Organisational determinants of the use of physical restraints: a multilevel approach

'Becoming restrained': Conceptualising restrictive practices in the care of people living with dementia in acute hospital settings

The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze's concepts of 'assemblage' and 'event' to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio-political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas 'events' and 'assemblages' have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.

Physical Restraint Use in Nursing Homes-Regional Variances and Ethical Considerations: A Scoping Review of Empirical Studies

BACKGROUND

Physical restraints are known to violate human rights, yet their use persists in long-term care facilities. This study aimed to explore the prevalence, methods, and interventions related to physical restraint use among the elderly in nursing homes.

METHODS

The method described by Joanna Briggs was followed to conduct a scoping review without a quality assessment of the selected studies. An electronic search was conducted to find eligible empirical articles using MEDLINE, PsycINFO, EMBASE, Web of Science, Scopus, Google Scholar, CINAHL, and grey literature. The database search was performed using EndNote software (version X9, Clarivate Analytics), and the data were imported into Excel for analysis.

RESULTS

The prevalence of physical restraint use was found to be highest in Spain (84.9%) and lowest in the USA (1.9%). The most common device reported was bed rails, with the highest prevalence in Singapore (98%) and the lowest (4.7%) in Germany, followed by chair restraint (57%). The largest number of studies reported the prevention and/or risk of falls to be the main reason for using physical restraints, followed by behavioral problems such as wandering, verbal or physical agitation, and cognitive impairment. Most studies reported guideline- and/or theory-based multicomponent interventions consisting of the training and education of nursing home staff.

CONCLUSIONS

This review provides valuable insights into the use of physical restraints among elderly residents in nursing homes. Despite efforts to minimize their use, physical restraints continue to be employed, particularly with elderly individuals who have cognitive impairments. Patient-related factors such as wandering, agitation, and cognitive impairment were identified as the second most common reasons for using physical restraints in this population. To address this issue, it is crucial to enhance the skills of nursing home staff, especially nurses, in providing safe and ethical care for elderly residents with cognitive and functional impairments, aggressive behaviors, and fall risks.

Variation of the Occurrence of Physical Restraint Use in the Long-Term Care: A Scoping Review

Physical restraints in the long-term care setting are still commonly used in several countries with a prevalence ranging from 6% to 85%. Trying to have a broad and extensive overlook on the physical restraints use in long-term care is important to design interventions to prevent and/or reduce their use. Therefore, the aim of this scoping review was to analyze the range of occurrence of physical restraint in nursing homes, long-term care facilities, and psychogeriatric units. Pubmed, CINAHL, Ovid PsycINFO- databases were searched for studies with concepts about physical restraint use in the European long-term care setting published between 2009 and 2019, along with a hand search of the bibliographies of the included studies. Data on study design, data sources, clinical setting and sample characteristics were extracted. A total of 24 studies were included. The median occurrence of physical restraint in the European long-term care setting was still high (26.5%; IQR 16.5% to 38.5%) with a significant variability across the studies. The heterogeneity of data varied according to study design, data sources, clinical setting, physical restraint's definition, and patient characteristics, such as ADLs dependence, presence of dementia and psychoactive drugs prescription.

Physical Restraint Use in Intensive Care Units: Exploring the Decision-Making Process and New Proposals. A Multimethod Study

Aim: The general aim of this study was to explore the decision-making process followed by Intensive Care Unit (ICU) health professionals with respect to physical restraint (PR) administration and management, along with the factors that influence it. Method: A qual-quant multimethod design was sequenced in two stages: an initial stage following a qualitative methodology; and second, quantitative with a predominant descriptive approach. The multicenter study was undertaken at 17 ICUs belonging to 11 public hospitals in the Madrid region (Spain) across the period 2015 through 2019. The qualitative stage was performed from an interpretative phenomenological perspective. A total of eight discussion groups (DG) were held, with the participation of 23 nurses, 12 patient care nursing assistants, and seven physicians. Intentional purposive sampling was carried out. DG were tape-recorded and transcribed. A thematic analysis of the latent content was performed. In the quantitative stage, we maintained a 96-h observation period at each ICU. Variables pertaining to general descriptive elements of each ICU, institutional pain-agitation/sedation-delirium (PAD) monitoring policies and elements linked to quality of PR use were recorded. A descriptive analysis was performed, and the relationship between the variables was analyzed. The level of significance was set at p ≤ 0.05. Findings: A total of 1070 patients were observed, amounting to a median prevalence of PR use of 19.11% (min: 0%–max: 44.44%). The differences observed between ICUs could be explained by a difference in restraint conceptualization. The various actors involved jointly build up a health care culture and a conceptualization of the terms “safety-risk”, which determine decision-making about the use of restraints at each ICU. These shared meanings are the germ of beliefs, values, and rituals which, in this case, determine the greater or lesser use of restraints. There were different profiles of PR use among the units studied: preventive restraints versus “Zero” restraints. The differences corresponded to aspects such as: systematic use of tools for assessment of PAD; interpretation of patient behavior; the decision-making process, the significance attributed to patient safety and restraints; and the feelings generated by PR use. The restraint–free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family.

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'.

Determinants of Non-emergency Use of Control Interventions in Older Canadian Psychiatric Inpatients: Analysizing the InterRAI Mental Health Electronic Health Records

Background: The use of control interventions (CIs; acute control medications, physical/mechanical restraint) is associated with negative physical and psychological outcomes, particularly in older adults who are physically vulnerable. The aims of this study were to: (i) report the rates of CI use in older psychiatric inpatients (age 65 - 84 and age 85+), and compare them with younger age groups (18 - 44, age 45 - 64); and (ii) identify the factors associated with non-emergency CI use in older psychiatric inpatients. Methods: Routinely collected interRAI Mental Health assessments from 2005 - 2018 in Ontario, Canada, were analyzed to determine the rates of CI use. Logistic regression models were used to examine the sociodemographic and clinical determinants of non-emergency and any CI use. Results: There were 226,119 (female: 48.6%) interRAI assessments, and 85% of those assessed were under 65 years of age. The rates of non-emergency CI use in the four age groups were: 18 - 44 = 9.4%, 45 - 64 = 8.3%, 65 - 84 = 9.9%, 85+ = 13.2%. The most significant determinants of non-emergency CI use in older adults were highest impairments in activities of daily living (ADL Short Form score 8-16: OR = 2.72, 95% CI = 2.42 - 3.06), highest levels of aggression (Aggressive Behavior Scale score 4 - 6: OR = 1.76, 95% CI = 1.57 - 1.98), and highest levels of positive psychotic symptoms (Positive Symptoms Scale score 9+: OR = 1.65, 95% CI = 1.43 - 1.90). Delirium, cognitive disorder diagnosis, cognitive impairment, and falls were also associated with increased CI use odds, as were having the reasons for admission be danger to self, danger to others or inability to care for self. Females were less likely to have non-emergency CI use (OR = 0.84, 95% CI = 0.73 - 0.95). Patients admitted from long-term care homes had significantly greater odds of non-emergency CI use compared with community admissions (OR = 1.18; 95% CI = 1.07 - 1.29). Conclusion: The higher rates of non-emergency CI use in older psychiatric inpatients is concerning. Alternative non-pharmacological and person-centered management strategies should be considered to support older psychiatric inpatients with functional impairment, positive symptoms, aggressive behavior, cognitive impairment and delirium. The use of CIs could be incorporated as a quality improvement activity to monitor changes at various service provision levels.

Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: A systematic review and meta-analysis

BACKGROUND

Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths.

OBJECTIVE

To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates.

METHODS

Six health science databases were searched from inception up to 21st January 2020. Quantitative studies investigating restraint use in residential aged care facilities that reported data from year 2000 onwards were included. Meta-analyses of binomial data using a random effect model were performed to pool proportions of physical or chemical restraints with 95% confidence intervals. Univariable meta-regression analyses were used to assess factors that may contribute to the variability in physical and chemical restraint prevalence. Multiple meta-regression analyses were performed where possible to construct models of factors contributing to these variations.

RESULTS

Eighty-five papers were included. The pooled proportion of physical and chemical restraint use in residential aged care facilities were 33% and 32% respectively. Bedrails (44%) and benzodiazepines (42%) were the most prevalent forms of physical and chemical restraint respectively. Studies from North America (lower prevalence) [coefficient (95% CI): -0.15 (-0.27, -0.03)], measurement approaches using direct observation (higher prevalence) [0.17 (0.02, 0.33)] and a combination of multiple measurement approaches (higher prevalence) [0.17 (0.05, 0.29)] explained 25.5% of variability in the prevalence of physical restraint. Multiple meta-regression analyses were not performed to identify factors that may explain the observed variability in chemical restraint prevalence due to the small number of studies with data available.

CONCLUSION

Variability in prevalence of physical restraint could be explained partly by different measurement approaches and geographical regions. Valid and reliable measurement approaches across different regions is required to understand cultural differences due to geographical region effects on the prevalence of physical restraint use.

The use of physical restraints in Chinese long-term care facilities and its risk factors: An observational and cross-sectional study

AIM

To investigate the use of physical restraints among Chinese long-term care facilities older adults and to identify its risk factors.

DESIGN

Observational and cross-sectional study.

METHODS

A total of 1,026 older adults from six long-term care facilities in Chongqing were recruited by cluster sampling method from July - November 2019. Data on physical restraint use and older adults' characteristics were collected using physical restraints observation forms and older adults' records. Organizational data were collected by questionnaires asking nursing managers. The independent risk factors for physical restraints use were assessed using chi-square test and binary logistic regression.

RESULTS

The study found that the prevalence of physical restraints in six long-term care facilities in China was 25.83%. Waist belt (55.47%) and wrist restraint (52.83%) were most frequently used. Only 61.51% of physical restraints were signed with informed consent. 71.70% of physical restraints were caused by the prevention of falls, 89.06% of physical restraints were without nursing documentation, and 13.58% restrained older adults were observed to have physical complications. According to the binary logistic regression analysis, facility type and ownership, older adults per nursing assistant, length of residence, cognitive impairment, care dependency, mobility restriction, fall risk, physical agitation, and indwelling tubes emerged as important risk factors for the use of physical restraints.

CONCLUSION

The use of physical restraints among Chinese long-term care facilities older adults was at a relatively high level and lack standardized and regulated practices. Moreover, Physical restraint use was associated with facility type and ownership, older adults per nursing assistant, length of residence, cognitive impairment, care dependency, mobility restriction, fall risks, physical agitation, and indwelling tube.

IMPACT

This study will provide an effective reference for nursing staff in long-term care facilities to assess high-risk older adults in their use of physical restraints, which can support them to implement effective minimized restraint approaches to targeted people.

Reducing physical restraints by older adults in home care: development of an evidence-based guideline

Background

Restraint use is a complex and challenging issue in home care. Due to socio-demographic trends, worldwide home healthcare providers are faced with an increasing demand for restraint use from informal caregivers, patients and healthcare providers, resulting in the use of various types of restraints in home care. Awareness and knowledge of restraint use in home care, its implications and the ethical challenges surrounding it are of crucial importance to its reduction. This research aimed to describe the development process of an evidence-based practice guideline to support caregivers to optimize home care.

Method

The practice guideline was developed according to the framework of the Belgian Centre for Evidence-Based Medicine and AGREE II. The guideline was developed over several stages: (1) determination of the target population and scope, (2) literature search, (3) drafting and (4) validation. A multidisciplinary working group determined the proposed purpose, target group, and six clinical questions for the guideline. A consensus procedure and consultation by experts were used to develop the guideline.

Results

The guideline provides an answer to six clinical questions and contains ten key recommendations based on the classification of GRADE, with the objective of increasing healthcare providers’ awareness, knowledge and competence to adequately deal with situations or questions related to restraint use. The guideline also includes a flowchart for dealing with complex situations where the use of restraints is requested, already present or considered.

Conclusions

The guideline was validated by the Belgian Centre for Evidence-Based Medicine. Increasing competence, awareness and knowledge related to restraint use are key objectives of the guideline for reducing restraint use in home care. A multicomponent intervention to support healthcare workers in implementing the guideline in clinical practice needs to be developed.

[Factors associated with physical restraint use in acute care hospitals: A comparison of patient characteristics between patients with and without restraints]

AIM

Physical restraints are defined as limitations on patients' freedom of movement, such as bed/chair belts and/or the use of mittens. Such restraints may be harmful, and the predictors of or factors reducing physical restraint use are unclear. This study investigated the factors determining physical restraint use in patients with stroke admitted to an acute care hospital.

METHODS

This retrospective study analyzed patients' data obtained between August 2014 and September 2015. The variables analyzed were age, sex, physical restraint use, operations performed, presence of tubes, stroke severity, psychotropic medication use, disturbance of consciousness, motor paralysis, cognitive status, independence in activities of daily living, and presence of behavioral disorders. Patient characteristics associated with physical restraints were analyzed using the t-test, Fisher's exact test, and a logistic regression analysis.

RESULTS

The analysis included 253 patients (179 in the non-restraint group and 74 in the restraint group). The prevalence of physical restraint use was 29.2%. The age, cognitive status, stroke severity, operations performed, presence of tubes, disturbance of consciousness, motor paralysis, independence in the activities of daily living, presence of behavioral disorders, and psychotropic medication use significantly differed between the two groups. A logistic regression analysis showed that the age, cognitive status, stroke severity, and presence of behavioral disorders were risk factors.

CONCLUSION

Physical restraint use is more likely in elderly patients and those with cognitive impairment, behavioral disorders, or serious strokes. Physical restraints are also more likely to be applied in patients with cognitive impairment than in those with merely physical impairment.

Informal use of restraint in nursing homes: A threat to human rights or necessary care to preserve residents' dignity?

Use of restraint in nursing homes is highly controversial and fundamentally transgresses human rights and freedom of movement and choice. While different forms of formal restraint use in nursing homes are broadly delineated, the use of informal restraint is less understood. The aim of this article is to identify different kinds of informal restraint, and how staff use informal restraint under which circumstances. This article illuminates informal restraint use based on an ethnographic study in four nursing homes in the Western part of Norway. We have identified five different forms of informal restraint use which are as follows: (1) diversion of residents' attention; (2) white lies; (3) persuasion and interpersonal pressure; (4) offers and finally (5) threats. These different forms of informal restraint are actions by staff against residents' will, limiting residents' freedom of movement and their personal preferences. In addition, we have identified 'grey-zone restraint' which comprises actions by staff towards residents which lie in-between formal and informal restraint. The use of informal restraint can be explained by institutional circumstances such as location, architecture and institutional collectivist constraints in relation to care work. Moreover, and paradoxically, informal restraint can be explained as a consequence of neo-liberal policies with establishment of extended premises for freedom of movement and practices of resident preferences in nursing homes. Informal restraint practices call into question whether these practices are compatible with fundamental human rights and the preservation of residents' dignity.

Factors associated with use of restraints on older adults with home care: A secondary analysis of a cross-sectional survey study

BACKGROUND

Although there is evidence that use of restraints in home care is increasing, research into the factors associated with restraints in this setting is scarce.

OBJECTIVE

To gain insight into the factors associated with restraints in older adults receiving home care.

DESIGN

A secondary analysis of a cross-sectional survey about restraint use in home care.

SETTINGS

Older adults receiving home care in Belgium.

PARTICIPANTS

8000 subjects were randomly selected from a total of 45,700 older adults. The mean age of the sample (n = 6397) was 80.6 years, 66.8% were women and 46.4% lived alone.

METHODS

A cross-sectional survey of restraint use on older adults receiving home care from a nursing organisation in Belgium was completed by the patients' primary care nurses. A binary logistic regression model with generalised estimating equations was used to evaluate factors associated with restraint use. Additional analyses focused on the subgroups with and without an informal caregiver and living alone / with others. Data from 6397 participants were analysed in detail.

RESULTS

Multivariate logistic regression indicated that restraint use was associated with supervision [OR = 2.433, 95% CI = 1.948-3.038]; dependency in activities of daily living (i.e. eating [OR = 2.181, 95% CI = 1.212-3.925], transfer [OR = 2.131, 95% CI = 1.191-3.812] and continence [OR = 1.436, 95% CI = 0.925-2.231]; perceived risk of falling in the nurses' clinical judgement [OR = 1.994, 95% CI = 1.710-2.324], daily behavioural problems [OR = 1.935, 95% CI = 1.316-2.846] and less than daily behavioural problems [OR = 1.446, 95% CI = 1.048-1.995]; decreased well-being of the informal caregiver [OR = 1.472, 95% CI = 1.126-1.925], the informal caregiver's dissatisfaction with family support [OR = 1.339, 95% CI = 1.003-1.788]; patient's cognitive impairment [OR = 1.398, 95% CI = 1.290-1.515]; and polypharmacy [OR = 1.415, 95% CI = 1.219-1.641]. The nurses' perception of risk of falling, cognitive impairment (observed with the Cognitive Performance Scale) and supervision are the only variables consistently associated with restraint use across all the analyses.

CONCLUSION

The study results provide insight into new and context-specific factors associated with restraint use in home care (e.g. supervision, informal caregiver's decreased well-being and dissatisfaction with family support). These insights could support the development of interventions to reduce restraint use in home care.

Physical restraints and associations with neuropsychiatric symptoms and personal characteristics in residential care: a cross-sectional study

BACKGROUND

Physical restraints are widely used in residential care. The objective was to investigate restraint use and its associations with neuropsychiatric symptoms and personal characteristics in residential care.

METHODS

Data were collected in the South Savo Hospital District from 66 of 68 public or private institutions providing long-term residential care. Nurses assessed the use of physical restraints and neuropsychiatric symptoms (NPS) included in the symptom list of the Neuropsychiatric Inventory (NPI). Drug use was obtained from medical records, and activities of daily living (ADL) were assessed by the nurses according to the Barthel Index.

RESULTS

The total number of persons in residential care was 1386. Any restraint was used for 721 patients (52%) in the preceding 24 h. Bedrails were the most common restraints. In the multivariate analysis, psychotic symptoms (OR 1.94, 95% CI 1.14-3.31) and use of benzodiazepines (OR 1.69, 95% CI 1.18-2.41) were positively associated with restraint use, whereas antipsychotic (OR 0.62, 95% CI 0.44-0.87) and antidepressant drug use (OR 0.64, 95% CI 0.45-0.90) and higher ADL score (OR 0.9, 95% CI 0.92-0.93) were negatively associated. Concomitant use of at least two restraints was associated with high prevalence of hyperactivity NPS symptoms.

CONCLUSIONS

More than half of the residents were exposed to some physical restraint, most frequently bedrails, within the last 24 h. Psychotic symptoms and benzodiazepine use increased while good ADL and antipsychotic or antidepressant use decreased the risk of restraint use. Bedridden persons were the most frequently restrained which may pose an ethical problem. Copyright © 2016 John Wiley & Sons, Ltd.

Restraint use in older adults in home care: A systematic review

OBJECTIVES

To get insight into restraint use in older adults receiving home care and, more specifically, into the definition, prevalence and types of restraint, as well as the reasons for restraint use and the people involved in the decision-making process.

DESIGN

Systematic review.

DATA SOURCES

Four databases (i.e. Pubmed, CINAHL, Embase, Cochrane Library) were systematically searched from inception to end of April 2017.

REVIEW METHODS

The study encompassed qualitative and quantitative research on restraint use in older adults receiving home care that reported definitions of restraint, prevalence of use, types of restraint, reasons for use or the people involved. We considered publications written in English, French, Dutch and German. One reviewer performed the search and made the initial selection based on titles and abstracts. The final selection was made by two reviewers working independently; they also assessed study quality. We used an integrated design to synthesise the findings.

RESULTS

Eight studies were reviewed (one qualitative, seven quantitative) ranging in quality from moderate to high. The review indicated there was no single, clear definition of restraint. The prevalence of restraint use ranged from 5% to 24.7%, with various types of restraint being used. Families played an important role in the decision-making process and application of restraints; general practitioners were less involved. Specific reasons, other than safety for using restraints in home care were noted (e.g. delay to nursing home admission; to provide respite for an informal caregiver).

CONCLUSIONS

Contrary to the current socio demographical evolutions resulting in an increasing demand of restraint use in home care, research on this subject is still scarce and recent. The limited evidence however points to the challenging complexity and specificity of home care regarding restraint use. Given these serious challenges for clinical practice, more research about restraint use in home care is urgently needed.

Restraint Use in Older Adults Receiving Home Care

OBJECTIVES

To determine the prevalence, types, frequency, and duration of restraint use in older adults receiving home nursing care and to determine factors involved in the decision-making process for restraint use and application.

DESIGN

Cross-sectional survey of restraint use in older adults receiving home care completed by primary care nurses.

SETTING

Homes of older adults receiving care from a home nursing organization in Belgium.

PARTICIPANTS

Randomized sample of older adults receiving home care (N = 6,397; mean age 80.6; 66.8% female).

MEASUREMENTS

For each participant, nurses completed an investigator-constructed and -validated questionnaire collecting information demographic, clinical, and behavioral characteristics and aspects of restraint use. A broad definition of restraint was used that includes a range of restrictive actions.

RESULTS

Restraints were used in 24.7% of the participants, mostly on a daily basis (85%) and often for a long period (54.5%, 24 h/d). The most common reason for restraint use was safety (50.2%). Other reasons were that the individual wanted to remain at home longer, which necessitated the use of restraints (18.2%) and to provide respite for the informal caregiver (8.6%). The latter played an important role in the decision and application process. The physician was less involved in the process. In 64.5% of cases, there was no evaluation after restraint use was initiated.

CONCLUSION

Use of restraints is common in older adults receiving home care nursing in Belgium. These results contribute to a better understanding of the complexity of use of restraints in home care, a situation that may be even more complex than in nursing homes and acute hospital settings.

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.

The use of physical restraints in long-term care in Spain: a multi-center cross-sectional study

BACKGROUND

Physical restraint is a procedure used frequently in long-term care. It is a controversial practice because its use is associated with numerous complications and also affects freedom and individual autonomy. The objective of this study was to examine the use of physical restraint of long-term care residents with the ability to move voluntarily.

METHODS

We conducted a cross-sectional observational and correlational multi-center study. Nine centers agreed to participate. Of the 1,200 people present at the time of data collection, those without voluntary movement or in the facility for less than a month were excluded. Thus, the final sample was 920 residents. Data on the use of restraints was collected by direct observation. Information about the age, gender, length of stay, falls, mobility, cognition and functional status of residents was gathered by reviewing clinical records and interviewing nursing staff. A descriptive analysis of the data obtained was conducted. The generalized linear model was used, considering only the principal effects of each variable and using the logit link function. The model has been adjusted for clusters and for other possibly confounding factors. For all analyses, a confidence interval (CI) of 95% was estimated.

RESULTS

The prevalence of residents with at least one physical restraint was 84.9% (95% CI: 81.7-88.1), with variability between centers of 70.3 to 96.6% (p-value Kruskal Wallis test <0.001). Full-enclosure side rails were most often used (84.5; 95% CI: 81.1-87.9), but other types of restraints were also used frequently. Multivariate analysis showed that the degree of functional impairment increased the probability of the use of restraint. A significant association was also found between restraint use and the impaired cognitive status of residents.

CONCLUSIONS

The prevalence was higher than in studies from other countries. The results emphasize the need to improve the training of nursing staff in the care of residents with impairments in functional and cognitive status. The use of alternative devices and nurse consultants need to be evaluated, and the introduction of specific laws considered.

How do staff influence the quality of long-term dementia care and the lives of residents? A systematic review of the evidence

BACKGROUND

Research suggests and common sense indicates that there are relationships between staff variables in residential dementia care and the quality of life (QOL) of residents, with poor care due to staff factors increasing resident suffering. Despite these indications, we do not have a coherent picture of these relationships, which variables are important, and where to intervene in order to minimize suffering for people with dementia.

METHODS

This systematic review examined associations between staff variables, quality of care (QOC), and QOL for residents, using published peer-reviewed literature from the last 20 years. A comprehensive search was conducted using an exhaustive list of search terms, leading to the identification of 33,204 unique papers, which was reduced to 35 on-topic papers.

RESULTS

In the main, we were able to provide collective evidence to suggest there are relationships between potentially adjustable staff variables and QOC on to QOL. When staff treat and interact empathetically and humanely in care, there is a relationship with better mood for residents, delayed functional dependence and better food intake. Where staff are more skilled and educated, there is less psychotropic medication use. Unlimited empathy about the risk of residents falling or being in pain is not enough; staff need to know about the dangers of restraint.

CONCLUSIONS

Confidence in these indicative links is weakened by a lack of high-quality prospective longitudinal studies focusing on potentially adjustable staff variables, with a bias towards cross-sectional studies including only variables that are fixed or unlikely to change. (Review registration no. PROSPERO 2014:CRD42014015224).

Is an unhealthy work environment in nursing home care for people with dementia associated with the prescription of psychotropic drugs and physical restraints?

BACKGROUND

Research showed that long-term care facilities differ widely in the use of psychotropic drugs and physical restraints. The aim of this study is to investigate whether characteristics of an unhealthy work environment in facilities for people with dementia are associated with more prescription of psychotropic drugs and physical restraints.

METHODS

Data were derived from the first wave (2008-2009) of a national monitoring study in the Netherlands. This paper used data on prescription of psychotropic drugs and physical restraints from 111 long-term care facilities, residing 4,796 residents. Survey data of a sample of 996 staff and 1,138 residents were considered. The number of residents with prescribed benzodiazepines and anti-psychotic drugs, and physical restraints were registered. Work environment was assessed using the Leiden Quality of Work Questionnaire (LQWQ).

RESULTS

Logistic regression analyses showed that more supervisor support was associated with less prescription of benzodiazepines. Coworker support was found to be related to less prescription of deep chairs. Job demands and decision authority were not found to be predictors of psychotropic drugs and physical restraints.

CONCLUSIONS

Staff's job characteristics were scarcely related to the prescription of psychotropic drugs and physical restraints. This finding indicates that in facilities with an unhealthy work environment for nursing staff, one is not more likely to prescribe drugs or restraints. Further longitudinal research is needed with special attention for multidisciplinary decision making - especially role of physician, staff's knowledge, philosophy of care and institutional policy to gain further insight into factors influencing the use of psychotropic drugs and restraints.

[Therapeutic restraint management in Intensive Care Units: Phenomenological approach to nursing reality]

AIMS

To identify nursing experience on physical restraint management in Critical Care Units. To analyse similarities and differences in nursing experience on physical restraint management according to the clinical context that they are involved in.

METHOD

A multicentre phenomenological study was carried out including 14 Critical Care Units in Madrid, classified according to physical restraint use: Common/systematic use, lacking/personalised use, and mixed use. Five focus groups (23 participants were selected following purposeful sampling) were convened, concluding in data saturation. Data analysis was focused on thematic content analysis following Colaizzi's method.

FINDINGS

Six main themes: Physical restraint meaning in Critical Care Units, safety (self-retreat vital devices), contribution factors, feelings, alternatives, and pending issues. Although some themes are common to the 3 Critical Care Unit types, discourse differences are found as regards to indication, feelings, systematic use of pain and sedation measurement tools.

CONCLUSIONS

In order to achieve real physical restraint reduction in Critical Care Units, it is necessary to have a deep understanding of restraints use in the specific clinical context. As self-retreat vital devices emerge as central concept, some interventions proposed in other settings could not be effective, requiring alternatives for critical care patients. Discourse variations laid out in the different Critical Care Unit types could highlight key items that determine the use and different attitudes towards physical restraint.

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.

Physical restraints among the elderly in the acute care setting: Prevalence, complications and its association with patients’ characteristics

Aims:

This study aimed to identify the prevalence and circumstances of the use of physical restraints, complications associated with its use and its association with patients’ characteristics.

Methods:

This is a prospective observational study design. A convenience sample of elderly patients (aged 65 and above) who were admitted to an acute care hospital from February 2012 to August 2012 were tracked daily to monitor the use of physical restraints during hospitalization. Patient-related variables and type of physical restraint used were gathered from the medical records and the Multi-Dimensional Dementia Assessment Scale was completed through interviews with nurses who had cared for the patients. Independent t-test or Chi-square (χ2) tests were used to examine the effect of a single variable on the use of physical restraints. Multiple logistic regression was done to predict the patient-related variables to the likelihood of being placed on physical restraints.

Results:

Altogether, 998 patients accounting for 1048 admission episodes, were included in this study, of which 84 admission episodes involved the use of physical restraints (8%). Major reasons for restraints include ‘Behavioural/confused/violent’ ( n= 55; 65%) and to prevent falls ( n=53; 62%). Regression analysis indicated that male gender, behavioural changes, memory disturbance, impaired physical function, the use of anti-psychotic drugs and higher psychiatric workload predicted the likelihood of being put on physical restraints. The strongest predictor was memory disturbances with an odds ratio of 30.

Conclusion:

The prevalence of physical restraints used was higher than that in published literature for acute care hospitals. Preventive strategies would need to be targeted for the elderly, who suffered from memory disturbances upon admission.

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.

Clinical and organizational factors related to the reduction of mechanical restraint application in an acute ward: an 8-year retrospective analysis

Background:

The purpose of this study was to describe the frequency of mechanical restraint use in an acute psychiatric ward and to analyze which variables may have significantly influenced the use of this procedure. Methods: This retrospective study was conducted in the Servizio Psichiatrico di Diagnosi e Cura (SPDC) of Modena Centro. The following variables of our sample, represented by all restrained patients admitted from 1-1-2005 to 31-12-2012, were analyzed: age, gender, nationality, psychiatric diagnoses, organic comorbidity, state and duration of admission, motivation and duration of restraints, nursing shift and hospitalization day of restraint, number of patients admitted at the time of restraint and institutional changes during the observation period. The above variables were statistically compared with those of all other non-restrained patients admitted to our ward in the same period. Results: Mechanical restraints were primarily used as a safety procedure to manage aggressive behavior of male patients, during the first days of hospitalization and night shifts. Neurocognitive disorders, organic comorbidity, compulsory state and long duration of admission were statistically significantly related to the increase of restraint use (p<.001, multivariate logistic regression). Institutional changes, especially more restricted guidelines concerning restraint application, were statistically significantly related to restraint use reduction (p<.001, chi2 test, multivariate logistic regression). Conclusion: The data obtained highlight that mechanical restraint use was influenced not only by clinical factors, but mainly by staff and policy factors, which have permitted a gradual but significant reduction in the use of this procedure through a multidimensional approach.

Contextual influences on nurses' decision-making in cases of physical restraint

BACKGROUND

In order to fully understand nurses' ethical decision-making in cases of physical restraint in acute older people care, contextual influences on the process of decision-making should be clarified.

RESEARCH QUESTIONS

What is the influence of context on nurses' decision-making process in cases of physical restraint, and what is the impact of context on the prioritizing of ethical values when making a decision on physical restraint?

RESEARCH DESIGN

A qualitative descriptive study inspired by the Grounded Theory approach was carried out.

PARTICIPANTS AND RESEARCH CONTEXT

In total, 21 in-depth interviews were carried out with nurses working on acute geriatric wards in Flanders, Belgium.

ETHICAL CONSIDERATIONS

The research protocol was approved by the Ethics Committee of the Faculty of Medicine, Leuven.

FINDINGS

Relationships with nursing colleagues and the patient's family form an inter-personal network. Nurses also point to the importance of the procedural-legal context as expressed in an institutional ethics policy and procedures, or through legal requirements concerning physical restraint. Furthermore, the architectural structure of a ward, the availability of materials and alternatives for restraint use can be decisive in nurses' decision-making. All interviewed nurses highlighted the unquestionable role of the practical context of care. Context can have a guiding, supportive, or decisive role in decision-making concerning the application of physical restraint.

DISCUSSION

The discussion focuses on the role of the inter-personal network of nurses on the process of decision-making.

CONCLUSION

An institutional ethics policy and a value-supportive care environment can support nurses in their challenge to take ethically sound decisions.

Staffing levels and the use of physical restraints in nursing homes: a multicenter study

There is an unclear relation between staffing levels and the use of physical restraints in nursing homes (NHs). A survey design was used in 570 older adults (median age = 86; 77.2% women), living on 23 wards within seven NHs. Restraint use was high (50% of residents, of which 80% were restrained on a daily basis). Multivariate analysis was conducted at the level of the individual wards. Neither staff intensity nor staff mix was a determinant of restraint use. Bathing dependency, transfer difficulties, risk for falls, frequent restlessness/agitation, and depression were independent predictors of restraint use. Patient characteristics have significant greater impact on physical restraint use than staffing levels. Therefore, improving knowledge and skills of NH staff to better deal with restlessness/agitation, mobility problems, and risk for falls is encouraged to decrease the use of physical restraints in NH residents.

Knowledge, attitudes, and practices of Turkish intern nurses regarding physical restraints

OBJECTIVE

This study was carried out to determine knowledge, attitudes, and practices of intern nurses who completed the nursing internship program on the use of physical restraints.

DESIGN

This research was conducted using descriptive and cross-sectional research design.

METHODS

The study sample comprises 91 fourth-grade students who took an integrated curriculum and completed the nursing internship program. The data were collected with the Demographic Characteristics Questionnaire and the Levels of Knowledge, Attitudes and Practices of Staff Regarding Physical Restraints Questionnaire. For the assessment of the data, percentages, the arithmetic mean, and t test were used.

RESULTS

The findings indicated that, of the intern nurses, 95.6% observed the use of physical restraints during their education, and 69.2% applied physical restraints. The mean knowledge, attitude, and practice scores of the nurses for physical restraint were 9.38 ± 1.19 (0-11 points), 34.70 ± 5.62 (12-48 points), and 37.95 ± 2.32 (14-42 points), respectively.

CONCLUSIONS

Intern nurses' knowledge about how to use physical restraints was at a very good level; they displayed positive attitudes, and they used their knowledge and attitudes in their practices to a great extent.

IMPLICATIONS

Although there are studies on the knowledge, attitudes, and practices of nurses working in the fields of elderly care, rehabilitation, and psychiatry in acute care units, there are no studies investigating intern nurses and other nursing students. However, intern nurses about to begin their careers should make accurate decisions regarding the use of physical restrains if they are to ensure patient safety and to fulfill this application effectively in their professional lives.

Physical restraint use and older patients' length of hospital stay

In both acute care and residential care settings, physical restraints are frequently used in the management of patients, older people in particular. Recently, the negative outcomes of physical restraint use have often been reported, but very limited research effort has been made to examine whether such nursing practice have any adverse effects on patients' length of stay (LOS) in hospitals. The aim of this study was to examine the association between physical restraint use on older patients during hospitalization and their LOS. Medical records of 910 older patients aged 60 years and above admitted to one of the Hong Kong public hospitals in 2007 were randomly selected and recorded during July to September 2011. The recorded items included patients' general health status, physical and cognitive function, the use of physical restraints, and patients' LOS. Hierarchical regression analysis was conducted to analyze the data. The results indicated that older patients' general health status, physical, and cognitive function were important factors affecting their LOS. Independent of these factors, the physical restraint use was still significantly predictive of longer LOS, and these two blocks of variables together served as an effective model in predicting older patients' LOS in the hospital. Since physical restraint use has been found to be predictive of longer hospital stay, physical restraints should be used with more caution and the use of it should be reduced on older patients in the hospital caring setting. All relevant health care staff should be aware of the negative effects of physical restraint use and should reduce the use of it in hospital caring and nursing home settings.

[A Dutch roadmap for care without belts usage]

The use of physical restraints still is highly prevalent in institutional long term care settings for older people. We know that the use of restrictive measures, such as belt restraints, do have many negative consequences for residents, and even can be harmful to their health. However, this knowledge does not result in a reduction of physical restraints. This paper describes the search for an intervention (EXBELT) aiming to safely reduce and prevent the use of belt restraints in nursing homes. EXBELT consists of a promotion of institutional policy change that discourages use of belt restraints, nursing home staff education, availability of alternative interventions, and consultation by a nurse specialist. Effect evaluations show that EXBELT is effective on the short and long term. According to a process evaluation, EXBELT was largely performed according to protocol and very well received by nursing home staff and resident's relatives. However, concurrently it is stated that the reduction of physical restraints in Dutch nursing home care runs slowly. The conclusion is that continuing focus is needed to reduce physical restraints in nursing homes and to prevent its use in home care.

Characteristics of nursing home residents and physical restraint: a systematic literature review

AIMS AND OBJECTIVES

To analyse and to summarise factors associated with nursing home residents' characteristics which could lead to physical restraint, and to investigate the consequences of physical restraint use for this population.

BACKGROUND

Even though the application of physical restraint is highly controversial, prevalence rates show that it is a common intervention in nursing homes. Residents' characteristics seem to be important to predict the use of physical restraint. Evidence suggests that restrained nursing home residents may have physical and psychological disadvantages as a consequence of being restrained.

METHODS

A systematic literature research involving the databases PubMed, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science and Cochrane Library was carried out for articles published from January 2005-November 2011. Nine Studies fulfilled the inclusion criteria and the quality assessment.

RESULTS

Restrained residents had low activities of daily living (ADL) scores and severe cognitive impairment. Residents with low cognitive status and serious mobility impairments were at high risk to be restrained, as well as residents with previous fall and/or fracture. Repeated verbal and physical agitation was found to be positively associated with restraint use. Possible consequences of physical restraint were as follows: lower cognitive and ADL performance, higher walking dependence, furthermore falls, pressure ulcers, urinary and faecal incontinence.

CONCLUSIONS

This systematic literature review reveals notable resident-related factors for physical restraint use. The consequences of restraint seem to negatively influence residents' physical and psychological well-being. Physical restraint seems to be an important risk factor for residents' further health problems.

RELEVANCE TO CLINICAL PRACTICE

Resident's characteristics appear to be decisive factors for the use of physical restraint. Nurses need a high level of expertise and competence in evaluating the individual residents' situation and deciding further steps, with respect for the autonomy and dignity of the person.

[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.

Risk factors associated with physical restraints in residential aged care facilities: a community-based epidemiological survey in Taiwan

AIM

To identify the rate and risk factors of physical restraint in residential aged care facilities in Taiwan.

BACKGROUND

In Taiwan, physical restraint is commonly used in aged care facilities to prevent accidents. Many are unaware of the associated risks. Restrained residents cannot move freely, increasing the risk of atrophy and leading to reduced physical functioning.

DESIGN

A community-based epidemiological survey.

METHODS

Data were collected from June-December 2007 across 178 residential aged care facilities with 5,173 residential beds in the target city of Taiwan. Twenty facilities were sampled using probability proportional to size by beds and accreditation ranking. In all, 256 primary caregivers (78 nurses and 178 care aides) and 847 residents completed the study questionnaires and tests. A multilevel analysis approach was used to identify individual- and facility-level risk factors for physical restraint and assess the variation in physical restraint at the individual- and facility-level.

RESULTS

Of 847 residents, 62% (527) were restrained during the study period. The main reasons for restraint use were fall prevention and prevention of tube removal. Resident level risk factors for physical restraint included lower Barthel Index scores (more dependent) and an agreement allowing the use of physical restraint to avoid injury signed by a family member or social worker. A facility-level risk factor for physical restraint was younger primary caregivers.

CONCLUSION

To reduce the incidence of physical restraint in residential aged care facilities in Taiwan, educational programmes should target primary caregivers and families in facilities.

Process evaluation of a multicomponent intervention program (EXBELT) to reduce belt restraints in nursing homes

OBJECTIVE

The current study describes the process evaluation of a multicomponent intervention program (Expelling Belts [EXBELT]) to reduce the use of belt restraints in psychogeriatric nursing homes. The aim was to assess the feasibility and ascertain suggestions for optimization of the EXBELT program.

DESIGN

A descriptive study comprising longitudinal elements.

SETTING

Fifteen psychogeriatric nursing home wards in 6 Dutch nursing homes.

PARTICIPANTS

The study population consisted of 4 different groups of participants who took part in the intervention arm of the quasi-experimental study examining the effectiveness of EXBELT: nursing home staff who attended the final session of the educational program; 2 nurse specialists who delivered the educational program and did the consultations; 4 groups of delegates representing the nursing home associations where the EXBELT program was implemented; and the relatives of those residents in the intervention group who were restrained with a belt at the start of the study.

MEASUREMENTS

Both quantitative and qualitative data were collected from the study population. Data were assessed by means of self-administered questionnaires, recording forms, group interviews, telephone interviews, and monthly meetings.

RESULTS

The EXBELT study was largely performed according to protocol and very well received by nursing home staff as well as resident's relatives. Suggestions to improve the EXBELT program include the addition of examples of how to communicate about the policy change, improving the reach of the intended target population, adding more case-based learning strategies, and embedding the available consultants more proactively.

CONCLUSIONS

The implementation of EXBELT was highly successful in the current research population and is likely to be feasible in psychogeriatric nursing homes in general.

How to avoid and prevent coercion in nursing homes

In many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia. This article examines what kinds of strategies or alternative interventions nursing staff in Norway used when patients resist care and treatment and what conditions the staff considered as necessary to succeed in avoiding the use of coercion. The data are based on interdisciplinary focus group interviews with nursing home staff. The study revealed that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion. The most common strategies were deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care. According to the staff, their opportunities to use alternative strategies effectively are greatly affected by the nursing home’s resources, by the organization of care and by the staff’s competence.

Interventions for preventing and reducing the use of physical restraints in long-term geriatric care - a Cochrane review

AIMS AND OBJECTIVES

To evaluate the effectiveness of interventions to prevent and reduce the use of physical restraints in older people requiring long-term nursing care.

BACKGROUND

Physical restraints are commonly used in geriatric long-term care. However, they are associated with adverse outcomes. Therefore, freedom from physical restraints should be the aim of high-quality nursing care.

DESIGN

Systematic review of randomised controlled trials.

METHODS

This review followed the methods of the Cochrane Handbook of systematic reviews of interventions. The systematic search (September 2009) covered the Cochrane Dementia and Cognitive Improvement Group's Specialized Register, MEDLINE, EMBASE, CINAHL, PsycINFO and LILACS.

RESULTS

Six cluster-randomised controlled trials met the inclusion criteria. All studies investigated educational approaches targeting nursing staff. In addition, two studies offered consultation, two guidance and one support and free access to technical aids. Five studies examined nursing home residents and one study residents in group dwelling units. No studies in community settings were included. Overall, the methodological quality of studies was low. Their results were inconsistent. One study with good methodological quality in the nursing home setting documented an increase in physical restraints use in both groups, while the other four studies with lower quality found reduced use of physical restraints in the intervention group. The single study in group dwelling units found no change in physical restraints use in the intervention group but a significant increase in the control group.

CONCLUSIONS

There is insufficient evidence supporting the effectiveness of educational interventions targeting nursing staff for preventing or reducing the use of physical restraints in geriatric long-term care. Relevance to clinical practice.  Our findings indicate that educational programmes targeting nursing staff might not be effective in reducing the use of physical restraints in geriatric long-term care. It remains unclear which components should be included in educational programmes aiming to reduce physical restraints.

Physical restraint use in institutional care of old people in Sweden in 2000 and 2007

BACKGROUND

Physical restraint use is common in institutional care for old people and mainly used to prevent falls, despite the fall-preventive effect of physical restraints being questioned in previous research. The aim of the study was to investigate the use of physical restraints in Sweden in 2000 and 2007.

METHODS

Data were collected from two comparable census surveys conducted in all institutional care units for old people in 2000 (n = 3,669) and 2007 (n = 2,914). Information on residents' characteristics and physical restraint use was collected using the Multi-Dimensional Dementia Assessment Scale (MDDAS).

RESULTS

In 2000 16.0% (95% confidence interval (CI) 14.8%-17.2%) of the residents were restrained compared to 18.2% (95% CI 16.8%-19.6%) in 2007 (p = 0.017). Adjusting for residents' characteristics showed that residents in 2007 were more likely to be physically restrained, relative to the residents in 2000 (odds ratio (OR) 1.031, 95% CI 1.005-1.058, p = 0.017). In 2007 the residents had been restrained longer, and a higher proportion were restrained for unknown reasons.

CONCLUSIONS

Physical restraint use is still common. Moreover, the findings of this study suggest a small increase (OR 1.031) in the prevalence of physical restraint use from 2000 to 2007 adjusted for residents' characteristics.

A national survey of the use of physical restraint in long-term care hospitals in Japan

AIMS AND OBJECTIVES

To investigate the prevalence of physical restraints in the long-term care hospitals in Japan and to examine the factors of physical restraint use, including the specific skills/techniques that the staff use to minimise the restraints. Background.  Despite the national efforts to nullify physical restraint, it is still prevalent in long-term care facilities in and out of Japan. More detailed information regarding what affects physical restraint is needed.

DESIGN

Cross-sectional mail survey.

METHOD

A questionnaire was sent to a nursing ward manager of the random sample of long-term care facilities in Japan.

RESULTS

The average rate of physical restraint was 25·5%. Altogether, 81·0% of the restrained clients were under restraint for more than one month. The most prevalent method of restraint was bilateral bedrails, followed by the use of coveralls and gloves. Factors of restraint were different depending on the type of restraint, suggesting specific approaches are needed for specific type of restraint.

CONCLUSIONS

Physical restraint is still prevalent in Japanese long-term care hospitals, and nurses need to develop effective intervention approach to redesigning practice related to physical restraints. Specialised intervention approach seems needed depending on the types of restraint.

RELEVANCE TO CLINICAL PRACTICE

Specific approach should be developed to minimise the physical restraint in long-term care hospitals in Japan.

Education on physical restraint reduction in dementia care: a review of the literature

Dementia is a priority area for all countries as populations age and dementia prevalence increases. The use of physical restraint is a possible clinical practice for persons with dementia across settings when behaviours indicate a perceived need. Indeed, this may be the first choice in practice, occurring in part because of lack of education, safety concerns, perceived costs and staffing issues. This article reviews the literature on the issues surrounding, and use of, physical restraint for people with dementia, highlighting the rationales for use and the benefits and barriers to physical restraint. Recommendations include the importance of education and policy to reduce or eliminate physical restraint of persons with dementia to overcome identified barriers at the individual, cultural and organizational levels. An educational programme from the literature review is proposed specific to the reduction or elimination of physical restraint.

Interventions for preventing and reducing the use of physical restraints in long-term geriatric care

BACKGROUND

Physical restraints (PR) are commonly used in geriatric long-term care. Restraint-free care should be the aim of high quality nursing care.

OBJECTIVES

To evaluate the effectiveness of interventions to prevent and reduce the use of physical restraints in older people who require long-term nursing care (either in community nursing care or in residential care facilities).

SEARCH STRATEGY

The Cochrane Dementia and Cognitive Improvement Group's Specialized Register, MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, a number of trial registers and grey literature sources were searched on 7 September 2009. The following search terms were used: "physical restraint*", bedrail*, bedchair*, "containment measure*, elderly, "old people", geriatric*, aged, "nursing home*", "care home*", "geriatric care", "residential facilit*".

SELECTION CRITERIA

Individual or cluster-randomised controlled trials comparing an intervention aimed at reducing the use of physical restraints with usual care in long-term geriatric care settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the retrieved articles for relevance and methodological quality and extracted data. Critical appraisal of studies addressed risk of bias through selection bias, performance bias, attrition bias, and detection bias, as well as critera related to cluster designa. We contacted study authors for additional information where necessary. PR were defined heterogeneously throughout the studies. Not all studies offered sufficient data for aggregated data meta-analysis, and therefore study results are presented in a narrative form.

MAIN RESULTS

Five cluster-randomised controlled studies met the inclusion criteria. All of them investigated educational approaches. Two studies offered consultation in addition and two other studies offered guidance for nursing staff in addition. Four studies examined nursing home residents and one study residents in group dwelling units. No studies in community settings were included. Three studies included only one or two nursing homes per study condition. Overall, methodological quality of studies was low.The studies revealed inconsistent results. One study in the nursing home setting documented an increase of PR use in both groups after eight months, while the other three studies found reduced use of PR in the intervention groups after seven and 12 months of follow up respectively. The single study examining residents in group dwelling units found no change in PR use in the intervention group after six months whereas PR use increased significantly in the control group.

AUTHORS' CONCLUSIONS

There is insufficient evidence supporting the effectiveness of educational interventions targeting nursing staff for preventing or reducing the use of physical restraints in geriatric long-term care.

Nursing staff perceptions of the use of physical restraint in institutional care of older people in Finland

AIMS AND OBJECTIVES

To describe the perceptions of nursing staff on the use of physical restraints in institutional care of older people.

BACKGROUND

Physical restraint of older people is a common practice in institutional care in many countries, including Finland. As the nursing staff plays a major role in deciding on physically restraining older patient and in the care the patient receives, new research information is needed on the nursing staff's attitudes towards the use of physical restraints.

DESIGN

A qualitative study.

METHOD

The data consisted of focus group interviews with staff and supervisors. There were four focus groups: nurses, practical nurses, institutional assistants and care supervisors.

RESULTS

In addition to traditional methods of restraint, such as belts and locked doors, the nursing staff also used indirect restraint by removing the patient's mobility aid. Factors contributing to the use of restraints included requests by the patient's family members to use restraint to ensure the patient's safety and social reasons, in the form of lack of legislation on the use of restraint. The use of restraints caused feelings of guilt among the nursing staff, but on the other hand, it was seen as a way of making older patient feel more secure.

CONCLUSIONS

There is a need for official guidelines on the use of physical restraints in care of older people. This would require the entire nursing team to make a joint decision on the use of restraints and constant reassessment of the need of using restraints.

RELEVANCE TO CLINICAL PRACTICE

The results of the study provide nursing staff and supervisors a chance to ethically deliberate and evaluate their own work. Alternative practices for physical restraint can also be directly applied to practical care of older people.

Cuidado de enfermagem ao paciente com comorbidade clínico-psiquiátrica em um pronto atendimento hospitalar

Pesquisa qualitativa, descritiva, exploratória desenvolvida em 2009 no pronto atendimento de um hospital geral de Curitiba, Paraná. Teve como objetivo conhecer o cuidado de enfermagem desenvolvido ao paciente com comorbidade clínico-psiquiátrica. Participaram seis enfermeiros, sete técnicos de enfermagem e 14 auxiliares de enfermagem. Os dados foram obtidos mediante entrevista semiestruturada e submetidos à análise de conteúdo temático-categorial. As categorias que emergiram dos dados foram: O cuidado é técnico e sem especificidade; Segurança e proteção ao paciente; e Contenção física e química como medidas de proteção. Evidenciou-se que os cuidados de enfermagem desenvolvidos aos pacientes com comorbidade clínico-psiquiátrica são sem especificidade, com ênfase em cuidados básicos, contenção química e física. Concluiu-se que há necessidade da implantação de programas locais de capacitação em saúde mental e sensibilização dos profissionais de enfermagem quanto aos cuidados a tal clientela.

Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study

OBJECTIVES

This study compares inter- and intra-country differences in the prevalence of physical restraints and antipsychotic medications in nursing homes, and examines aggregated resident conditions and organizational characteristics correlated with these treatments.

METHODS

Population-based, cross-sectional data were collected using a standardized Resident Assessment Instrument (RAI) from 14,504 long-term care facilities providing nursing home level services in five countries participating in the interRAI consortium, including Canada, Finland, Hong Kong (Special Administrative Region, China), Switzerland, and the United States. Facility-level prevalence rates of physical restraints and antipsychotic use were examined both between and within the study countries.

RESULTS

The prevalence of physical restraint use varied more than five-fold across the study countries, from an average 6% in Switzerland, 9% in the US, 20% in Hong Kong, 28% in Finland, and over 31% in Canada. The prevalence of antipsychotic use ranged from 11% in Hong Kong, between 26-27% in Canada and the US, 34% in Switzerland, and nearly 38% in Finland. Within each country, substantial variations existed across facilities in both physical restraint and antipsychotic use rates. In all countries, neither facility case mix nor organizational characteristics were particularly predictive of the prevalence of either treatment.

CONCLUSIONS

There exists large, unexplained variability in the prevalence of physical restraint and antipsychotic use in nursing home facilities both between and within countries. Since restraints and antipsychotics are associated with adverse outcomes, it is important to understand the idiosyncratic factors specific to each country that contribute to variation in use rates.