Reducing physical restraints: developing an educational program

Improving practice and informing policy development: The impact of gerontological nursing research

Nurses have always approached the clinical care challenges they encounter with a combination of critical observation and a profound concern for human suffering. Beginning in earnest in the early 1980s, nurse researchers have pursued the answers to questions about the wellbeing of older adults, particularly those suffering from serious, chronic conditions. This paper offers three exemplars of nursing research domains that illustrate the creativity and commitment of nurse researchers seeking to understand and improve pervasive clinical problems experienced by older adults and to demonstrate the profound influence these activities have had on the evolution of the science and the quality of care for older adults. The impact of this work is reflected in practice protocols, institutional policies, government oversight, and improved outcomes for patients.

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

PURPOSE

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

DESIGN

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Changes in Attitudes Toward Restraints Among Nursing Home Staff and Residents' Families Following Restraint Reduction

Changes in attitudes toward using physical restraints, and the benefits of restraint elimination were examined by interviewing 161 staff and 153 family members of residents in four long-term care facilities before and afterformal restraint reduction programs were instituted. The four sites were divided into two groups: one group was composed of two sites that had initiated restraint reduction prior to this study, while the other group initiated restraint reduction as a result of this study. Both groups experienced statistically significant declines in restraint prevalence rates from pre- to posttest. Although both staff and families cited fewer reasons for using restraints from pre- to posttest, staff along with families of previously restrained residents, did not perceive increased benefits to residents or their relatives following restraint reduction. Restraint reduc tion, therefore, could lead to an acceptance of nursing practices that emphasize dignity even without an accompanying perception of improvement in relatives' or residents'daily lives.

Attitudes of Nursing Staff Toward Restraint Use in Long-Term Care

Although legislation has forced discretion in using physical restraints for institutionalized elders, considerable discussion continues about this matter. In particular, decision making around restraint use is not adequately understood. Awareness of the perceptions of nursing staff, who are usually involved in most decisions about restraint use, would be helpful to an understanding of the continued use of restraints. This study examined attitudes held by staff in long-term care settings and explored relationships of education and employment characteristics to physical restraint use. Licensed and unlicensed nursing personnel (N = 140) from 4 long-term care facilities were surveyed using a previously developed questionnaire. Results of stepwise regres sion showed that concerns about resident falls, resident disability, and staff harm explained a large portion of the variation in recommendations regarding restraint use Other findings suggest there is reason to believe improvements in perceptions about restraint use are occurring. Implications for staff education and areas for change in the work environment are provided

The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review

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.

A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence?

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.

A systematic review of the effectiveness of advanced practice nurses in long-term care

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.

Impact of a restraint training module on paramedic students' likelihood to use restraint techniques

OBJECTIVES

The purpose of this study was to evaluate a restraint training module for paramedic students. The hypotheses were that the effect of an hour-long restraint training module on paramedic students would (1) improve their understanding of concepts about patient restraints and (2) change their likelihood to use restraint techniques on patients in emergency situations.

METHODS

This was a cross-sectional study. A five-person panel of highly experienced emergency medical services (EMS) personnel compiled an hour-long restraint training module based on a compiled list of important concepts. A pretest and posttest were designed to contain the following two parts: (1) a knowledge quiz consisting of ten content-based questions and (2) a questionnaire on the likelihood to use restraint techniques in emergency situations, consisting of a five-question validated scale (Video Assessment of Propensity to use Emergency Restraints Scale [VAPERS]).

RESULTS

Thirty-four paramedic students at our training institution participated. We found that the paramedic students had a significant increase in their knowledge of the content shown (66% vs. 85%, p<0.05). There was no significant overall difference between pretest scores on the VAPERS (56+/-17 on a 0-100 scale) and posttest scores (57+/-16 on a 0-100 scale).

CONCLUSIONS

Paramedic students had improved understanding of important restraint concepts following a training module. The training module did not significantly change overall likelihood to use restraint techniques.

Effectiveness of staff training programs for behavioral problems among older people with dementia

This paper reviewed studies on staff training programs to address the behavioral problems associated with dementia among older people in residential care. The papers were classified according to whether or not the studies included a control group in the research design. The results of the review demonstrate that there has been a wide range of psychosocial and educational interventions to reduce behavioral problems among older people with dementia, with inconsistent results being obtained. However, many of these studies suffer from problems in their research design that make it difficult to evaluate their effectiveness. Problems in conducting research in the nursing home setting are highlighted, and suggestions for future research in this area are discussed.

Development of the Video Assessment of Propensity to Use Emergency Restraints Scale (VAPERS): results of the VAPERS Study Group

BACKGROUND

Emergency physicians (EPs) may disagree on when or whether patients need restraints. There is no good objective measure of the likelihood of EPs to restrain patients.

OBJECTIVES

To 1) develop a scale to determine the likelihood that an EP would restrain a patient, 2) develop subscale scoring, and 3) determine a shortened version that correlates highly with the full scale.

METHODS

This was a prospective cross sectional study. The Video Assessment of Propensity to use Emergency Restraints Scale (VAPERS), consisting of 17 scenarios utilizing actors, was videotaped to produce a research video assessment tool. The VAPERS was designed by development experts to reflect the spectrum of patients who are considered for restraint in an emergency department. The VAPERS was piloted among a 22-member pilot panel of EPs (faculty and residents). The pilot panel was asked to determine the degree to which each video patient possessed the following patient characteristics: medical instability, trauma, belligerence, agitation, and altered mental status. Each "degree of characteristic" was measured on a separate 100-mm visual analog scale. Participants were then asked whether or not they would restrain each patient and whether the patient exhibited the potential to harm him- or herself or others. VAPERS subscales were developed for the likelihood to restrain patients with each of the patient characteristics. Spearman correlations were used for all comparisons. Linear regression was used to determine which patient characteristics were most related to likelihood to restrain and to develop a reduced scale to predict the overall likelihood to restrain.

RESULTS

The overall VAPERS score ranged from 0 to 100, with a median of 50 (interquartile range [IQR], 24-88). The visual analog scale results of how likely each video patient possessed specific characteristics were as follows: medical instability ranged from 0 to 100 (median, 32; IQR, 12-64), trauma ranged from 0 to 69 (median, 0; IQR, 0-31), belligerence ranged from 20 to 93 (median, 28; IQR, 14-63), agitation ranged from 3 to 84 (median, 52; IQR, 23-72), and altered mental status ranged from 1 to 93 (median, 29; IQR, 16-69). Linear regression indicated that two characteristic variables (danger to self and degree of agitation) in the video scenarios were highly correlated (0.87) with overall likelihood to restrain. Based on the results, the authors developed a shortened video assessment tool consisting of five of the original videos that were highly correlated (R = 0.94) with the full VAPERS scale on overall likelihood to restrain.

CONCLUSIONS

The VAPERS scale covers a wide range of important variables in emergency situations. It successfully measured likelihood to restrain in this pilot study for overall situations, and for subgroups, based on patient characteristics. A shortened five-video VAPERS also successfully measured the overall likelihood to restrain.

Minimizing the use of restrictive devices in dementia patients at risk for falling

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.

BedSAFE: A Bed Safety Project for Frail Older Adults

In response to heightened awareness of patient safety, restraint reduction, and the potential for life-threatening entrapment caused by bed rails, a quality improvement program entitled BedSAFE was conducted to systematically and safely decrease the use of bed rails in three nursing home care units. This article describes an interdisciplinary process of individualized patient assessment, selection of appropriate alternatives for residents, compliance monitoring, training, and monitoring of patient outcomes including falls and injuries related to falls from bed.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

Statewide strategy to improve quality of care in nursing facilities

PURPOSE

We describe the development of a statewide strategy to improve resident outcomes in nursing facilities, and we present some evaluative data from this strategy.

DESIGN AND METHODS

Key components of the strategy include (a) a partnership between the state agency responsible for the nursing home survey and certification and the school of nursing in an academic health sciences center; and (b) on-site clinical expert technical assistance and support to facilities throughout the state.

RESULTS

The partnership has resulted in state agency staff having information from analyses about resident needs and outcomes in the state and facilities having access to the quarterly electronic "Show-Me Quality Indicator Report." On-site clinical expert technical assistance is now used widely across the state, with 569 site visits conducted in 286 different facilities to help them interpret their quality indicator (QI) reports and implement quality improvement programs; statewide improvements in QI scores have been measured in several key QIs.

IMPLICATIONS

Other states should consider building partnerships with schools of nursing in an academic health sciences center. Programs using on-site clinical consultation can facilitate improving quality of care in nursing facilities.

The Impact of Education on the Use of Physical Restraints in the Acute Care Setting

BACKGROUND

Physical restraints have become an acceptable standard of practice for managing safety and behavior control in acute care settings. Although the primary intent for using physical restraints is for patient protection, there are many negative outcomes related to their use. Heightened awareness by recent Joint Commission on Accreditation of Healthcare Organizations and the Center for Medicare and Medicaid Services standards for restraint use has led health care administrators and nursing staff to explore methods of reducing or eliminating the use of restraints. An educational program was planned and implemented for nursing staff emphasizing the risks of physical restraints and the benefits of innovative optional measures including nonrestraint devices. The program was tested to determine whether increased awareness through education would reduce the use of restraints.

METHOD

After current practice patterns and restraint utilization were established, a comprehensive educational program was provided to all nursing personnel. Twenty-three formal classroom inservice offerings were provided with follow-up reinforcement of self-study modules. Education included nursing assessment strategies and practical restraint optional interventions for managing patients exhibiting disruptive behaviors.

FINDINGS

After the educational program, the overall use of physical restraints decreased as well as the length of time patients were restrained.

CONCLUSION

Results of this study reinforce the need to increase staff awareness and knowledge of nonrestraint interventions to manage disruptive behaviors in the acute care setting.

A review of physical restraint minimization in the acute and residential care settings

OBJECTIVES

The objective of this review was to investigate physical restraint minimization in acute and residential care settings. The first aim was to determine the effectiveness of attempts to minimize the use of physical restraint, and the second was to generate a description of the characteristics of restraint minimization programmes.

METHOD

A comprehensive search was undertaken involving all major databases and the reference lists of all relevant papers. To be included in the review studies had to be an evaluation of restraint minimization in an acute or residential care setting. As only a single randomized controlled trial (RCT) was identified, it was not possible statistically to pool the findings of different studies on the effectiveness of restraint minimization. To generate a description of the characteristics of restraint minimization programmes, the reported components of these programmes were identified and categorized.

RESULTS

A total of 16 studies evaluating restraint minimization were identified: three in acute care and 13 in residential care. Of these, only one was an RCT, with the most common approach being the before and after study design. Based on the findings of the single RCT, education supported by expert consultation effectively reduced the use of restraint in residential care. There has been little evaluation of restraint minimization in acute care settings. The common approach to restraint minimization has involved a programme of multiple activities, with restraint education being the characteristic common to most programmes.

DISCUSSION

Evidence suggests that physical restraint can be safely reduced in residential care settings through a combination of education and expert clinical consultation. There is little information on restraint minimization in acute care settings. The major finding of this review is the need for further investigation into all aspects of restraint minimization.

The use of physical restraints as a safety measure in the care of older people in four rehabilitation wards: findings from an exploratory study

We investigated the prevalence and type of physical restraint used with older persons on four rehabilitation wards in Northern Ireland. A longitudinal observational approach was used. One hundred and two patients were observed on four occasions over a three-day period. Most of the patients (68%) were subjected to some form of physical restraint, side-rails being the most commonly observed method. Those who were restrained were dependent on nursing care to meet their needs and received more drugs than those whose mobility was not restricted. No association was found between restraint use and nursing staffing levels, nor was there any association with the incidence of falls. Nurses rationalised their use of restraint as being linked to wandering and patient protection in cases of confusional type behaviours. An association was found between stroke and the maintenance of positional support through the use of restraints (side-rails and screw-on tabletops). Approximately, one-third of those restrained had this noted in their care plans, with concomitant evidence of patient/family involvement in the restraining decision.

Randomized clinical trial of a quality improvement intervention in nursing homes

PURPOSE

The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practices and subsequently improve resident outcomes, or if a stronger intervention, expert clinical consultation with nursing facility staff, is needed.

DESIGN AND METHODS

Nursing facilities (n = 113) were randomly assigned to one of three groups: workshop and feedback reports only, workshop and feedback reports with clinical consultation, and control. Minimum Data Set (MDS) Quality Indicator (QI) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year. Clinical consultation by a gerontological clinical nurse specialist (GCNS) was offered to those in the second group.

RESULTS

With the exception of MDS QI 27 (little or no activity), no significant differences in resident assessment measures were detected between the groups of facilities. However, outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls, behavioral symptoms, little or no activity, and pressure ulcers (overall and for low-risk residents).

IMPLICATIONS

Simply providing comparative performance feedback is not enough to improve resident outcomes. It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly.

Perceptions of older people who have experienced physical restraint

It is well documented that the use of physical restraints on older people has been linked to negative clinical outcomes. However, less is known about the personal perspective of those who have been restrained. This study examines the perceptions of older people who have experienced physical restraints in a rehabilitation ward. A purposive sample was used of 17 male and female patients who were restrained. The patients were interviewed using the Subjective Experience of Being Restrained instrument (Strumpf and Evans, 1988) which is a semi-structured interview schedule. The most commonly used restraint devices included side rails, screw-on tabletops and reclining chairs. The data were analysed using content analysis. The results indicate mixed feelings regarding physical restraints. Patients' impressions of physical restraints included indifference of the devices to their perceived safety value. Overall, a minority of patients (n = 4) had positive feelings about physical restraints as they provided a sense of security to them. However, the negative comments of the patients were more prevalent and their responses were categorized in terms of institutional control, ritualised care, entrapment and discomfort, and possible alternatives.

Developing a restraint-reduction program for child/adolescent inpatient treatment

TOPIC

Meeting mandated guidelines to reduce, if not eliminate, the use of restraints with children and adolescents hospitalized on inpatient psychiatric units.

PURPOSE

To present eight promising options for restraint reduction with inpatient children and adolescents, and the research that supports their efficacy.

SOURCES

Review of the literature.

CONCLUSION

By combining what is known about child/adolescent restraint use with restraint-reduction research in the adult field, several options for restraint reduction can be derived.

Using restraint with nursing home residents: a qualitative study of nursing staff perceptions and decision-making

The study reported in this paper applied a qualitative and interpretative approach to nursing staff perceptions of the use of restraint with elderly nursing home residents, and into nurses' decision-making on restraint use. The data were collected using unstructured interviews with a purposive sample of 20 trained and untrained nursing staff from two Swiss nursing homes. Data analysis was based on Colaizzi's phenomenological method. Three main themes were extracted from the data: (1) understanding the term restraint, (2) situations in which the decision to apply restraint is considered justified and (3) situations in which nursing staff are uncertain about the use of restraint. The underlying bases with respect to decision-making were: understanding restraint, the rights and responsibilities of both residents and staff, and the duties of staff. Staff members were ambiguous in their understanding of restraint and they showed positive as well as confused attitudes towards its use. Their behaviour was defensive and protective rather than challenging. Further research is required on what is meant by safety in care of the elderly nursing today. In nursing practice, as far as issues of restraint are concerned, greater attention should be devoted to the relationship between elderly residents' self-determination and responsibility for their actions.

Restraint reduction: research utilization and case study with cognitive impairment

Although great strides have been made in restraint reduction, restraints still present a challenge for long-term care facilities. Restraint reduction is particularly difficult with cognitively impaired residents. This article presents the implementation of a research-based approach to restraint reduction and a case study with a cognitively impaired resident. Two year after implementing the research-based approach, the restraint rate had decreased 28%. The case study with the cognitively impaired resident revealed an increase in nurse contacts but a decrease in nurse time after restraint reduction. Concern for the cognitively impaired resident's safety remained an issue for the staff. Discussion includes weighing the risk/benefit ratio of restraint use and considering dignity and quality of life.

Reducing Restraints: Where to Start

To begin a restraint reduction program at a large neuropsychiatric Veterans Affairs medical center, nursing educators examined perceptions of and knowledge about restraint use among 113 nursing staff members employed on one acute, two intermediate, and five long-term care units. Strumpf and Evans' (1988) Perceptions of Restraint Use Questionnaire, a knowledge test, and questions about personal characteristics were used. Top reasons for restraint use identified were to prevent pulling on an intravenous line, to prevent breaking open sutures, and to protect from a fall. Although knowledge scores were high, they did not correlate significantly with ability to suggest alternatives. Respondents viewed restraint use as a somewhat important intervention. Statistically significant differences were found between level of practice and number of alternatives listed, knowledge score, and personal perception score. Implications for nursing educators embarking on a restraint reduction program are discussed including myths and quality-of-life issues.

Evaluation of an inservice training program on dementia and wandering

This study assessed the impact of an inservice training program in four nursing homes on nursing staff's knowledge of dementia, pacing/wandering behavior and management strategies, staff satisfaction, and their perceptions of work difficulty and quality of care. Additionally, unit-level behavioral observations of agitated behavior and the nature of resident interactions with staff members and other residents were also performed to assess whether changes in nursing staff's knowledge impacted the residents or interactions with the residents. Analyses revealed that quiz scores were significantly improved immediately following the inservice program as compared to pretest but returned to near pretest levels at the 1-month follow-up. Additionally, nursing staff reported that residents were allowed to pace/wander to a greater extent at follow-up compared to pretest. Methods for improving the effectiveness of inservice training are discussed.

A clinical trial to reduce restraints in nursing homes

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.

Research-based practice: reducing restraints in an acute care setting--phase I

The purpose of this research utilization project was to select and implement a research-based Restraint Education Program for reducing the use of restraints in an acute care setting by changing the perception of the restraint coordinators about restraints in the direction of decreased importance. The Iowa Model, Research Based Practice to Promote Quality Care (Titler et al., 1994) was selected to guide the change process. A multidisciplinary team reviewed the restraint policy and procedure, new restraint products and alternative restraint methods. After a review of the literature on restraint education programs, the committee concluded that education was the key component in decreasing the use of physical restraints. The research-based Restraint Education Program developed by Drs. Strumpf and Evans was selected as the educational program. Education sessions were developed and a pilot study was conducted with the restraint coordinators. The Perceptions of Restraint Use Questionnaire (PRUQ) (Strumpf & Evans, 1988) was administered before and after the education sessions. The results of the t-test showed a decrease in the post-test mean scores on 7 of the 17 items indicating a less important perception by the staff about the use of restraints. Four items had an increase in mean scores on the post-test indicating the restraint coordinators increased their perception of the importance of physical restraints with these items. The restraint education program was presented to the nursing staff throughout the institution. Risk management and quality assurance will monitor patients restrained and evaluate the nursing staff with the PRUQ in 3 months.

Restraint-free care for acutely ill patients in the hospital

A growing body of empirical evidence documenting the negative effects and the limited effectiveness of physical restraints continues to shape policy and professional standards. In addition to occurrences of serious harm from restraint devices, ethical concerns about care with dignity have supported reevaluation of restraints in all settings for all patients. Lessons from considerable research conducted in nursing homes and clinical experience with restraint reduction in long-term care facilities are applicable to acute care settings, where restraint-free care can and should be embraced.

Restraint-free care: how does a nurse decide?

Decisions by nurses to avoid physical restraint use in older adults is a complex process that requires individualized, comprehensive assessment and creative problem-solving. Institutional and social policy increasingly support a standard of restraint elimination influencing care decisions with frail older adults. It has become clear that the decision to avoid or use physical restraint is influenced as well by nurses' attitude or beliefs about the efficacy of restraint. To further understand how decisions are made to avoid physical restraint, it is important to also explore the degree to which nurses possess knowledge, autonomy, and accountability in this decision-making process. Understanding how decisions are influenced will advance the development of restraint-free care interventions for older adults.

Reducing the use of physical restraints in long-term care facilities

1. There has been increasing recognition of the role of education as a catalyst for changing restraint use practices and policies of long-term care facilities in Canada and other Western countries. 2. Findings of this longitudinal study documented the positive outcome of a structured restraint education program in reducing the use of physical restraints and promoting non-restrictive alternatives. 3. With continuing education and inservice programs, restraint-free elderly care can be attained in a cost-effective manner and without an increase in resident falls and injuries.

Use of restraints; changes in nurses' attitudes

Patients can become more agitated after the application of restraints. Restraints may be necessary to prevent injury to patients. Diversions, presence of family members, recliner chairs, day rooms, or sitters are alternatives to physical restraints.

Reducing restraints. Impact on staff attitudes

1. Changing the practice of using physical restraints must include nursing staff members as one of the main targets for change. 2. Following education and the implementation of a restraint-reduction program, 58% of the nursing staff participants found restraint use to be less important in caring for the elderly. Changes were more significant, however, immediately after the mandatory inservice program. 3. Nursing staff members whose perceptions changed tended to be registered nurses or licensed practical nurses who had more years of experience and more seniority at work. 4. The provision of ongoing education to nursing staff members is a necessary step to decrease feelings of frustration and stress and to assist the staff in being aware of alternatives to restraints.

Culture, environment, and restraints: a conceptual model for research and practice

1. Despite its importance to the care of the elderly, little research has focused on the effects of the environment on health and well-being. 2. It is hypothesized that environmental factors, including cultural attitudes and beliefs of nursing home staff, contribute to restraint of nursing home residents. 3. Nurses can be instrumental in creating a nursing home culture that values a restraint-free environment.