Development of the Physical Restraint Decision-Making Assessment Instrument – A Validation Study

This abstract has open access
Abstract Description
Submission ID :
HAC699
Submission Type
Authors (including presenting author) :
So KF, Tsang LF, Ng CF, Cheung TP, Tang SK, Leung LM
Affiliation :
Nursing Services Division, United Christian Hospital
Introduction :
Physical restraint (PR) is commonly used in acute hospital settings to promote safety and prevent harm. However, evidence suggests that PR is associated with adverse outcomes, including falls, agitation, prolonged hospital stays, and ethical dilemmas due to its impact on patients' autonomy and dignity. Despite the need for ethical and systematic decision-making, no effective tool exists to support nurses in this process. To address this gap, an evidence-based assessment instrument was developed to guide nurses through five domains: mental/behavior level, device level, independence level, consequence level, and alternative level.
Objectives :
1. Develop an assessment tool to guide the decision-making process for PR application
2. Evaluate the tool’s content and face validity using a modified electronic Delphi (e-Delphi) technique
3. Measure the tool’s reliability in clinical settings
Methodology :
This prospective validation study followed a two-stage process: instrument development and validation. The instrument was developed based on a preceding systematic review and refined through a focus group discussion with five nurses from various specialties and a gerontologist. The focus group reviewed the tool's domains and items for relevance and clarity. Two rounds of modified e-Delphi were conducted with five interprofessional experts (a psychiatrist, nurse consultants, a gerontologist, and a nursing professor), each with over 10 years of PR management experience. Experts rated the tool's relevance and clarity using a 4-point content validity index (CVI) scale via an online platform. Face validity was assessed by 10 nurses from the clinical teaching team to evaluate clarity and comprehension using a 4-point face validity index (FVI) scale online. Inter-rater reliability was measured using Fleiss’ Kappa to evaluate the consistency of nurses' decisions on physical restraint application, with three nurses applying the tool to assess 30 identical patients respectively.
Result & Outcome :
The tool demonstrated strong content validity, with scale-level CVI (S-CVI) values of 0.99 for both relevance and clarity. Face validity scores met acceptable thresholds (S-FVI ≥ 0.89), confirming the tool's clarity and comprehensibility. Fleiss’ Kappa yielded 0.82 (SE = 0.105, z = 7.97, p < 0.001, 95% CI: 0.62–1.0), indicating almost perfect agreement among nurses in their decisions to apply restraints after using the tool. These findings confirm the tool’s validity and reliability for clinical use and highlight its potential to support consistent and ethical decision-making in clinical practice. Future research will evaluate the instrument’s effect on minimizing PR use and improving patient outcomes in general adult wards.
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