Restraint in the 90s. Restraints as nurse's aides see them

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

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

Programme d'intervention visant à réduire l'utilisation des contentions physiques dans des unités de soins de longue durée — mise en oeuvre et effets sur le personnel soignant

This study aimed at (a) developing a restraint reduction program, (b) describing its implementation in long-term care units, and (c) examining its effects on care staff's perceptions of and knowledge about the use of restraints. The program was composed of three parts: consciousness-raising meetings, staff education, and clinical follow-up. The study was a randomized, controlled clinical trial with eight intervention care units (five nursing homes) and 11 controls (five additional nursing homes). Care staff was surveyed at two time intervals over a 7-month period (pre- and post-test intervention; intervention care units: N = 171 [T0] and N = 158 [T1]; controls: N = 181 [T0] and N = 166 [T1]). The implementation of the program was successful and results showed significant changes in care staff perceptions of and knowledge about the use of restraints.

Opening up: psychiatric nurses' experiences of participating in reflection groups focusing on the use of coercion

Psychiatric staff report that the use of coercion towards patients in psychiatric care engenders feelings of discomfort and conflicts. The aim of this study was to describe psychiatric nurses' experiences of participating in reflection groups focused on the use of coercion, in relation to their views regarding systematic clinical supervision and staff support. Twenty-one nurses who had participated in reflection groups were interviewed retrospectively. The structured interview focused on: (i) their views of clinical supervision and support in general; (ii) their views of clinical supervision and support specifically concerning the use of coercion; and (iii) their experiences of participating in groups reflecting the use of coercion. Nurses were largely positive about participating in reflection groups, as expressed in the subthemes: having time for reflection; being confirmed; gaining new perspectives; sharing fellowship with colleagues; and relating more effectively to patients. Complications concerning participation in the reflection groups and other forms of clinical supervision as reported by nurses were: providing time for participation; having a common aim; being vulnerable in difficult situations; and assuming that the need for supervision and support could indicate that they were not coping with their job.

Factors relating to the use of physical restraints in geriatric care settings

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.

A plea for respect: involuntarily hospitalized psychiatric patients' narratives about being subjected to coercion

Eighteen involuntarily hospitalized psychiatric patients narrated their experiences of being subjected to coercion and their thoughts on how to prevent the coercion. A qualitative content analysis identified recurring themes, which were incorporated in two core themes describing the participants' experience. The core theme Not being respected as a human being included most of their narrated experiences, described in the themes Not being involved in one's own care, Receiving care perceived as meaningless and not good, and Being an inferior kind of human being. The core theme Being respected as a human being included a minor part of the narrated experiences and how the participants wanted things to be, described in the themes Being involved in one's own care, Receiving good care, and Being a human being like other people. The participants' plea for respect is discussed in relation to the ongoing deinstitutionalization of psychiatric care and the need for attitude changes in care and community, leading to the treating of mentally disordered people with more respect.

Individualized care: perceptions of certified nurse's aides

Despite substantial attention devoted to the development of individualized care in nursing homes during recent years, empirical research assessing progress is limited. Further, few studies have explored the experiences of certified nurse's aides (CNAs) in this regard. This survey examines the perceptions and experiences of CNAs in providing individualized care. CNAs (n = 254) were asked to describe a number of current practices and obstacles to implementing individualized care in nursing homes. The majority of respondents reported experiencing: flexibility to change daily schedules; supervisor assistance with challenging residents; active participation in care planning; freedom to test new approaches to care; and supervisors who are open to CNA suggestions. Several barriers to individualized care were also described, including: inadequate staffing; poor team communication; staff attitudes; and a lack of knowledge and training in alternative approaches. These findings provide important insights into the supports and obstacles to implementing individualized care in nursing homes from the perspective of CNAs.

Developing individualized care in nursing homes: integrating the views of nurses and certified nurse aides

Despite recent attention devoted to the development of individualized care in nursing homes, empirical research assessing changes in practice is quite limited, and very few studies have explored specifically the experiences and perceptions of certified nurse aides (CNAs). This study reports findings from a comparative analysis conducted on a data set including quantitative and qualitative data from CNAs (N = 289) and nurses in Connecticut (N = 245). Measures of obstacles to individualized care and needs for future supports were explored. A number of significant differences in perceptions of obstacles to providing individualized care were found. The nurses were significantly more likely to identify the following impediments to change: cost (p < .0001), concepts not integrated into work (p < .0001), lack of administrative support (p < .10), and staff attitudes (p < .10). The CNAs were significantly more likely to report inadequate staffing (p < .001), lack of interdisciplinary teams (p < .001), and resident and family attitudes (p < .01) as problematic. These findings suggest substantial discordance among nurses and CNAs on a number of important issues surrounding individualized care. Such disparate perceptions pose challenges to nursing homes committed to the implementation of individualized care alternatives. Successful approaches must consider the various vantage points of caregivers and administrators.

Nurses' narratives about using coercion in psychiatric care

To illuminate nurses' experience of using coercion against psychiatric patients, a phenomenological hermeneutic study was conducted with seven registered nurses and seven enrolled mental nurses. The findings revealed that these nurses desired to be seen by themselves, their co-workers and patients as doing good, being good and providing good care but they experienced the use of coercion as not good. This conflict made it difficult for these nurses to question the use of coercion and consider alternative solutions. The theory of change by Watzlawick et al. (1974) served as a theoretical framework for the interpretation of all interviews regarded as one text. In order to explore alternatives to the use of coercion in psychiatric care, nurses need assistance to step outside the traditional way of regarding coercion in psychiatric care and seek to create new solutions.

Reducing Restraints: Where to Start

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

Physical restraints in geriatric care in Sweden: prevalence and patient characteristics

OBJECTIVE

Physical restraints are used frequently in geriatric care to promote the safety of frail older patients. This study investigated the prevalence of the use of physical restraints in geriatric care and the way in which patient characteristics are related to the use of physical restraints.

DESIGN

A point prevalence study of patients cared for in various types of geriatric settings.

SETTING

Eight nursing homes, 15 old people's homes, a somatic geriatric clinic, and a psychogeriatric clinic in a health care district in northern Sweden.

PARTICIPANTS

A total of 1325 patients, mean age 82 years, 64% of whom were women.

MEASUREMENTS

The Multi-Dimensional Dementia Assessment Scale (MDDAS) was used to measure motor function, vision, hearing, speech, ADLs, behavioral symptoms, psychiatric symptoms, use of psychoactive drugs, and the physical and psychological workload of the staff. In addition, questions concerning the use of physical restraints were added to the instrument.

RESULTS

Twenty-four percent of the patients were physically restrained. The highest prevalence was found in nursing homes and psychogeriatric care. Physical restraints were found to relate most strongly to cognitive impairment, impaired ADLs, and speech and walking ability. Ninety-four percent of the restrained patients were cognitively impaired. Other variables relating to the use of physical restraints were psychiatric symptoms and behavioral disturbances.

CONCLUSIONS

This study has shown that physical restraints are used frequently in geriatric care in Sweden and that cognitive and physical impairments relate very closely to the use of physical restraints.

Hospital nurses' views about physical restraint use with older patients

1. A survey of knowledge, practice and attitudes about physical restraints was completed by nursing staff (RN, LPN, CNA) from four hospitals. 2. Nurses from both geriatric and geropsychiatric units reported significantly more educational activities about restraint use than did nurses on medical units. 3. RNs had the highest knowledge scores (56%), but lacked specific information about the dangers associated with restraint use. 4. While education about restraints is important, staff need role models who can help them problem solve and examine alternatives to restraints.

Reducing restraints. Impact on staff attitudes

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