Nursing Skill Mix, Nurse Staffing Level, and Physical Restraint Use in US Hospitals: a Longitudinal Study

BACKGROUND: Although it is plausible that nurse staffing is associated with use of physical restraints in hospitals, this has not been well established. This may be due to limitations in previous cross-sectional analyses lacking adequate control for unmeasured differences in patient-level variables among nursing units. OBJECTIVE: To conduct a longitudinal study, with units serving as their own control, examining whether nurse staffing relative to a unit’s long-term average is associated with restraint use. DESIGN: We analyzed 17 quarters of longitudinal data using mixed logistic regression, modeling quarterly odds of unit restraint use as a function of quarterly staffing relative to the unit’s average staffing across study quarters. SUBJECTS: 3101 medical, surgical, and medical-surgical units in US hospitals participating in the National Database of Nursing Quality Indicators during 2006–2010. Units had to report at least one quarter with restraint use and one quarter without. MAIN MEASURES: We studied two nurse staffing variables: staffing level (total nursing hours per patient day) and nursing skill mix (proportion of nursing hours provided by RNs). Outcomes were any use of restraint, regardless of reason, and use of restraint for fall prevention. KEY RESULTS: Nursing skill mix was inversely correlated with restraint use for fall prevention and for any reason. Compared to average quarters, odds of fall prevention restraint and of any restraint were respectively 16 % (95 % CI: 3–29 %) and 18 % (95 % CI: 8–29 %) higher for quarters with very low skill mix. CONCLUSIONS: In this longitudinal study there was a strong negative correlation between nursing skill mix and physical restraint use. Ensuring that skill mix is consistently adequate should reduce use of restraint.