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Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restraints for older people in all long-term care settings. Cochrane Database Syst Rev 2023; 7:CD007546. [PMID: 37500094 PMCID: PMC10374410 DOI: 10.1002/14651858.cd007546.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND Physical restraints (PR), such as bedrails and belts in chairs or beds, are commonly used for older people receiving long-term care, despite clear evidence for the lack of effectiveness and safety, and widespread recommendations that their use should be avoided. This systematic review of the efficacy and safety of interventions to prevent and reduce the use of physical restraints outside hospital settings, i.e. in care homes and the community, updates our previous review published in 2011. OBJECTIVES To evaluate the effects of interventions to prevent and reduce the use of physical restraints for older people who require long-term care (either at home or in residential care facilities) SEARCH METHODS: We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid Sp), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register, the International Clinical Trials Registry Portal, on 3 August 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that investigated the effects of interventions intended to prevent or reduce the use of physical restraints in older people who require long-term care. Studies conducted in residential care institutions or in the community, including patients' homes, were eligible for inclusion. We assigned all included interventions to categories based on their mechanisms and components. DATA COLLECTION AND ANALYSIS Two review authors independently selected the publications for inclusion, extracted study data, and assessed the risk of bias of all included studies. Primary outcomes were the number or proportion of people with at least one physical restraint, and serious adverse events related to PR use, such as death or serious injuries. We performed meta-analyses if necessary data were available. If meta-analyses were not feasible, we reported results narratively. We used GRADE methods to describe the certainty of the evidence. MAIN RESULTS We identified six new studies and included 11 studies with 19,003 participants in this review update. All studies were conducted in long-term residential care facilities. Ten studies were RCTs and one study a CCT. All studies included people with dementia. The mean age of the participants was approximately 85 years. Four studies investigated organisational interventions aiming to implement a least-restraint policy; six studies investigated simple educational interventions; and one study tested an intervention that provided staff with information about residents' fall risk. The control groups received usual care only in most studies although, in two studies, additional information materials about physical restraint reduction were provided. We judged the risk of selection bias to be high or unclear in eight studies. Risk of reporting bias was high in one study and unclear in eight studies. The organisational interventions intended to promote a least-restraint policy included a variety of components, such as education of staff, training of 'champions' of low-restraint practice, and components which aimed to facilitate a change in institutional policies and culture of care. We found moderate-certainty evidence that organisational interventions aimed at implementation of a least-restraint policy probably lead to a reduction in the number of residents with at least one use of PR (RR 0.86, 95% CI 0.78 to 0.94; 3849 participants, 4 studies) and a large reduction in the number of residents with at least one use of a belt for restraint (RR 0.54, 95% CI 0.40 to 0.73; 2711 participants, 3 studies). No adverse events occurred in the one study which reported this outcome. There was evidence from one study that organisational interventions probably reduce the duration of physical restraint use. We found that the interventions may have little or no effect on the number of falls or fall-related injuries (low-certainty evidence) and probably have little or no effect on the number of prescribed psychotropic medications (moderate-certainty evidence). One study found that organisational interventions result in little or no difference in quality of life (high-certainty evidence) and another study found that they may make little or no difference to agitation (low-certainty evidence). The simple educational interventions were intended to increase knowledge and change staff attitudes towards PR. As well as providing education, some interventions included further components to support change, such as ward-based guidance. We found pronounced between-group baseline imbalances in PR prevalence in some of the studies, which might have occurred because of the small number of clusters in the intervention and control groups. One study did not assess bedrails, which is the most commonly used method of restraint in nursing homes. Regarding the number of residents with at least one restraint, the results were inconsistent. We found very-low certainty evidence and we are uncertain about the effects of simple educational interventions on the number of residents with PR. None of the studies assessed or reported any serious adverse events. We found moderate-certainty evidence that simple educational interventions probably result in little or no difference in restraint intensity and may have little or no effect on falls, fall-related injuries, or agitation (low-certainty evidence each). Based on very low-certainty evidence we are uncertain about the effects of simple educational interventions on the number of participants with a prescription of at least one psychotropic medication. One study investigated an intervention that provided information about residents' fall risk to the nursing staff. We found low-certainty evidence that providing information about residents' fall risk may result in little or no difference in the mean number of PR or the number of falls. The study did not assess overall adverse events. AUTHORS' CONCLUSIONS Organisational interventions aimed to implement a least-restraint policy probably reduce the number of residents with at least one PR and probably largely reduce the number of residents with at least one belt. We are uncertain whether simple educational interventions reduce the use of physical restraints, and interventions providing information about residents' fall risk may result in little to no difference in the use of physical restraints. These results apply to long-term care institutions; we found no studies from community settings.
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Affiliation(s)
- Ralph Möhler
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Tanja Richter
- Unit of Health Sciences and Education, University of Hamburg, Hamburg, Germany
| | - Sascha Köpke
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gabriele Meyer
- Institute of Health and Nursing Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Bryant-Lukosius D, Valaitis R, Martin-Misener R, Donald F, Peña LM, Brousseau L. Advanced Practice Nursing: A Strategy for Achieving Universal Health Coverage and Universal Access to Health. Rev Lat Am Enfermagem 2017; 25:e2826. [PMID: 28146177 PMCID: PMC5288863 DOI: 10.1590/1518-8345.1677.2826] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 09/26/2016] [Indexed: 11/21/2022] Open
Abstract
Objective: to examine advanced practice nursing (APN) roles internationally to inform role
development in Latin America and the Caribbean to support universal health
coverage and universal access to health. Method: we examined literature related to APN roles, their global deployment, and APN
effectiveness in relation to universal health coverage and access to health. Results: given evidence of their effectiveness in many countries, APN roles are ideally
suited as part of a primary health care workforce strategy in Latin America to
enhance universal health coverage and access to health. Brazil, Chile, Colombia,
and Mexico are well positioned to build this workforce. Role implementation
barriers include lack of role clarity, legislation/regulation, education, funding,
and physician resistance. Strong nursing leadership to align APN roles with policy
priorities, and to work in partnership with primary care providers and policy
makers is needed for successful role implementation. Conclusions: given the diversity of contexts across nations, it is important to systematically
assess country and population health needs to introduce the most appropriate
complement and mix of APN roles and inform implementation. Successful APN role
introduction in Latin America and the Caribbean could provide a roadmap for
similar roles in other low/middle income countries.
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Affiliation(s)
| | - Ruta Valaitis
- PhD, Associate Professor, School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Ruth Martin-Misener
- PhD, Professor, School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Faith Donald
- PhD, Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON, Canada
| | - Laura Morán Peña
- PhD, Professor, Escuela Nacional de Enfermería y Obstetricia de la Universidad Nacional Autónoma de México, Ciudad de México, DF, Mexico
| | - Linda Brousseau
- MSc, Nurse Practitioner (NP), Halton Region Health Unit, Oakville, ON, Canada
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Kilpatrick K, Kaasalainen S, Donald F, Reid K, Carter N, Bryant-Lukosius D, Martin-Misener R, Harbman P, Marshall DA, Charbonneau-Smith R, DiCenso A. The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review. J Eval Clin Pract 2014; 20:1106-23. [PMID: 25040492 DOI: 10.1111/jep.12219] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Increasing numbers of clinical nurse specialists (CNSs) are working in outpatient settings. The objective of this paper is to describe a systematic review of randomized controlled trials (RCTs) evaluating the cost-effectiveness of CNSs delivering outpatient care in alternative or complementary provider roles. METHODS We searched CINAHL, MEDLINE, EMBASE and seven other electronic databases, 1980 to July 2012 and hand-searched bibliographies and key journals. RCTs that evaluated formally trained CNSs and health system outcomes were included. Study quality was assessed using the Cochrane risk of bias tool and the Quality of Health Economic Studies instrument. We used the Grading of Recommendations Assessment, Development and Evaluation to assess quality of evidence for individual outcomes. RESULTS Eleven RCTs, four evaluating alternative provider (n = 683 participants) and seven evaluating complementary provider roles (n = 1464 participants), were identified. Results of the alternative provider RCTs (low-to-moderate quality evidence) were fairly consistent across study populations with similar patient outcomes to usual care, some evidence of reduced resource use and costs, and two economic analyses (one fair and one high quality) favouring CNS care. Results of the complementary provider RCTs (low-to-moderate quality evidence) were also fairly consistent across study populations with similar or improved patient outcomes and mostly similar health system outcomes when compared with usual care; however, the economic analyses were weak. CONCLUSIONS Low-to-moderate quality evidence supports the effectiveness and two fair-to-high quality economic analyses support the cost-effectiveness of outpatient alternative provider CNSs. Low-to-moderate quality evidence supports the effectiveness of outpatient complementary provider CNSs; however, robust economic evaluations are needed to address cost-effectiveness.
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Affiliation(s)
- Kelley Kilpatrick
- Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada; Faculty of Nursing, Université de Montreal, Montreal, Quebec, Canada; Hôpital Maisonneuve-Rosemont Research Centre, Montreal, Quebec, Canada
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Donald F, Kilpatrick K, Reid K, Carter N, Martin-Misener R, Bryant-Lukosius D, Harbman P, Kaasalainen S, Marshall DA, Charbonneau-Smith R, Donald EE, Lloyd M, Wickson-Griffiths A, Yost J, Baxter P, Sangster-Gormley E, Hubley P, Laflamme C, Campbell–Yeo M, Price S, Boyko J, DiCenso A. A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence? Nurs Res Pract 2014; 2014:896587. [PMID: 25258683 PMCID: PMC4167459 DOI: 10.1155/2014/896587] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 12/25/2022] Open
Abstract
Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.
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Affiliation(s)
- Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montreal and Research Centre of Hôpital Maisonneuve-Rosemont, CSA-RC-Aile Bleue-Room F121, 5415 boulevard l'Assomption, Montréal, QC, Canada H1T 2M4
| | - Kim Reid
- KJ Research, Rosemere, QC, Canada J7A 4N8
| | - Nancy Carter
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Denise Bryant-Lukosius
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Department of Oncology, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, Canada L8S 4L8
| | - Patricia Harbman
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Health Interventions Research Centre, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Deborah A. Marshall
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, Calgary, AB, Canada T2N 4Z6
| | | | - Erin E. Donald
- Fraser Health Authority, Suite 400-13450 102nd Avenue, Surrey, BC, Canada V3T 0H1
| | - Monique Lloyd
- International Affairs and Best Practice Guidelines Centre, Registered Nurses' Association of Ontario, 158 Pearl Street, Toronto, ON, Canada M5H 1L3
| | | | - Jennifer Yost
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Pamela Baxter
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Esther Sangster-Gormley
- School of Nursing, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC, Canada V8W 2Y2
| | - Pamela Hubley
- The Hospital for Sick Children, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 555 University Avenue, Toronto, ON, Canada M5G 1X8
| | - Célyne Laflamme
- Primary Health Care Nurse Practitioner Program, School of Nursing, University of Ottawa, 600 Peter Morand Crescent, Suite 101, Ottawa, ON, Canada K1G 5Z3
| | - Marsha Campbell–Yeo
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Sheri Price
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Jennifer Boyko
- School of Health Studies, Western University, Health Sciences Building, Room 403, London, ON, Canada N6A 5B9
| | - Alba DiCenso
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
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Donald F, Martin-Misener R, Carter N, Donald EE, Kaasalainen S, Wickson-Griffiths A, Lloyd M, Akhtar-Danesh N, DiCenso A. A systematic review of the effectiveness of advanced practice nurses in long-term care. J Adv Nurs 2013; 69:2148-61. [PMID: 23527481 DOI: 10.1111/jan.12140] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2013] [Indexed: 11/29/2022]
Abstract
AIM To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long-term care residential settings. BACKGROUND Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted. DESIGN Quantitative systematic review. DATA SOURCES Twelve electronic databases were searched (1966-2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group. REVIEW METHODS Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria. RESULTS Four prospective studies conducted in the USA and reported in 15 papers were included. Long-term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services. CONCLUSION Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long-term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.
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Affiliation(s)
- Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
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6
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Wagner LM, McDonald SM, Castle NG. Nursing home deficiency citations for physical restraints and restrictive side rails. West J Nurs Res 2012; 35:546-65. [PMID: 22390907 DOI: 10.1177/0193945912437382] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article examines whether nursing home facility-level characteristics are associated with the likelihood of receiving deficiency citations for physical restraints, including restrictive side rails. Data from the on-line survey certification of automated records were used to calculate odds ratios for facility-level characteristics associated with these deficiency citations. Repeat records from 2000 to 2007 were combined to produce longitudinal data. The results of this study show that restraint/side rail deficiency citations were negatively associated with higher staffing levels of registered nurses and licensed practical nurses (p ≤ .001) and higher Medicaid reimbursement rates (p ≤ .01). Citations were positively associated with greater nurse aide staffing (p ≤ .01) and higher quality-of-care deficiency citation percentiles (p ≤ .001). The extent of physical restraint and restrictive side rail misuse within nursing homes appears to vary according to various facility characteristics. It is less clear how internal processes within a facility bring about these observed patterns of variation.
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Affiliation(s)
- Laura M Wagner
- New York University College of Nursing, New York 10003, USA.
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7
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Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restraints in long-term geriatric care. Cochrane Database Syst Rev 2011; 2011:CD007546. [PMID: 21328295 PMCID: PMC8978305 DOI: 10.1002/14651858.cd007546.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Ralph Möhler
- Witten/Herdecke UniversityDepartment of Nursing Science, Faculty of HealthStockumer Straße 12WittenGermany58453
| | - Tanja Richter
- University of HamburgUnit of Health Sciences and EducationMartin‐Luther‐King‐Platz 6HamburgGermanyD‐20146
| | - Sascha Köpke
- University of HamburgUnit of Health Sciences and EducationMartin‐Luther‐King‐Platz 6HamburgGermanyD‐20146
| | - Gabriele Meyer
- Witten/Herdecke UniversityDepartment of Nursing Science, Faculty of HealthStockumer Straße 12WittenGermany58453
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9
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Wagner LM, Capezuti E, Brush B, Boltz M, Renz S, Talerico KA. Description of an advanced practice nursing consultative model to reduce restrictive siderail use in nursing homes. Res Nurs Health 2007; 30:131-40. [PMID: 17380514 DOI: 10.1002/nur.20185] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Researchers have demonstrated that the use of physical restraints in nursing homes can be reduced, particularly where advanced practice nurses (APNs) are utilized. We examined the link between APN practice, siderail reduction, and the costs of siderail alternatives in 273 residents in four Philadelphia nursing homes. The majority of participants were cognitively and physically impaired with multiple co-morbidities. APNs recommended a total of 1,275 siderail-alternative interventions aimed at reducing fall risk. The median cost of siderail alternatives to prevent falls per resident was $135. Residents with a fall history experienced a significantly higher cost of recommendation compared to non-fallers. Findings suggest that an APN consultation model can effectively be implemented through comprehensive, individualized assessment without incurring substantial costs to the nursing home.
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Affiliation(s)
- Laura M Wagner
- Baycrest Centre for Geriatric Care, Kunin-Lunenfeld Applied Research Unit, 3560 Bathurst Street, Toronto, Ontario, Canada M6A 2E1.
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Harvath TA, Beck C, Flaherty-Robb M, Hartz CH, Specht J, Sullivan-Marx E, Archbold P. Best practice initiatives in geriatric nursing: Experiences from the John A. Hartford Foundation Centers of Geriatric Nursing Excellence. Nurs Outlook 2006; 54:212-8. [PMID: 16890040 DOI: 10.1016/j.outlook.2006.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Indexed: 11/22/2022]
Affiliation(s)
- Theresa A Harvath
- Oregon Health & Science University, School of Nursing, Portland, OR 97239-2941, USA.
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11
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Hamers JPH, Huizing AR. Why do we use physical restraints in the elderly? Z Gerontol Geriatr 2005; 38:19-25. [PMID: 15756483 DOI: 10.1007/s00391-005-0286-x] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2004] [Accepted: 01/10/2005] [Indexed: 11/25/2022]
Abstract
The use of physical restraints in the elderly is a common practice in many countries. This paper summarizes the current knowledge on the use of restraints in home care, hospitals and nursing homes. Between 1999-2004 the reported prevalence numbers range from 41-64% in nursing homes and 33-68% in hospitals; numbers of restraint use in home care are unknown. Bed rails and belts have been reported as the most frequently used restraints in bed; chairs with a table and belts are the most frequently reported restraints in a chair. It is evident that physical restraints in most cases are used as safety measures; the main reason is the prevention of falls. In the hospital setting, the safe use of medical devices is also an important reason for restraint use. Predictors for the use of physical restraints are poor mobility, impaired cognitive status and high dependency of the elderly patient and the risk of falls in the nurses' opinion. Furthermore, there are indications that restraint use is related to organizational characteristics. Finally, many adverse effects of restraint use have been reported in the literature, like falls, pressure sores, depression, aggression, and death. Because of the adverse effects of restraints and the growing evidence that physical restraints are no adequate measure for the prevention of falls, measures for the reduction of physical restraints are discussed and recommendations are made for future research.
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Affiliation(s)
- J P H Hamers
- Universiteit Maastricht, Department of Health Care Studies, Section of Nursing Science, 6200 MD Maastricht, The Netherlands.
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Abstract
During the past two decades, significant research and several government and health care quality groups have advised against the use of physical restraints in hospitals and nursing homes, yet older adults are continuing to die, become injured or experience the iatrogenic complications associated with this practice. Deaths are usually caused by asphyxiation, but also occur from strangulation, or cardiac arrest. Older adults with dementia are at high risk for restraint use because of impaired memory, language, judgment and visual perception. In moderate to severe dementia, the risk of falls is greater because of gait apraxia and unsteadiness. Agitation, disorientation, and pacing behaviors from delirium or dementia can precipitate staff to use restraints to prevent harm to the older adult or to others. Physical restraints should be eliminated as an intervention in older adults with dementia because they are also very likely to cause acute functional decline, incontinence, pressure ulcers and regressive behaviors in a short period of time. The purpose of this paper is to disseminate the dangers of this clinical practice and to summarize the latest research in restraint free care and restraint alternatives in the United States.
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Affiliation(s)
- Valerie T Cotter
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
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13
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Capezuti E. Minimizing the use of restrictive devices in dementia patients at risk for falling. Nurs Clin North Am 2004; 39:625-47. [PMID: 15331306 DOI: 10.1016/j.cnur.2004.02.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.
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Affiliation(s)
- Elizabeth Capezuti
- John A. Hartford Foundation Institute for Geriatric Nursing, Division of Nursing, Steinhardt School of Education, New York University, 246 Greene Street, 6th Floor, New York, NY 10003-6677, USA.
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Abstract
Models of care for frail older adults have increasingly used advanced practice nurses (APNs) to achieve outcomes. Knowledge of the common APN functions and skills that contribute to the success of these models could better inform education and evidence-based practice and guide further research, but published investigations associated with models of gerontologic care neither describe fully these functions and skills nor link the activities of the APN with specific outcomes. Using examples primarily from the University of Pennsylvania School of Nursing, this paper identifies, describes, and analyzes common functions and skills of APNs in published gerontologic care models; examines the strength of the evidence for the effect of APNs on outcomes of care; and identifies areas for further study.
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Affiliation(s)
- Meg Bourbonniere
- School of Nursing, University of Pennsylvania, Philadelphia, USA.
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15
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Abstract
BACKGROUND Seclusion and restraint are interventions used in the treatment and management of disruptive and violent behaviours in psychiatry. The use of seclusion varies widely across institutions. The literature does offer numerous suggestions for interventions to reduce or prevent aggression. OBJECTIVES 1. To estimate the effects of seclusion and restraint compared to the alternatives for those with serious mental illnesses. 2. To estimate the effects of strategies to prevent seclusion and restraint in those with serious mental illnesses. SEARCH STRATEGY Electronic searches of The Cochrane Controlled Trials Register (Issue 1, 1999) and The Cochrane Schizophrenia Group's Register (January 1999) were supplemented with additional searches of Biological Abstracts (1989-1999), CINAHL (1982-1999), EMbase (1980-1999), MEDLINE (1966-1999), MEDIC (1979-1999), PsycLIT (1974-1999), Sociofile (1974-1999), SPRI & SWEMED (1982-1999), Social Sciences Citation Index (1996-1999), and WILP (1983-1999). In addition, trials were sought by hand searching the reference lists of all identified studies and conference abstracts and contacting the first author of each relevant study. SELECTION CRITERIA Randomised controlled trials were included if they focused on the use (i) of restraint or seclusion; or (ii) of strategies designed to reduce the need for restraint or seclusion in the treatment of serious mental illness. DATA COLLECTION AND ANALYSIS Studies were reliably selected, quality rated and data extracted. For dichotomous data relative risks (RR) with 95% confidence intervals (CI) were estimated. Normal continuous data were summated using the weighted mean difference (WMD). MAIN RESULTS 1. Effect of seclusion and restraint The search strategy yielded 2155 citations. Of these, the full articles for 35 studies were obtained. No studies met minimum inclusion criteria and no data were synthesised. Most of the 24 excluded studies focused upon the restraint of elderly, confused people and preventing them from wandering or falling. 2. Prevention of seclusion and restraint Work ongoing. REVIEWER'S CONCLUSIONS No controlled studies exist that evaluate the value of seclusion or restraint in those with serious mental illness. There are reports of serious adverse effects for these techniques in qualitative reviews. Alternative ways of dealing with unwanted or harmful behaviours need to be developed. Continuing use of seclusion or restraint must therefore be questioned from within well-designed and reported randomised trials that are generalisable to routine practice.
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Affiliation(s)
- E Sailas
- Department of Psychiatry, University of Helsinki, Lapinlahdentie 1, Helsinki, Finland, FIN-00029 HUCH.
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16
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Sullivan-Marx EM, Strumpf NE, Evans LK, Baumgarten M, Maislin G. Initiation of physical restraint in nursing home residents following restraint reduction efforts. Res Nurs Health 1999; 22:369-79. [PMID: 10520189 DOI: 10.1002/(sici)1098-240x(199910)22:5<369::aid-nur3>3.0.co;2-g] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In this pilot study a one group pretest posttest design was employed to identify resident characteristics and environmental factors associated with initiation of physical restraint. Predictors of restraint initiation for older adults were examined using secondary analysis of an existing data set of nursing home residents who were subjected to a federal mandate and significant restraint reduction efforts. Lower cognitive status (OR = 1.5 [for every 7-point decrease in Mini-Mental State Examination], 95% CI = 1.0, 2.1) and a higher ratio of licensed nursing personnel (OR = 3.7, 95% CI = 1.2, 11.9) were predictive of restraint initiation. Key findings suggest that restraint initiation occurs, despite significant restraint reduction efforts, when a nursing home resident is cognitively impaired or when more licensed nursing personnel (predominantly licensed practical nurses) are available for resident care. Achievement of restraint-free care in nursing homes requires specific and individualized approaches for residents who are cognitively impaired, as well as greater attention to staff mix of registered nurses, licensed practical nurses, and nursing aides.
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Affiliation(s)
- E M Sullivan-Marx
- University of Pennsylvania, School of Nursing, 420 Guardian Drive, Philadelphia, PA 19104-6096, USA
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17
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Evans LK, Strumpf NE, Allen-Taylor SL, Capezuti E, Maislin G, Jacobsen B. A clinical trial to reduce restraints in nursing homes. J Am Geriatr Soc 1997; 45:675-81. [PMID: 9180659 DOI: 10.1111/j.1532-5415.1997.tb01469.x] [Citation(s) in RCA: 179] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the relative effects of two experimental interventions on the use of physical restraints. DESIGN Prospective 12-month clinical trial in which three nursing homes were randomly assigned to restraint education (RE), restraint education-with-consultation (REC), or control (C). SETTING Three voluntary nursing homes in the Philadelphia area providing both skilled and intermediate care. PARTICIPANTS A total of 643 nursing home residents over the age of 60 were enrolled at baseline, and 463 remained to completion (1 year). INTERVENTIONS Both RE and REC homes received intensive education by a masters-prepared gerontologic nurse to increase staff awareness of restraint hazards and knowledge about assessing and managing resident behaviors likely to lead to use of restraints. In addition, the REC home received 12 hours per week of unit-based nursing consultation to facilitate restraint reduction in residents with more complex conditions. MEASUREMENTS Restraint status was observed systematically at baseline, immediately after the 6-month intervention, and again at 9 and 12 months. Staff levels, psychoactive drug use, and injuries were also determined. RESULTS Compared with baseline, the REC home had a statistically significant reduction in restraint prevalence, whereas RE and C homes did not. At 9 months (3 months post-intervention), absolute decline in the percents restrained were 7% RE, 7% C, and 20% REC; at 12 months (6 months post-intervention) declines were 4% RE, 6% C, and 18% REC. However, relative to baseline, these declines represent an average reduction in restraint use of 23% RE, 11% C, and 56% REC. The differences in changes over time were consistently significant (P = .01), whether considering survivors or those present at each time point, and also when controlling for differences between groups at baseline. Further, given any change in restraint use, REC-residents were between 25% and 40% more likely than either RE or C residents to experience decreased restraint use. Results were achieved without increased staff, psychoactive drugs, or serious fall-related injuries. CONCLUSION A 6-month-long educational program combined with unit-based, resident-centered consultation can reduce use of physical restraints in nursing homes effectively and safely. Whether extending the intervention will achieve greater reduction is not known from these results.
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Affiliation(s)
- L K Evans
- School of Nursing, University of Pennsylvania, Philadelphia 19104-2676, USA
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18
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Dunbar JM, Neufeld RR, Libow LS, Cohen CE, Foley WJ. Taking charge. The role of nursing administrators in removing restraints. J Nurs Adm 1997; 27:42-8. [PMID: 9084472 DOI: 10.1097/00005110-199703000-00009] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The leadership and commitment of nursing administrators play a pivotal role in minimizing the use of restraints and maintaining a restraint-free environment. This article describes the role of nursing administrators in reducing the use of physical restraints as part of a 2-year, national nursing home restraint-reduction project. It reviews important information about restraint-free care the benefits of restraint-free care, and strategies to reduce the use of restraints in nursing homes, much of which is applicable to settings other than nursing homes.
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Affiliation(s)
- J M Dunbar
- National Restraint Minimization Project, Jewish Home and Hospital, New York, USA
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