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The prevalence and correlates of the use of restraint and force on hospitalised older people
Abstract
Aims. This study examined the prevalence and correlates of the use of restraint and force in care for older people in the hospital setting in Hong Kong.
Background. The use of restraint and force is common in care for older people. Although some knowledge exists on the potential consequences and characteristics of patients where restraint is used, little is known about the profiles of the nursing staff administering restraint.
Design. Descriptive cross-sectional study.
Method. Data were collected in 2006. A total of 187 nursing staff provided information on their demographic characteristics, coworker emotional support, burnout symptoms, attitudes toward patients with dementia, as well as their perceptions of the use of restraint and force in care for older people and their experiences with it.
Results. More than two-thirds (73·8%) of the participants reported using restraint or force in the past three months, with physical restraint endorsed by 69%, the use of force in examination or treatment endorsed by 48·1% and the use of force in activities of daily living endorsed by 46·5% of the participants. Pearson correlation analysis results show that use of physical restraint was negatively correlated with the age of participants (r = −0·44, p<0·01) and coworker emotional support (r = −0·20, p<0·05), but positively correlated with emotional exhaustion (r = 0·21, p<0·01). Use of force in examination or treatment and in relation to activities of daily living was negatively correlated with the age of participants (r = −0·32 & −0·18, p<0·01 & 0·05), but positively correlated with emotional exhaustion (r = 0·16 & 0·15, p<0·05) and lack of personal achievement (r = 0·18 & 0·19, p<0·05). Years of experience in dementia care, training in dementia care, attitudes toward people with dementia and perception of the use of restraint were not related to the use of physical restraint or force (p > 0·05).
Conclusion. The use of restraint and force is common among nurses in hospital medical wards in Hong Kong. To reduce restraint use in patient care, steps need to be taken to mitigate feelings of burnout and to foster sense of social support among nurses.
Relevance to clinical practice. The hospital administration can take a leading role in restraint reduction by setting standards of care and by formulating institutional policy regarding the use of restraint or force.
... The use of physical restraints, such as bedrails, limb restraints, safety vests, hand mitt restraints, belts, and geriatric armchairs, is common in care home settings, with prevalence ranging from 26.5% to 85% ( Ambrosi et al., 2021 ;Hofmann, Schorro, Haastert, & Meyer, 2015 ;Huang, Huang, Lin, & Kuo, 2014 ;Yan, Kwok, Lee, & Tang, 2009 ). A longitudinal study reported an increasing trend in restraint use from 52.7% in 2005 to 74.2% in 2015 in care home settings in Hong Kong ( Lam et al., 2017 ). ...
... The care home staff members were asked about their experience of using restraints to manage res- JID: COLEGN [m5G;July 3, 2022;9:55 ] idents with dementia in the past month. The Chinese version ( Yan et al., 2009 ) of the items developed for a national study on restraint use in Norway ( Kirkevold, Laake, & Engedal, 2003 ) was used for this assessment. In addition to the staff's self-reported practices, a research team member observed restraint use for 8 hours in each care home over a week. ...
... The care homes included in our study probably more tended to be support-ive of a restraint-free culture after capacity building for dementia care. The prevalence of physical restraint use at baseline in the two care homes in this study was lower than that reported in other local studies ( Lam et al., 2017 ;Shum et al., 2016 ;Yan et al., 2009 ). The positive changes in this study uncover that continuous support from the care home administrators to improve care quality, including the least-restraint policy, is indispensable in promoting cultural change. ...
Problem
Physical restraints have been widely applied as a means to prevent accidents among care home residents with cognitive impairment.
Background
Evidence has shown the risks and harms of physical restraints to the physical and psychosocial health of care home residents. Research on reducing restraint use has been sporadic with inconclusive results.
Question
Can a multicomponent program reduce inappropriate use of physical restraints in care home settings?
Methods
A pretest–post-test study was conducted in two care homes in Hong Kong. The multicomponent program comprised staff education, case conferences, and consultation. Data were triangulated using self-administered questionnaires, observations of restraint use practice, and documentary reviews. The following study outcomes were evaluated at baseline and 12-month follow-up: care home staff's use of restraints, knowledge of physical restraints, and perceived competence in dementia care.
Findings
Restraint use was reduced by 30.9% in 12 months (p < .001), but no significant difference in the mean scores of knowledge of physical restraints and perceived competence in dementia care was noted among care home staff between baseline and the 12-month follow-up (p = .387 and p = .287, respectively).
Discussion
The findings suggest that our multicomponent program, underpinned by organisational support, was instrumental in reducing the use of physical restraints in care home settings, but its effects on care home staff and residents remain unclear.
Conclusion
This study suggests the feasibility and preliminary effects of using a multicomponent program to reduce restraint use in care homes. A more robust study design is needed to evaluate the sustained effects of our multicomponent program and also its effects on the outcomes of care home staff and residents.
... In Hong Kong, the use of physical restraint is very common in the care for older people in the hospital and nursing home settings. 16,17 For example, in a survey of nursing staff in medical wards in Hong Kong, Yan et al 16 found that more than two-thirds reported using restraint or force in the past 3 months. The results further revealed that the use of restraint was positively correlated with emotional exhaustion but negatively correlated with coworker emotional support. ...
... In Hong Kong, the use of physical restraint is very common in the care for older people in the hospital and nursing home settings. 16,17 For example, in a survey of nursing staff in medical wards in Hong Kong, Yan et al 16 found that more than two-thirds reported using restraint or force in the past 3 months. The results further revealed that the use of restraint was positively correlated with emotional exhaustion but negatively correlated with coworker emotional support. ...
... To reduce the use of restraint, measures such as fostering the sense of social support among nurses and implementing relevant institutional policies were recommended. 16 In 2008, the Department of Medicine and Geriatrics of a convalescent hospital in Hong Kong successfully implemented a restraint reduction program through an action research project guided by Rogers' diffusion of innovation model. 18 This retrospective study examined the potential effect of restraint reduction on the length of hospital stay (LOS), mobility, and self-care ability of the older patients. ...
Objectives:
Physical restraints are often used to prevent falls and to secure medical devices in older people in hospitals. Restraint reduction has been advocated on the grounds that physical restraints have negative psychological effects and are not effective in preventing falls. The potential effect of restraint reduction on length of hospital stay (LOS) has not been investigated. This study was undertaken to compare the average length of stay of older patients in a convalescent medical ward setting before and after a restraint reduction program.
Design:
This is a retrospective study.
Setting:
A convalescent hospital in Hong Kong.
Participants:
This study included 2000 patient episodes.
Measurements:
The use of physical restraint, LOS, and clinical outcomes of randomly selected patient episodes in the year before and after the implementation of a restraint reduction program were compared. The clinical outcomes included Modified Functional Ambulatory Categories and modified Barthel index. Subgroup analysis was performed on those with confusion as defined by dementia diagnosis, low abbreviated mental test score, or abnormal mental domain of Norton Score.
Results:
A total of 958 and 988 patient episodes admitted to 10 medical wards in a convalescent hospital in 2007 and 2009 were examined. There were no significant differences in the baseline characteristics of patients in the 2 years. With the implementation of the restraint reduction scheme, the rate of physical restraint use declined significantly from 13.3% in 2007 to 4.1% in 2009 for all patients. The average LOS of patients was significantly lower in the year after the implementation of restraint reduction (19.5 ± 20.7 versus 16.8 ± 13.4 days in 2007 and 2009 respectively, P < .001). On subgroup analysis, the reduction in LOS was significant in the cognitively impaired patients (23.0 ± 26.5 to 17.8 ± 15.0 days in 2007 and 2009 respectively, P < .001), but not in the cognitively normal patients. There were no significant differences between the 2 years in the incidence of fall, mobility, and activities of daily living on discharge.
Conclusion:
Physical restraint reduction was associated with significant reduction in average length of stay in convalescent medical wards, especially in the cognitively impaired patients.
... Physical restraint is defined as using a device attached or adjacent to the target body from which the person cannot unravel themselves, in order to restrict the target freedom of movement [42]. Bilateral bedside rails, trunk restraint, chair-boards (which consist of a chair with a fixed tray table), boxing gloves and straitjackets are common types of physical restraint in the health sector [43,44]. Physical restraints can also protect the safety of the elderly during the use of medical equipment, such as mechanical ventilators [45], control behaviours such as aggression and restlessness, and promote positional support [45][46][47]. ...
Older people are increasingly dependent on others to support their daily activities due to geriatric symptoms such as dementia. Some of them stay in long-term care facilities. Elderly people with night wandering behaviour may lose their way, leading to a significant risk of injuries. The eNightLog system was developed to monitor the night-time bedside activities of older people in order to help them cope with this issue. It comprises a 3D time-of-flight near-infrared sensor and an ultra-wideband sensor for detecting human presence and to determine postures without a video camera. A threshold-based algorithm was developed to classify different activities, such as leaving the bed. The system is able to send alarm messages to caregivers if an elderly user performs undesirable activities. In this study, 17 sets of eNightLog systems were installed in an elderly hostel with 17 beds in 9 bedrooms. During the three-month field test, 26 older people with different periods of stay were included in the study. The accuracy, sensitivity and specificity of detecting non-assisted bed-leaving events was 99.8%, 100%, and 99.6%, respectively. There were only three false alarms out of 2762 bed-exiting events. Our results demonstrated that the eNightLog system is sufficiently accurate to be applied in the hostel environment. Machine learning with instance segmentation and online learning will enable the system to be used for widely different environments and people, with improvements to be made in future studies.
... Physical restraint is defined as any device adjacent to or attached to a person's body that cannot be easily removed by the person and is deliberately designed to restrict the person's freedom of movement and/or prevent the person from accessing their body normally [17]. Common types of physical restraint used in hospital and nursing home settings include bilateral bedside rails, trunk restraint, chair-boards composed of a chair with a fixed tray table [18], boxing gloves, and straitjackets [19]. In Hong Kong, physical restraint was applied to about 20% of the residents in homes for the elderly, to minimize the risk of elderly wandering and thus falls [20]. ...
Wandering is a common behavioral disorder in the community-dwelling elderly. More than two-thirds of caregivers believe that wandering would cause falls. While physical restraint is a common measure to address wandering, it could trigger challenging behavior in approximately 80% of the elderly with dementia. This study aims to develop a virtual restraint using a night monitoring system (eNightLog) to provide a safe environment for the elderly and mitigate the caregiver burden. The eNightLog system consisted of remote sensors, including a near infra-red 3D time-of-flight sensor and ultrawideband sensors. An alarm system was controlled by customized software and algorithm based on the respiration rate and body posture of the elderly. The performance of the eNightLog system was evaluated in both single and double bed settings by comparing to that of a pressure mat and an infrared fence system, under simulated bed-exiting scenarios. The accuracy and precision for the three systems were 99.0%, 98.8%, 85.9% and 99.2%, 97.8%, 78.6%, respectively. With higher accuracy, precision, and a lower false alarm rate, eNightLog demonstrated its potential as an alternative to physical restraint to remedy the workload of the caregivers and the psychological impact of the elderly.
... Furthermore, practices of nurses towards restraint use are indirectly and directly related to nurse's knowledge level and the underlying attitude towards restraints 21 . To eliminate physical restraint use, measures such as implementing relevant institutional policies and raising the sense of social support between nurses were recommended 22 . ...
Background: The use of physical restraints with elderly is a common practice in many countries. It is frequently used in the management of hospitalized elderly to ensure safety, facilitate treatment and to compensate for understaffing. There was a lack of studies concentrated on nurse’s knowledge, attitude and intention towards physical restraint use with geriatric patients. Aim: Assess nurses' knowledge, intention and attitude towards the use of physical restraint in geriatric care. Method: A descriptive correlation research design was used. The study was conducted at the medical and surgical inpatient’s units and intensive care units at Mansoura University hospitals. The study included a convenient sample of 150 nurses dealing with geriatric patients in the previously mentioned settings. Tools: Four tools were used: Nurses’ demographic and professional characteristics structured questionnaire sheet, Nurses’ knowledge about the use of physical restraint questionnaire, Nurses’ intention towards the use of physical restraint questionnaire, and Nurses’ attitude towards the use of physical restraint questionnaire. Results: The age of 72.7% of the studied nurses ranged between 20 and 30 years old. Seventy one of the studied nurses have good knowledge about the physical restraint of geriatric patients. The total mean score of the studied nurses’ intention and attitude towards the use of physical restraint is 19.05±5.67 and 25.4±5.67 respectively. Moreover, a statistically significant positive correlation was found between the knowledge and attitude score of the studied nurses (P=0.001). Conclusion: Most of the studied nurses have good knowledge, neutral attitude and a high intention to use physical restraint in geriatric care. Recommendation: In-service training programs should be applied in hospitals to improve nurses' attitude and intention toward restraint use with geriatric patients as well as update their knowledge.
... In spite of the above issues, the use of physical restraints is still common in caring for older people in the hospital setting in Hong Kong (Yan, Kwok, Lee, & Tang, 2009). Previous research has chiefly focused on the effect of physical restraint use in reducing fall rate. ...
In both acute care and residential care settings, physical restraints are frequently used in the management of patients, older people in particular. Recently, the negative outcomes of physical restraint use have often been reported, but very limited research effort has been made to examine whether such nursing practice have any adverse effects on patients' length of stay (LOS) in hospitals. The aim of this study was to examine the association between physical restraint use on older patients during hospitalization and their LOS. Medical records of 910 older patients aged 60 years and above admitted to one of the Hong Kong public hospitals in 2007 were randomly selected and recorded during July to September 2011. The recorded items included patients' general health status, physical and cognitive function, the use of physical restraints, and patients' LOS. Hierarchical regression analysis was conducted to analyze the data. The results indicated that older patients' general health status, physical, and cognitive function were important factors affecting their LOS. Independent of these factors, the physical restraint use was still significantly predictive of longer LOS, and these two blocks of variables together served as an effective model in predicting older patients' LOS in the hospital. Since physical restraint use has been found to be predictive of longer hospital stay, physical restraints should be used with more caution and the use of it should be reduced on older patients in the hospital caring setting. All relevant health care staff should be aware of the negative effects of physical restraint use and should reduce the use of it in hospital caring and nursing home settings.
... In Hong Kong, the rate of bedrail use was about 62.5% in local nursing homes, while the rate of use of other physical restraints was about 25% [22]. Another local study mentioned that 69% of nursing staff reported that they had used at least one form of physical restraint in the previous three months [23]. The paucity of local interest illustrates the immediacy of the need for attention to restraint education for health professionals and other health workers. ...
. In view of the adverse effects of using restraints, studies examining the use of restraint reduction programs (RRPs) are needed.
Objectives
. To investigate the effect of an RRP on the reduction of physical restraint rates in rehabilitation hospitals.
Methods
. A prospective quasi-experimental clinical trial was conducted. Demographic data, medical and health-related information on recruited patients from two rehabilitation hospitals, as well as facility data on restraint rates were collected.
Results
. The increase in the restraint rate in the control site was 4.3 times greater than that in the intervention site. Changes in the restraint mode, from continuous to intermittent, and the type of restraint used were found between the pre- and postintervention periods in both the control site and the intervention site.
Discussion
. Compared with that in the control site, the RRP in the intervention site helped arrest any increase in the restraint rate although it had no effect on physical restraint reduction. The shift of restraint mode from continuous to intermittent in the intervention site was one of the positive outcomes of the RRP.
The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze’s concepts of ‘assemblage’ and ‘event’ to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio‐political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas ‘events’ and ‘assemblages’ have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.
Amaç: Araştırma, cerrahi yoğun bakım ünitelerinde fiziksel tespit kullanım nedenlerini ve hastalarda görülebilecek sonuçlarını değerlendirmek amacıyla gerçekleştirildi. Gereç ve Yöntem: Tanımlayıcı tipteki araştırma yoğun bakım ünitesinde fiziksel tespit uygulanan 81 hasta ve bu hastalara yapılan 1003 fiziksel tespit değerlendirmesini kapsamaktadır. Soru formları, Richmond Ajitasyon Sedasyon Ölçeği ve Glaskow Koma Ölçeği ile toplanan veriler Wilcoxon testi, Friedman testi, Mann Whitney U testi ile analiz edildi. Bulgular: Yoğun bakım ünitesindeki hastaların %38.0’ine fiziksel tespit uygulandığı saptandı. Fiziksel tespite başvurma nedenleri arasında ilk sırada tıbbi ekipmanın çekilmesini önlemek (%87.7) yer almaktadır. Fiziksel tespit uygulanan hastaların tespit süresi uzadıkça tespite bağlı cilt ve davranışsal değişiklik gelişme sıklığının arttığı bulundu. Çalışmaya dahil edilen hastaların %47.6’sında tespit bölgesinde cilt değişikliği gözlemlendi. Bu değişikliklerin en sık, ciltte kızarıklık (%47.6), şişme/ödem (%42.7) ve çökme (%22.2) olduğu saptandı. Fiziksel tespit süresi uzadıkça hastaların ajitasyon düzeylerinin anlamlı şekilde azaldığı (p=0.000), Glaskow Koma Ölçeği ortalama puanlarının ise arttığı saptandı (p=0.002). Sonuç: Çalışma sonuçları hastaların kendisine zarar vermemesi amacıyla yapılan fiziksel tespitin hastaların konforunu olumsuz etkileyecek sorunlara yol açtığını göstermektedir. Tespit süresi uzadıkça sorunların arttığı sonucunu da gözeterek bu uygulamanın kararının çok dikkatli verilmesi ve tespit süresince hastaların düzenli değerlendirilmesi önerilir.
Objective:
To explore the feasibility of a multicomponent intervention programme and to evaluate its impacts on behavioural and psychological symptoms of dementia (BPSD) and psychological health of caregivers.
Methods:
Fifty-six community-dwelling people with dementia (PWD) and knee osteoarthritis (OA), and their caregivers were recruited and randomized into the intervention group (IG) or comparison group (CG). Each participant in both groups received an individual physiotherapy session (personalized home exercises and care education) and underwent 8 weeks of a 1-hour structured group exercise session weekly at a day care centre. They were instructed to follow the prescribed home exercise. The IG received a multicomponent programme, combining knee OA-specific therapeutic exercise with self-management support, while the CG attended the routine group exercise programme. The attendance rate and reasons for non-attendance were recorded for evaluating the feasibility. The Chinese versions of the Revised Scale for Caregiving Self-Efficacy (RSCSE) and the Neuropsychiatric Inventory Questionnaire (NPI-Q) were measured at the baseline and post-intervention.
Results:
Fifty-four dyads completed the programme with high attendance rate (94.4%). Compared with the CG, caregivers in the IG significantly improved in three domains of RSCSE scores (p ≤ 0.005) and caregivers' distress (p = 0.004) after the intervention. However, no effects were observed in terms of BPSD severity in PWD. No adverse events or falls were reported.
Conclusion:
This multicomponent programme is feasible and safe for dementia caregivers and older people with mild-to-moderate dementia and knee OA. The programme has beneficial effects on caregiving self-efficacy and distress of dementia caregivers.
Design:
A systematic review with meta-analysis and meta-regression. Eight databases, including Cochrane Library, ProQuest, PubMed, EMBASE, EBSCO, Web of Science, Ovid Medline and Physiotherapy Evidence Database (PEDro), were searched up to January 2017. Eligible studies were classified by intervention and accessed for quality using the Quality Assessment Tool for quantitative studies. Sixteen research articles were eligible in the final review; 10 randomize control trail studies were included in the analysis. The meta-analysis revealed that the use of physical restraint was significantly less often in the experimental (education) group (OR = 0.55, 95% CI: 0.39 to 0.78, p < 0.001) compared to the control group. Meta-regression revealed the period of post education would have decreased the effect of the restraint educational program (β: 0.08, p = 0.002); instead, the longer education period and more times of education would have a stronger effect of reducing the use of physical restraint (β: -0.07, p < 0.001; β: -0.04, p = 0.056). The educational program had an effect on the reduced use of physical restraint. The results of meta-regression suggest that long-term care facilities should provide a continuous education program of physical restraint for caregivers.
While much of the literature on elder mistreatment is developed in non-Chinese cultures, it remains unclear as to whether the present definition accurately reflects the meaning of "elder mistreatment" in the Chinese lens. It is essential to develop a culturally relevant definition for elder mistreatment. 2. Elder mistreatment is prevalent in Chinese societies as it is in other parts of the world. 3. Compared with older Chinese who are intact, those who were subjected to verbal or physical abuse reported higher levels of somatic complaints, anxiety, depressive symptoms, and social dysfunctions. 4. There is some preliminary evidence for the applicability of various theoretical models developed in non-Chinese populations on the Chinese population, including the caregiver stress model, the social exchange theory, and the social learning theory. It would be desirable to incorporate Chinese cultural values into existing theoretical frameworks. 5. Research on elder abuse in Chinese societies is complicated by the lack of valid and reliable instruments in the Chinese language.
Background. This study reports on the experience and insights of a clinical trial to reduce physical restraints on patients during hospitalisation/rehabilitation. Staff education and management input were the key components of the restraint reduction programme. Methods. This study involved one control hospital, one intervention hospital, and a school of nursing. The restraint reduction programme consisted of staff education and setting up of a restraint reduction committee. A stepwise cyclical model of identifying goals and obstacles, determining strategies, and evaluating outcomes was used. A number of alternatives to the use of restraints were introduced to the staff, and family involvement was encouraged. Interviews were conducted before and after intervention using a physical restraint questionnaire to examine any change in staff knowledge, attitudes, and behaviours on physical restraints. The restraint and fall rates before and after intervention were also compared. Results. This intervention succeeded in bringing about positive changes in the use of restraints, as the staff tended to use less restrictive measures when applying restraints, although the restraint rates remained unchanged. Implementation of the project was beset by numerous challenges. The threat from severe acute respiratory syndrome, the dynamics of human relationships in a bureaucratic organisation, territorial issues among professional disciplines, and interactions with the broader environment of health service manpower and provision limited the research team's control over the way the study was conducted, and the staff became generally frustrated with the project. Conclusion. When embarking on a project of this type, the interests of multiple stakeholders need to be balanced, and personal, professional, and inter-disciplinary dynamics should be considered. Cultivating hospital management and its staff a sense of ownership over a project is important for a project to succeed. Restraint reduction projects should be initiated by health care facilities.
This study examined the impact of the Nursing Home Reform Act of 1987 on resident-and-facility-level risk factors for physical restraint use in nursing homes. Data on the 1990 and 1993 cohorts were obtained from 268 facilities in 10 states, and data on a 1996 cohort were obtained from the Medical Expenditure Panel Survey, which sampled more than 800 nursing homes nationwide. Multivariate logistic regression models were generated for each cohort to identify the impact of resident- and facility-level risk factors for restraint use. The results indicate that the use of physical restraints continues to decline. Thirty-six percent of the 1990 cohort, 26 percent of the 1993 cohort, and 17 percent of the 1996 cohort were physically restrained. Although there was a reduced rate of restraint use from 1990 to 1996, similar resident-level factors but different facility-level factors were associated with restraint use at different points in time.
Studies of the moderating effect of social support on the direct effects of occupational stressors have yielded conflicting results that have differed in direction and significance. These differences may have been due to the narrow range and/or poor quality of the measures used. Also, males and females may differ in their perceptions of stress sources and outcomes and their use of social support across stressors. This study used the well-validated Pressure Management Indicator (PMI) to measure social support and eight sources and nine outcomes of occupational stress in a sample of 204 Australian managers (55 per cent females, mean age 41.4 years) from various companies. Multiple regression revealed that for both males and females, social support moderated the effects of stressors on energy levels, job satisfaction, organizational security and organizational commitment, although social support interacted with different stressors across genders. Social support had a significant interaction effect on organizational commitment for males only, and, for females only, a significant interaction effect on state of mind. These results suggest that social support interventions will not reduce the effects of stress on all outcomes, and will produce different results for males and females. Copyright © 2003 John Wiley & Sons, Ltd.
Twenty elderly restrained patients and their primary nurses (N = 18) were studied to determine (a) the subjective impact of physical restraints on the patient and (b) the nurses' beliefs about use of restraints. Despite reported cognitive impairments, patients vividly described anger, discomfort, resistance, and fear in response to the experience of physical restraint. The decision to restrain posed a conflict between protection of the patient and beliefs about professional behavior for the nursing staff. Lack of interdisciplinary collaboration in decisions to use a physical restraint was also apparent. The findings suggest that the use of physical restraint is not a benign practice and support the need for developing alternatives more consistent with professional practice and quality care.
Looking into a future marked by intense competition for talent, growing numbers of employers are striving to create "workplaces of choice." Yet, despite the consensus that health human resources are a vital piece of the healthcare reform puzzle, few health service organizations have developed comprehensive strategies to address work environment issues. The cumulative impact of years of cost-cutting, downsizing and restructuring have left Canada's healthcare workforce demoralized, overworked and coping with working conditions that diminish both the quality of working life and organizational performance.
In summary, we should not lose sight of the crucial differences between restraint which violates rights or dignity and restraint which does not violate any autonomously expressed wishes, protects the patient from self-harm is in the patient's best interests. Prolonged and repeated use of sedatives has the potential to cause many immediate and long-term complications. In the words of Pinel 'it is an art of no little importance to administer medications properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether omit them'. The importance of timely withdrawal of sedation cannot be overemphasized and the judicious use of physical restraints may legitimately be built into an overall treatment plan in a cohort of ICU patients to achieve this objective safely. The decision to use physical restraints (as all other interventions) should be subject to regular mandatory multi-disciplinary reviews as suggested by the University of Texas Cancer Centre Restraints Improvement Group. Such an approach, in our view, cannot rationally be considered unethical, cruel or primitive. © The Board of Management and Trustees of the British Journal of Anaesthesia 2004.
The purpose of this study was to address one component of the complex topic "elder abuse". A prospective observational study in the psychogeriatric unit of an acute psychiatric hospital demonstrated that 30% (n=37) of all included patients (n=122) were physically restrained. The highest incidence (48%) was found in elderly patients with severe cognitive impairments (diagnosis of dementia and/or delirium) (n=60). The most commonly used devices of physical restraints were bed rails (100%), belts (trunk 93%, limbs 40%) and chair-tables ("gerichair") (41%). Most restraints occurred at the beginning of hospitalization (83%). Physical restraints were continued for many days and on average of many hours a day. Patients with low cognitive status and serious mobility impairments showed a very high risk of being restrained (p=0.015; OR 32.0 [95% CI:2.0-515.1]). Inability to perform ADL activities increased the frequency of restraint use (p=0.035; OR27.7 [95%CI: 1.3-604.1]). As possible co-factors repetitive disruptive behaviors were found. There was no significant difference between the frequency of falls in restrained or unrestrained patients during the observational period, but fall-related fractures (n=2) only occurred in restrained patients. It is possible that restraints increase the use of benzodiazepines and classical neuroleptics. These results confirm that physical restraints remain a common practice in psychogeriatric care. No evidence-based data support the value of restraints in regard to fall prevention and control of behavioral disturbances in elderly people with serious mental illness. In contrast, these devices can have serious adverse effects and mean one of the most severe interventions in fundamental human rights.
Frail older nursing home residents are particularly vulnerable to physical restraint during hospitalization. Over the past ten years, federal agencies and professional organizations have advocated the reduction or elimination of physical restraints in acute care. Understaffing remains a consistent theme in the literature on restraint use in hospitals although relationships between organizational characteristics and restraint use have rarely been tested. The purpose of this study was to examine the impact of organizational characteristics on physical restraint use for hospitalized nursing home residents. This secondary analysis used data from a clinical trial employing an advanced practice nurse (APN) intervention to reduce restraint use in hospitalized nursing home residents. Using generalized estimating equations, three models were constructed to evaluate relationships between unit-level organizational characteristics (day of week, patient registered nurse ratio, patient-total nursing staff ratio, and skill mix) and restraint use for 174 nursing home residents over 1085 inpatient days. 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: OR: 1.92, 95% CI: 1.38, 2.68, p = 0.0001; Weekend day and patient-total staff ratio on physical restraint use: OR: 1.91, 95% CI: 1.37, 2.66, p = 0.0001; Weekend day and skill mix on physical restraint use: OR: 1.91, 95% CI: 1.37, 2.67, p = 0.0001). The 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, or sensory-perceptual losses, may be overlooked variables in restraint use.
Job burnout is a prolonged response to chronic emotional and interpersonal stressors on the job and is defined here by the three dimensions of exhaustion, cynicism, and sense of inefficacy. Its presence as a social problem in many human services professions was the impetus for the research that is now taking place in many countries. That research has established the complexity of the problem and has examined the individual stress experience within a larger social and organizational context of people's response to their work. The framework, which focuses attention on the interpersonal dynamics between the worker and other people in the workplace, has yielded new insights into the sources of stress, but effective interventions have yet to be developed and evaluated.
Three hundred and seventy-four Chinese human service professionals were surveyed to examine the associations between burnout and gender role stress. Gender role stress refers to people's gender-based cognitive appraisal of specific situations that are role dystonic and stressful. Results showed that gender role stress was the best predictor for emotional exhaustion and depersonalization, while professional type was the best predictor for personal accomplishment. Masculine gender role stress was related to emotional exhaustion and depersonalization for both male and female professionals, whereas feminine gender role stress was related to similar burnout dimensions for male professionals only. Gender role stress and burnout associations were found only in gender-typed professions of police officers and nurses, but not in a nongender-typed profession of secondary school teacher. Among the three groups, nurses experienced a higher level of gender role stress and lack of personal accomplishment than police officers and teachers.
a considerable body of literature has shown that social support is related to increased psychological well-being and to a lower probability of physical illness / it is evident that resources provided by interpersonal relationships play an important role in determining people's adaptive functioning and health outcomes / to clarify the theoretical basis of this phenomenon, 2 questions can be posed: 1st, what are the specific supportive functions provided by interpersonal relationships, and 2nd, what are the psychological processes through which these functions have their effects
[discuss] social-psychological theories relevant to supportive functions and . . . consider a model of psychosocial stress that delineates the functions most relevant for coping effectively with stressful occurrences / from this theoretical background I distinguish several different functions that can be provided through interpersonal relationships: esteem support; informational support; instrumental support [and] social companionship / discuss how these different functions may be indexed in current measures of social support / suggest which functions are probably involved in main effect processes . . . and buffering processes (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Use of physical restraints on elderly patients: an exploratory study of the perceptions of nurses in Hong Kong¶ A qualitative study was designed to explore nurses’ perceptions of the use of physical restraints on elderly patients in Hong Kong. Content analysis of semi-structured interviews with 20 registered nurses working in medical and geriatric settings of two regional hospitals revealed that although nurses generally had mixed feelings about the use of physical restraints on elderly patients, they did not question this ‘routine’ practice and their knowledge about the consequences and alternatives to the use of restraint was limited. It was found that nurses had an overriding concern in ensuring elderly patients’ physical safety and using restraints therefore provided them with a sense of security. The deleterious impact of restraint on the care received by elderly patients was largely unrecognized. Implications for practice and future studies are discussed in the light of these findings.
• This study aimed to illuminate nurses’ reasons for using physical restraint in nursing practice, and in addition, to explore the relationship between nurses’ attitudes and decisions regarding physical restraint use.
• To provide data about nurses’ reasoning when deciding whether or not to use restraints, 30 registered nurses working in two nursing homes were asked to read a written clinical vignette describing a fall-prone person with dementia who refused to be physically restrained. The association between the decision made and the nurses’ attitudes toward restraint use was measured by Perceptions of Restraint Use Questionnaire (PRUQ).
• Twenty-one nurses would at first disregard the patient’s wish and use the restraint in the given situation while nine would not. When new relevant facts were provided all nurses except two were ready to change their decision. A significant relationship between nurses’ decisions and their attitudes toward restraint use was also found.
• The results showed that, although nurses endeavour to decide what they consider to be in the patient’s best interests, this ambition is affected by a variety of variables, especially in relation to the working conditions and the nurses’ willingness to take the risk when not restraining the patient.
Many aspects of the management of acutely disturbed behaviour have only relatively recently come under systematic scrutiny. Perhaps regrettably one of the last amongst the range of strategies that may be employed to be subjected to rigorous examination has been physical restraint. Considerable debate has recently taken place around what represents good practice in this sensitive and controversial area but the continuing dearth of research in some aspects of this area of practice has meant that this discussion has arguably been over reliant on ‘expert’ opinion. Questions continue regarding some fundamental issues of restraint, including the relative risks involved in alternative approaches, and anxieties have been expressed about the potential for injuries and death to result from restraint. This article outlines the results of a survey that sought to explore the incidence of deaths associated with restraint in health and social care settings in the UK. The outcome of an initial analysis of the cases identified is then discussed, with reference to the literature on restraint-related deaths, in order to identify the implications for practice.
Sixty nursing staff in geriatric and psychogeriatric care (RNs, LPNs and nurse's aides) were selected to be studied on two occasions with an interval of one year regarding the relationships between their experience of burnout, empathy and attitudes towards demented patients. A semistructured interview was performed on the second occasion to learn more about their work experience and to relate the ratings of burnout, empathy and attitudes to their experience at work. The staff's experience of burnout changed from a mean score of 2.7 in 1987 to 2.5 in 1988. Their empathic ability was moderately high and increased from 398 (m) in (1987) to 450 (m) in 1988. The attitudes of staff remained unchanged from 1987 to 1988 and no differences were found regarding the staff's age, place of work or time at present place of work. As for the staff's empathy, there was no difference with respect to sex, category of staff or place of work. RN's showed the most positive attitudes towards demented patients both in 1987 and 1988 and differed compared to the nurse's aides and LPN's. Burnout correlated with lower empathy and less positive attitudes in the staff. Regression analysis showed that ‘experience of feed-back at work’ and ‘time spent at present place of work’ were the most important factors when explaining burnout among the staff. Staff with high empathy experienced “a close contact with the patient” as the most stimulating factor at work while staff with low empathy experienced “improvement of the patient's health” and “contact with colleagues” as the most stimulating factors. The importance of counteracting burnout in the care of demented patients is stressed.
(a) Determine the frequency and types of physical restraints used by nurses in intensive care units, emergency departments, and neurosurgery wards; (b) understand nurses' attitudes toward physical restraint; and (c) identify complications in physically restrained patients.
This descriptive, cross-sectional study was carried out on 254 nurses working in intensive care units, emergency departments, and neurosurgery wards in four Turkish hospitals where physical restraints were used. The whole population was studied without any sampling, and data were collected via semistructured interviews from July 20 to September 6, 2005.
Nurses used either wrist, ankle, or whole body restraints at various levels. Those nurses who worked in surgical intensive care units and emergency departments and had in-service training used more physical restraint than did others. Only a third of nurses decided on physical restraint together with physicians and three-fourths tried alternative methods. Nurses reported edema and cyanosis on wrist and arm regions, pressure ulcers on various regions, and aspiration and breathing difficulties in relation to physical restraint. Moreover, they reported 9 deaths of patients in chest restraints. Reduction in the frequency of caregiving was related to complications.
Actions to reduce use of and complications from physical restraints should include attention to nurse staffing and education about use of restraints.
To describe physical restraint (PR) rates and contexts in U.S. hospitals.
This 2003-2005 descriptive study was done to measure PR prevalence and contexts (census, gender, age, ventilation status, PR type, and rationale) at 40 randomly selected acute care hospitals in six U.S. metropolitan areas. All units except psychiatric, emergency, operative, obstetric, and long-term care were included.
On 18 randomly selected days between 0500 and 0700 (5:00 am and 7:00 am), data collectors determined PR use and contexts via observation and nurse report.
PR prevalence was 50 per 1,000 patient days (based on 155,412 patient days). Preventing disruption of therapy was the chief reason cited. PR rates varied by unit type, with adult ICU rates the highest obtained. Intra- and interinstitutional variation was as high as 10-fold. Ventilator use was strongly associated with PR use. Elderly patients were over-represented among the physically restrained on some units (e.g., medical) but on many unit types (including most ICUs) their PR use was consistent with those of other adults.
Wide rate variation indicates the need to examine administratively mediated variables and the promotion of unit-based improvement efforts. Anesthetic and sedation practices have contributed to high variation in ICU PR rates. Determining the types of units to target to achieve improvements in care of older adults requires study of PR sequelae rate by unit type.
Administrators and key informants in restraint-free nursing homes participated in a telephone survey to improve understanding of the process, resources, and measures for successful adoption of restraint-free care. Respondents expressed a strong opinion that each facility must develop its own individualized approach to restraint removal. However, similar approaches were found which suggest that efficiencies in conversion may be gained through application of change theory informed by restraint removal experience.
To investigate the relative effects of two experimental interventions on the use of physical restraints.
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).
Three voluntary nursing homes in the Philadelphia area providing both skilled and intermediate care.
A total of 643 nursing home residents over the age of 60 were enrolled at baseline, and 463 remained to completion (1 year).
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.
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.
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.
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.
The aim of the present study was to investigate the use of physical restraints in institutional elder care and staff knowledge about and attitudes toward the use of these restraints. Poor knowledge and negative attitudes toward the use of restraints were found among staff. Significant differences between various staff categories were found concerning knowledge about the use of restraints; nurse aids had the lowest and physicians the highest scores on the knowledge test. Nurse aids demonstrated the least negative attitudes (were most prone to use restraints) and physicians the most negative. Furthermore, there was a significant relation between attitudes and knowledge, i.e. staff with poor knowledge also demonstrated the least negative attitudes toward the use of restraints. Despite these negative attitudes among staff, we found a large proportion of restrained patients in the institutions investigated. Twenty-nine percent of the patients at the investigated clinics were physically restrained. The most common reason given was that restraints were used to prevent falls. No documentation of the observed use of restraints was found in any of the restrained patients' hospital records.
To change from a crisis to a proactive mode for staffing, scheduling, resource pool utilization, information management, and unit workload, nursing leaders developed a resource management plan. Changes that assisted in achieving that goal included: revision of department scheduling guidelines, elimination of day shift central supervisor, responsibility for daily staffing moved to unit-based managers, creation of a staffing model for the nursing resource pool staff, establishment of ideal complement of positions for every unit, expectation for unit to meet its staffing model every shift, reinforced department efforts to fill vacant positions, participation in computerized databases to study the use of resources, and identified critical staffing indicators for each unit.
The use of physical restraint has been a controversial intervention in the nursing management of hospitalized elderly patients in many countries. This ethnographic study was conducted in one psychogeriatric ward in Hong Kong in order to explore what determines psychiatric nurses' decisions to use restraints on their elderly patients. By comparing the findings of three data sources, comprising semistructured interviews, observations, and clinical records, five main themes were identified with regard to the nurses decision of restraint use. They included the rationale of physical restraint, consideration of alternative measures, consideration of adverse consequences, ethical considerations, and policy and documentation of restraint use. The findings of this study demonstrate that nurses must question the established practice myths about restraint use being the best way to maintain patient safety. Most importantly, nurses need cognitive and ethical preparation to face different situations in which physical restraint may be used.
After reviewing the literature and regulatory requirements, a multidisciplinary team developed a comprehensive restraint reduction program that has reduced the use of restraints by more than 60% in the acute care setting. The authors discuss the research-based restraint education program and the implementation of a restraint consultant role.
• This study examined staff perceptions of the behaviour of older nursing home residents and how these perceptions govern their decision making on restraint use.
• Data were collected in unstructured interviews with 20 trained and untrained nursing staff from two Swiss nursing homes.
• Data analysis was based on Colaizzi's phenomenological method.
• Two main themes were extracted from the data: (i) situations in which behaviour is perceived in terms of a problem that needs to be controlled and consequently leads to restraint use; and (ii) situations in which behaviour is perceived in terms of something one has to learn to live with and consequently leads to avoidance of restraint.
• Staff members’ choices to perceive resident's behaviour from the angle they did were clearly associated with the rights and responsibilities of both nursing staff and older people.
• It is concluded that the primary source of change towards the avoidance of restraint use does not necessarily lie in external factors, but in staff members themselves.
Physical restraints are commonly used on older persons living in geriatric care settings. The aim of this study was to investigate the influence of environmental and organizational variations and resident and staff characteristics on restraint prevalence. In this cross-sectional study of 33 nursing home wards and 12 group living units for old persons with dementia in two municipalities in northern Sweden, 540 residents (mean age 82) and 529 staff members were evaluated for resident and staff characteristics and organizational and environmental variables. The proportion of residents with impaired mobility function, the number of behavioral disturbances, and nursing staff's attitudes towards use of restraints were the strongest discriminators between restraint-free wards and wards that used restraints. A classification function analysis showed that these three variables could correctly classify the wards as restraint-free, low-use, and high-use wards in 63.6% of the cases, with the highest figures for restraint-free wards (91%). This study has shown that the use of physical restraints is strongly connected with residents' functional status and nursing staffs' attitudes toward their use.
Reduction of physical restraint use in the acute and critical care setting is a complex issue. Ethical considerations, regulatory and professional standards, legal liability concerns, healthcare team members' knowledge and attitudes, and unit culture and practice traditions must all be considered. Restraint reduction programs may use a process improvement format that engages the support of the organization's leadership. Specific interventions for restraint reduction, such as understanding the meaning of a patient's behavior, using a team approach, and involving the family can be evaluated and modified for application in the acute and critical care setting. Successful initiatives to decrease the use of restraint in this setting require an understanding of the many factors that support and oppose this practice.
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.
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.
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.
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.
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.
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.
After the educational program, the overall use of physical restraints decreased as well as the length of time patients were restrained.
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.
Many aspects of the management of acutely disturbed behaviour have only relatively recently come under systematic scrutiny. Perhaps regrettably one of the last amongst the range of strategies that may be employed to be subjected to rigorous examination has been physical restraint. Considerable debate has recently taken place around what represents good practice in this sensitive and controversial area but the continuing dearth of research in some aspects of this area of practice has meant that this discussion has arguably been over reliant on 'expert' opinion. Questions continue regarding some fundamental issues of restraint, including the relative risks involved in alternative approaches, and anxieties have been expressed about the potential for injuries and death to result from restraint. This article outlines the results of a survey that sought to explore the incidence of deaths associated with restraint in health and social care settings in the UK. The outcome of an initial analysis of the cases identified is then discussed, with reference to the literature on restraint-related deaths, in order to identify the implications for practice.
To investigate physical restraint-related injuries. Areas of interest were the prevalence of injury, types of injuries, risk of sustaining an injury and specific restraint devices associated with injury.
Injury in the context of this review was considered to be either direct injury, such as lacerations and strangulation, or indirect injury considered to be an adverse outcome such as increased mortality rates or duration of hospitalization.
A comprehensive search was undertaken that involved all major databases and the reference list of all relevant papers. To be included in the review studies had to involve people in acute or residential care settings and report data related to injury caused by restraint devices. A number of different types of research designs were included in the review. The findings of studies were pooled using odds ratio and narrative discussion.
The search identified 11 papers reporting the findings of 12 observational studies. These studies were supplemented with the findings of a number of other types of studies that reported restraint-related data. The review highlights the potential danger of using physical restraint in acute and residential health care facilities. Observational studies suggest that physical restraint may increase the risk of death, falls, serious injury and increased duration of hospitalization. However, there is little information to enable the magnitude of the problem to be determined.
Many of the findings highlight the urgent need for further investigation into the use of physical restraint in health care facilities. Further research should investigate the magnitude of the problem and specific restraint devices associated with injury. However, given the limited nature of the evidence, this association should be investigated further using rigorous research methods.
To describe the use of constraints and surveillance and their correlates in a nationwide sample of wards in institutions for the elderly in Norway.
Questionnaires were sent to 975 institutions and returned by 623 (64%) with 1398 wards. The wards' head nurses were asked whether any patient was currently subjected to physical restraints, electronic surveillance, force or pressure in medical examination or treatment, and force or pressure in ADL. The reporting of constraints was found reliable.
In all, 79% of the head nurses reported daily or occasional use of constraints in their wards. Most frequently reported were force or pressure in the performing of activities of daily living (reported by 61%, 95% Confidence Intervals (CI) 59-64), use of force or pressure in medical treatment or examination (49%, 95% CI 47-53) and use of physical restraints (38%, 95% CI 36-41). Electronic surveillance was used less frequently (14%, 95% CI 13-16). All classes of constraints, except physical constraints, were used significantly more frequently in special care units for persons with dementia than in ordinary nursing home units. The methodology does not allow conclusions to be drawn regarding the role of ward size and person characteristics. The staffing was unrelated to the use of constraints which varied significantly across the counties.
Constraints are widely used in Norwegian institutions for the elderly. A different pattern in use of constraints was found between special care units for demented patients and ordinary units in nursing homes.
To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.
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.
Eleven medical and surgical units in one 600-bed teaching hospital.
One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.
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.
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).
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.
This descriptive study investigated the patterns of use of physical restraints in a Korean Intensive Care Unit (ICU) with the aim of identifying the factors that would best discriminate the times of application and removal of restraints in the same patients.
• The subjects of the study were 23 physically restrained patients out of 51 patients who were admitted to a medical ICU in a university hospital admitted during a 6‐week period, and the 29 nurses who applied or removed the restraints. Ninety‐four incidents of restraint application and removal on the 23 patients were analysed.
• Data were collected using a self‐reporting questionnaire of attitudes towards restraint application for nurses, restraint document sheets, ICU flowsheets and patient chart reviews. Restraint‐related patient data were collected on a restraint document sheet by the nurse in charge at each instance of application and removal of restraint.
• The most common type of restraint was the bilateral wrist restraint. The mean number of restraint applications per patient was 3.62 ± 3.56 (mean ± SD), and the mean restrained period per incident was 22.64 ± 58 hours. There were no significant differences in the frequency of restraint use during the day, evening and night shifts. The most significant discriminators for restraint application and removal were the restless‐behaviour score and the presence of a nasogastric tube – the classification accuracy by these two factors was 70.2%. More than 90% of the decisions to apply restraints were made by nurses. Nurses reported that preventing the patient from removing medical devices (48.6%) was the primary reason for application, and improvement of cognitive status (29.3%) was the primary reason for removal of restraint.
• In conclusion, as the most discriminating factor of application or removal of restraints was the patient's restless behaviour, providing nurses with tools for the accurate evaluation of patient restlessness will shorten restraint application periods in ICUs.
This study examined the role of individual, interpersonal, and organizational factors in mitigating burnout among elderly Chinese volunteers in Hong Kong.
A total of 295 elderly Chinese volunteers were individually interviewed on their demographic characteristics, voluntary service experience, physical health status, general self-efficacy, social support, satisfaction and perceived benefit from volunteer work, and burnout symptoms. Exploratory factor analysis was first performed to determine the underlying dimensions of burnout experience. Correlation analyses were then conducted to explore associations among major variables. Hierarchical regression analyses were also performed to unearth the relative contribution of various factors in predicting burnout among elderly volunteers.
A two-factor structure of burnout, namely lack of personal accomplishment and emotional depletion, was found. Demographics, individual, interpersonal, and organizational factors were significant predictors of lack of personal accomplishment. In particular, personal accomplishment was best predicted by a long duration of voluntary work service and high levels of self-efficacy, work satisfaction, and perceived benefit. For emotional depletion, only demographics and individual factors were significant predictors. A low level of emotional depletion was best predicted by older age, a short duration of voluntary work experience, and good health.
Burnout experience was evident among elderly Chinese volunteers. There were different predictors of affective and cognitive components of burnout. Findings have significant implications to attenuate burnout symptoms among elderly volunteers.
The number of elderly patients who do not have acute-care needs has increased in many North American hospitals. These alternate level care (ALC) patients are often cognitively impaired or physically dependent. The physical and psychosocial demands on caregivers may be growing with the increased presence of ALC patients leading to greater risk for injury among staff.
This prospective cohort study characterized several models for ALC care in four acute-care hospitals in British Columbia, Canada. A cohort of 2,854 patient care staff was identified and followed for 6 months. The association between ALC model of care and type and severity of injury was examined using multinomial and ordinal logistic regression.
Regression models demonstrated that the workers on ALC/medical nursing units with "high" ALC patient loads and specialized geriatric assessment units had the greatest risk for injury and the greatest risk for incurring serious injury. Among staff caring for ALC patients, those on dedicated ALC units had the least risk for injury and the least risk for incurring serious injury.
The way in which ALC care is organized in hospitals affects the risk and severity of injuries among patient care staff.
Occupational and resident characteristics affect levels of staff stress and satisfaction in nursing homes, and levels of staff turnover are high. Working with more cognitively impaired residents, especially on day shift, is associated with high levels of stress in nursing home staff. Workload is highly predictive of the experience of burden and job pressure, while these outcomes vary according to whether staff work full- or part-time.
To investigate the attitudes of nursing home staff towards residents, strain related to dementia care and satisfaction with work and their associations with demographic, occupational and behavioural disturbance in the home.
A cross-sectional design was adopted, using a self-completion questionnaire survey of 253 nursing home staff from 12 nursing homes in Sydney's eastern suburbs, and behavioural assessment of all 647 residents from 11 of the 12 homes. Staff attitudes and strain were measured using the Swedish Strain in Nursing Care Assessment Scale and satisfaction using the Swedish Satisfaction with Nursing Care and Work Assessment Scale.
Staff members' five most prevalent perceptions of residents with dementia were that they are anxious, have little control over their difficult behaviour, are unpredictable, lonely and frightened/vulnerable. The five attributes staff found most difficult to cope with were being aggressive/hostile, having little control over their difficult behaviour, being stubborn/resistive, deliberately difficult, and unpredictable. Although 91% of staff reported that they were happy in their job, a quarter reported that residents provided no job satisfaction. The five satisfaction statements most agreed with were "The patients/residents at work nearly always receive good care", "It is important to try and enter into the way patients experience what happens to them", "Relatives are given enough information about care and treatment", "I enjoy my current work situation" and "Our work organisation is good". There were significant differences between homes in levels of strain related to dementia care that were not accounted for by the level of behavioural disturbance.
Nursing home staff tended to perceive residents in more negative than positive ways. Staff were generally satisfied with their work. Factors other than resident behavioural disturbance are important influences in nursing staff strain.
The aim of the study was to examine the prevalence of physical restraint use in cognitively impaired nursing home residents, the manner in which restraints are used, reasons for using them, and relationships between residents' characteristics and use of physical restraints.
A point prevalence study was conducted on the use of physical restraints among all residents cared for in two Dutch nursing homes and one nursing home unit (n = 265). Data about the nursing home residents and the use of restraints were collected by means of a questionnaire, which was filled in by the nurses. The response rate was 98%. The mean age of residents was 81 years (sd = 8.6), 74% of whom were female.
One or more restraints were used with 49% of the residents. The most frequently used physical restraints were bed rails, a waist belt, and a chair with a table. In almost all situations (90%), residents were continuously restrained and restraints were used for longer than 3 months. The most common reason (90%) for use of restraints was to prevent falls. Logistic regression analysis revealed that use of restraints was highly associated with poor mobility, care dependency and risk of falling in the opinion of nursing staff.
The results of this study are comparable with those of other studies. However, since recent studies have reported that physical restraints are inadequate to prevent falls, recommendations are made to re-evaluate critically the use of restraints and to conduct future research into a responsible and safe way of decreasing the use of physical restraints.
A recent questionnaire showed that different kinds of constraint such as physical restraint, electronic surveillance, use of force or pressure in medical treatment and in activities of daily living (ADL) are frequently used in Norwegian nursing homes. The study did not include information at patient level, and except for studies about physical restraints, we have not found any studies reporting the prevalence of various forms of constraint.
To describe the prevalence of various types of constraint in Norwegian nursing homes. MATERIALS and
A structured interview was carried out with the primary carers of a random sample of 1501 patients from 222 nursing-home wards in 54 municipalities representing all five health regions in Norway. Data were collected from regular units (RUs) and special care units (SCUs) for persons with dementia. Episodes of constraint during 1 week were recorded. Five main groups of constraint were aggregated, mechanical restraint, nonmechanical restraint, electronic surveillance, force or pressure in medical examination or treatment and force or pressure in ADL.
Patients (36.7%) in RUs and 45.0% of the patients in SCUs were subjected to any constraint. Most frequent was use of mechanical restraint (23.3% in RUs; 12.8% in SCUs) and use of force or pressure in ADL (20.9% in SCUs; 16.6% in RUs). Use of force or pressure in medical examination or treatment was more frequent used in SCUs (19.1%) compared with RUs (13.5%). Nonmechanical restraint was less frequently used (8.3% in SCUs; 3.0% in RUs) and electronic surveillance was seldom used (7.2% in RUs; 0.9% in SCUs).
The use of constraint is a problem in Norwegian nursing homes. Studies are needed to learn more about why constraint is used, and if there is patient or ward characteristics that can explain the use of constraint.
To the Editor: Use of physical and chemical restraint may be considered to be an indicator of the quality of care in an institutional setting. In Hong Kong, 9% of the population aged 65 years and older reside in long-term care facilities. The quality of care in these facilities is only recently being reviewed, with a view to setting up regulatory guidelines. We examined the prevalence of and factors associated with the use of chemical and physical restraints among residential care homes for elderly people in China as a quality of care indicator in comparison with other countries. A total of 1820 of 1914 residents in 14 residential case institutions were successfully assessed (95% response rate) using the Minimum Data Set–Residential Assessment Instrument translated into Chinese (1). Participants were classified into four categories to enable comparison with other countries, ranging from those with minimal impairment (Low ADL [activities of daily living] 1 Low CP [cognitive performance]) to those highly dependent (High ADL 1 High CP), where high ADL represents an ADL score . 9 and high CP represents a cognitive performance scale score . 1 (2). The overall prevalence of chemical restraint was 11.4%. Bedside rails were used in 62.5% of residents, while other physical restraints were used in approximately 25% of residents, with trunk restraint being most commonly used, followed by limb restraint and chair restraint. In multivariate logistic regression, factors positively associated with physical restraint use were dependent ADL, impaired balance, dementia, need for artificial nutrition and hydration, and socially inappropriate behavior. Low staff number was not a significant factor. Dependency and impaired balance were not associated with increased risk of falls, suggesting that the perceived risk may be much higher than the actual risk, prompting use of physical restraints that may not be indicated. Adjusting for case mix, the use of physical restraint was
The common use of physical restraints in older people in hospitals and nursing homes has been associated with injurious falls, decreased mobility and disorientation. By offering access to bed-chair pressure sensors in hospitalized patients with perceived fall risk, nurses may be less inclined to resort to physical restraints, thereby improving clinical outcomes.
To investigate whether the access of bed-chair pressure sensors reduces physical restraint use in geriatric rehabilitation wards.
Randomized controlled trial.
Consecutively, patients admitted to two geriatric wards specialized in stroke rehabilitation in a convalescent hospital in Hong Kong, and who were perceived by nurses to be at risk of falls were randomly assigned to intervention and control groups. For the intervention group subjects, nurses were given access to bed-chair pressure sensors. These sensors were not available to control group subjects, as in usual practice. The trial continued until discharge. The primary outcomes were the proportion of subjects restrained by trunk restraint, bedrails or chair-board and the proportion of trial days in which each type of physical restraint was applied. The secondary outcomes were the proportions of those who improved in the mobility and transfer domains of modified Barthel index on discharge and of those who fell.
One hundred and eighty subjects were randomized. Fifty (55.6%) out of the 90 intervention group subjects received the intervention. There was no significant difference between the intervention and control groups in the proportions and duration of having the three types of physical restraints. There was also no group difference in the chance of improving in mobility and transfer ability, and of having a fall.
Access to bed-chair pressure sensor device neither reduced the use of physical restraints nor improved the clinical outcomes of older patients with perceived fall risk.
The provision of bed-chair pressure sensors may only be effective in reducing physical restraints when it is combined with an organized physical restraint reduction programme.
This paper reports a study examining the knowledge, attitudes and practices of staff with regard to the use of restraints in rehabilitative settings, and quantifying the direct and indirect effects of the factors that influenced these practices.
Nursing staff hold many misconceptions that support the continued use of physical restraints as a desirable technique in clinical settings to control clients. A number of previous studies measuring the knowledge, attitudes and/or practices of nursing staff towards the use of restraints have been conducted in acute, elder care, or psychiatric settings. However, not many have examined the predictors of staff practices when restraints are applied. In the study reported here, physical restraint was defined as any manual method or physical/mechanical device, material or equipment attached to a client's body so that their free movement was restricted.
A questionnaire was administered to 168 nursing staff in two rehabilitation centres in Hong Kong. The data were collected in 2002-2003 and the response rate was 80%.
Inadequate knowledge and negative attitudes on the use of restraints were found among staff. Most believed that good alternatives to restraints are not available, or they underestimated the physical and psychological impact of restraints on clients. Path analysis indicated that staff attitudes and their clinical experiences had positive direct effects on restraint use. In addition, level of knowledge and clinical experience had a positive indirect effect on practice by influencing attitudes.
These data could serve as a basis for re-educating nursing staff on the subject. Staff with more clinical experience could give appropriate guidance to other members of staff on decisions to apply restraints. More effective alternative interventions to restraining clients should be explored. Once the gaps in knowledge are closed, more positive attitudes among staff towards the use of restraints can be cultivated, thus leading to a higher standard of nursing practice.
We investigate the nexus between mental health outcomes in nursing home residents and the use of physical restraints. Previous studies in this area used limited statistical tests such as correlations and t-tests, that could not account for potential biases, such as residents who become mentally disturbed may be most likely to be restrained. We use propensity matching models that are less susceptible to this bias and data from the Minimum Data Set, representing approximately 2,000 residents over a period of 6 years. Our results clearly show that restrained residents are more likely to become more impaired with respect to cognitive performance, depression, and social engagement. We conclude that if facilities reduce restraint use then the prevalence of resident mental health problems will also likely decline.
To explore nurses' feelings and thoughts about physically restraining older hospitalized patients.
The use of physical restraints is still highly prevalent in hospitals; furthermore, older patients are most likely to be so restrained. Studies in acute care settings have focused mainly on nurses' knowledge, attitudes, or practice concerning physical restraints, on physical restraint reduction programmes, on nurses' perceptions about the use of physical restraints, or on elderly patients' experiences with physical restraints. To the best of our knowledge no studies have been conducted on hospital nurses' feelings and thoughts about the use of physical restraints in Taiwan.
A qualitative approach was used to understand this phenomenon. Semi-structured interviews were carried out, from August 2002 to March 2003, with 12 nurses working in three hospitals. The interviews were audiotaped and transcribed verbatim; content analysis was used to analyse the data.
Nurses reported a variety of emotional responses regarding the use of physical restraints, including sadness, guilt, conflicts, retribution, absence of feelings, security, and pity for the restrained older people. Rationalization, sharing with colleagues, and compensating behaviours were ways that nurses used to manage their negative feelings.
Most nurses had negative feelings towards the use of physical restraints. Among these nurses there was a struggle between patients' autonomy and the practice of care. However, other nurses said they had 'no feelings' or 'feeling of security' while using physical restraints.
The findings of this study may contribute to filling the gaps in nursing knowledge, to improving protocols for physical restraint use in hospitals, and may also assist nurse managers to create a supportive practice environment. It is recommended that in-service training programmes should cover misconceptions regarding physical restraint use, ethical issues and how to cope with feelings while using physical restraints.
This paper is a report of a study to compare perspectives of staff in residential elder care facilities with those of residents and family members from the same facilities about barriers to reducing the use of physical, chemical and environmental restraints.
There is growing research evidence of the potential risk of physical and emotional harm of restraining residents in residential elder care facilities. Despite the potential harms, restraints continue to be a common practice in facilities across Australia. Little research has been undertaken to explore the barriers to reducing the use of restraints.
Eighteen individual interviews were conducted with staff, general practitioners and a pharmacist and three focus groups were conducted with a total of 12 residents and 17 family members associated with three residential elder care facilities in Melbourne, Australia in 2004.
The three participating facilities were committed to reducing the use of restraints, although physical, chemical and environmental restraints were used in all three facilities. Barriers to reducing restraint use included fear of resident injury, staff and resource limitations, lack of education and information about alternatives to restraints, environmental constraints, policy and management issues, beliefs and expectations (of staff, family and residents), inadequate review practices and communication barriers.
Further education and support for staff and family members in evidence-based practice in relation to resident care and restraint use is needed in at least some residential elder care facilities.
This paper reports a study of the relationship between the use of physical restraints with psycho-geriatric nursing home residents and the characteristics of organisations and residents. It is hypothesised that impairment in residents and organisational characteristics, such as a high workload of nursing staff and a low full-time equivalent (FTE) ratio on the wards, are associated with increased restraint use. In a cross-sectional study involving 15 Dutch psycho-geriatric nursing home wards, 432 residents were selected for participation, of which 371 actually participated. Restraint status was measured using observations. Other resident characteristics, such as cognitive status, were determined using the Minimum Data Set (MDS). Job characteristics, such as workload, were determined by different self-reported measures. Characteristics of the wards, such as the FTE ratio, were derived from the registration system of the wards. Physical restraints were used with 56% of the psycho-geriatric nursing home residents. Bivariate analysis showed that job and ward characteristics were not associated with restraint use. Bivariate and multilevel analysis showed that residents' characteristics, such as mobility and cognitive status were significantly associated with restraint use. Furthermore, multilevel analysis showed that higher job autonomy experienced by nursing staff and a higher FTE ratio on the wards were also associated with increased restraint use. In conclusion, job and ward characteristics were not as strongly associated as residents' characteristics with restraint use. Impairments in residents, such as immobility, were strongly related to the use of restraints. Therefore, education and support of nursing staff in caring for psycho-geriatric nursing home residents with poor mobility is recommended to reduce the use of physical restraints in nursing homes.
The aim of this study was to identify risk factors for falls in older people living in nursing homes.
Impaired cognitive function and a poor sense of orientation could lead to an increase in falls among those with impaired freedom of movement. Many accidents occur while an older person is walking or being moved.
The study was carried out over four years (2000-2003) and 21 nursing home units in five municipal homes for older people in Stockholm, Sweden, participated. A questionnaire was sent to staff nurses, including questions on fall risk assessments, falls, fractures, medication and freedom-restricting measures, such as wheelchairs with belts and bed rails. The data were aggregated and not patient-bound. The study covered 2,343 reported incidents.
There was a significant correlation between falls and fractures (r = 0.365, p = 0.004), fall risk and use of wheelchairs (r = 0.406, p = 0.001, safety belts (r = 0.403, p = 0.001 and bed rails (r = 0.446, p = 0.000) and between the occurrence of fractures and the use of sleeping pills with benzodiazepines (r = 0.352, p = 0.005). Associations were also found between fall risk and the use of anti-depressants (r = 0.412, p = 0.001).
In clinical practice, patient safety is very important. Preventative measures should focus on risk factors associated with individuals, including their environment. Wheelchairs with safety belts and bed rails did not eliminate falls but our results support the hypothesis that they might be protective when used selectively with less anti-depressants and sleeping pills, especially benzodiazepines.
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