In a recent study (Beerens et al. 2014), physical restraint use (belt restraints, locked chair/table, deep/overturned chair, bedrails) in persons with dementia was assessed in eight European countries and resulted in an average prevalence number of 31%. However, the variety between countries was very wide, ranging from 6% to 83%. These results are in line with earlier studies, showing a wide variety in prevalence numbers of physical restraints in institutionalized long-term care facilities such as nursing homes, ranging from about 6% to 70% (e.g., Hamers and Huizing 2005; Heinze et al. 2012; Schüssler et al. 2014). This variety in prevalence numbers is partly attributed to the use of different methods and definitions of physical restraint. To illustrate, some studies have excluded bedrails as a measure of physical restraint. Others have included sensor alarms that by some authors are not viewed as a restraint measure. As a result, prevalence rates of different studies are difficult to compare, and consensus on a consistent definition of physical restraints is needed.

Therefore, an international group of 48 experts consisting of researchers and clinicians from 13 countries (Australia, Belgium, Canada, Finland, Germany, Hong Kong, the Netherlands, Norway, Spain, Sweden, Switzerland, the United Kingdom, the United States) who have made sustained contribution to research and clinical application in the field of physical restraint in clinical care has agreed upon a new definition of physical restraint recently (Bleijlevens et al. 2016). They define physical restraint 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” (Bleijlevens et al. 2016). Examples of physical restraints are the use of two-sided full-enclosed bedrails, waist belts, overturned geriatric chairs, and chairs with a locked tray table.

The opinion of many people is that the use of physical restraints is a result of shortages in nursing home staff, or other organizational characteristics are debatable. Although Wagner et al. (2012), conducting secondary analyses using OSCAR data, found an association between decreased likelihood of deficiency citations for physical restraints (indicating better quality of care) and higher RN staffing levels, this was not supported by observational studies (e.g., Engberg et al. 2008; Heinze et al. 2012) investigating associations of organizational characteristics and restraint use. For instance, Huizing et al. (2007) examined objective and subjective measures of workload, social support, sickness absence, and FTE ratio and found no associations with restraint use (as assessed by blinded independent raters) in persons with cognitive impairment, including dementia. They even reported more restraint use, when more staff was available (Huizing et al. 2007).

Residents’ characteristics are the most important determinants of physical restraint use in persons with cognitive impairment. Poor cognitive status, poor mobility, and dependence in activities of daily living seem to be important predictors of restraint use (e.g., Capezuti 2004; Hofmann and Hahn 2013; Kirkevold et al. 2004; Meyer et al. 2008; Pellfolk et al. 2012). The most important reason to use physical restraint is to increase the residents’ safety. The assumption is that the use of physical restraints will prevent falls and severe injuries (e.g., fractures) as a result from falls (Hamers et al. 2004; Pellfolk et al. 2012). However, it is known that the use of physical restraints has many negative consequences. Some residents will become incontinent as a result of being restrained; they cannot go to the toilet independently. Other residents will develop apathetic or aggressive behavior, as they are willing to free themselves from a belt restraint. In a study by Castle (2006), it was concluded that belt restraints led to a decrease in cognitive performance, an increase of depression, and a decrease of social engagement. Furthermore, restraining a person will negatively affect the person’s muscle strength and balance, increasing the risk of falls and creating a vicious circle (Hamers et al. 2009). Finally, it has been reported that the use of physical restraints can result in injuries and even fatal accidents, just because people want to free themselves. It is evident that physical restraint use in older people does not contribute to better health or quality of life. Therefore, restraint use should be prevented and reduced in institutional long-term care settings.

During decennia, in most countries, nursing home staff has been educated that the use of physical restraints is an adequate care in order to prevent harm in nursing home residents with cognitive impairment. This may explain why the development of training programs has been the main approach in order to reduce the use of physical restraints (e.g., Kuske et al. 2009; Lai et al. 2006; Huizing et al. 2009a, b; Testad et al. 2005). Some approaches are elaborated by introducing a nurse specialist who acts as a consultant aiming at the further reduction of restraints in complex individual cases (Capezuti et al. 2007; Evans et al. 1997; Huizing et al. 2009a, b).

Different research designs (ranging from chart reviews to randomized clinical trials) have been employed to evaluate the effectiveness of the different approaches. Controlled studies report negative results (“the approach is not effective”) more often than uncontrolled studies. In general, training programs aiming at the reduction of physical restraints seem to improve the knowledge of nursing staff regarding restraint use, its determinants and consequences, and the need to prevent restraint use (Kuske et al. 2009; Mac Dermaid and Byrne 2006). However, educational programs are insufficiently effective in reducing the use of physical restraints (Kuske et al. 2009; Testad et al. 2005; Möhler et al. 2012). This was also found in a study by our research group in the Netherlands; a randomized controlled study by Huizing et al. (2009a) using an intensive educational training program in combination with a nurse specialist showed no effect in preventing or reducing the use of physical restraints in nursing home residents with cognitive impairment (most suffering from dementia). Different explanations were brought up for this negative outcome. First, nursing staff said that they experienced no or insufficient support from the nursing home management by emphasizing the need to reduce physical restraints. Furthermore, nursing staff said that direct staff members who did not attend the training program were hindering initiatives to reduce restraints. Finally, alternative measures (e.g., infrared warning alarm, physical exercises by physiotherapist) were insufficiently available. These results have led to the further development of an approach in the Living Lab in Ageing and Long-Term Care (Verbeek et al. 2013) aiming at the reduction of physical restraints in persons with cognitive impairment living in long-term care facilities: “EXBELT.”

The EXBELT approach comprises four key components (Gulpers et al. 2011):