Association of Surveillance Technology and Staff Opinions With Physical Restraint Use in Nursing Homes

Cross-sectional Study

Lauriane Favez MSc; Michael Simon PhD; Michel H.C. Bleijlevens PhD; Christine Serdaly MSc; Franziska Zúñiga PhD


J Am Geriatr Soc. 2022;70(8):2298-2309. 

In This Article

Abstract and Introduction


Background: Physical restraints are used in nursing homes (NHs) despite their negative consequences. Use of surveillance technologies as alternatives to physical forms of restraints and negative staff opinions about the appropriateness of restraint use have been postulated to reduce this practice; however, these have rarely been investigated alongside resident outcome data. This study aimed to measure physical restraint prevalence in Swiss NHs and its associations with (a) the use of surveillance technologies and (b) staff's opinion about the appropriateness of physical restraint use.

Methods: This cross-sectional multicenter study analyzed data on 3,137 staff and 6,149 residents of 292 units in 86 Swiss NHs (2018–2019). Based on routine resident data, we measured the prevalence of two classes of physical restraint: (a) bedrails or (b) trunk fixation or seating option that prevents standing. To assess potential factors associated with restraint use, we applied a logistic multilevel model.

Results: A 11.1% of residents were restrained with at least one form of physical restraint. Against our hypothesis, surveillance technologies were not significantly associated with restraint use, and staff members' opinion that the use of physical restraints was appropriate on their unit was associated with decreased odds of residents being restrained (odds ratio (OR): 0.48; 95% confidence interval (CI) 0.29–0.80).

Conclusions: Although Swiss NHs have a low prevalence of physical restraint use, only a minority of NH units do not use any restraints with their residents. Surveillance technologies seem to be used concurrently with restraints and not as an alternative. Further research should investigate staff's current and intended uses of surveillance technologies in practice. Staff members' opinion that they use restraints inappropriately might correctly reflect overuse of restraints on their unit. If so, staff ratings of inappropriate restraint use may identify units that need improvement.


Despite physical restraints' known lack of effectiveness and safety,[1,2] they are commonly used in nursing homes (NHs). Defined as "any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to his/her body by the use of any method, attached or adjacent to a person's body that he/she cannot control or remove easily,"[3] physical restraints include measures such as wrist or ankle belts, bedrails, tightly tucked sheets, or (wheel)chairs with locked tray tables or brakes.[2] In addition to the risk of serious and harmful consequences, physical restraint use reduces residents' quality of life.[4,5] While restraint use raises ethical questions concerning residents' autonomy, self-determination, and dignity,[6] many NHs still consider it a necessary safety measure, for example, against falls, or to deal with certain problem behaviors, for example, aggression and wandering.[7–9]

Prevalence for physical restraint use ranges widely internationally. Beyond country-specific differences, the heterogeneity of research methods and wide variations in conceptual and operational definitions impedes international comparisons.[1,2,10] A 2021 meta-analysis reported a pooled prevalence of 37% in Europe and of 22% in North America[2] while a 2021 scoping review reported a median occurrence of 26.5% in European NHs, with substantial variability (range: 7.7%–60.5%).[10] Several factors have been investigated in relation to physical restraint use, such as public reporting policies, organizational characteristics (e.g., staffing), organizational culture, and resident characteristics. While resident characteristics—especially higher levels of cognitive deficiency and dependency—have been repeatedly significantly associated with increased restraint use, most other factors have produced mixed results.[11–16]

The last two decades have seen many changes in the NH sector in relation to physical restraint use. On one hand, many countries, including Switzerland in 2013, have implemented least-restraint policies or laws aiming to restrict restraint use, which have been hypothesized to have influenced prevalence rates, staff' practices, and opinions.[1] In the United States, for instance, the passage of the Omnibus Budget Reconciliation Act of 1987 has been associated with a large reduction of the proportion of restrained residents.[17] On the other hand, technologies have developed and have been increasingly used in NHs.[18] Specifically, the use of surveillance technologies (e.g., sensor-based, cameras, GPS tracking) has been hypothesized to lead to the reduction of physical restraint use as they could be used as a less restrictive alternative to physical restraints. For instance, residents can wear bracelets that allow them to go through some doors but not others, for example, ensuring they do not leave the facility' premises but allowing them to walk freely within the facility.[18–21] However, despite its increased use, there is a striking lack of research on the use of such technologies in NHs and their effects on physical restraint use.

Staff attitudes about the use of physical restraints have been explored across many countries. A 2014 systematic review concluded that, despite a generally negative attitude toward restraint use, geriatric care staff often consider restraints necessary.[8] The main hypothesis in the literature is that staff who find the use of restraints inappropriate are less likely to use such restraints. However, few studies have linked staff opinions (i.e., their opinion about the appropriateness of restraint use) to resident-level measurements of physical restraint use, and those studies date back from the early 2000s, before many least-restraint policies were introduced.[8,22]

In this article, we used a socio-technical approach, which highlights how interactions between social and technical elements contribute to organizational achievements, to recognize the interactions between staff and technology and their influence on restraint use.[23,24]

To address the knowledge gaps highlighted before, the study has two aims: (1) to describe the prevalence of physical restraint use in Swiss NHs and (2) to explore the association between physical restraint use and (a) surveillance technology use, hypothesizing less restraint use with more surveillance technology use, and (b) staff opinion toward the appropriateness of restraint use, hypothesizing more restraint use with more positive opinion regarding its appropriateness.