Physical restraining of nursing home residents in the last week of life: An epidemiological study in six European countries

Current Status of Nursing Home Distribution in China: A National Cross-Sectional Study

AIMS

Population aging is a challenge that the whole world is facing, especially in China. This study aims to investigate the current distribution status of nursing homes in China using spatial epidemiology methods.

DESIGN

Cross-sectional study in China.

METHODS

The data were obtained from the Integrated Civil Affairs Government Service Platform 'China County Statistical Yearbook' for 2020 and the 'China City Statistical Yearbook' for 2020. Using global Moran's index to test the clustering of nursing homes, inter-group and intra-group Theil index was utilised to differentiate the sources of differences. The coupling coordination analysis was conducted to explore the coordination. Geographically weighted regression was utilised to investigate the impact of economic development and aging on nursing home resources. All analyses were conducted by Arcgis 10.8 and R Studio 4.3.2.

RESULTS

Global Moran's index indicated that the distribution of nursing homes in China exhibited clustering. The Theil index values for institutions and beds at the national county were 0.32450 and 0.30675. However, upon comparing provinces and regions, it was found that the differences across the country mainly stem from within provinces (contribution rate: institutions 65.0%; beds 73.0%) and within regions (contribution rate: institutions 99.0%; beds 91.0%). The majority of districts and counties had a coupling coordination index of institutions and bed numbers, both of which were < 0.5.

CONCLUSION

The development of nursing home resources in China has been rapid, generally presenting a balanced state, but further optimisation is needed. This study established a foundation for the targeted distribution of essential public services, focusing on nursing home healthcare resources tailored to the needs of older persons.

IMPLICATIONS

The study underscored the urgent need for targeted elderly care policies, emphasising the optimisation of resource distribution to enhance the overall quality of care provided to the aging population.

NO PATIENTS OR PUBLIC CONTRIBUTION

The study did not involve humans.

Caregiver-reported use of physical restraints among community-dwelling older adults with severe dementia in Singapore

BACKGROUND

Older adults with severe dementia are at increased risk of being physically restrained in nursing homes and acute care settings, but little is known about restraint use among those cared for at home. This study explores caregiver-reported use of restraints among community-dwelling older adults with severe dementia.

METHODS

Using cross-sectional data from 215 family caregivers, we describe restraint use among older adults with severe dementia living at home. We then use multivariable logistic regression to identify factors associated with restraint use.

RESULTS

Nearly half (47%) of caregivers reported on older adults who had been subject to restraints. Most caregivers reporting restraint use suggested safety reasons, such as prevention of falls (68%), wandering (30%), and removal of catheters or feeding tubes (29%); and 44% indicated doctors or other health care providers were involved in the decision to restrain. Feeding tubes (OR = 4.16, 95% CI: 1.27-13.59) and physically aggressive agitation behaviors (OR = 1.93, 95% CI: 1.09-3.40) were associated with higher odds of restraint use among older adults with severe dementia. Caregivers who received strong emotional support from friends (OR = 0.45, 95% CI: 0.21-0.95) were less likely to report restraint use while serving as a caregiver to others (OR = 2.77, 95% CI: 1.36-5.63) increased the odds of restraint use.

CONCLUSIONS

The pervasiveness of restraint use is concerning and suggests a lack of evidence-based guidance and support for both caregivers and healthcare providers to prevent restraint use among older adults with severe dementia cared for at home.

Nursing students' experiences regarding physical restraint use in long-term care facilities: A qualitative descriptive study

BACKGROUND

Despite many harmful effects, physical restraints are still used in long-term care facilities. Most existing studies have focused on staff. Nursing students observe staff's use of restraints during gerontological nursing practicums, but there are few studies on nursing students' experiences regarding restraint use in long-term care settings.

OBJECTIVE

This study aimed to explore nursing students' experiences with physical restraint use in order to enhance nursing education and improve care quality in long-term care facilities.

METHODS

Using convenience sampling method, three nursing schools from three provinces were recruited. Twenty-six senior undergraduate nursing students who had taken a gerontological nursing practicum course participated in this study. A qualitative descriptive method was utilized to provide a clear account of the students' experiences. In-depth interviews were conducted using a semi-structured interview guide. Thematic analysis was used for data analysis.

RESULTS

Four themes were identified, which included overuse of restraints, ambivalent response to restraints, becoming accustomed to restraints, and lack of education regarding restraints. Students frequently observed the use of various restraints, which elicited both negative and positive responses, ultimately leading to their desensitization to the overuse of restraints. They expressed a lack of knowledge and educational needs regarding restraint reduction.

CONCLUSION

Nursing students encountered the overuse of various restraints, exhibited ambivalent responses, and became desensitized to this practice in long-term care facilities. They perceived a lack of education and educational needs regarding restraint reduction. This study adds important new knowledge to existing literature and provides important insights into restraint use in long-term care facilities. Future studies need to develop and evaluate educational programs for restraint-free and person-centered care targeting nursing students. Long-term care facilities should offer organizational support and implement continuous mandatory training to promote restraint-free care.

Physical restraints applied to people diagnosed with dementia in home care from the perceptions of family caregivers: A qualitative study in China

WHAT IS KNOWN ON THE SUBJECT?: Physical restraint is widely used in the elderly at home, and cognitive impairment is an important risk factor. Family caregivers of people with dementia are the main decision makers and implementers of physical restraint at home. Most people with dementia in China receive home care, and family caregivers face enormous care and moral pressures influenced by Confucian culture. Current research on physical restraints focuses on quantitative analysis of its prevalence and reasons within the institutions. There is little research on how family caregivers perceive physical restraints in home care context, especially under Chinese culture. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Many family caregivers face approach - avoidance conflict and moral dilemmas when making decisions to restrain, and they make difficult choices in these dilemmas. In China, family caregivers are influenced by many unique factors, including traditional Confucian culture, family affection, and rural home environment. Inadequate laws and policies provide the ground for abuse of physical restraints, and family caregivers rarely consider legal and policy restrictions when using physical restraints. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: With limited medical resources, nurse-led dementia management is the hope to reduce physical restraints in home. Mental health nurses need to assess for the appropriateness of physical restraints associated with psychiatric symptoms in people with dementia. At both organizational and community levels, improving effective communication and relationships between professionals and family caregivers are important to address. Improvements in this context require education and time for staff to develop skills and experience which is necessary to provide family caregivers with ongoing information and psychological support within their communities. Considering Confucian culture will be of value for mental health nurses working in other countries where there are Chinese communities to better understand perceptions of family caregivers.

ABSTRACT

INTRODUCTION: The use of physical restraints is a common practice in home care. Family caregivers face care-related and moral pressures due to the influence of Confucian culture in China. The use of physical restraints in the Chinese cultural environment may differ from the use of such restraints in other cultures.

SCIENTIFIC RATIONALE

Current research on physical restraints focuses on quantitative analysis of its prevalence and reasons within the institutions. However, there is little research on how family caregivers perceive physical restraints in home care context, especially under Chinese culture.

AIM

To explore the perceptions of family caregivers on physical restraints in people diagnosed with dementia receiving home care.

METHOD

A descriptive, qualitative study of Chinese family caregivers of people diagnosed with dementia in home care. Framework method analysis was adopted using the multilevel socio-ecological model.

RESULTS

Beliefs about benefit lead to a dilemma for family caregivers. Cherishing family's affection encourages caregivers to reduce physical restraints, but lack of help from family members, professionals and the community forces them to restrain their loved ones.

DISCUSSION

Future research should explore the complex issue of culturally specific physical restraints decisions.

IMPLICATIONS FOR PRACTICE

Mental health nurses must receive education regarding the negative outcomes of the use of physical restraints for family members of people diagnosed with dementia. A more liberal approach to mental health and relevant legislation, which is an emerging global phenomenon that is currently in an early phase of development in China, grants human rights to people diagnosed with dementia. Effective communication and relationships between professionals and family caregivers can contribute to the establishment of a dementia-friendly community in China.

Physical Restraint Use in Nursing Homes-Regional Variances and Ethical Considerations: A Scoping Review of Empirical Studies

BACKGROUND

Physical restraints are known to violate human rights, yet their use persists in long-term care facilities. This study aimed to explore the prevalence, methods, and interventions related to physical restraint use among the elderly in nursing homes.

METHODS

The method described by Joanna Briggs was followed to conduct a scoping review without a quality assessment of the selected studies. An electronic search was conducted to find eligible empirical articles using MEDLINE, PsycINFO, EMBASE, Web of Science, Scopus, Google Scholar, CINAHL, and grey literature. The database search was performed using EndNote software (version X9, Clarivate Analytics), and the data were imported into Excel for analysis.

RESULTS

The prevalence of physical restraint use was found to be highest in Spain (84.9%) and lowest in the USA (1.9%). The most common device reported was bed rails, with the highest prevalence in Singapore (98%) and the lowest (4.7%) in Germany, followed by chair restraint (57%). The largest number of studies reported the prevention and/or risk of falls to be the main reason for using physical restraints, followed by behavioral problems such as wandering, verbal or physical agitation, and cognitive impairment. Most studies reported guideline- and/or theory-based multicomponent interventions consisting of the training and education of nursing home staff.

CONCLUSIONS

This review provides valuable insights into the use of physical restraints among elderly residents in nursing homes. Despite efforts to minimize their use, physical restraints continue to be employed, particularly with elderly individuals who have cognitive impairments. Patient-related factors such as wandering, agitation, and cognitive impairment were identified as the second most common reasons for using physical restraints in this population. To address this issue, it is crucial to enhance the skills of nursing home staff, especially nurses, in providing safe and ethical care for elderly residents with cognitive and functional impairments, aggressive behaviors, and fall risks.

Interventions for preventing and reducing the use of physical restraints for older people in all long-term care settings

BACKGROUND

Physical restraints (PR), such as bedrails and belts in chairs or beds, are commonly used for older people receiving long-term care, despite clear evidence for the lack of effectiveness and safety, and widespread recommendations that their use should be avoided. This systematic review of the efficacy and safety of interventions to prevent and reduce the use of physical restraints outside hospital settings, i.e. in care homes and the community, updates our previous review published in 2011.

OBJECTIVES

To evaluate the effects of interventions to prevent and reduce the use of physical restraints for older people who require long-term care (either at home or in residential care facilities) SEARCH METHODS: We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid Sp), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register, the International Clinical Trials Registry Portal, on 3 August 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that investigated the effects of interventions intended to prevent or reduce the use of physical restraints in older people who require long-term care. Studies conducted in residential care institutions or in the community, including patients' homes, were eligible for inclusion. We assigned all included interventions to categories based on their mechanisms and components.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the publications for inclusion, extracted study data, and assessed the risk of bias of all included studies. Primary outcomes were the number or proportion of people with at least one physical restraint, and serious adverse events related to PR use, such as death or serious injuries. We performed meta-analyses if necessary data were available. If meta-analyses were not feasible, we reported results narratively. We used GRADE methods to describe the certainty of the evidence.

MAIN RESULTS

We identified six new studies and included 11 studies with 19,003 participants in this review update. All studies were conducted in long-term residential care facilities. Ten studies were RCTs and one study a CCT. All studies included people with dementia. The mean age of the participants was approximately 85 years. Four studies investigated organisational interventions aiming to implement a least-restraint policy; six studies investigated simple educational interventions; and one study tested an intervention that provided staff with information about residents' fall risk. The control groups received usual care only in most studies although, in two studies, additional information materials about physical restraint reduction were provided. We judged the risk of selection bias to be high or unclear in eight studies. Risk of reporting bias was high in one study and unclear in eight studies. The organisational interventions intended to promote a least-restraint policy included a variety of components, such as education of staff, training of 'champions' of low-restraint practice, and components which aimed to facilitate a change in institutional policies and culture of care. We found moderate-certainty evidence that organisational interventions aimed at implementation of a least-restraint policy probably lead to a reduction in the number of residents with at least one use of PR (RR 0.86, 95% CI 0.78 to 0.94; 3849 participants, 4 studies) and a large reduction in the number of residents with at least one use of a belt for restraint (RR 0.54, 95% CI 0.40 to 0.73; 2711 participants, 3 studies). No adverse events occurred in the one study which reported this outcome. There was evidence from one study that organisational interventions probably reduce the duration of physical restraint use. We found that the interventions may have little or no effect on the number of falls or fall-related injuries (low-certainty evidence) and probably have little or no effect on the number of prescribed psychotropic medications (moderate-certainty evidence). One study found that organisational interventions result in little or no difference in quality of life (high-certainty evidence) and another study found that they may make little or no difference to agitation (low-certainty evidence). The simple educational interventions were intended to increase knowledge and change staff attitudes towards PR. As well as providing education, some interventions included further components to support change, such as ward-based guidance. We found pronounced between-group baseline imbalances in PR prevalence in some of the studies, which might have occurred because of the small number of clusters in the intervention and control groups. One study did not assess bedrails, which is the most commonly used method of restraint in nursing homes. Regarding the number of residents with at least one restraint, the results were inconsistent. We found very-low certainty evidence and we are uncertain about the effects of simple educational interventions on the number of residents with PR. None of the studies assessed or reported any serious adverse events. We found moderate-certainty evidence that simple educational interventions probably result in little or no difference in restraint intensity and may have little or no effect on falls, fall-related injuries, or agitation (low-certainty evidence each). Based on very low-certainty evidence we are uncertain about the effects of simple educational interventions on the number of participants with a prescription of at least one psychotropic medication. One study investigated an intervention that provided information about residents' fall risk to the nursing staff. We found low-certainty evidence that providing information about residents' fall risk may result in little or no difference in the mean number of PR or the number of falls. The study did not assess overall adverse events.

AUTHORS' CONCLUSIONS

Organisational interventions aimed to implement a least-restraint policy probably reduce the number of residents with at least one PR and probably largely reduce the number of residents with at least one belt. We are uncertain whether simple educational interventions reduce the use of physical restraints, and interventions providing information about residents' fall risk may result in little to no difference in the use of physical restraints. These results apply to long-term care institutions; we found no studies from community settings.

Physical Restraint Experiences of Family Caregivers of Patients With Stroke in Turkey: A Qualitative Study

The purpose of this study was to explore the experiences and needs of family caregivers of stroke patients who require physical restraints. The themes and sub-themes that emerged included "the reason for the use of PR" (disruptive behaviors of the patient and personal reasons of caregivers), "the turmoil of having to use PR" (inevitableness, comparing benefits and harms, the emotional effect of PR, and physical effects), and "unmet needs and suggestions" (unmeet needs and suggestions). Nurses should take the experiences of patient relatives into account in the process of PR application, organize training programs, and determine application standards for PR.

Use of physical restraints and its associated risk factors in the aged care facilities: A multicentre cross-sectional study

AIMS AND OBJECTIVES

To investigate the use of physical restraints in aged care facilities(ACFs)and analyse its associated risk factors.

BACKGROUND

Physical restraints have been widely used in ACFs worldwide, but they can cause physical and mental harm to older people. It is important to regulate the use of physical restraint.

DESIGN

A cross-sectional observational and correlational multicentre study.

METHODS

By convenience sampling method, we selected eight ACFs in four representative regions of Hunan province, China, for this study. The ACF-related information was obtained by interviewing the managers and reviewing records. We conducted investigation and observation on the elderly in the ACFs to understand the use of physical restraints at three different times: 9:30-11:30, 16:00-18:00 and 19:30-21:30 on a working day. The STROBE checklist was followed for this cross-sectional study.

RESULTS

This study found that the utilisation rate of physical restraints was 23.2%. The critical risk factors affecting the use of physical restrains include the following: (1) the ratio of nursing staff to the elderly residents; (2)whether there is a dementia care unit at the facility; (3) the number of elderly residents in each room; (4) the elderly residents' age, degree of education, marital status, care dependence and cognitive impairment; (5) whether the elderly has suffered from a stroke or senile dementia; (6) whether the elderly carries medical catheters.

CONCLUSION

There is a lack of standardisation in the use of physical restraints in ACFs of central China. Chinese ACFs should develop guidelines and reduction measures to standardise the use of physical restraints, basing on the key factors affecting the use of physical restraints.

RELEVANCE TO CLINICAL PRACTICE

The use of physical restraints in ACFs is threatening the safety of the elderly residents. Understanding the implementation of physical restraint in ACFs can provide reference for reducing the use of physical restraint.

Advance care planning in nursing homes: new conversation and documentation tools

Although advance care planning (ACP) is highly relevant for nursing home residents, its uptake in nursing homes is low. To meet the need for context-specific ACP tools to support nursing home staff in conducting ACP conversations, we developed the ACP+intervention. At its core, we designed three ACP tools to aid care staff in discussing and documenting nursing home resident's wishes and preferences for future treatment and care: (1) an extensive ACP conversation guide, (2) a one-page conversation tool and (3) an ACP document to record outcomes of conversations. These nursing home-specific ACP tools aim to avoid a purely document-driven or 'tick-box' approach to the ACP process and to involve residents, including those living with dementia according to their capacity, their families and healthcare professionals.

Variation in restraint use between hospitals: a multilevel analysis of multicentre prevalence measurements in Switzerland and Austria

BACKGROUND

In restraint use in the somatic acute-care hospital setting, routine and institutional culture seem to play an important role. This implies that similar patient situations would be managed with restraints in one hospital, while in another hospital the situation would be managed without restraints. This practice variation appears to be ethically and legally questionable. The influence of organisation-specific factors such as the availability of guidelines is discussed. However, the relevance of such factors at the hospital level has been rarely investigated to date. Therefore, the aims of this study were a) to determine how much variance in restraint use can be explained on the hospital level (hospital general effect) and b) to examine the impact of organisational factors on restraint use (specific contextual effects).

METHODS

A secondary data analysis of cross-sectional multicentre data was performed. Data were collected during three quality measurements (2016-2018) in acute-care hospitals in Switzerland and Austria. Hospitalised patients from different medical specialties aged 18+ with informed consent were included. Descriptive analysis and multilevel logistic regression analysis were performed.

RESULTS

The study included 29,477 patients from a total of 140 hospitals. The 30-day prevalence rate of patients with at least one restraint was 8.7% (n = 2577). The availability of guidelines regarding restraint use and refresher courses for nursing staff were associated with less restraint use (odds ratios = 0.60 and 0.75). By adding the hospital as a random effect, the explained variance of the model increased from 24 to 55%.

CONCLUSIONS

The use of restraints varies widely between hospitals, even considering patient characteristics. The identification of situations in which restraints were used out of routine or institutional culture appears to be an important approach in restraint reduction. Investments in appropriate structures and employee knowledge can facilitate providing restraint-free care as much as possible.