Staffing and pattern of mechanical restraint use across a multiple hospital system

Development of management indicators of nursing for minimizing physical restraints focused on older adult patients hospitalized in acute care settings: A Delphi consensus study

Nursing management activities are important in influencing staff nurses' action to prevent or withdraw physical restraints. However, limited studies have been conducted empirically to determine the nursing management activities required for minimizing physical restraints. Therefore, there is a need for basic standards of nursing management activities to minimize physical restraints in acute care settings. This study aimed to develop nursing management indicators to minimize physical restraint (MaIN-PR) in hospitalized older adult patients in an acute care setting. It was conducted between June and October 2021 in Japan using a Delphi consensus approach. Fifty nurses working at top or middle management levels or as certified nurse specialists in gerontological nursing enrolled as participants. The potential indicators obtained from the literature review and interviews were organized inductively to develop two types of draft indicators: (1) 35 items for top management and (2) 33 items for middle management. We asked the nursing managers and certified nurse specialists in gerontological nursing to assess the validity of each indicator in three rounds. Of the 50 initial panelists, 12 from top management and 13 from middle management continued till the third round. MaIN-PR contained 35 indicators for top management and 28 indicators for middle management and were classified into the following six metrics: planning, motivating, training, commanding, organizing, and controlling. To the best of our knowledge, the current MaIN-PR are the first set of nursing management indicators for minimizing physical restraint, including perspectives on geriatric nursing in acute care settings. These indicators could guide both top and middle nursing management, thus supporting staff nurses' judgment in minimizing physical restraints to enhance the quality of older adult patient care.

A Cross-Sectional Study to Assess the Frequency of Restraint, and Knowledge and Attitudes of the Caregivers of Patients Toward Restraint in a General Hospital Psychiatry Setting from South India

Background

There is limited Indian data on the epidemiology of hospital-based restraint practices and the knowledge and attitude of caregivers toward restraint. Therefore, this study aimed to report the frequency and pattern of restraints in a general hospital psychiatry setting and assess the knowledge and attitude about restraint practices among caregivers of patients.

Methods

We calculated the frequency of restraints (physical and chemical) over one year. The knowledge and attitude toward restraint were assessed in 75 caregivers each of patients from inpatient and outpatient settings, using a questionnaire designed by the authors and pretested in a pilot study.

Results

The frequency of any form of restraint was 19%. The frequency of chemical and physical restraints was 19% and 0.5%, respectively. Less than 20% of caregivers in both groups reported that restraint was either stigmatizing (5.33% inpatient caregivers vs. 12% outpatient caregivers), cruel (8% inpatient caregivers vs. 15.33% outpatient caregivers), or a measure of punishment (9% inpatient caregivers vs. 16% outpatient caregivers). No significant difference was found between knowledge and attitude about restraint between caregivers of outpatients and inpatients, except for a significantly greater number of caregivers of outpatients reporting that the restraint practices in the hospital were similar to those adopted by faith healers or religious/spiritual centers.

Conclusion

The frequency of either physical or chemical restraint was less compared to the existing international and Indian data. In addition, most caregivers of patients of both outpatients and inpatients did not report a negative attitude toward restraints.

The Attitudes Towards the Use of Restraint and Restrictive Intervention Amongst Healthcare Staff on Acute Medical and Frailty Wards-A Brief Literature Review

Restraint in modern non-psychiatric-based healthcare is often regarded as a rare occurrence. It is deemed to be used as a last resort to prevent patients from directly harming themselves. However, techniques are used in modern day practice which are considered direct and indirect restraints with the justification of maintaining patient safety, but they are often not classified as “restraints”. Examples of these include the use of bed rails or tables to prevent patients from “wandering” and to reduce the risk of falls and injuries. More indirect techniques would involve passive interactions with patients or leaving mobility aids out of reach. Staff subconsciously restrain patients and reduce their liberties despite agreeing that patient autonomy should be upheld—a necessary evil to maintain a duty of care. Whilst the use of restraints is often justified to ensure patient care and prevent injury, it is not without consequence. There are physical and psychological health risks such as pressure sores from the inability to mobilise, or the brewing of anger and frustration when denied access to everyday actions. The reasons why restraints are used, whilst stemming from maintaining patient safety, are often due to low staffing levels and the inability to constantly watch at-risk patients due to a large workload. Inadequate training is another factor; by improving education in direct and indirect restraint and providing alternative methods, more ethical decisions and positive outcomes can be implemented. Healthcare professionals are reluctant to use restraint but often conduct it without realising it; assessing their understanding of restraint and providing education to raise awareness of the consequences of direct and indirect methods would result in positive steps toward reducing their use at the same time as looking to provide alternatives to uphold patient care whilst maintaining their dignity and liberty.

Mechanical restraint and characteristics of patient, staff and shifts in a psychiatric ward

BACKGROUND

The use of coercion is a balance between depriving the patients' autonomy and dignity and preventing endangerment of the body or health of self or others. It is of importance to obtain more knowledge about mechanisms leading to mechanical restraint in the attempt of reducing it.

OBJECTIVE

To analyse for associations between incidence of mechanical restraint (MR) and staffing level, staff demographics, patient characteristics, type of shift (day/evening/night) and change of shifts.

METHOD

A naturalistic descriptive method was used to study cases of MR in a psychiatric ward. Data for each case of MR was obtained from an electronic reporting system. Care workers from each shift were identified using duty rosters. Analyses included binary logistic regression analyses.

RESULTS

In 82% of the 114 cases of MR, the patient was diagnosed with personality disorders. In the multiple regression analysis, a significant association was found between the use of MR and the presence of male care workers on the ward (OR:1.44, 95% CI: 1.01-2.05; p = .04). Moreover, MR was associated with evening shifts, compared with day and night shifts (OR =1,29, 95% CI: 1.14-2.57, p = .01). Besides, months from January to December was associated with a decrease in MRs (OR: 0.88, 95% CI: 0.83-0.94; p = 7.3 E-6). No significant associations were found between MR and staffing level or experience.

CONCLUSIONS

MR was associated with evening shifts, higher number of male care workers on duty and a decrease from January to December.

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

BACKGROUND

Although it is plausible that nurse staffing is associated with use of physical restraints in hospitals, this has not been well established. This may be due to limitations in previous cross-sectional analyses lacking adequate control for unmeasured differences in patient-level variables among nursing units.

OBJECTIVE

To conduct a longitudinal study, with units serving as their own control, examining whether nurse staffing relative to a unit's long-term average is associated with restraint use.

DESIGN

We analyzed 17 quarters of longitudinal data using mixed logistic regression, modeling quarterly odds of unit restraint use as a function of quarterly staffing relative to the unit's average staffing across study quarters.

SUBJECTS

3101 medical, surgical, and medical-surgical units in US hospitals participating in the National Database of Nursing Quality Indicators during 2006-2010. Units had to report at least one quarter with restraint use and one quarter without.

MAIN MEASURES

We studied two nurse staffing variables: staffing level (total nursing hours per patient day) and nursing skill mix (proportion of nursing hours provided by RNs). Outcomes were any use of restraint, regardless of reason, and use of restraint for fall prevention.

KEY RESULTS

Nursing skill mix was inversely correlated with restraint use for fall prevention and for any reason. Compared to average quarters, odds of fall prevention restraint and of any restraint were respectively 16 % (95 % CI: 3-29 %) and 18 % (95 % CI: 8-29 %) higher for quarters with very low skill mix.

CONCLUSIONS

In this longitudinal study there was a strong negative correlation between nursing skill mix and physical restraint use. Ensuring that skill mix is consistently adequate should reduce use of restraint.

Performance Measurement of Nursing Care

Concerns about nurse staffing in hospitals, nursing's influence on patient safety and health care outcomes, and nurses' work environment (e.g., equipment failures, documentation burden) have led to increased interest in measuring and reporting nursing's performance. This article reviews recent efforts and issues involved in identifying a set of nursing-sensitive performance measures. Sustaining and strengthening current efforts requires developing measures that address all the domains of nursing, addressing technical issues needed to analyze the impact of nursing on patient safety and health care outcomes, developing data systems that provide the information needed to implement the model system, regularly improving the set of endorsed standards to reflect the most current science and empirical evidence, and persuading all health care stakeholders that measurement and reporting nursing-sensitive standards make a difference in the care and quality that are delivered. Each of these tasks requires substantial development work and construction and maintenance of the infrastructure to sustain the performance measurement efforts.

Mental Health Nursing, Mechanical Restraint Measures and Patients' Legal Rights

Coercive mechanical restraint (MR) in psychiatry constitutes the perhaps most extensive exception from the common health law requirement for involving patients in health care decisions and achieving their informed consent prior to treatment. Coercive measures and particularly MR seriously collide with patient autonomy principles, pose a particular challenge to psychiatric patients' legal rights, and put intensified demands on health professional performance. Legal rights principles require rationale for coercive measure use be thoroughly considered and rigorously documented. This article presents an in-principle Danish Psychiatric Complaint Board decision concerning MR use initiated by untrained staff. The case illustrates that, judicially, weight must be put on the patient perspective on course of happenings and especially when health professional documentation is scant, patients' rights call for taking notice of patient evaluations. Consequently, if it comes out that psychiatric staff failed to pay appropriate consideration for the patient's mental state, perspective, and expressions, patient response deviations are to be judicially interpreted in this light potentially rendering MR use illegitimated. While specification of law criteria might possibly improve law use and promote patients' rights, education of psychiatry professionals must address the need for, as far as possible, paying due regard to meeting patient perspectives and participation principles as well as formal law and documentation requirements.

Characteristics of patients frequently subjected to pharmacological and mechanical restraint--a register study in three Norwegian acute psychiatric wards

This retrospective study from three catchment-area-based acute psychiatric wards showed that of all the pharmacologically and mechanically restrained patients (n=373) 34 (9.1%) had been frequently restrained (6 or more times). These patients accounted for 39.2% of all restraint episodes during the two-year study period. Adjusted binary logistic regression analyses showed that the odds for being frequently restrained were 91% lower among patients above 50 years compared to those aged 18-29 years; a threefold increase (OR=3.1) for those admitted 3 times or more compared to patients with only one stay; and, finally, a threefold increase (OR=3.1) if the length of stay was 16 days or more compared to those admitted for 0-4 days. Among frequently restrained patients, males (n=15) had significantly longer stays than women (n=19), and 8 of the females had a diagnosis of personality disorder, compared to none among males. Our study showed that being frequently restrained was associated with long inpatient stay, many admissions and young age. Teasing out patient characteristics associated with the risk of being frequently restraint may contribute to reduce use of restraint by developing alternative interventions for these patients.

The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis

OBJECTIVE

To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals.

STUDY SELECTION

Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol.

DATA SYNTHESIS

Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86).

CONCLUSIONS

Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.

Predicting research use in nursing organizations: a multilevel analysis

BACKGROUND

No empirical literature was found that explained how organizational context (operationalized as a composite of leadership, culture, and evaluation) influences research utilization. Similarly, no work was found on the interaction of individuals and contextual factors, or the relative importance or contribution of forces at different organizational levels to either such proposed interactions or, ultimately, to research utilization.

OBJECTIVE

To determine independent factors that predict research utilization among nurses, taking into account influences at individual nurse, specialty, and hospital levels.

DESIGN

Cross-sectional survey data for 4,421 registered nurses in Alberta, Canada were used in a series of multilevel (three levels) modeling analyses to predict research utilization.

METHODS

A multilevel model was developed in MLwiN version 2.0 and used to: (a) estimate simultaneous effects of several predictors and (b) quantify the amount of explained variance in research utilization that could be apportioned to individual, specialty, and hospital levels.

FINDINGS

There was significant variation in research utilization (p <.05). Factors (remaining in the final model at statistically significant levels) found to predict more research utilization at the three levels of analysis were as follows. At the individual nurse level (Level 1): time spent on the Internet and lower levels of emotional exhaustion. At the specialty level (Level 2): facilitation, nurse-to-nurse collaboration, a higher context (i.e., of nursing culture, leadership, and evaluation), and perceived ability to control policy. At the hospital level (Level 3): only hospital size was significant in the final model. The total variance in research utilization was 1.04, and the intraclass correlations (the percent contribution by contextual factors) were 4% (variance = 0.04, p <.01) at the hospital level and 8% (variance = 0.09, p <.05) at the specialty level. The contribution attributable to individual factors alone was 87% (variance = 0.91, p <.01).

CONCLUSIONS

Variation in research utilization was explained mainly by differences in individual characteristics, with specialty- and organizational-level factors contributing relatively little by comparison. Among hospital-level factors, hospital size was the only significant determinant of research utilization. Although organizational determinants explained less variance in the model, they were still statistically significant when analyzed alone. These findings suggest that investigations into mechanisms that influence research utilization must address influences at multiple levels of the organization. Such investigations will require careful attention to both methodological and interpretative challenges present when dealing with multiple units of analysis.

Understanding Hierarchical Linear Models

Nurses practice within hierarchical organizations and occupational structures. Hence, data emanating from nursing environments are structured, often inherently, hierarchically. From the perspective of ordinary regression, such structuring constitutes a statistical problem because this violates the assumption that we have observed independent and identical cases. A preferable approach is to employ analytical methods that mesh with the kinds of natural aggregations present in nursing environments. Consequently, there has been increasing interest in applying hierarchical, or multilevel, linear models to nursing contexts because this powerful analytical tool recognizes and accommodates naturally hierarchical data structures. The purpose of this article is to foster an understanding of both the strengths and limitations of hierarchical models. A hypothetical nursing example is progressively extended from the most basic hierarchical linear model toward a full two-level model. The structural similarities between two-level and three-level models are pointed out while focusing on the hierarchical nature of models rather than statistical technicalities. The limitations of hierarchical models are discussed also.

Changing the practice of physical restraint use in acute care

Older adults are more likely to be restrained during hospital stays than are younger individuals. Use of physical restraints significantly undermines quality patient care and represents substandard care. Rather than using restraints, nursing staff should determine the source of the patient's behaviors through comprehensive assessment and try to detect patterns to move toward restraint-free care. This evidence-based practice guideline can be used to facilitate the recognition of older adults at risk for physical restraints use and the implementation of appropriate interventions to move toward restraint-free patient care. This, in turn, helps to maintain or promote older adults' quality of life.

An Analytic Strategy for Modeling Multiple-Item Responses

BACKGROUND

Item Response Theory (IRT) is increasingly applied in health research to combine information from multiple-item responses. IRT posits that a person's susceptibility to a symptom is driven by the interaction of the characteristics of the symptom and person. This article describes the statistical background of incorporating IRT into a multilevel framework and extends this approach to longitudinal health outcomes, where the self-report method is used to construct a multi-item scale.

METHODS

A secondary analysis of data from 2 descriptive longitudinal studies is performed. The data include 21 symptoms reported across time by 350 women with breast cancer. A 3-level hierarchical linear model (HLM) was used for the analysis. Level 1 models the item responses, consisting of symptom presence or absence. Level 2 models the trajectory of each individual, representing change over time of the IRT-created latent variable symptom experience. Level 3 explains that trajectory using person-specific characteristics such as age and location of care. The purpose of the analysis is to examine if older and younger women with breast cancer differ in their symptom experience trajectory after controlling for location of care.

RESULTS

Fatigue and pain were the most prevalent symptoms. The symptom experience of women with breast cancer was found to improve over time. Neither age nor location of care was significantly associated with the symptom experience trajectory.

DISCUSSION

Embedding IRT into an HLM framework produces several benefits. The example provided demonstrates benefits through the creation of a latent symptom experience variable that can be used either as an outcome or as a covariate in another model, examining the latent symptom experience trajectory and its relationship with covariates at the individual level, and managing symptom nonresponse.

Organizational characteristics and restraint use for hospitalized nursing home residents

OBJECTIVES

To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.

DESIGN

Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents.

SETTING

Eleven medical and surgical units in one 600-bed teaching hospital.

PARTICIPANTS

One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.

MEASUREMENTS

Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient-registered nurse (RN) ratio, patient-total nursing staff ratio, and skill mix.

RESULTS

Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient-RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38-2.68, P <.001; weekend day and patient-total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37-2.66, P <.001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37-2.67, P <.001).

CONCLUSION

Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.

Using multilevel analysis in patient and organizational outcomes research

BACKGROUND

Outcomes research often compares patient and organizational outcomes across institutions, dealing with variables measured at different hierarchical levels. A traditional approach to analyzing multilevel data has been to aggregate individual-level variables at the institutional level.

OBJECTIVES

To introduce the conceptual and statistical background of multilevel analysis and provide an example of multilevel analysis that was used to examine the relationship between nurse staffing and patient outcome.

METHODS

A two-level model was presented employing multilevel logistic regression analysis.

RESULTS

Outputs from multilevel analysis were interpreted. Other statistics were presented for model specification and testing.

CONCLUSION

Researchers should consider multilevel modeling at the study design stage to select theoretically and statistically sound research methods.

The impact of staffing on patient outcomes across specialty units

OBJECTIVE

Determine the relationships between nursing staffing and specific nurse-sensitive outcomes (central line blood-associated infection, pressure ulcer, fall, medication error, and restraint application duration rates) across specialty units (cardiac and noncardiac intensive care, cardiac and noncardiac intermediate care, and medical-surgical).

BACKGROUND

A number of hospital-level studies have demonstrated that lower staffing levels are associated with higher adverse patient outcomes. However, insufficient insight into unit-level staffing relationships is available. Further unit-level inquiry is necessary to fully explicate the relationships between staffing and outcomes and to provide assistance to nurse administrators as they seek to develop blueprints for staffing plans that are linked to quality outcomes.

METHODS

Secondary analysis of prospective, observational data from 95 patient care units (cardiac intensive care, n = 15; noncardiac intensive care, n = 7; cardiac intermediate care, n = 18; noncardiac intermediate care, n = 12, and medical-surgical, n = 43) across 10 acute care hospitals.

RESULTS

No statistically significant relationships were found between central line infection and pressure ulcer rates and staffing across specialty units. Significant inverse relationships were present between staffing and falls in cardiac intensive care, medication errors in both cardiac and noncardiac intensive care units, and restraint rates in the medical-surgical units.

CONCLUSIONS

Results from this study suggest that the impact of staffing on outcomes is highly variable across specialty units; however, when present, the relationships are inversely related with lower staffing levels, resulting in higher rates of all outcomes.