NEW YORK NURSE: July/August 2007
by Rona F. Levin, Ph.D, RN, Professor and Chair of Graduate Studies, Linehard School of Nursing, Pace University, New York: Visiting Faculty, Visiting Nurse Service of New York; Chair, Foundation of New York State Nurses Center for Nursing Research Planning Committee
The June 2007 issue of American Nurse Today included an article entitled “Understanding the New Standards for Patient Restraint and Seclusion” (Anstine, 2007). I read this article with interest because I had previously read the systematic review on these practices. What struck me immediately was that the article in American Nurse Today was updating nurses on new regulatory practices regarding restraint and seclusion, but did not include any references to evidence about the effectiveness or safety of these practices.
Practices of restraint and seclusion for disturbed or violent behavior have been around for some time. The question, however, of whether these interventions are safe and/or effective has not been asked until recently (Nelstrop, Chandler-Oatts, Bingley, Bleetman, Corr, Cronin-Davis, et al., 2006). Nelstrop and colleagues conducted a systematic review of the available evidence to answer this question. This column will serve at least two purposes. One is to add to your understanding of how to identify and understand a systematic review. The other is to enhance your knowledge about the use of restraints/seclusion as an intervention.
A systematic review is a structured approach to conducting a synthesis of evidence on a question. The review may be either quantitative (a meta-analysis) or narrative (an integrative review) in nature. Such reviews follow a predetermined method for accessing, reviewing, and including relevant evidence. Systematic reviews differ from the type of literature reviews you are used to because they follow a proscribed method, establish specific criteria for inclusion of evidence, and narrow the type of evidence included in the review.
The Nelstrop et al. (2006) review was a narrative, integrative review and specified the aim of the review as: “…to assess whether restraint and seclusion are safe and effective interventions for the short-term management of disturbed/violent behavior.” In addition they were interested in assessing staff user viewpoints on this intervention. The authors detail their search strategies and explain why they included or excluded available evidence. They tell us the timeframe searched and the databases used. The authors also tell us the kinds of articles considered eligible by preset criteria based on the study’s aims.
Interestingly, only 35 out of 133 identified studies related to the clinical question met all inclusion and quality criteria. Consider then that you may be reading a lot of literature that does not meet quality standards for evidence about these practices.
Okay, so what did they find? First, there were no randomized, controlled clinical trials (RCTs) available to answer this question. RCTs are the preferred method to answer clinical questions about treatment effectiveness. Therefore, we can’t be confident about the existing evidence. Determining the “level of evidence” of existing research helps us make a recommendation.
Table 1 outlines the levels of evidence used in this article. The evidence statements and the range for the level of evidence found in the literature for that statement follow:
Anstine, J.D. (2007). Understanding the new standards for patient restraint and seclusion. American Nurse Today, 2(6), 15-17.
Nelstrop, L., Chandler-Oatts, J., Bingley, W., Bleetman, T., Corr, F., Cronin-Davis, J., et al. (2006). A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments. Worldviews on Evidence-Based Nursing, 3(1), 8-18.
Table 1 — Evidence Hierarchy
Levels of evidence