, and also their particular tion of results.
workplace. These characteristics were also studied. The
largest part of the sample group consisted of nurses working Data analysis

Statistical data processing was performed using SPSS 15.0

statistical applications. To test the differences in average
Table 2 Amount of nursing experience.
values of selected variables, ANOVA was used, followed by
Overall experience N % Bonferroni post hoc test. To determine the existence of
Less than a year 17 2.2 association, a symmetrical test with Gamma calculation for
15 yrs 115 14.9 ordinal variables was used. The observed relations were also
610 yrs 148 19.2 interpreted with the help of proportion of the explained
1115 yrs 115 14.9 variability, which represents the percentage of those that can
1620 yrs 154 19.9 be explained with the offered variables. Everything was tested
21 and more yrs 223 28.9
at the 5% signicance level.
e76 kontakt 17 (2015) e73e79
Results
The research was focused on the issues of the safety of
patients during the use of restraints in patients in hospitals in
the Czech Republic from the perspective of nurses.
Specically, we were interested in the probability of the
incidence of undesirable situations an injury to a patient
when bedridden (strapping) and an injury to a patient when
isolated or placed in a net bed.
The nurses were to indicate the likelihood with the following
options: 1 negligible the incidence is expected; 2 low occurs
rarely; 3 maybe may occur occasionally, 12 times a
year; 4 expected high probability of incidence; 5 certain
high probability of daily incidence. For the evaluation of
the likelihood of the risk, a scale by krla and krlov [13]
was used.
The rst and second options were most frequently
represented, the nurses believe the probability of an injury
to a patient using restraints (specically when strapping a
patient) to be negligible (48%) and low (36.9%); 8.7% of nurses
consider the likelihood of an injury to a patient using restraints
to be possible; 1.6% of nurses deems the incidence anticipated;
0.1% of nurses rate it to be certain. The answer I do not know
was surprisingly selected by 4.7% of nurses.
Testing differences in the average values of answers with
the ANOVA test and subsequent Bonferroni post hoc test
showed a statistically signicant difference between nurses
working in surgeries and departments of internal medicine
(here smaller), who reported a higher probability of injuring a
patient when bedridden than nurses working at other
departments (Table 4).
The nurses' opinions on the probability of an injury to a
patient during isolation or placement in a net bed reect the
fact that it is largely an issue of psychiatric wards, and most
nurses do not have personal professional experience; it is
considered to be negligible by 55.1% and low by 22.4% of
nurses, 8.3% of nurses consider it possible. The results showed
that 0.4% of nurses considered the occurrence as expected. The
answer I do not know was chosen by 13.3% of nurses.
Table 4 Testing differences (using ANOVA) in average values of responses by the department where the respondent
works.
Internal Surgery
Injury to the patient while bedridden 1.65 1.73
Table 5 Nursing interventions carried out by nurses during a restraint of a patient.
Character
1. Monitor blood pressure, pulse, consciousness every hour,
unless the doctor determines otherwise
2. Tracks blood pressure, pulse, consciousness
3. Monitor blood pressure, pulse every 2 h
4. I do not know
5. Did not answer
Total
The nurses were also asked whether they had hospital
regulations or standards that would regulate the procedure for
the use of restraints if the patient is restless, aggressive or at
risk of self-harm. This fact was researched with the question:
Do you have hospital regulations or standards which regulate the
procedure for the use of restraints if the patient is restless, aggressive,
or if there is a risk of self-harm?. The existence of this standard
or regulation was conrmed by 91.3% of nurses, 8.5% of nurses
did not conrm it. 0.1% of nurses failed to respond.
Whether nurses carry out justied immobilization and a
restraint of a patient in surgeries, was researched by the
question: Do you carry out justied immobilization and a restraint
of a patient in surgeries?.
Justied immobilization and a restraint of a patient in
surgeries is performed by 65.5% of nurses, 26.0% of nurses
chose the answer rather yes, rather not 5.6% of nurses.
Justied immobilization and a restraint of a patient in
surgeries is not performed by 2.7% of nurses.
We were also interested whether the nurses documented
use of a restraint and nursing interventions carried out by a
nurse during a restraint of a patient (Table 5).
The record when restraints are used is made by 79.3% of
nurses, the answer rather yes was chosen by 14.6% of nurses,
rather not by 4.5% of nurses, 1.4% of nurses do not make the
record.
In order to prevent an injury to a patient when restrained,
we asked the nurses: What interventions are carried out by a
nurse when restraining a patient?. The nurses were offered four
options including the possibility to choose the answer I do not
know. The most abundant was the group of nurses (60.2%)
who stated the following interventions: monitoring of blood
pressure and pulse, checking consciousness every hour,
unless the doctor determines otherwise.
The research also investigated the opinion of nurses on
general issues of a patient safety at their workplace. Their
agreement or disagreement with the statement At our
department we have problems with the safety of patients they
expressed selecting one of the ve options offered (I totally
disagree, I disagree, I partially agree, I agree, I totally agree).
Testing the context of this question with a view to restraining a
Intensive care Other departments Total Sig.
1.68 1.42 1.62 0.001
Absolute frequency Relative frequency (%)
465 60.2
194 25.1
56 7.3
51 6.6
6 0.8
772 100.0
 kontakt 17 (2015) e73e79
Table 6 The rate of association on the issue of probability of an injury to a patient during isolation and strapping.
Injury when being strapped
Gamma
test
Problems with the patient's safety 0.326
The degree of the patient's safety 0.214
The probability of a patient attacking another patient 0.459
The probability of the patient's approval 0.457
with the treatment
The probability of the patient falling down 0.419
The probability of an attempted/completed suicide 0.561
patient (except for the questions concerning the documenta-
tion on restraining) conrmed the existence of their relation-
ship. We can say that with an increasing agreement with the
statement that the departments have problems with the
safety of patients, the probability of an injury to a patient while
bedridden or isolated also increases. This may explain 10% of
the cases of restraining to a bed/strapping and 13% of cases of
isolating a patient/placement in a net bed. Furthermore,
nurses evaluated the safety of the patients at their workplace
or department on a 5-point scale (1 excellent, 5 insufcient).
The degree of safety and the placement of a restrained patient
was conrmed in three variables, where again the strongest of
them is the probability of an injury to a patient while isolated/
placed in a net bed (that can explain almost 10% of cases). This
probability increases with the diminishing degree of safety.
In connection with the use of restraints we were interested
in the nurses' opinions on some selected risks to patients
during hospitalization (physical or verbal attack from one
patient to another, the problem with obtaining the approval of
a patient with a treatment or surgery, a patient falling down or
over, or an attempted or successfully completed suicide of a
patient). The nurses evaluated the probability of incidence of
these undesirable situations. As the results of the analyses
showed, statistically signicant and the closest relationship is
between restraining a patient and the probability of unpre-
dictable behavior from the patients. With the increasing
probability of one patient attacking another, the probability of
an injury to a patient increases as well this can explain 21% of
cases of strapping and 17% of isolation/placement in a net bed.
With the increasing probability of problems in connection with
granting an approval to a treatment, the probability of an
injury to a patient by strapping also increases, which may
explain 21% of cases, and in cases of isolation/placement in a
net bed, which may explain 14% of cases. With the increasing
probability of falling down or over, the injury when being
strapped (explaining 17% of cases), and during isolation/
placement in a net bed (explaining 13% of cases) also increases.
The analysis showed the highest proportion of the explained
variability in the probability of attempted or a successfully
completed suicide in connection with an injury to a patient; i.e.
with the increasing probability of an attempted or completed
suicide, the probability of an injury while being restrained
increases as well. And that would explain 31% of cases of
strapping and 45% of cases of isolation/placement in a net bed.
The values of the Gamma coefcient on the issue of restraining
a patient and following risks is further described in Table 6.
e77
Injury when isolated
The proportion Sig. Gamma The proportion of Sig.
of the variability test the variability
explained (in %) explained (in %)
10.6 0.000 0.361 13.1 0.000
4.6 0.000 0.303 9.2 0.000
21.0 0.000 0.411 16.9 0.000
20.9 0.000 0.379 14.4 0.000
17.5 0.000 0.364 13.2 0.000
31.4 0.000 0.675 45.5 0.000
Discussion
The aim of the research was to investigate the nurses' opinions
regarding the issue of safety in the use of restraints in
hospitals in the Czech Republic. The data showed that nurses
consider the likelihood of an injury to a patient when using
restraints (specically when strapping the patient) to be
negligible (48%) and low (36.9%). Nurses working in surgeries
and departments of internal medicine reported a higher
probability of an injury when restraining a patient on a bed
than nurses working at other departments. Other results of
testing relations between a hospital department where a nurse
worked and issues related directly with the restraints of
patients did not show a dependence usable to explain the
context. The same applies to the level of education of
the nurses. The amount of nursing experience and also the
amount of experience at a current workplace, appeared to be
unrelated to the questions regarding a restriction of a patient.
The necessity and importance of the issue is conrmed
with the researches carried out abroad. The research, whose
aim was to determine the frequency and types of physical
restrictions that are used by the nurses at intensive care units,
emergency and neurosurgical departments, understanding
the attitudes of the nurses toward physical restrictions and
identifying complications dealing with physically restricted
patients, was carried out in 254 nurses in four Turkish
hospitals. Nurses who worked in surgical intensive care units
and emergency departments used restraints to a greater
extent than nurses from other departments. Only 1/3 of the
nurses consulted the restriction with a doctor and 3/4 have
tried alternative methods [14]. Justication for the use of
restraints, such as controlling psychomotoric agitation and
risk of falling down, is increasingly questioned [15]. Krger
et al. [15] investigated the prevalence of physical restraints and
associations with the use of physical (mechanical) restrictions
in four hospitals providing acute care in North Rhine-
Westphalia, Germany. An observer visited each hospital
department in three randomly allocated time periods on
randomly selected days in three months. This involved 3434
direct observations in a state of a physical restraint were
carried out. The prevalence of the use of physical restraints in
hospitals was between 6.2 and 16.6%. Multivariate regression
analysis showed a statistically signicant characteristic of the
use of physical restraints: the age of 8099 compared to the age
of 1854 (adjusted risk ratio from 4.34, 95% CI 2.188.64),
e78 kontakt 17 (2015) e73e79
inserted gastroenteric probe (2.70, 1.405.22), inserted perma-
nent urinary catheter (6.52, 3.7511.34) and attendance of a
respondent at the intensive care unit (3.39, 1.298.92). For
patients with severe psychiatric and neurological symptoms
when the patient is a threat to themself (yanks out the inserted
catheters, probes, risks injury due to restlessness and falling
down/over) or their surrounding (attacking fellow patients and
staff), it is not possible to avoid the use of restraints for a limited
time, usually determined for the patient to recover from an
acute state of illness [16]. In connection with the use of
restraints, it is necessary to mention the importance of a
comprehensive examination of a patient's health. It should
detect health problems such as hypoxia, hypoglycemia,
electrolyte imbalance, drug interactions and side effects of
medications that can cause confusion, agitation and an
aggressive behavior of a patient.
Treating these health problems can often eliminate the
need to use them.
The nurses were also asked whether they had hospital
regulations or standards that would regulate the procedure for
the use of restraints if the patient is restless, aggressive or at risk
of self-harm. According to Kare et al. [17] a standard nursing
procedure is comprehended as a minimum level of care
provided, put in writing. The existence of this standard or
regulation was conrmed by 91.3% of nurses, 8.5% of nurses did
not conrm it. 0.1% of nurses did not respond. Similar results
also conrmed the research of Polvkov et al. [18], in which the
vast majority of the nurses (92.7%) stated that their department
had a standard of a bed restraining of a patient. However,
Papoukov et al. [19] emphasized an important supervisory
role of head nurses, who determine, with auditing, whether the
nurses know the standard procedures and follow them in
practice. During the period of using restraints, health workers
are obliged to ensure an adequate supervision of the severity of a
patient's condition. Measures to prevent a risk to their health
must be adopted [20]. Under any circumstances there must
not occur that the patient where we used restraints be left
unattended [9]. Another question concerned the competence
of the personnel in the use of restraints. Justied immobiliza-
tion and a restraint of a patient in surgeries is performed by
65.5% of nurses, 26.0% of nurses chose the answer rather
yes, rather not 5.6% of nurses. Justied immobilization
and a restraint of a patient in a surgery is performed by 2.7%
of nurses. According to the Act no. 372/2011 Coll., the use of
restraints is always indicated by a physician [11]. The results
mentioned above can be explained by the fact that in
exceptional cases requiring immediate solution, another
non-professional health worker that is present can indicate
the use of restraints. The doctor must immediately be
notied of such use and conrm the justication of their use
[11]. It is used only when no other options are available and
the principle is never to be ordered in an advance case of
need [21]. In other cases it may consider the answers of the
nurses from workplaces which do not usually use restraints,
or even the answers of the nurses with no knowledge on the
issue.
The Act no. 98/2012 Coll. on medical documentation sets
the requirements for the record on restraining a patient. The
record should provide indications of restraints including
specication of the kind, reason and purpose of them and
determination of inspection intervals and their extent, the
initiation and ending of restraints, records on continuous
assessment of the reasons for the use of restraints, records of
continuous assessment of the patient's health condition while
restrained, in case of complications, their description, name,
or name and surname of the medical worker who indicated the
use of the restraints. In case that a restraint was not indicated
by a physician, also the name or name and surname of the
doctor who was additionally informed on the use of restraints,
the record of a doctor on the justication of the restraint,
including the time when it was conrmed, the information
that the legitimate representative of a minor patient or the
patient who was deprived of their legal rights, has been
informed about the use of restraints [22]. Our investigation
revealed that the record in the documentation on used
restraints was taken by 79.3% of nurses, the answer rather
yes was chosen by 14.6% of nurses rather not by 4.5% of
nurses, 1.4% of the nurses do not take record. This begs the
question why the nurses do not take record. It may concern not
respecting the effective standards of the facilities or their
absence, also the answers of the nurses from workplaces
where the use of restraints is not typical, but also the answers
of the nurses with no knowledge on the issue.
The documentation on the use of restraints also serves as a
valuable source of information for the management of quality
of care of their own healthcare institution [23].
Conclusion
The use of restraints applies not only to psychiatric wards and
hospitals, but they can also be seen at departments of internal
medicine, surgeries, traumatological and neurosurgical wards
and aftercare departments. The use of these means is often
associated with negative impressions from both the medical
staff and the patients and their family members and the public.
Due to the fact that a nurse is responsible for carrying out the
restraining, we were interested in the opinion of the nurses on
the probability of an injury to a patient during their use.
The data revealed that the nurses consider the probability
of an injury to a patient in the use of restraints (specically
when strapping the patient) to be negligible (48%) and low
(36.9%). Nurses working in departments of internal medicine
and surgeries reported a higher probability of an injury to a
patient when a patient is bedridden than nurses working at
other departments. This can be explained by the higher
frequency of the use of restraints at these departments in
comparison to other departments (except psychiatric wards).
The existence of a standard or regulation that would regulate
the procedure for the use of restraints if a patient is restless,
aggressive or if there is a risk of self-harm, was conrmed by
91.3% of nurses. These results conrm that hospitals have an
internal regulation that solves the issue of the use of restraints.
The researched nurses were also asked about the issues
related to a general patient safety at their workplace. The
results showed that with the increasing agreement with the
statement that the departments have problems with patient
safety, the probability of an injury to a patient while bedridden
or isolated was also increasing. The nurses also evaluated the
safety of patients at their workplace or department on a
 kontakt 17 (2015) e73e79
5-point scale. The connection between the degree of safety and
restraining a patient was conrmed in three variables, the
strongest of which is the probability of an injury to a patient
during isolation or placement on a net bed. This probability
increases with a progressively failing degree of safety.
It is important to consider continuous training of medical
staff on the principles which are to be respected not only
during the actual performance of restraining a patient, but also
before carrying it out and after documenting it; then regular
nursing audits of keeping to the standards of the nursing care
and the prevention of the complications associated with the
use of such restrictive procedures.
The rst step in the prevention and management of
complications is their early identication. Here, the nurses
are irreplaceable. The use of restraints should be common-
place only in necessary and justied cases with the aim of
providing a safe and humane care. The question then is the
increasing of the number of medical personnel, the appropri-
ate modication of the environment, so that other resources
can be used to ensure the safety of patients.
Ethical aspects and conict of interest
The authors state that the study has no conict of interest and
during processing, ethical aspects of research have been
maintained. The research project has been approved by the
Ethics Committee of the Health and Social Faculty in esk
Budjovice. The management of the hospitals surveyed agreed
with the research. The respondents were informed about the
purpose of the research and they agreed to be included in the
research sample group.
Acknowledgement
The research was carried out with the support of the Internal
Grant Agency of the Ministry of Health of the Czech Republic
within the project reg. No. 14133 NT entitled Improving the
Safety of Nursing Care.
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