A cross-sectional study on nurses' attitudes towards physical restraints use in nursing homes in Portugal

A Risk Prediction Model for Physical Restraints Among Older Chinese Adults in Long-term Care Facilities: Machine Learning Study

BACKGROUND

Numerous studies have identified risk factors for physical restraint (PR) use in older adults in long-term care facilities. Nevertheless, there is a lack of predictive tools to identify high-risk individuals.

OBJECTIVE

We aimed to develop machine learning (ML)-based models to predict the risk of PR in older adults.

METHODS

This study conducted a cross-sectional secondary data analysis based on 1026 older adults from 6 long-term care facilities in Chongqing, China, from July 2019 to November 2019. The primary outcome was the use of PR (yes or no), identified by 2 collectors' direct observation. A total of 15 candidate predictors (older adults' demographic and clinical factors) that could be commonly and easily collected from clinical practice were used to build 9 independent ML models: Gaussian Naïve Bayesian (GNB), k-nearest neighbor (KNN), decision tree (DT), logistic regression (LR), support vector machine (SVM), random forest (RF), multilayer perceptron (MLP), extreme gradient boosting (XGBoost), and light gradient boosting machine (Lightgbm), as well as stacking ensemble ML. Performance was evaluated using accuracy, precision, recall, an F score, a comprehensive evaluation indicator (CEI) weighed by the above indicators, and the area under the receiver operating characteristic curve (AUC). A net benefit approach using the decision curve analysis (DCA) was performed to evaluate the clinical utility of the best model. Models were tested via 10-fold cross-validation. Feature importance was interpreted using Shapley Additive Explanations (SHAP).

RESULTS

A total of 1026 older adults (mean 83.5, SD 7.6 years; n=586, 57.1% male older adults) and 265 restrained older adults were included in the study. All ML models performed well, with an AUC above 0.905 and an F score above 0.900. The 2 best independent models are RF (AUC 0.938, 95% CI 0.914-0.947) and SVM (AUC 0.949, 95% CI 0.911-0.953). The DCA demonstrated that the RF model displayed better clinical utility than other models. The stacking model combined with SVM, RF, and MLP performed best with AUC (0.950) and CEI (0.943) values, as well as the DCA curve indicated the best clinical utility. The SHAP plots demonstrated that the significant contributors to model performance were related to cognitive impairment, care dependency, mobility decline, physical agitation, and an indwelling tube.

CONCLUSIONS

The RF and stacking models had high performance and clinical utility. ML prediction models for predicting the probability of PR in older adults could offer clinical screening and decision support, which could help medical staff in the early identification and PR management of older adults.

The optimal intervention for preventing physical restraints among older adults living in the nursing home: A systematic review

AIM

This study aimed to evaluate the effectiveness of restraint reduction programs for nursing home care providers in enforcing physical restraint on residents and identify the best strategies for such programs.

DESIGN

Systematic Review.

METHODS

We searched for randomized controlled trials published until February 2021 for systematic review. The systematic review captured multifactorial interventions, education and consultation measures, including nursing home residents' and care providers' results. Study quality was assessed using the Cochrane Collaboration criteria.

RESULTS

In all seven trials, the interventions were led by a nurse specialist or unit leader and targeted at care providers. Five of the restraint reduction programs effectively reduced the rate of physical restraint use; two increased knowledge of restraint reduction for care providers; and one each promoted positive attitudes and behaviours. Duration of at least 6 weeks significantly improved the knowledge of care providers.

District nurses' attitudes towards involuntary treatment in dementia care at home: A cross-sectional study

One in two persons living with dementia (PLWD) at home receive care which they resist to and/or have not given consent to, defined as involuntary treatment. District nurses play a key role in the use of involuntary treatment. However, little is known how their attitudes and opinions influence the use of involuntary treatment. This cross-sectional study aims to investigate the attitudes of district nurses towards the use of involuntary treatment in dementia care at home, determinants and their opinion about its restrictiveness and discomfort. Results show that district nurses perceive involuntary treatment as regular part of nursing care, having neither positive nor negative attitude towards its appropriateness. They consider involuntary treatment usage as moderately restrictive to PLWD and feel moderately uncomfortable when using it. These findings underscore the need to increase the awareness of district nurses regarding the negative consequences of involuntary treatment use to PLWD at home.

Attitudes of Nursing Staff in Hospitals towards Restraint Use: A Cross-Sectional Study

The attitude of nursing staff towards restraint use can be decisive for whether restraints are used. So far, nursing staff’s attitudes have been studied primarily in long-term and mental health care settings, while findings from somatic acute care hospital settings are largely lacking. Therefore, we aimed to investigate (a) the attitudes of hospital nursing staff towards restraint use, and (b) the construct validity and reliability of a measurement instrument for use in hospital settings that was developed and validated in long-term care settings (Maastricht Attitude Questionnaire (MAQ)). Using a cross-sectional design, the attitudes of 180 nursing staff towards restraint use were assessed. The data were analysed descriptively and by means of regression analysis and factor analysis. We found that nursing staff in hospitals have a neutral attitude towards restraint use and that the MAQ, with minor adaptations, can be used in hospital settings, although further testing is recommended. Neutral attitudes of nursing staff have also been observed in long-term and mental health care settings, where changing attitudes were found to be challenging. Interventions at the national level (e.g., legal regulations) and management level (e.g., providing alternatives and changing institutional culture) are suggested.

Restraint practice in the somatic acute care hospital: A participant observation study

AIMS AND OBJECTIVES

We aimed to describe daily restraint practices and the factors which influence their use, from an outsider's perspective.

BACKGROUND

A reduction in restraint use is recommended in health care. However, somatic acute care hospital settings currently lack effective reduction strategies. Thus far, hospital restraint practice is described in terms of quantitative assessments and the 'insider' view of healthcare professionals. However, as factors such as routine or personal beliefs seem to play a relevant role in restraint use, these approaches might be incomplete and biased.

DESIGN

A qualitative observation study design was employed.

METHODS

Fieldwork with unstructured participant observation was conducted at a department of geriatrics and a department of intensive care in Switzerland between November 2019 and January 2020. Data were recorded as field notes. The analysis was conducted iteratively in two coding cycles using descriptive coding followed by pattern coding. We adhered to the Standards for Reporting Qualitative Research (SRQR).

RESULTS

A total of 67 hours of observation were conducted. We found that daily restraint practice can be described in three categories: the context in which restraints are used, the decision-making process on the use and continued use of restraints, and the avoidance of restraint use. Most processes and decisions seem to take place unconsciously, and their standardisation is weak.

CONCLUSIONS

The lack of standardisation favours intuitive and unreflective action, which is prompted by what is also known as heuristic decision-making. To transform daily restraint practice, a technical solution that leads restraint management in line with ethical and legal requirements might be useful.

RELEVANCE TO CLINICAL PRACTICE

The outsider perspective has allowed daily restraint practice to be described independently of existing routines, departmental cultures and personal attitudes. This is important to comprehensively describe restrictive practices, which is a prerequisite for the development of effective restraint reduction strategies.

Difference of Physical Restraint Knowledge, Attitudes and Practice Between Nurses and Nursing Assistants in Long-Term Care Facilities: A Cross-Sectional Study

Background

Purpose

Methods

Results

Conclusion

Israeli nursing home staff perspectives on challenges to quality care for residents with dementia

This study examines nursing home employees' perspectives concerning barriers to quality care for people with dementia. Data were derived from observations of care units and interviews with forty-one employees, including chief executive officers, social workers, nurses, occupational therapists, activity workers and nursing assistants at five Israeli nursing homes. Residents' behavior was reported as challenging for staff. Physical restraints and psychotropic medication were commonly used to address behavioral challenges, while few staff acknowledged these practices as problematic. Staff complained that some co-workers were insufficiently caring and wages and overall funding were inadequate, resulting in unsatisfactory staffing levels and insufficient activities for residents. Rigid care routines failed to meet resident needs, and staff failed to notice the relationship between care practices and resident behavior. While problems were described concerning multiple aspects of care, the root causes seemed to include the need for additional funding and for greater expertise in dementia care.

Between Restrictive and Supportive Devices in the Context of Physical Restraints: Findings from a Large Mixed-Method Study Design

Physical restraints are still a common problem across healthcare settings: they are triggered by patient-related factors, nurses, and context-related factors. However, the role of some devices (e.g., bed rails), and those applied according to relatives'/patients' requests have been little investigated to date. A mixed-method study in 2018, according to the Good Reporting of a Mixed Methods Study criteria was performed. In the quantitative phase, patients with one or more physical restraint(s) as detected through observation of a single index day in 37 Italian facilities (27 long-term, 10 hospital units, =4562 patients) were identified. Then, for each patient with one or more restraint(s), the nurse responsible was interviewed to gather purposes and reasons for physical restraints use. A thematic analysis of the narratives was conducted to (a) clarify the decision-making framework that had been used and (b) to assess the differences, if any, between hospital and long-term settings. The categories 'Restrictive' and 'Supportive' devices aimed at 'Preventing risks' and at 'Promoting support', respectively, have emerged. Reasons triggering 'restrictive devices' involved patients' risks, the health professionals' and/or the relatives' concerns. In contrast, the 'supportive' ones were triggered by patients' problems/needs. 'Restrictive' and 'Supportive' devices were applied based on the decision of the team or through a process of shared decision-making involving relatives and patients. According to the framework that emerged, long-term care patients are at increased risk of being treated with 'restrictive devices' (Odds Ratio 1.87, Confidence Interval 95% 1.44; 2.43; p < 0.001) as compared to those hospitalized. This study contributes to the improvement in knowledge of the definition, classification and measurement of physical devices across settings.

A cross-sectional study on nurses' attitudes towards physical restraints use in nursing homes in Portugal

Aim

To explore nurses' opinions regarding restraint measures and attitudes towards physical restraints use in nursing homes.

Design

Cross‐sectional study.

Methods

Nursing staff of 33 Portuguese nursing homes was asked to complete the Portuguese version of the Maastricht Attitude Questionnaire (MAQ), an instrument on attitudes regarding physical restraints (reasons, consequences and appropriateness of restraint use) and opinions about restraint measures (restrictiveness and discomfort). Descriptive statistics and bivariate analysis were performed.

Results

Data from 186 nurses were included in the analysis. Overall, nurses expressed neutral to moderately positive attitudes towards physical restraints usage. Nurses with longer professional experience reported a more positive attitude regarding the appropriateness of restraint use in their clinical practice. Wrist and ankle restraints were the measures that nurses reported feeling most uncomfortable using, and the most restrictive. Bilateral bedrails were globally assessed as a slightly restrictive measure and nurses reported not feeling uncomfortable using them.