Table 3.

Summary of interventions to reduce physical restraints, their effectiveness and challenges.

Author, Year, Country	Aims and Objectives	Design and Study Population	Intervention	Effectiveness	Challenges and Suggestions
Abraham et al., 2019 [47], Germany	To evaluate the effectiveness of two versions of a guideline and theory-based multicomponent intervention to reduce physical restraints in nursing homes. The authors conducted a pragmatic cluster randomized controlled trial with a twelve-month follow-up including 120 nursing homes.	A pragmatic cluster RCT with 12,245 residents (4126 and 3547 in IG 1 and 2 and 4572 in CG)	Guideline-based multicomponent intervention. IG 1 received an updated version of a successfully tested guideline-based multicomponent intervention (comprising brief education for the nursing staff, intensive training of nominated key nurses in each cluster, introduction of a least-restraint policy and supportive material); IG 2 received a concise version of the original program, and the control group received optimized usual care (I.e., supportive materials only).	Neither intervention showed a clear advantage compared to the control.	Increased heterogeneity data, risk of bias in randomization. Other approaches, like legal or governmental policies, seem to be necessary to sustainably change physical restraint practice and reduce center variations in nursing homes.
Gulpers et al., 2011 [35], the Netherlands	To test the effectiveness of EXBELT on reducing belt restraint usage in psychogeriatric nursing home care.	A quasi-experimental longitudinal design with 714 residents in a nursing home	The intervention program included four major components: promotion of institutional policy change that discourages use of belt restraint, nursing home staff education, consultation by a nurse specialist aimed at nursing home staff, and availability of alternative interventions.	The intervention led to a substantial reduction in use of belts, full-enclosure bed rails, and sleep suits without increasing the use of other physical restraints, psychoactive drugs, or falls and fall related injuries.	Further research is recommended.
Huizing et al., 2009 [52], the Netherlands	To investigate the effects of an educational intervention on the use of physical restraints with psychogeriatric nursing home residents.	A cluster randomized trial of 371 residents in a psychogeriatric nursing home	The intervention consisted of five 2-h educational sessions for selected staff delivered over a 2-month period, one 90-min plenary session for all staff, and consultation with a nurse specialist (RN level). The educational program was designed to encourage nursing staff to adopt a restraint-free care philosophy and familiarize themselves with individualized care techniques.	No effect was had on the restraint status, restraint intensity, or multiple restraint usage in any of the three post-intervention measurements.	No information about factors potentially influencing the intervention’s lack of effectiveness due to contamination bias, insufficient consultation (one nurse specialist performed consultation). Future studies should include an effect evaluation and a process evaluation.
Koczy et al., 2011 [54], Germany	To evaluate the effectiveness of a multifactorial intervention to reduce the use of physical restraints in residents of nursing homes.	Cluster-randomized controlled trial with 333 residents	Persons responsible for the intervention in the nursing homes attended a 6-h training course that included education about the reasons for restraint use, its adverse effects, and alternatives to its use. The following components were selected: increasing awareness, improving knowledge, clarifying legal arguments, demonstrating alternatives, providing related equipment and supplies, and empowering staff members to participate in the decision-making process. Technical aids, such as hip protectors and sensor mats, were provided. The training was designed to give the change agents tools for problem-solving to prevent behavioral symptoms and injuries from falls without using physical restraints.	The intervention reduced restraint use (belts tied to a chair or to bed and chairs with fixed tables) without a significant increase in falling, behavioral symptoms, or medication.	Unblinded documentation of physical restraints and falls by the staff members of the nursing homes. An interdisciplinary approach based on medical and nursing science including ethical and legal aspects is likely to yield the greatest benefits.
Köpke et al., 2012 [55], Germany	To reduce physical restraint prevalence in nursing homes using a guideline- and theory-based multicomponent intervention.	Parallel group cluster RCT with 2283 (IG), 2166 (CG) residents of nursing homes	A guideline- and theory-based multicomponent intervention. Components were group sessions for all nursing staff; additional training for nominated key nurses; and supportive material for nurses, residents, relatives, and legal guardians. Control group clusters received standard information. As opposed to other guideline-based interventions, the central recommendation is not to perform a certain action, i.e., not to apply physical restraints, aiming to implement a “practice culture” without physical restraints.	A guideline- and theory-based multicomponent intervention compared with standard information reduced physical restraint use (bilateral bed rails, belts, fixed tables, and other measures limiting free body movement) without significant differences in falls, fall-related fractures, or psychotropic medication prescriptions.	Information leakage between head nurses and staff nurses who performed the assessment of the use of physical restraint.
Muniz et al., 2016 [40], Spain	To implement a dementia-friendly culture, as well as specific organizational skills relevant to person-centered care and environmental improvement.	A two-wave longitudinal study with 4361 residents with dementia	The intervention was initiated in April 2010 and combined training, consultation, and consultancy at various levels of the organization. “Dementia champions” (1 per nursing home) received in-depth training about a wide array of dementia topics (e.g., biological basis of dementia, genesis and management of behavioral and psychological symptoms of dementia, person-centered care) needed to coordinate the implementation of several dementia care approaches.	Physical restraints can almost be eliminated along with psychotropic medication.	Recliner chairs used as physical restraints were not tracked in the database. Future research is recommended to address ways to avoid injurious falls in restraint-free nursing homes for people with severe dementia.
Pellfolk et al., 2010 [58], Sweden	To evaluate the effects of a restraint minimization education program on staff knowledge, attitudes and use of physical restraints.	Cluster RCT with 156 staff and 185 residents (IG) and 133 staff and 165 residents (CG)	The intervention consisted of a six-month education program comprised of six different themes, one for each month, for nursing staff. The education included 30 min of videotaped lectures. Three of the lectures also included a clinical vignette presented in writing, which could be used for group discussions.	Staff education in small group dwellings can increase knowledge, change attitudes, and reduce the use of physical restraints in the care of elderly people suffering from dementia, without increasing the incidence of falls or the use of psychoactive drugs.	The effects In this study were measured immediately after the completion of the intervention. Thus, the long-term effects of the intervention cannot be evaluated based on this study; more studies are recommended.
te Boekhorst et al., 2013 [62], the Netherlands	To explore the social, mood, and behavioral dimensions of the quality of life of residents under surveillance technology compared with those of residents under physical restraints.	An explorative study with 150 residents	The use of surveillance technology versus physical restraints. Surveillance cameras, acoustic monitoring systems, chips worn in clothing or shoes that close doors or sound an alarm when off-limits doors are opened, tracking chips with GPS, inactivity sensors, movement sensors in beds or chairs, door sensors, and bed pressure sensors were defined as surveillance technology.	Not effective. Surveillance technology may only benefit those who can already move without the help of others.	There was no measurement made before residents were put under surveillance technology or physical restraint so as to establish potential baseline differences between these two groups. More robust design research is needed with surveillance technology.
Testad et al., 2016 [60], Norway	To evaluate the effect of a tailored 7-month training intervention, entitled “Trust Before Restraint”, on reducing the use of restraints, agitation, and antipsychotic medications in care home residents with dementia.	RCT with 197 residents with dementia and 35 staff	The intervention included the seven-step guidance group, where the care staff chose a situation includingthe use of restraint and the DMP model (to emphasize and understand the relationship between resident and care staff, and to support the identification and effective management of unmet needs in order to reduce the use of restraint and improve care).	Training intervention reduced the use of restraints in both the intervention and control groups, with a greater reduction in the control group.	Possible bias between the two groups that may have influenced the main findings of the study.
Verbeek et al., 2014 [63], the Netherlands	To examine the effects of small-scale living facilities on the behavior of residents with dementia and the use of physical restraints and psychotropic drugs.	A quasi-experimental study of 124 (IG) and 135 (CG) nursing home residents with AD or dementia	Comparing residents in two types of long-term institutional nursing care: small-scale living facilities versus traditional psychogeriatric wards on three time points—at baseline and at follow-ups after six and 12 months.	Positive effects of small-scale living facilities on the use of physical restraints and psychotropic drugs	Sample bias (residents were not randomized in a dementia care facility), risk of underreporting physical restraints (measurement of physical restraints was based on nurses’ self-reports instead of independent observers). Studies need to determine which elements of small-scale living facilities are essential for improving outcome measures and how they work together.

CG: Control group; IG: Intervention group; RCT: Randomized Controlled Trial.