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Purpose: Attitudes of nursing home staff, residents, and their relatives determine the decision-making process about the use of physical restraints. Knowledge of staffs’ attitudes toward physical restraints is sparse; even less is known about relatives’ attitudes. Therefore, we surveyed relatives’ attitudes and opinions toward physical restraints and compared the results to a survey of nursing home staff.
Design: Cross-sectional survey comparing 177 nursing home residents’ relatives from 13 German facilities in 2008 to 258 nursing home nurses from 25 German facilities in 2007.
Methods: The German version of the Maastricht Attitude Questionnaire was administered. Part I contains 22 items with three subscales (reasons, consequences, and appropriateness of restraints); Part II contains 16 items evaluating restrictiveness and discomfort of restraint measures, respectively. Descriptive and explorative inferential statistics were used for data analyses.
Findings: Response rate in both samples was above 90%. Mean age was 62 years (SD 12.60; range 24–93) in relatives and 44 years (SD 11.40; range 19–65) in nurses; 72% and 82% were female, respectively. Relatives assess physical restraints a little more positively compared to nurses, with an average of 3.40 (SD 0.60) versus 3.07 (SD 0.48) on a 5-point scale (5=strongly positive attitude). Relatives assess physical restraints as slightly less restrictive, with 2.11 (SD 0.33), and as less discomforting, with 2.10 (SD 0.38) points, compared to nursing staff, who assess the restraints’ restrictiveness with 2.19 (SD 0.29) points and its discomfort with 2.17 (SD 0.32) on a 3-point scale (3=very restrictive/discomforting). Both groups consider wrist and ankle belts as most restrictive and uncomfortable, while sensor mats, infrared systems, and unilateral bedrails were rated as the lowest for restrictiveness and discomfort.
Conclusions: Attitudes of nursing home residents’ relatives toward physical restraints are rather positive and generally comparable with nursing home staffs’ attitudes.
Clinical Relevance: Interventions aimed to reduce physical restraints need to include education of both staff and relatives of nursing home residents.
International studies suggest prevalence rates of physical restraint use in nursing homes between 2% and 70% (Feng et al., 2009). Differences may be due to varying definitions of physical restraints, data collection methods, sample sizes, care settings, legislation, and nursing traditions (Hamers & Huizing, 2005). Many healthcare providers continue to consider physical restraints as a safety measure, primarily for the prevention of falls, but also for controlling disruptive behavior and preventing interference with medical devices (Hamers, Gulpers, & Strik, 2004; Hamers & Huizing). It remains highly questionable whether this practice can be justified for controlling psychomotor agitation and reducing the risk for falling and fall-related injury (Evans, Wood, Lambert, & Fitzgerald, 2002; Healey, Oliver, Milne, & Connelly, 2008). In fact, physical restraint use has been shown to be associated with adverse outcomes, such as serious injuries, increased mortality, and other adverse events like reduced psychological well-being, lower cognitive performance, and decreased mobility (Engberg, Castel, & McCaffrey, 2008; Evans et al.).
Since a restraint-free nursing home environment is promoted as the preferred standard of care, efforts have been undertaken worldwide to reduce the use of physical restraints (Flaherty, 2004). The first programs for the reduction of physical restraints were introduced in the United States in the 1980s (Castle & Mor, 1998). These American studies, as well as a number of studies conducted later in Europe and Asia in both hospitals and nursing homes, however, have not consistently resulted in clinically meaningful reductions of physical restraints (Capezuti et al., 2007; Huizing, Hamers, Gulpers, & Berger, 2006, 2009; Lai et al., 2007; Testad, Aasland, & Aarsland, 2005). Recent intervention studies in nursing homes in the Netherlands providing an education approach with nurse specialist consultation (Huizing et al., 2009) and in Norway providing an education approach with guidance (Testad et al.) also demonstrated inconsistent results. Thus, it might not be sufficient to focus on nurses’ education alone to change practice conditions. Rather, a combination of approaches might be indicated that includes education, role modeling by consultation, institutional commitment to restraint reduction, policy changes, as well as availability of alternative interventions (Hamers & Gulpers, 2009). All these approaches imply nurses’ and families’ attitudes toward physical restraints as powerful determinants, which need to be addressed. Hamers et al. (2009), concluding from a survey with nurses of three European countries, emphasized the importance of more tailored and culturally sensitive interventions, since the effectiveness of interventions depends on cultural mores and country-specific laws and regulations.
In Germany the use of physical restraints is common practice in nursing homes, as indicated by questionnaire surveys with nursing staff (Hoffman & Klie, 2004), and a recent epidemiological study including 30 nursing homes with 2,367 residents (Meyer, Köpke, Haastert, & Mühlhauser, 2009). The latter shows a prevalence of 26% (95% confidence interval 21–31). Despite the availability of alternative interventions such as half bedrails, bedrails used as restraints (two full-length or one full-length with the other side of the bed positioned against the wall) were the type of restraint most often used (25% of the residents). Other types were comparably rarely used and included waist belts in chair or bed (3%), chairs with a table (2%), and other devices (2%). Center prevalence ranged from 4% to 59%. Consistent with prior studies conducted in other countries, restraint use was associated with residents’ characteristics, such as degree of care dependency, cognitive impairment, and history of fall-related fractures. The resident case mix of the participating nursing homes was comparable and could therefore not explain the wide variation of restraint prevalence among the homes. Remarkably, the majority of nursing homes employed policies or protocols meant to minimize physical restraint use. Sixty percent indicated having an in-house standard of care and 80% used a special nursing documentation sheet specific to physical restraints. Institutional characteristics, such as staff-to-resident ratio or ownership of the home, also did not reveal any significant results. Since easily measurable resident and institutional characteristics could not explain center differences, it seems that other factors, such as the philosophy of care determining attitudes and beliefs within the nursing home setting, are most likely to be a powerful determinant of physical restraint use.
Attitudes of nursing staff and nursing home residents’ relatives, which are known to influence the decision to use restraints, have been described as an important barrier for restraint reduction (Hamers & Huizing, 2005; Moore & Haralambous, 2007). International studies on nurses’ and relatives’ attitudes are mainly based on questionnaire surveys and qualitative studies. Several European studies have shown that nurses’ attitudes significantly influence the use and frequency of physical restraints (Karlsson, Bucht, Eriksson, & Sandman, 2001; Werner & Mendelsson, 2001). Thus, interventions for the reduction of physical restraints need to address nurses’ attitudes (Meyer, Möhler, & Köpke, 2009), and thus require a thorough knowledge of the respective attitudes (Hamers & Huizing; Hantikainen & Käppeli, 2000).
Several studies suggest that nurses’ attitudes toward physical restraints in nursing homes are ambivalent. Their attitudes are characterized by respect toward the residents’ dignity and self-determination, but even more are marked by anxiety and a responsibility for the residents’ safety and security. According to studies from Switzerland (Hantikainen, 1998), Sweden (Karlsson, Bucht, Rasmussen, & Sandman, 2000), and the United States (Hennessy, McNeely, Whittington, Strasser, & Archea, 1997; Michello, Neufeld, Mulvihill, & Libow, 1993), when restraints are used against the residents’ will, nurses are faced with a moral dilemma that results in feeling frustrated, uncomfortable, and concerned. On the other hand, American (Hennessy et al.; Hill & Schirm, 1996; Michello et al.; Scherer, Janelli, Kanski, Neary, & Morth, 1991) and Swiss nurses (Hantikainen, 2001) regard physical restraints as appropriate measures to prevent falls and injuries and guarantee safety. According to Swiss and Swedish studies (Hantikainen, 2001; Karlsson et al., 2000), nurses regard physical restraints as a necessary measure and as an appropriate reaction toward residents’ challenging behavior. They also report finding it necessary to strictly follow physicians’ orders to restrain patients. In summary, nurses’ attitudes differ depending on their definition and understanding of physical restraints as well as on their national and cultural affiliation. These findings confirm those of a recent study with nurses from three European countries including Germany that demonstrated that nurses generally approve of physical restraints, especially bedrails used as restraints (Hamers et al., 2009).
Nurses often justify restraint use in nursing homes based on their perceived pressure from relatives to use these devices. Nurses’ decisions regarding restraints depend decisively on the cooperation with the resident's relative, and thus relatives’ attitudes are important to understand. Few international studies, however, have investigated relatives’ attitudes toward physical restraints in nursing homes (Evans & Fitzgerald, 2002; Hardin et al., 1993; Moore & Haralambous, 2007; Newbern & Lindsey, 1994), and none have been conducted in Germany so far. International literature discloses ambivalent, but rather negative, attitudes from relatives toward physical restraint use in nursing homes insofar as they regard it as degrading and humiliating (Evans & Fitzgerald). According to studies from the United States (Hardin et al.; Newbern & Lindsey) and Australia (Moore & Haralambous), relatives feel uncomfortable, guilty, and helpless, being burdened by emotional stress. They show no understanding for physical restraint use, especially when nurses consider restraints to reduce their workload, and do not involve relatives in the decision-making process. On the other hand, the same studies revealed that relatives regard restraints as appropriate and positive, approving it as a safety measure for fall prevention based on their trust in the clinical expertise of nurses. A recent Spanish study in the community care setting confirmed these findings (Fariña-López, Estévez-Guerra, Núñez González, Montilla Fernández, & Santana Santana, 2008).
The aim of the current study was to explore the attitudes of residents’ relatives regarding physical restraint use in German nursing homes in order to understand possible barriers or facilitators nurses are confronted with during the decision-making process for physical restraint use. Relatives’ attitudes regarding reasons, consequences, and appropriateness as well as their opinions on restrictiveness and discomfort of different physical restraints measures are surveyed. Results are compared with the German subsample of a large three-country survey of nurses’ attitudes toward restraints during a similar time period (Hamers et al., 2009) to explore differences in attitudes between the two groups.
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Study findings suggest that nurses and relatives have rather positive attitudes and opinions toward physical restraint use in German nursing homes. Similar to a study in the acute care setting, relatives’ attitudes are a little more positive and they assess restraints as slightly less restricting and discomforting than do nurses (Vassallo et al., 2005). Relatives who visit their family members less often seem to be more positive toward restraints and assess them as less discomforting. This may reflect their lack of knowledge about physical restraints and restraint alternatives, as well as their inability to imagine how it feels to be restrained (Fariña-López et al., 2008). Relatives’ rather positive attitudes reflect their belief that restraints can guarantee security and safety for the resident, since high restraint use in some nursing homes may indicate an institutional culture marked by fear of the legal ramifications of fall-related injuries (Moore & Haralambous, 2007). These findings suggest that education interventions aimed to reduce restraints need to target nursing home residents’ relatives.
Relatives and nurses assess restrictiveness and discomfort of physical restraints similarly and rather highly, with only a few differences in terms of restraint types. Thus, physical restraints are predominantly judged negatively, an issue also well described in qualitative studies (Evans & Fitzgerald, 2002; Moore & Haralambous, 2007). Both groups consider restraints placed next to the body, such as wrist and ankle belts, as the most restrictive and discomforting measures. Close placement to the body provides a strong visual reminder of how these devices immobilize the resident. In contrast, technical devices that can be used as restraints, such as sensor mats, infrared systems, and unilateral bedrails, that are not adjacent to the body, are rated by both groups as least restricting and discomforting. These results, similar to those of Vassallo and colleagues (2005), indicate that relatives accept restraints close to the body less readily than technical devices. Relatives might have a limited understanding of the potential immobilizing effect of these devices. However, there is also an ongoing professional debate whether technical measures should be regarded as restraints or alternative interventions (Gerlach, Seidenstücker, & Köpke, 2009). As already shown in earlier studies, both nurses and relatives judge bedrails used as restraints as an appropriate measure (Hamers et al., 2004; O’Keeffe, 2004).
The results of this study are based on small numbers and should therefore be interpreted with caution. We cannot exclude that relatives viewing physical restraints more critically were not captured by this survey. Since attitudes and opinions are a culturally sensitive matter, which reflects both national and institutional contextual factors, the results are not necessarily applicable to other cultural contexts.
Given the high prevalence of physical restraint use in German nursing homes, knowledge about relatives’ attitudes and its further investigation are a decisive key to approach restraint reduction adequately. A systematic review of both relatives’ and nurses’ attitudes toward physical restraints in nursing homes is needed to evaluate the methodological and cultural aspects of existing studies. Both nurses’ and relatives’ attitudes play an equally important role in the decision-making process on physical restraint use, depending on the respective contextual situation. Further, there is a need for research to investigate relatives’ attitudes in-depth in order to ascertain the underlying motives and reasons for their perceptions of restraints. Qualitative interviews of German relatives are needed to describe in detail the cultural and other underlying determinants of their perceptions. These data are needed to develop interventions that represent the unique cultural aspects of this population.
In conclusion, this study provides some explanations for relatives’ and nurses’ resistance and scepticism toward physical restraint reduction efforts (Moore & Haralambous, 2007) and the high restraint prevalence in German nursing homes (Meyer et al., 2009). The results call for a more thorough and culturally sensitive investigation of relatives’ as well as nurses’ attitudes toward physical restraints in the elderly in order to contribute effectively to restraint reduction programs.