Attitudes of Dutch, German and Swiss nursing staff towards physical restraint use in nursing home residents, a cross-sectional study

Theories for interventions to reduce physical and verbal abuse: A mixed methods review of the health and social care literature to inform future maternity care

Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.

District nurses' attitudes towards involuntary treatment in dementia care at home: A cross-sectional study

One in two persons living with dementia (PLWD) at home receive care which they resist to and/or have not given consent to, defined as involuntary treatment. District nurses play a key role in the use of involuntary treatment. However, little is known how their attitudes and opinions influence the use of involuntary treatment. This cross-sectional study aims to investigate the attitudes of district nurses towards the use of involuntary treatment in dementia care at home, determinants and their opinion about its restrictiveness and discomfort. Results show that district nurses perceive involuntary treatment as regular part of nursing care, having neither positive nor negative attitude towards its appropriateness. They consider involuntary treatment usage as moderately restrictive to PLWD and feel moderately uncomfortable when using it. These findings underscore the need to increase the awareness of district nurses regarding the negative consequences of involuntary treatment use to PLWD at home.

Attitudes of Nursing Staff in Hospitals towards Restraint Use: A Cross-Sectional Study

The attitude of nursing staff towards restraint use can be decisive for whether restraints are used. So far, nursing staff’s attitudes have been studied primarily in long-term and mental health care settings, while findings from somatic acute care hospital settings are largely lacking. Therefore, we aimed to investigate (a) the attitudes of hospital nursing staff towards restraint use, and (b) the construct validity and reliability of a measurement instrument for use in hospital settings that was developed and validated in long-term care settings (Maastricht Attitude Questionnaire (MAQ)). Using a cross-sectional design, the attitudes of 180 nursing staff towards restraint use were assessed. The data were analysed descriptively and by means of regression analysis and factor analysis. We found that nursing staff in hospitals have a neutral attitude towards restraint use and that the MAQ, with minor adaptations, can be used in hospital settings, although further testing is recommended. Neutral attitudes of nursing staff have also been observed in long-term and mental health care settings, where changing attitudes were found to be challenging. Interventions at the national level (e.g., legal regulations) and management level (e.g., providing alternatives and changing institutional culture) are suggested.

Knowledge, Attitude, and Practice of Nursing Home Staff Regarding Physical Restraint in China: A Cross-Sectional Multicenter Study

Background

Restraint is widely used in nursing homes to address safety concerns. However, many studies have shown that improper restraint can lead to many adverse outcomes. Nursing staff are the main practitioners of physical restraint in nursing homes and play an important role in restraint decision-making and management. In China, there is still a lack of large-scale surveys on the current situation regarding the use of restraint. This study aimed to identify this situation and the influencing factors of the knowledge, attitude, and practice of nursing staff regarding physical restraint in elderly care institutions.

Methods

A cross-sectional multicenter descriptive study was conducted. A total of 311 staff in 25 elderly care institutions in Zhejiang Province were recruited using a quota sampling method. A homemade questionnaire was administered to collect general information and information on knowledge, attitude and practice regarding physical restraint.

Results

The average scoring rates of the knowledge and attitude dimensions of the 311 staff were 48.7 and 75.6%, respectively. The average scoring rate of the practice dimension of 140 staff who implemented restraint was 80.1%. Educational background and training experience were the influencing factors of restraint knowledge. Training experience, educational background and professional title were the influencing factors of restraint attitude. Restraint knowledge and length of service were the influencing factors of restraint practice.

Conclusions

Knowledge of physical restraint among nursing staff is not promising. Their attitude toward restraint was inappropriate or irresponsible in some aspects. Restraint practice is not sufficiently standardized. It is necessary to strengthen restraint training for nursing staff to improve their overall level of restraint knowledge, attitude and practice.

Restraint practice in the somatic acute care hospital: A participant observation study

AIMS AND OBJECTIVES

We aimed to describe daily restraint practices and the factors which influence their use, from an outsider's perspective.

BACKGROUND

A reduction in restraint use is recommended in health care. However, somatic acute care hospital settings currently lack effective reduction strategies. Thus far, hospital restraint practice is described in terms of quantitative assessments and the 'insider' view of healthcare professionals. However, as factors such as routine or personal beliefs seem to play a relevant role in restraint use, these approaches might be incomplete and biased.

DESIGN

A qualitative observation study design was employed.

METHODS

Fieldwork with unstructured participant observation was conducted at a department of geriatrics and a department of intensive care in Switzerland between November 2019 and January 2020. Data were recorded as field notes. The analysis was conducted iteratively in two coding cycles using descriptive coding followed by pattern coding. We adhered to the Standards for Reporting Qualitative Research (SRQR).

RESULTS

A total of 67 hours of observation were conducted. We found that daily restraint practice can be described in three categories: the context in which restraints are used, the decision-making process on the use and continued use of restraints, and the avoidance of restraint use. Most processes and decisions seem to take place unconsciously, and their standardisation is weak.

CONCLUSIONS

The lack of standardisation favours intuitive and unreflective action, which is prompted by what is also known as heuristic decision-making. To transform daily restraint practice, a technical solution that leads restraint management in line with ethical and legal requirements might be useful.

RELEVANCE TO CLINICAL PRACTICE

The outsider perspective has allowed daily restraint practice to be described independently of existing routines, departmental cultures and personal attitudes. This is important to comprehensively describe restrictive practices, which is a prerequisite for the development of effective restraint reduction strategies.

Physical Restraint in the Critical Care Unit: A Narrative Review

Restraint has been used within health care settings for many centuries. Initially physical restraint (PR) was the method of choice, in present times. Within critical care units PR and chemical restraint are used, frequently in tandem. Restraint is not a benign intervention and PR specifically is associated with physical and psychological trauma towards those receiving it. Healthcare staff also suffer psychological consequences. This paper has reviewed the literature (using the terms 'physical restraint'; 'hospital'; 'care home critical care'; 'intensive care' 'attitudes'; 'knowledge' 'use of'; 'healthcare') to investigate the reasons for the use of restraints, its consequences and the attitudes of healthcare professionals' attitudes towards physical restraint currently present in critical care. Restraint use remains common practice in Critical Care Units (for 'patient safety'), initiated outside of institutional protocols, despite evidence questioning its effectiveness and the resulting harm to patients and staff.

Difference of Physical Restraint Knowledge, Attitudes and Practice Between Nurses and Nursing Assistants in Long-Term Care Facilities: A Cross-Sectional Study

Background

Purpose

Methods

Results

Conclusion

Between Restrictive and Supportive Devices in the Context of Physical Restraints: Findings from a Large Mixed-Method Study Design

Physical restraints are still a common problem across healthcare settings: they are triggered by patient-related factors, nurses, and context-related factors. However, the role of some devices (e.g., bed rails), and those applied according to relatives'/patients' requests have been little investigated to date. A mixed-method study in 2018, according to the Good Reporting of a Mixed Methods Study criteria was performed. In the quantitative phase, patients with one or more physical restraint(s) as detected through observation of a single index day in 37 Italian facilities (27 long-term, 10 hospital units, =4562 patients) were identified. Then, for each patient with one or more restraint(s), the nurse responsible was interviewed to gather purposes and reasons for physical restraints use. A thematic analysis of the narratives was conducted to (a) clarify the decision-making framework that had been used and (b) to assess the differences, if any, between hospital and long-term settings. The categories 'Restrictive' and 'Supportive' devices aimed at 'Preventing risks' and at 'Promoting support', respectively, have emerged. Reasons triggering 'restrictive devices' involved patients' risks, the health professionals' and/or the relatives' concerns. In contrast, the 'supportive' ones were triggered by patients' problems/needs. 'Restrictive' and 'Supportive' devices were applied based on the decision of the team or through a process of shared decision-making involving relatives and patients. According to the framework that emerged, long-term care patients are at increased risk of being treated with 'restrictive devices' (Odds Ratio 1.87, Confidence Interval 95% 1.44; 2.43; p < 0.001) as compared to those hospitalized. This study contributes to the improvement in knowledge of the definition, classification and measurement of physical devices across settings.

Exploring restrictive measures using action research: A participative observational study by nursing staff in nursing homes

AIM

In nursing homes, nursing staff have a key role in the use of restrictive measures. However, their active role in reducing restrictive measures has so far been limited. The aim of this study is to explore how and when the application of restrictive measures in nursing homes occurs including underlying factors, together with nursing staff.

DESIGN

Participatory action research was chosen for a bottom-up understanding of the use of restrictive measures.

METHOD

Two Dutch nursing homes participated in 2016/2017 with 18 nursing staff members in the action research team. Nursing staff carried out 33 observations followed by a reflective interview.

RESULTS

Nursing staff observed a wide range of restrictions, including restrictions in freedom of choice, not being able to go outside, not being in charge of medication, and a directive/unresponsive care attitude. Factors influencing restrictions included habits and institutionalization, cognitive ability of the resident, availability of personnel, and responsibility for safety. A responsive care attitude and raising awareness were seen as good practices to enhance freedom.

CONCLUSIONS

By taking a distant view on their work, nursing staff discovered a broad range of restrictions, including 'less obvious' restrictions. Active forms of learning may position nursing staff to discuss and reduce restrictive measures.

IMPACT

What problem did the study address?: Restrictive measures are still common in nursing homes. Despite their key role in using restrictive measures, nursing staff's active role in research has been limited. What were the main findings?: By participating as researchers, nursing staff gained a broader perspective on restrictive measures. Many 'less obvious' restrictions were related to routines and institutionalization and were considered as eye opening by nursing staff. Where and on whom will the research have impact?: Active forms of learning such as observing and reflecting has the potential to position nursing staff as 'agents of change'.

An Application of the Theory of Planned Behavior to Predict the Intention and Practice of Nursing Staff Toward Physical Restraint Use in Long-Term Care Facilities: Structural Equation Modeling

PURPOSE

Understanding the factors that affect nursing staffs' intention and practice of physical restraint (PR) on older adults help develop restraint-reduction programs. This study aimed to identify the relationship between the Theory of Planned Behavior (TPB) constructs and nursing staffs' practice to use PR in long-term care (LTC) facilities.

PATIENTS AND METHODS

A cross-sectional survey was conducted via convenience sampling among 316 nursing staff in six Chinese LTC facilities. PR-TPB questionnaire and the practice subscale of the Chinese version of the Staff Knowledge, Attitudes and Practices Questionnaire regarding PR were used to collect the data. Structural equation modeling (SEM) was used to examine the relationship between variables.

RESULTS

The SEM fit well with the data (χ2/df =1.639, RMSEA = 0.045, CFI= 0.955, GFI=0.945). Attitude (β=0.536, P<0.001) and perceived behavioral control (PBC) (β=0.139, P<0.05) predicted intention (R2 =0.359). PBC was a significant predictor of practice, with R2 accounting for 0.151.

CONCLUSION

TPB provided useful insight into better understanding nursing staffs' PR practices, although it did not support all the TPB principles significantly. Prospective studies may be conducted to design and implement multi-component interventions based on TPB and explore the effectiveness of PR reduction in LTC facilities in-depth.

Reducing the use of physical restraints in home care: development and feasibility testing of a multicomponent program to support the implementation of a guideline

BACKGROUND

A validated evidence-based guideline was developed to reduce physical restraint use in home care. However, the implementation of guidelines in home care is challenging. Therefore, this study aims to systematically develop and evaluate a multicomponent program for the implementation of the guideline for reducing the use of physical restraints in home care.

METHODS

Intervention Mapping was used to develop a multicomponent program. This method contains six steps. Each step comprises several tasks towards the design, implementation and evaluation of an intervention; which is theory and evidence informed, as well as practical. To ensure that the multicomponent program would support the implementation of the guideline in home care, a feasibility study of 8 months was organized in one primary care district in Flanders, Belgium. A concurrent triangulation mixed methods design was used to evaluate the multicomponent program consisting of a knowledge test, focus groups and an online survey.

RESULTS

The Social Cognitive Theory and the Theory of Planned Behavior are the foundations of the multicomponent program. Based on modeling, active learning, guided practice, belief selection and resistance to social pressure, eight practical applications were developed to operationalize these methods. The key components of the program are: the ambassadors for restraint-free home care (n = 15), the tutorials, the physical restraint checklist and the flyer. The results of the feasibility study show the necessity to select uniform terminology and definition for physical restraints, to involve all stakeholders from the beginning of the process, to take time for the implementation process, to select competent ambassadors and to collaborate with other home care providers.

CONCLUSIONS

The multicomponent program shows promising results. Prior to future use, further research needs to focus on the last two steps of Intervention Mapping (program implementation plan and developing an evaluation plan), to guide implementation on a larger scale and to formally evaluate the effectiveness of the multicomponent program.

A cross-sectional study on nurses' attitudes towards physical restraints use in nursing homes in Portugal

Aim

To explore nurses' opinions regarding restraint measures and attitudes towards physical restraints use in nursing homes.

Design

Cross‐sectional study.

Methods

Nursing staff of 33 Portuguese nursing homes was asked to complete the Portuguese version of the Maastricht Attitude Questionnaire (MAQ), an instrument on attitudes regarding physical restraints (reasons, consequences and appropriateness of restraint use) and opinions about restraint measures (restrictiveness and discomfort). Descriptive statistics and bivariate analysis were performed.

Results

Data from 186 nurses were included in the analysis. Overall, nurses expressed neutral to moderately positive attitudes towards physical restraints usage. Nurses with longer professional experience reported a more positive attitude regarding the appropriateness of restraint use in their clinical practice. Wrist and ankle restraints were the measures that nurses reported feeling most uncomfortable using, and the most restrictive. Bilateral bedrails were globally assessed as a slightly restrictive measure and nurses reported not feeling uncomfortable using them.

Patient safety and bedrail use as a global phenomenon: A prevalence study

Background: Although bedrail use may increase the risk of accidents among patients, bedrails are still extensively used in healthcare facilities. Therefore, the field calls for a review of bedrail use in practice. Objective: This report examined the prevalence and implications of bedrail use in rehabilitation facilities in Hong Kong. The findings are compared with the current state of bedrail use worldwide. Design and methods: This work is a cross-sectional, observational study. A secondary analysis was conducted on the database of a prospective trial. Bilateral bedrail use was observed in two Hong Kong rehabilitation hospitals. Logistic regression was performed to examine the factors associated with bedrail use. Results: A total of 3,384 restraint observations were made. The bedrail rate was 31.34%, which revealed that bedrail use was the second most commonly used physical restraint. The fall history (OR: 2.84), cognitive impairment (OR: 0.91) and functional dependency (OR: 0.79) of patients were significant predictors of bedrail use, p < .05. Conclusion: This study examines bedrail prevalence through direct observation, which is the preferred method for examining bedrail use in practice. We found that actual bedrail use is higher than the numbers reported in previous studies in Hong Kong. In addition, our research reveals that bedrails are commonly used for vulnerable patients. This finding highlights the need to change nurses' beliefs on bedrail use through education. The management of these health facilities should also aim to create an institutional environment that promotes the reduction of bedrail use. Implementation strategies on restraint reduction should also fit the culture of the organisation and local nursing practices, as well as the staff's values. Impact Statement: This study provides preliminary information about the widespread use of bedrails in Hong Kong and other countries. The research also introduces effective ways to achieve the reduction of bedrail use.

Nurses' behaviours towards physical restraint use in the ICU: A descriptive qualitative study

AIMS AND OBJECTIVES

The study aims to explore and describe nurses' behaviours towards physical restraint (PR) use in intensive care units (ICUs) and identify key characteristics of these experiences.

BACKGROUND

Patients within the ICU are always vulnerable, which requires a thoughtful deliberation when employing PR in ethically laden situations. Considering that the qualitative study on nurses' behaviours towards PR use in ICUs is limited, a deep understanding of how nurses reason and restrict patients is necessary before developing a minimizing programme in hospitals.

METHODS

A descriptive qualitative study was conducted in this paper. Data were collected by 24 semistructured, in-depth and individual interviews about PR, where 24 nurses were drawn from six ICUs of four hospital settings from a comprehensive tertiary care hospital in Qingdao. The QSR NVivo 11.0 software program was used to manage the interview data, and data analysis was guided by the Qualitative Analysis Guide of Leuven. The checklist of Consolidated Criteria for Reporting Qualitative Studies was followed as a guideline in reporting the study.

RESULTS

Regarding PR, nurses' behaviours start with a hazard perception, followed by hesitation about whether to restrict the patient. They would usually decide to apply PR when they think that no other choice to control the situation is available. Then, they would reflect on and rationalize their behaviours. Nurses, intensivists, patients and their families participate in and affect this process directly or indirectly.

CONCLUSIONS

Nurses' behaviours towards PR use comprise a series of complex processes centred on safety. Nurses' decision making should be performed with the participation of intensivists, patients and family caregivers.

Improvement Plan of Nurse Staffing Standards in Korea

PURPOSE

This study compares the expected nurse-to-patient ratio, penalties for violating these regulations, and the laws enacted in the medical and nursing fields in Korea and advanced countries like Germany, Australia, the United States, and Japan.

METHODS

This study deployed an integrative review method and used search terms such as "nursing law," "nurse ratio," "nurse," "nurse staffing," "health," and "staffing" to find articles published in English, Korean, German, or Japanese through Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, the Westlaw (International Materials-Jurisdiction) site, US government and state sites (federal parliament, National Conference of State Legislatures), and Google Scholar.

RESULTS

Compared with medical laws in other advanced countries, Korean laws are quite crude and its nurse-to-patient ratio does not reflect patients' status. Korea also lacks strict penalties for nurse staffing ratio violations.

CONCLUSION

Korea requires a strong regulatory apparatus for nurse staffing in health-care organizations to improve the quality of its health-care services and patient safety.

Prevention and reduction of involuntary treatment at home: A feasibility study of the PRITAH intervention

Sometimes care is provided to a cognitively impaired person against the person's will, referred to as involuntary treatment. We developed the PRITAH intervention, aimed at prevention and reduction of involuntary treatment at home. PRITAH consists of a policy discouraging involuntary treatment, workshops, coaching by a specialized nurse and alternative interventions. A feasibility study was conducted including 30 professional caregivers. Feasibility was assessed by attendance lists (reach), a logbook (dose delivered and fidelity), evaluation questionnaires and focus group interviews (dose received, satisfaction & barriers). The workshops and coach were positively evaluated and the average attendance rate was 73%. Participants gained more awareness and knowledge and received practical tips and advice to prevent involuntary treatment. Implementation of the intervention was feasible with minor deviations from protocol. Recommendations for improvement included more emphasis on involvement of family caregivers and general practitioners and development of an extensive guideline to comply with the policy.

Workshop and package education intervention to knowledge, attitude and practice of ICU nurses on the use of physical restraints

Background The purpose of this study was to compare the effect of the two training methods: educational workshop and electronic package on the knowledge, attitude and practice of nurses in intensive care units (ICUs). Materials and Methods In this experimental study, 64 nurses working in ICU at Imam Hossein and Bahar Hospitals in 2017 in Shahroud were randomly selected into two groups of training: workshops and educational package. At first, knowledge, attitude and performance of the two groups were measured and then 2 weeks after the post-test training. Data were analyzed by Fisher exact, Wilcoxon, independent t-test, Mann-Whitney test with a significance level ≤0.05. Results A significant difference was found between knowledge score in the workshop (10.40 ± 1.41) and educational package (11.25 ± 0.95) (p=0.007). However, No significant difference was found between the nurses attitude in the workshop group (28.59 ± 2.74) and the trained by educational package (28.25 ± 2.85) (p=0.617). Also, no significant difference was found between the mean practice scores in two groups (p=0/143). Conclusion The results of this study indicated that the educational package was more effective than the workshop on improving the level of knowledge of nurses about physical restriction, but both methods increased the attitude and practice of nurses.

[Physical restraint use in relation to falls risk in a nursing home]

BACKGROUNDS AND OBJECTIVES

The use of physical restraints (PR) is common in the care of the elderly. However, their efficacy and safety are not supported by scientific evidence. The aim of this study was to determine the role of PR in preventing falls.

MATERIALS AND METHODS

A retrospective cohort study design was used, in which each fall incident (n=575) was examined in the residents over 65 years of age who resided at the one nursing homes from February 2009 to September 2013. An analysis was made of the association between the use of PR and risk of falls using a multivariate logistic regression, adjusting for the characteristics of residents that were associated with the use of PR according to a bivariate analysis.

RESULTS

Risk factors for falls after accounting for PR use, include: risk of falling (Tinetti test) (OR 4.57; 95% CI 1.76-11.75); ability to walk (OR 6.40; 95% CI 2.78-14.74); hearing impairment (OR 2.12; 95% CI 1.05-4.29); and history of a previous fall (OR 17.81; 95% CI 8.83-35.93). The risk of falls was greater in restrained, ambulatory residents with cognitive impairment (OR 18.95; 95% CI 7.06-50.85). No differences were found in injuries between falls that occurred with and without PR.

CONCLUSIONS

Restraint use was not significantly associated with fewer falls and injuries. The risk of falls could increase in ambulatory residents with cognitive impairment. The study results suggest the need to consider whether restraints provide adequate protection against the risk of falls.

Development and initial validation of a Theory of Planned Behaviour questionnaire to assess critical care nurses' intention to use physical restraints

AIMS

To develop and psychometrically test a Theory of Planned Behaviour (TPB) questionnaire to assess nurses' intention to use physical restraints (PRs) in intubated patients.

DESIGN

A psychometric instrument validation study conducted in three phases.

METHODS

A theory-driven questionnaire was developed. Eight experts validated the content of the preliminary 58-item questionnaire. A pilot study was conducted including 101 critical care nurses to test the reliability of the items. Construct validity and reliability were tested in a cross-sectional study of 12 units from eight hospitals in Spain (N = 354) from October - December 2017. Participants completed the questions based on the TPB, and socio-demographic and professional variables.

RESULTS

The instrument comprised 48 items. All the direct and indirect constructs exhibited acceptable reliability. Confirmatory factor analysis indicated satisfactory fit indices for factorial structure according to the TPB. Nurses showed favourable attitudes, low perception of social pressure and modest perception of behaviour control. Perceived behavioural control and attitude were moderately positively correlated with the intention to use restraints, whereas subjective norm revealed the lowest correlation. Overall, the model explained 33% of the variance in intention.

CONCLUSIONS

The Physical Restraint TPB questionnaire is a 48-item self-reporting theoretically based instrument with acceptable reliability and construct validity to identify nurses' intentions to use PRs in intubated patients.

IMPACT

Unravelling the key determinants of nurses' intentions to use PRs should be examined to tailor quality improvement projects aimed at de-implementing restraints use in practice and to promote safer care.

Nursing professionals' attitudes toward use of physical restraints in Styrian nursing homes Austria

BACKGROUND

Given that nursing staff play a critical role in the decision regarding use of physical restraints, research has examined nursing professionals' attitudes toward this practice.

AIM

Since nursing professionals' views on physical restraint use have not yet been examined in Austria to date, we aimed to explore nursing professionals' attitudes concerning use of physical restraints in nursing homes of Styria (Austria).

METHOD

Data were collected from a convenience sample of nursing professionals (N = 355) within 19 Styrian nursing homes, based on a cross-sectional study design. Attitudes toward the practice of restraint use were assessed by means of the Maastricht Attitude Questionnaire in the German version.

RESULTS

The overall results showed rather positive attitudes toward the use of physical restraints, yet the findings regarding the sub-dimensions of the questionnaire were mixed. Although nursing professionals tended to deny "good reasons" for using physical restraints, they evaluated the consequences of physical restraint use rather positive and considered restraint use as an appropriate health care practice. Nursing professionals' views regarding the consequences of using specific physical restraints further showed that belts were considered as the most restricting and discomforting devices.

CONCLUSIONS

Overall, Austrian nursing professionals seemed to hold more positive attitudes toward the use of physical restraints than counterparts in other Western European countries. Future nationwide large-scale surveys will be needed to confirm our findings.

Professional and family caregivers' attitudes towards involuntary treatment in community-dwelling people with dementia

Aims

The aim of this study was to gain insight into professional and family caregivers’ attitudes towards involuntary treatment in community‐dwelling people with dementia (PwD).

Background

The number of PwD with complex care needs living at home is increasing rapidly. In some situations, caregivers provide care against the will of PwD, referred to as involuntary treatment, which includes non‐consensual care, psychotropic medication and physical restraints.

Design

A cross‐sectional study.

Methods

A total of 228 professional (nursing staff, general practitioners (GPs) and other healthcare professionals such as physical therapists and psychologists) and 77 family caregivers of PwD completed the Maastricht Attitude Questionnaire—Home Care. This questionnaire measures attitudes towards involuntary treatment and perceived restrictiveness of and experienced discomfort in using involuntary treatment. Data were collected in the Netherlands between June and November 2016.

Results

Family caregivers and GPs had more positive attitudes towards involuntary treatment than nursing staff and other healthcare professionals, indicating that they are more accepting of involuntary treatment. A more positive attitude was associated with higher perceived caregiver burden and being a family caregiver. Family caregivers and GPs found the use of involuntary treatment less restrictive and indicated feeling more comfortable when using these measures.

Conclusion

It is important to account for the differences in attitudes and foster dialogue among professional and family caregivers to find common ground about alternatives to involuntary treatment. These results will inform the development of an intervention that aims to prevent involuntary treatment in home care.

Nurses' knowledge, attitudes and practices related to physical restraint: a cross-sectional study

AIM

To investigate nurses' knowledge, attitudes and practices related to physical restraint in tertiary hospitals and identify the factors that influence physical restraint use.

BACKGROUND

Physical restraint is used to maintain patient safety. Nurses play an important role in the restraint process. It is important to identify their understanding, feelings and approach regarding the use of physical restraint.

INTRODUCTION

Physical restraint is widely practiced in hospitals in China. However, it results in a range of serious negative consequences. This article provides a clear description of nurses' knowledge, attitudes and practices related to physical restraint.

METHODS

A cross-sectional survey was conducted. The participants were asked to complete a questionnaire examining their knowledge, attitudes and practices related to physical restraint use. A total of 200 questionnaires were distributed in four tertiary hospitals in Hubei Province, China between August and October 2014.

RESULTS

The nurses' responses indicated a good level of knowledge regarding physical restraint use. However, they held some misconceptions. The nurses' attitudes towards physical restraint tended to be neutral. The nurses were well experienced in the use of physical restraint. Nurses who had received on-the-job training performed better than those who had received no training related to knowledge and practices regarding physical restraint use.

CONCLUSIONS AND IMPLICATION FOR NURSING/HEALTH POLICY

In-service training is highly recommended for nursing managers to improve nurses' physical restraint related knowledge and practices. Regulations regarding the use of restraints should be established as soon as possible by healthcare administration system.

IMPLICATIONS FOR NURSING

Nurses should be open to evaluate and improve their views and attitudes regarding effective physical restraint use via multidimensional interventions.

Investigating influencing factors of physical restraint use in China intensive care units: A prospective, cross-sectional, observational study

OBJECTIVE

In this study, we characterised the use of physical restraints in three intensive care units (ICUs) in a general hospital in Nantong, China. Additionally, we explored risk factors potentially related to physical restraint use.

BACKGROUND

Despite their numerous harmful effects, physical restraints are frequently used in ICUs worldwide. Few studies have investigated the factors that contribute to physical restraint use in Chinese hospitals.

METHODS

We conducted a prospective, cross-sectional, observational study of 312 patients in three ICUs at a general hospital in China. The quantitative data were collected during a 5-month period using a physical restraint observation form and patient records. The data obtained were analysed using descriptive statistics. The independent risk factors for physical restraint use were assessed using a logistic regression model.

RESULTS

Of the 312 patients in the three ICUs, 191 (61.2%) were restrained, and physical restraints were used more than once for 46 (24.1%) patients during their ICU stay. The median length of physical restrain use was 20 shifts (interquartile range = 10-36 shifts). Physical restraints were applied in 6664 of 12374 (53.9%) nurse shifts. The most common time at which physical restraints were applied was the beginning of the evening shift. According to the forward stepwise logistic regression analysis, delirium (P < 0.001), mechanical ventilation (P < 0.001), and age (P < 0.001) were independent risk factors for physical restraint use. The use of analgesics (P = 0.001) exerted an independent protective effect against physical restraint use.

CONCLUSIONS

The overall prevalence of physical restraint use in Chinese ICUs was higher than that reported in previous investigations. The patients' nursing notes lacked complete physical restraint records, reflecting a need for standard guidelines and policies for physical restraint use in hospital ICUs in China. In addition, in this study, we explored the risk factors related to physical restraint use and found that age, delirium, mechanical ventilation, and analgesic use are associated with physical restraint use.

Cross-sectional study on nurses' attitudes regarding coercive measures: the importance of socio-demographic characteristics, job satisfaction, and strategies for coping with stress

BACKGROUND

Coercive measures are containment methods used in psychiatry to curb patients' disruptive and aggressive behaviours towards themselves, others or objects. The prevalence of the practice of coercive measures in psychiatry is directly related to the attitudes of the staff. When discussing these attitudes, nurses are often particularly singled out. The purpose of the study is to research the impact of individual factors on nurses' attitudes in the decision-making process for the use of coercive measures.

METHODS

A cross-sectional study among all psychiatric nursing staff in Slovenia (n = 367, 79%) was conducted over the years 2013/2014. Standardized questionnaires were used, including a survey of nurses' attitudes to the use of seclusion, the Job Descriptive Index, and the Folkman-Lazarus test.

RESULTS

Nurses' attitudes towards special coercive measures are predominantly negative ([Formula: see text] = 11.312, SD = 2.641). The factors that explain a positive attitude are as follows: female gender (β = - 0.236, p <  0.001), fewer years of service (β = - 0.149, p = 0.023), emotion-focused strategies of coping with stress (β = 0.139, p = 0.020), and less-threatening patient behaviour (β = 0.157, p = 0.012).

CONCLUSIONS

The effects of some known factors did not prove important in the model. Newly recognized factors are "less-threatening patient behaviour" and "emotion-focused strategies of coping with stress". Therefore, attitudes towards special coercive measures in psychiatry must be regarded as contextualized, interactive, and multidimensional phenomena that cannot be explained merely through a defined set of factors.

Nurses' Information, Attıtude and Practices towards Use of Physical Restraint in Intensive Care Units

Introduction: Physical restraint may seem to be a useful and simple procedure to help the treatment but is a complex practice including physical, psychological, judicial, ethical and moral issues. Research was made on description basis in order to determine the knowledge, attitude and application levels of nurses working in critical care units about physical restraint applied on patients. Methods: The study was performed as a descriptive and correlation study. Working in ICUs, 158 nurses constituted the sampling. "Levels of Knowledge, Attitudes and Practices of Staff Regarding Physical Restraints Questionnaire" was used to collect data. Results: For information, attitude and practice scores, participants' scores were 7.1(1.7), 31.8 (4.6) and 36.6 (3.2), respectively. No association was found between information subscale, and age, professional years, working time in ICUs and weekly working hours. However, for attitude subscale, a negative and weak association was found between age (r=-0.229) and professional years (r=-0.174), and increasing these variables decreased attitude score. No association was found between attitude score, and working time in ICUs and weekly working hours. While there was no association between practice score, and age, professional years and working time in ICUs, the increase in weekly working hours (r=-0.243) was found to decrease practice score, and this association was found weak. Conclusion: In conclusion, we consider nurses' level of information is sufficient, but attitudes and practice were not at a positive level. It is recommendable that out of such conditions, novel approaches should be developed to decrease the use of physical restraint.

Physical restraint: perceptions of nurse managers, registered nurses and healthcare assistants

AIM

To examine the perceptions of nurse managers, registered nurses and healthcare assistants of physical restraint use on older people in a long-term care setting in the Republic of Ireland.

BACKGROUND

The use of physical restraint, although controversial, persists in long-term care settings, despite recommendations for restraint-free environments. Perception and attitude of staff can influence use of physical restraint.

METHODS

A descriptive cross-sectional design was used. A total of 250 nursing and healthcare assistant staff were recruited. A questionnaire incorporating demographics and the Perceptions of Restraint Use Questionnaire was used. Descriptive and inferential statistical analyses were conducted.

RESULTS

Mean age of respondents (n = 156) was 41 years, and the majority were female. Overall, a low level of importance was attached to the use of restraint. Nurse managers and registered nurses compared favourably with healthcare assistants who attached a higher importance to use of restraint. Across all three staff groups, greatest importance was attached to the use of physical restraint for reducing falls, followed by prevention of treatment interference. Restraint was least favoured as a means of impairment management. Education was not an explanatory factor in perceived importance of physical restraint use.

CONCLUSION

Nurse managers and registered nurses are unlikely to use physical restraint. However, there is concern regarding perception of healthcare assistants on use of restraint.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Results from this study compare favourably with those in countries that have no policy on physical restraint use. Educational programmes alone are insufficient to address use of physical restraint. Attention to skill mix with adequate support for healthcare assistants in long-term care settings is recommended.

Effects of a Multicomponent Restraint Reduction Program for Korean Nursing Home Staff

PURPOSE

Physical restraints are used frequently in Korea, suggesting a growing need for access to programs focused on reduction. The aim of this study was to evaluate the effects of a multicomponent restraint reduction program (MRRP) for nursing staff in Korean nursing homes.

DESIGN

A cluster-randomized, single-blind, controlled pretest-posttest design was used. A total of 122 nursing staff (nurses and geriatric care assistants) in two Korean nursing homes participated in this study: 62 in the experimental group (EG) and 60 in the control group (CG).

METHODS

Nursing staff in the EG home received the MRRP comprising three educational sessions (two classroom-based and one web-based) and two unit-based consultations. Three instruments were used to measure nursing staff's knowledge, perceptions, and attitudes regarding physical restraints. Data were collected immediately before and after the intervention, and again 1 and 3 months later.

FINDINGS

Repeated measures analysis of variance showed significant differences between groups in knowledge (p < .001), perceptions (p < .001), and attitudes (p = .011) over time. These significant improvements in the MRRP group (EG) were sustained over the 3-month period.

CONCLUSIONS

The MRRP effectively improved the knowledge, perceptions, and attitudes of nursing home staff about restraint use with older adults. Additional studies are recommended to evaluate effects of its components while using larger samples and rigorous research methods and measurements, and the inclusion of boosters or other supports to sustain change.

CLINICAL RELEVANCE

These results provide valuable knowledge regarding a multicomponent intervention for changing nursing home staff attributes that likely influence clinical practice. Elements of the educational content and methods found useful for nursing home staff may also be effective in vocational and continuing education as well as for families of older nursing home residents.

Do organisational constraints explain the use of restraint? A comparative ethnographic study from three nursing homes in Norway

AIMS AND OBJECTIVES

To investigate (1) what kind of restraint is used in three nursing homes in Norway and (2) how staff use restraint under what organisational conditions.

BACKGROUND

Restraint use in residents living with dementia in nursing homes is controversial, and at odds with fundamental human rights. Restraint is a matter of hindering residents' free movement and will by applying either interactional, physical, medical, surveillance or environmental restraint. Previous research has identified use of restraint related to individual resident characteristics such as agitation, aggressiveness and wandering.

DESIGN

This model is embedded in an overall mixed-method education intervention design study called Modelling and evaluating evidence-based continuing education program in dementia care (MEDCED), applying ethnography postintervention to examine the use of restraint in 24 nursing homes in Norway.

METHOD

Based on restraint diversity measured in the trial, ethnographic investigation was carried out in three different nursing homes in Norway over a 10-month period to examine restraint use in relation to organisational constraints.

RESULTS

Several forms of restraint were observed; among them, interactional restraint was used most frequently. We identified that use of restraint relates to the characteristics of individual residents, such as agitation, aggressiveness and wandering. However, restraint use should also be explained in relation to organisational conditions such as resident mix, staff culture and available human resources.

CONCLUSION

A fluctuating and dynamic interplay between different individual and contextual factors determines whether restraint is used - or not in particular situations with residents living with dementia.

RELEVANCE TO CLINICAL PRACTICE

Educational initiatives targeting staff to reduce restraint must be sensitive towards fluctuating organisational constraints.

Psychiatric Nurses' Attitude and Practice toward Physical Restraint

AIM

This study was to assess psychiatric nurses' attitude and practice toward physical restraint among mentally ill patients.

METHODS

A descriptive research design was used to achieve the study objective. The present study was carried out in three specialized governmental mental hospitals and two psychiatric wards in general hospital. A convenient purposive sample of 96 nurses who were working in the previously mentioned setting was included. The tool used for data collection was the Self-Administered Structured Questionnaire; it included three parts: The first comprised items concerned with demographic characteristics of the nurses, the second comprised 10 item measuring nurses' attitudes toward physical restraint, and the third was used to assess nurses' practices regarding use of physical restraint.

RESULTS

There were insignificant differences between attitudes and practices in relation to nurses' sex, level of education, years of experience and work place. Moreover, a positive significant correlation was found between nurses' total attitude scores, and practices regarding use of physical restraint.

CONCLUSION

Psychiatric nurses have positive attitude and adequate practice toward using physical restraints as an alternative management for psychiatric patients. It is important for psychiatric nurses to acknowledge that physical restraints should be implemented as the last resort. The study recommended that it is important for psychiatric nurses to acknowledge that physical restraints should be implemented as the last resort.

Physical Restraints: Consensus of a Research Definition Using a Modified Delphi Technique

OBJECTIVES

To develop an internationally accepted research definition of physical restraint.

DESIGN

Comprehensive literature search followed by a web-based, three-round, modified Delphi technique comprising reviews and feedback.

SETTING

Clinical care settings.

PARTICIPANTS

An international group of 48 experts consisting of researchers and clinicians from 14 countries who have made sustained contribution to research and clinical application in the field of physical restraint in clinical care.

MEASUREMENTS

Data were collected using an online survey program and one in-person meeting. Results of the online survey and the in-person meeting were used for distribution in subsequent rounds until consensus on a definition was reached. Consensus was defined as 90% of the participating experts agreeing with the proposed definition of physical restraint.

RESULTS

Thirty-four different definitions were identified during the literature search and served as a starting point for the modified Delphi technique. After three rounds, 45 (95.7%) of 47 remaining experts agreed with the newly proposed definition: "Physical restraint is 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."

CONCLUSION

A multidisciplinary, internationally representative panel of experts reached consensus on a research definition for physical restraints in older persons. This is a necessary step toward improved comparisons of the prevalence of physical restraint use across studies and countries. This definition can further guide research interventions aimed at reducing use of physical restraints.

Use of physical restraints in nursing homes: a multicentre cross-sectional study

Background

Although many countries have implemented strict legal rules, the prevalence of physical restraints in nursing homes seems to remain high. In Switzerland, data related to the frequency of physical restraints are scarce and little is known about associations with resident and nursing home characteristics. The aim of this study was to investigate the prevalence and types of physical restraints in nursing homes in two Swiss cantons and to explore whether resident-related and organisational factors are associated with the use of physical restraints.

Methods

We conducted a multicentre cross-sectional study. Twenty nursing homes with 1362 residents from two culturally different cantons were included. Data on physical restraints and residents’ characteristics were extracted from residents’ records (11/2013 to 2/2014). Organisational data were collected by questionnaires addressing nursing home directors or nursing managers. Sample size calculation and outcome analysis took cluster-adjustment into account. Descriptive statistics and multiple logistic regression analysis with nursing homes as random effect were used for investigation.

Results

The prevalence of residents with at least one physical restraint was 26.8 % (95 % confidence interval [CI] 19.8–33.8). Centre prevalence ranged from 2.6 to 61.2 %. Bilateral bedrails were most frequently used (20.3 %, 95 % CI 13.5–27.1). Length of residence, degrees of care dependency and mobility limitation were significantly positively associated with the use of physical restraint, but none of the organisational characteristics was significantly associated.

Conclusion

Approximately a quarter of the nursing home residents included in our study experienced physical restraints. Since variation between nursing homes was pronounced, it seems to be worthwhile to explore nursing homes with particularly low and high use of physical restraints in future research, especially by using qualitative methods. There is a need for effective interventions aiming at restraint-free nursing care. Development of interventional approaches should consider specific residents’ characteristics associated with restraint use.

Implementation of a Multicomponent intervention to Prevent Physical Restraints In Nursing home residenTs (IMPRINT): study protocol for a cluster-randomised controlled trial

BACKGROUND

Physical restraints such as bedrails and belts are regularly applied in German nursing homes despite clear evidence showing their lack of effectiveness and safety. In a cluster-randomised controlled trial, the efficacy and safety of a guideline-based multicomponent intervention programme has been proven. The present study aims to evaluate the effectiveness of two different versions of the original intervention in nursing home residents in four different regions throughout Germany.

METHODS/DESIGN

The study is a pragmatic cluster-randomised controlled trial comparing two intervention groups, i.e. (1) the updated original multicomponent intervention programme and (2) the concise version of the updated programme, with a control group receiving optimised usual care. The first intervention group receives an educational programme for all nurses, additional training and structured support for nominated key nurses, printed study material and other supportive material. In the second intervention group, nurses do not receive education as part of the intervention, but may be trained by nominated key nurses who have received a short train-the-trainer module. All other components are similar to the first intervention group. The control group receives the printed study material only. Overall, 120 nursing homes including approximately 10,800 residents will be recruited and randomly assigned to one of the three groups. The primary outcome is defined as the proportion of residents with at least one physical restraint after 12 months follow-up. The use of physical restraints will be assessed by direct observation. Secondary outcomes are the residents' quality of life and safety parameters, e.g. falls and fall-related fractures. In addition, comprehensive process and economic evaluations will be performed.

CONCLUSIONS

We expect a clinically relevant reduction in the proportion of residents with physical restraints. It is also expected that the process outcomes of this trial will enrich the knowledge about facilitators and barriers for the implementation of the multicomponent intervention programme.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02341898.

Perception of spanish nursing staff on the use of physical restraints

PURPOSE

To examine the perception of registered nurses and nursing assistants regarding the use of physical restraints with residents of nursing homes located in four of the regions of Spain; and to evaluate the relationship of these perceptions to the staff respondents' level of training.

DESIGN

Cross-sectional multicenter and correlational study. The research was conducted in 2013 in 19 Spanish nursing homes with 2,940 residential beds. A total of 785 nurses (170 registered nurses and 615 nursing assistants) participated in the study.

METHODS

The Perception of Restraint Use Questionnaire (PRUQ), consisting of 17 of the most cited reasons for using these devices, was used, as was a questionnaire capturing the sociodemographic characteristics and educational or experience level of staff respondents.

FINDINGS

Nurses reported the most important uses for restraints as prevention of falls and avoidance of medical device interference. As indicated by an average PRUQ score of 3.47, staff respondents supported restraint use, especially nursing assistants (3.59) as compared to registered nurses (3.00). With regard to training: 83.7% had participated in little, if any, training and only 29.2% had read three or more documents related to restraint use; 66.6% believed that their training was inadequate. No correlation was found between the results of the PRUQ and the respondents´ sociodemographic characteristics or participation in training activities. No differences were found among nurses by region.

CONCLUSIONS

In contrast to papers published in other countries, nurses in this study still consider it necessary to apply restraints in everyday practice. The education of nursing staff regarding restraint and knowledge of alternatives is needed; they should at least be aware of international standards of care regarding physical restraint use.

CLINICAL RELEVANCE

Most of the staff perceived their training related to the use of these devices as insufficient. Nursing assistants considered the use of restraints more important than did the registered nurses.

Knowledge, perceptions, and experiences of family caregivers and home care providers of physical restraint use with home-dwelling elders: a cross-sectional study in Japan

BACKGROUND

The use of physical restraints by family caregivers with home-dwelling elders has not been extensively studied but it might be widespread. Furthermore, it is also not clear how home care providers who support family caregivers perceive the use of physical restraint in elders' homes. This study assessed family caregivers' and home care providers' knowledge and perceptions of physical restraint used with elders living at home in Japan, a country with the highest proportion of elders in the world and where family caregiving is common.

METHODS

We undertook a cross-sectional study of 494 family caregivers, 201 home helpers, 78 visiting nurses, 131 visiting physicians, and 158 care managers of home-dwelling frail elders needing some care and medical support in Japan, using questionnaires on knowledge of 11 physical restraint procedures prohibited in institutions and 10 harmful effects of physical restraints, perceptions of 17 reasons for requiring physical restraints, and experiences involving physical restraint use.

RESULTS

Family caregivers were aware of significantly fewer recognized prohibited physical restraint procedures and recognized harmful effects of physical restraint than home care providers, and differences among home care providers were significant. The average importance rating from 1 (least) to 5 (most) of the 17 reasons for requiring physical restraints was significantly higher among family caregivers than home care providers, and significantly different among the home care providers. Moreover, these differences depended in part on participation in physical restraint education classes. While 20.1% of family caregivers had wavered over using physical restraints, 40.5% of home care providers had seen physical restraints used in elders' homes and 16.7% had advised physical restraint use or used physical restraints themselves.

CONCLUSIONS

Knowledge and perceptions of physical restraints differed between family caregivers and home care providers and were also diverse among home care providers. Because both groups might be involved in physical restraint use with home-dwelling elders, home care providers should acquire standardized and appropriate knowledge and perceptions of physical restraints to help family caregivers minimize abusive physical restraint use.

Portuguese nurses' knowledge of and attitudes toward hospitalized older adults

Portugal is impacted by the rapid growth of the aging population, which has significant implications for its health care system. However, nurses have received little education focusing on the unique and complex care needs of older adults. This gap in the nurses' education has an enormous impact in their knowledge and attitudes and affects the quality of nursing care provided to older adults. A cross-sectional study was conducted among 1068 Portuguese nurses in five hospitals (northern and central region) with the following purposes: (i) explore the knowledge and attitudes of nurses about four common geriatric syndromes (pressure ulcer, incontinence, restraint use and sleep disturbance) in Portuguese hospitals; and (ii) evaluate the influence of demographic, professional and nurses' perception about hospital educational support, geriatric knowledge, and burden of caring for older adults upon geriatric nursing knowledge and attitudes. The mean knowledge and attitudes scores were 0.41 ± 0.15 and 0.40 ± 0.21, respectively (the maximum score was 1). Knowledge of nurses in Portuguese hospitals about the four geriatric syndromes (pressure ulcers, sleep disturbance, urinary incontinence and restraint use) was found inadequate. The nurses' attitudes towards caring for hospitalized older adults were generally negative. Nurses who work in academic hospitals demonstrated significantly more knowledge than nurses in hospital centers. The attitudes of nurses were significantly associated with the hospital and unit type, region, hospital educational support, staff knowledge, and perceived burden of caring for older adults. The study findings support the need for improving nurses' knowledge and attitudes towards hospitalized older adults and implementing evidence-based guidelines in their practice.

Attitudes of nurses towards the use of physical restraints in geriatric care: a systematic review of qualitative and quantitative studies

OBJECTIVES

To examine nurses' attitudes towards the use of physical restraints in geriatric care.

DESIGN

Systematic review and synthesis of qualitative and quantitative studies.

DATA SOURCES

The following databases were searched: Medline, CINAHL, EMBASE, Psyndex, PsychInfo, Social SciSearch, SciSearch, Forum Qualitative Social Research (1/1990 to 8/2013). We performed backward and forward citation tracking to all of the included studies.

REVIEW METHODS

We included in the present review all qualitative and quantitative studies in English and German that investigated nurses' attitudes towards the use of physical restraints in geriatric care. Two independent reviewers selected the studies for inclusion and assessed the study quality. We performed a thematic synthesis for the qualitative studies and a content analysis of the questionnaires' items as well as a narrative synthesis for the quantitative surveys.

RESULTS

We included 31 publications in the review: 20 quantitative surveys, 10 qualitative and 1 mixed-method study. In the qualitative studies, nurses' attitudes towards the use of physical restraints in geriatric care were predominately characterised by negative feelings towards the use of restraints; however, the nurses also described a perceived need for using restraints in clinical practice. This discrepancy led to moral conflicts, and nurses described several strategies for coping with these conflicts when restraints were used. When nurses were in doubt regarding the use of restraints, they decided predominantly in favour of using restraints. The results of the quantitative surveys were inconsistent regarding nurses' feelings towards the use of restraints in geriatric care. Prevention of falls was identified as a primary reason for using restraints. However, the items of the questionnaires focussed primarily on the reasons for the use of restraints rather than on the attitudes of nurses.

CONCLUSIONS

Despite the lack of evidence regarding the benefits of restraints and the evidence on the adverse effects, nurses often decided in favour of using restraints when in doubt and they used strategies to cope with negative feelings when they used restraints. A clear policy change in geriatric care institutions towards restraint-free care seems to be warranted to change clinical practice. The results of this review should also be considered in the development of interventions aimed at reducing the use of restraints.

[Use of physical restraints on the elderly: attitudes, knowledge and practice among nursing staff]

OBJECTIVES

To investigate the attitudes, knowledge and practice on the use of physical restraints by nursing staff working with the elderly, as well as the relationship existing between these variables.

MATERIAL AND METHODS

A cross-sectional descriptive and correlational study was conducted among professionals from eight nursing homes. Three questionnaires asking about the mentioned variables were used.

RESULTS

A total of 378 questionnaires were finally included (94 nurses and 284 auxiliary nurses). The professionals' attitude was generally against the use of restraints, although they were in favour of using them to avoid falls. With regard to knowledge, they obtained 66% of the correct answers; only 32% believed that there were alternatives to restraints, and 69.1% were unaware that these procedures could cause the death of patients. A total of 69.8% said that their training regarding restraint was limited. The practice could be considered acceptable, although the 61.9% thought it was not necessary to get informed consent from the family, and only 47.1% of the nurses always recorded its use in the patient's history. Differences between attitudes, knowledge and practice were found among the two groups. A relationship between the variables was confirmed; less knowledge and more favourable attitude towards physical restraints correlate with a worst practice.

CONCLUSIONS

The attitude of the staff to physical restraints is ambiguous, and erroneous concepts have been detected in their knowledge and practice. Given the influence of knowledge on the rest of the variables, the training of the professionals needs to be improved.

The ethics of coercive treatment of people with dementia

The aim of the present study was to describe how registered nurses in nursing homes ensure legal security, good and safe nursing care and uphold the dignity of nursing home residents with severe dementia without violating residents’ integrity. Semi-structured interviews were conducted with 10 charge nurses in a county in central Sweden. The transcribed interviews were examined using manifest and latent content analyses. The manifest analysis identified actual local routines involving coercive treatment and registered nurses’ descriptions of complications and alternative measures. The latent analysis resulted in three themes describing nursing strategies: one with coercive treatment, one with coercive treatment under specific circumstances and one to prevent coercive treatment. Interpretations of legal terms regarding coercive treatment and inadequate gerontological nursing training and understaffing seem to preserve the use of coercive treatment.

Reduction of belt restraint use: long-term effects of the EXBELT intervention

OBJECTIVES

To assess the long-term effects of the EXBELT intervention program, which was designed to reduce belt restraint use and was found to be effective immediately after implementation, after 24 months.

DESIGN

Quasi-experimental longitudinal design.

SETTING

Thirteen nursing homes: seven assigned to control group and six to intervention group.

PARTICIPANTS

A panel group (n = 225) of residents present at baseline and 24 months after baseline and a survey group (n = 689) of all residents present 24 months after baseline. The survey group included the panel group.

INTERVENTION

EXBELT included four components: a policy change, an educational program, consultation, and availability of alternative interventions.

MEASUREMENTS

The use of belt restraints 24 months after baseline was the primary outcome measure. Secondary outcomes included other types of physical restraints. An independent observer collected data four times during a 24-hour period.

RESULTS

EXBELT resulted in a 65% decrease in belt use between baseline and 24 months after baseline in the panel group (odds ratio 0.35, 95% confidence interval = 0.13-0.93; P = .04). In the survey group, the proportion of residents using belts was 13% in the control and 3% in the intervention group (P < .001) 24 months after baseline. The use of the most restrictive types of restraints was significantly lower in the intervention group than the control group in the panel and survey groups.

CONCLUSION

The EXBELT intervention was associated with long-term minimization of belt restraint usage in older nursing home residents. A multicomponent intervention including institutional policy change, education, consultation, and the availability of alternative interventions had an enduring effect on successful restraint reduction.

A European study investigating patterns of transition from home care towards institutional dementia care: the protocol of a RightTimePlaceCare study

Background

Health care policies in many countries aim to enable people with dementia to live in their own homes as long as possible. However, at some point during the disease the needs of a significant number of people with dementia cannot be appropriately met at home and institutional care is required. Evidence as to best practice strategies enabling people with dementia to live at home as long as possible and also identifying the right time to trigger admission to a long-term nursing care facility is therefore urgently required. The current paper presents the rationale and methods of a study generating primary data for best-practice development in the transition from home towards institutional nursing care for people with dementia and their informal caregivers. The study has two main objectives: 1) investigate country-specific factors influencing institutionalization and 2) investigate the circumstances of people with dementia and their informal caregivers in eight European countries. Additionally, data for economic evaluation purposes are being collected.

Methods/design

This paper describes a prospective study, conducted in eight European countries (Estonia, Finland, France, Germany, Netherlands, Sweden, Spain, United Kingdom). A baseline assessment and follow-up measurement after 3 months will be performed. Two groups of people with dementia and their informal caregivers will be included: 1) newly admitted to institutional long-term nursing care facilities; and 2) receiving professional long-term home care, and being at risk for institutionalization. Data will be collected on outcomes for people with dementia (e.g. quality of life, quality of care), informal caregivers (e.g. caregiver burden, quality of life) and costs (e.g. resource utilization). Statistical analyses consist of descriptive and multivariate regression techniques and cross-country comparisons.

Discussion

The current study, which is part of a large European project 'RightTimePlaceCare', generates primary data on outcomes and costs of long-term nursing care for people with dementia and their informal caregivers, specifically focusing on the transition from home towards institutional care. Together with data collected in three other work packages, knowledge gathered in this study will be used to inform and empower patients, professionals, policy and related decision makers to manage and improve health and social dementia care services.

Belt restraint reduction in nursing homes: effects of a multicomponent intervention program

OBJECTIVES

To test the effects of a multicomponent intervention program to reduce the use of belt restraints in psychogeriatric nursing homes.

DESIGN

A quasi-experimental longitudinal design. Study duration was 8 months.

SETTING

Twenty-six psychogeriatric nursing home wards in 13 Dutch nursing homes were assigned to intervention or control groups.

PARTICIPANTS

Seven hundred fourteen residents were selected for participation. Legal representatives of 520 residents agreed on participation; complete data are available for 405 residents.

INTERVENTION

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.

MEASUREMENTS

The primary outcome measure was the frequency of belt restraint use. Secondary outcomes included other types of physical restraints, psychoactive drug use, falls, and fall-related injuries. These data were collected at baseline and after 4 and 8 months. A trained, blinded observer measured the use of belts and other physical restraints types four times during a 24-hour period.

RESULTS

The intervention resulted in a 50% decrease in belt use (odds ratio = 0.48, 95% confidence interval = 0.28-0.81; P = .005). No increase occurred in the use of other types of restraints. No marked differences between the groups were found regarding psychoactive drugs, falls, and fall-related injuries.

CONCLUSION

A multicomponent intervention program led to a substantial reduction in use of belts, full-enclosure bedrails, and sleep suits without increasing the use of other physical restraints, psychoactive drugs, or falls and fall-related injuries.

The concept of restraint in nursing home practice: a mixed-method study in nursing homes for people with dementia

INTRODUCTION

Although in most developed countries the use of restraints is regulated and restricted by law, the concept of restraint in nursing home care remains ambiguous. This study aims to explore how care professionals and family members of nursing home residents with dementia in the Netherlands experience and define the concept of restraint.

METHODS

Individual interviews were held with relatives (n = 7) and key persons (n = 9) in seven nursing homes. We also conducted eight focus group discussions with nursing home staff. In addition, a structured questionnaire was administered to the nurses of participating nursing homes.

RESULTS

In the questionnaire, over 80% of the respondents indicated considering "fixation" (e.g. use of belts) as a restraint and 50 to 70% of the respondents regarded other physical interventions, such as geriatric chairs and bedrails, as restraints. The interviews and focus group discussions show that the residents' perception of the intervention, the staff's intention behind the intervention and concerns of privacy are the criteria used by the respondents in defining an intervention as a restraint.

CONCLUSIONS

When trying to diminish restraint use, it is important to be aware of the "local logic" of care practice and to take into account the fact that, for staff and relatives, an intervention is only regarded as a restraint when it is bothering a resident or when an intervention is used for the sole purpose of restricting freedom and/or when interventions invade the privacy of a resident.

Attitudes of relatives of nursing home residents toward physical restraints

PURPOSE

Attitudes of nursing home staff, residents, and their relatives determine the decision-making process about the use of physical restraints. Knowledge of staffs' attitudes toward physical restraints is sparse; even less is known about relatives' attitudes. Therefore, we surveyed relatives' attitudes and opinions toward physical restraints and compared the results to a survey of nursing home staff.

DESIGN

Cross-sectional survey comparing 177 nursing home residents' relatives from 13 German facilities in 2008 to 258 nursing home nurses from 25 German facilities in 2007.

METHODS

The German version of the Maastricht Attitude Questionnaire was administered. Part I contains 22 items with three subscales (reasons, consequences, and appropriateness of restraints); Part II contains 16 items evaluating restrictiveness and discomfort of restraint measures, respectively. Descriptive and explorative inferential statistics were used for data analyses.

FINDINGS

Response rate in both samples was above 90%. Mean age was 62 years (SD 12.60; range 24-93) in relatives and 44 years (SD 11.40; range 19-65) in nurses; 72% and 82% were female, respectively. Relatives assess physical restraints a little more positively compared to nurses, with an average of 3.40 (SD 0.60) versus 3.07 (SD 0.48) on a 5-point scale (5=strongly positive attitude). Relatives assess physical restraints as slightly less restrictive, with 2.11 (SD 0.33), and as less discomforting, with 2.10 (SD 0.38) points, compared to nursing staff, who assess the restraints' restrictiveness with 2.19 (SD 0.29) points and its discomfort with 2.17 (SD 0.32) on a 3-point scale (3=very restrictive/discomforting). Both groups consider wrist and ankle belts as most restrictive and uncomfortable, while sensor mats, infrared systems, and unilateral bedrails were rated as the lowest for restrictiveness and discomfort.

CONCLUSIONS

Attitudes of nursing home residents' relatives toward physical restraints are rather positive and generally comparable with nursing home staffs' attitudes.

CLINICAL RELEVANCE

Interventions aimed to reduce physical restraints need to include education of both staff and relatives of nursing home residents.