Attitudes of Dutch, German and Swiss nursing staff towards physical restraint use in nursing home residents, a cross-sectional study

Abstract

Objective

To investigate the attitudes of nursing staff towards restraint measures and restraint use in nursing home residents, and to investigate if these attitudes are influenced by country of residence and individual characteristics of nursing staff.

Methods

A questionnaire on attitudes regarding restraints (subscales: reasons, consequences, and appropriateness of restraint use) and opinions regarding the restrictiveness of restraint measures and discomfort in using them was distributed to a convenience sample of nursing staff in The Netherlands (n = 166), Germany (n = 258), and Switzerland (n = 184).

Results

In general, nursing staff held rather neutral opinions regarding the use of physical restraints, but assessed the use of restraints as an appropriate measure in their clinical practice. Gender and age were not related to attitudes of nursing staff, but we did find some differences in attitudes between nursing staff from the different countries. Dutch nursing staff were most positive regarding the reasons of restraint use (p < 0.01), but were less positive than German and Swiss nursing staff regarding the appropriateness of restraint use (p < 0.01). Swiss nursing staff were less positive than German nursing staff regarding the appropriateness of restraint use (p < 0.01). Nursing staff with longer clinical experience showed a more negative attitude towards restraint use than nursing staff with less experience (p < 0.05) and charge nurses had the least positive attitude towards restraint use (p < 0.05).

Opinions regarding restraint measures differed between the three countries. The use of bilateral bedrails was considered as a moderate restrictive measure; the use of belts was rated as the most restrictive measure and nursing staff expressed pronounced discomfort on the use of these measures.

Conclusions

Nursing staff from three European countries have different attitudes and opinions regarding the use of physical restraints. The results underline the importance of more tailored, culturally sensitive interventions to reduce physical restraints in nursing homes.

Introduction

The use of physical restraints still is common practice in the nursing home care of older people with dementia in many countries. Physical restraints can be defined as any limitation in an individual's freedom of movement (Hantikainen, 1998). Examples of restraint measures are the use of (all types of) bilateral bedrails, belts and chairs with a table. The prevalence of restraint use in nursing homes reported in the literature ranges from 15 to 66% (Hamers and Huizing, 2005a).

In most cases physical restraints are used as safety measures; the main reason is the prevention of falls (e.g., Capezuti, 2004, Hamers et al., 2004, Werner, 2002). The use of physical restraints is associated with many adverse effects, like pressure sores, depression and death (e.g., Capezuti, 2004, Castle and Mor, 1998, Miles and Irvine, 1992) and there is growing evidence that physical restraints are no adequate measure for the prevention of falls (Capezuti et al., 1998, Capezuti et al., 2002, Neufeld et al., 1999). Several attempts have been made to reduce the number of restraints in clinical practice (Becker et al., 2007, Capezuti et al., 2007, Evans et al., 1997, Huizing et al., 2006, Testad et al., 2005). Most studies used educational approaches, aimed to improve nursing staff knowledge and confidence to avoid physical restraints and to use alternative measures (Evans et al., 1997, Huizing et al., 2006, Huizing et al., 2008, Testad et al., 2005, Wagner et al., 2007). All studies delivered intensive training sessions and introduced a nurse specialist as a consultant. However, the success rate of these interventions in different countries has been variable; a successful educational intervention in the USA (Evans et al., 1997) proved to be ineffective in The Netherlands (Huizing et al., 2006, Huizing et al., 2008).

It is unclear if these contradictory results can be explained by cultural differences and differences in health care systems or educational level of nursing staff in nursing homes between the countries. There are indications that the success of the educational intervention in the USA has also been supported by changes in regulations (OBRA’87) covering the use of restraints (Dunn, 2001, Marek et al., 1996).

The reduction of physical restraints in clinical practice remains a difficult task and probably should be regionally tailored, taking into account differences in characteristics of both residents (e.g., levels of care dependency) and nursing staff (e.g., educational levels). Knowing that nursing staff play a key role in the decision to use physical restraints (e.g., Hamers et al., 2004, Koch et al., 2007, Wagner et al., 2007), an important question is how attitudes and opinions are influencing the decision-making process.

Studies on attitudes of restraint use among nursing staff are rare, demonstrating differing results. In an Australian study (Meyers et al., 2001) it was found that attitudes of nursing staff did not predict their self-reported use of restraints. However, Karlsson et al. (2001) reported that the attitudes of Swedish nursing staff towards the use of physical restraints were strongly connected towards their use in practice. Nursing staff working on ‘restraint-free’ wards had more negative attitudes (were least prone to use restraints) towards restraint use than nursing staff working on ‘high-use’ wards. Finally, other researchers (Hamers et al., 2004, Koch et al., 2007) found that a large proportion of nursing staff often do not classify the use of bedrails as a restraint measure, indicating that nursing staff do have different opinions regarding the definition of physical restraints. Undoubtedly, these opinions will affect decision-making regarding the use of physical restraints in clinical practice.

For improvement of interventions aimed to reduce restraints, more insight into the attitudes and opinions of nursing staff regarding restraint measures is needed and it remains important to investigate if nursing staff differs across countries.

Therefore, the aim of the present study is to explore attitudes of nursing staff regarding restraint measures and restraint use in nursing home residents, and to investigate if attitudes are influenced by country of residence and individual characteristics of nursing staff. Four research questions have been formulated:

• What are the attitudes of nursing staff regarding the use of physical restraints in nursing homes?

• What are the opinions of nursing staff about the restrictiveness of physical restraint measures and discomfort in using these measures?

• Do attitudes and opinions differ between nursing staff from different countries?

• Are characteristics of nursing staff associated with their attitudes regarding the use of physical restraints?