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Physical restraint use and falls in institutional care of old people: effects of a restraint minimization program
Umeå University, Faculty of Medicine, Community Medicine and Rehabilitation, Geriatric Medicine.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Physical restraint use and falls are common in institutional care of old people and various attempts have been made to reduce their occurrence. Falls and concomitant injuries are a major problem due to their negative effect on morbidity and mortality. Prevention of falls and injuries is the most common reason for physically restraining old people in institutional care. Its use has, however, been questioned both from an ethical perspective, since restraints can be perceived as coercive and also because of the lack of sound evidence of their effectiveness in preventing falls, as well as the adverse effects associated with their use.

The main purposes of this thesis were to investigate differences in the us of physical restraints over time, to identifify risk factors for falls among people with dementia, to evaluate the effects of a restraint minimization program on staff knowledge, attitudes, and work environment and use of physical restraints and the quality of care.

The present thesis is based on three main data collections, two census surveys conducted within institutional care for old people in the county of Västerbotten in 2000 (n=3,804) and 2007 (n=2,970) and one cluster-Randomized Controlled Trial (RCT) including 40 group dwellings for people suffering from dementia where the intervention consisted of staff education.

The use of physical restraints increased slightly between 2000 and 2007 (16.2% to 18.4%, p=0.016). Analyses suggest that the increase might be independent of any change in resident characteristics. Restrained residents were also subjected to restraints for longer times in 2007.

During a six-month follow-up 64/160 (40.0%) residents in group dwellings for those with dementia sustained at least one fall. Independent risk factors for falls were ‘requiring help with hygiene’, ‘displaying verbally disruptive/attention-seeking behavior’, ‘able to rise from a chair’, ‘walking with assistive devices’, and ‘participating in outdoor walks’, which explained 36.1% of the falls. The majority of the 191 falls were un-witnessed, 35% occurred during the night and anxiety and confusion were the most common symptoms preceding the falls.

A six-month restraint minimization program showed a positive impact on staff knowledge, attitudes and work environment as well as on the use of physical restraints and subjectively estimated quality of care. Residents in the intervention group present throughout the entire study period had lower odds, relative to the residents in the control group of being physically restrained at follow-up (OR= 0.21, CI 95%=0.08-0.57) after controlling for potential confounders and the cluster effect. Adjusted analyses including all residents present at either baseline or follow-up also showed that the use of physical restraints was less in the intervention group relative to the control group at follow-up. There was no change in the occurrence of falls or use of psychoactive drugs. The intervention also reduced stress of conscience, job demands and strain in the staff, and improved their job control and the caring climate. Subgroup analysis indicated a greater effect in units where the use of physical restraints had been reduced or remained constant.

In conclusion, physical restraint use and falls remains common in institutional care of old people. The practice of physical restraint seems to have changed. In the RCT it was found that it is possible to change restraint practice and also to improve staff work environment. Falls among residents with dementia require a certain mobility function and anxiety and confusion are common symptoms preceding falls.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2010. , 101 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1336
Keyword [en]
Physical restraints, falls, dementia, care of the elderly, risk factors, work environment, restraint minimization education program, staff knowledge and attitude, and quality of care.
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
URN: urn:nbn:se:umu:diva-31952ISBN: 978-91-7264-960-6 (print)OAI: oai:DiVA.org:umu-31952DiVA: diva2:300041
Public defence
2010-03-19, Aulan vårdvetarhuset, Institutionen för omvårdnad, 90187 Umeå, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2010-03-01 Created: 2010-02-24 Last updated: 2010-03-01Bibliographically approved
List of papers
1. Physical restraint use in institutional care of old people in Sweden between 2000 and 2007
Open this publication in new window or tab >>Physical restraint use in institutional care of old people in Sweden between 2000 and 2007
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background Physical restraint use is common in institutional care for old people and mainly used to prevent falls, despite that the preventive effect has been questioned. The aim was to investigate the use of physical restraints in Sweden, between 2000 and 2007.

Method Data were collected from two comparable census surveys conducted in all institutional care units for old people in 2000 (n=3,804) and 2007 (n=2,970). Information on residents’ characteristics, physical restraint use and falls was collected by means of the Multi-Dimensional Dementia Assessment Scale (MDDAS).

Results In 2000 16.2% (95% confidence interval (CI) 15.2-17.4) of the residents were restrained compared to 18.4% (95% CI 17.0-19.8) in 2007 (P = 0.018). Adjusting for resident’s characteristics showed that residents in 2007 were 1.2 (95% CI 1.0-1.5) times more likely to be physically restrained, relative to the residents in 2000. In 2007 the residents had been restrained longer, and a higher proportion were restrained for an unknown reason.

Conclusion Physical restraint use increased between 2000 and 2007, residents were restrained for a longer time and a greater number were restrained for an unknown reason. It is possible that the changes in physical restraint use might be dependent on factors other than the residents’ characteristics.

Keyword
Physical restraints, falls, geriatric care, cross-sectional, retrospective study, elderly
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
urn:nbn:se:umu:diva-31947 (URN)
Available from: 2010-02-24 Created: 2010-02-24 Last updated: 2010-03-01Bibliographically approved
2. Risk factors for falls among residents with dementia living in group dwellings
Open this publication in new window or tab >>Risk factors for falls among residents with dementia living in group dwellings
2009 (English)In: International psychogeriatrics, ISSN 1041-6102, E-ISSN 1741-203X, Vol. 21, no 1, 187-194 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Falls are a major cause of morbidity and mortality among elderly people, and people with dementia run an increased risk of falling. The aim of this study is to identify risk factors for falls in people with dementia.

METHOD: The study was performed over a six-month period in northern Sweden using a sample of 160 residents living in 20 group dwellings for people with dementia.

RESULTS: Sixty-four residents (40%) sustained at least one fall during the period. The total number of falls during the study period was 191, and the fall incidence was 2.6 per person year (169 falls/130 residents). Using logistic regression analysis, the independent risk factors strongly associated with falling were: requiring help with hygiene, displaying verbally disruptive/attention-seeking behavior, able to rise from a chair, walking with assistive devices, and participating in outdoor walks. These factors explained 36.1% of the variance in falls with a concordance of 79.6%. Thirty-five percent of the falls occurred between 9 pm and 6 am, with a peak between 5 pm and 6 pm. Symptoms preceding the falls were anxiety (31.1%) and confusion (13.3%).

CONCLUSION: Among residents with dementia it is important to identify those who run an increased risk of falling and need more careful supervision, especially in the evening and during the night. In addition, the causes of anxiety and confusion have to be prevented and treated.

Place, publisher, year, edition, pages
United Kingdom: Cambridge University Press, 2009
Keyword
accidental falls, fall incidence, dementia, residential care, risk factors, ADL function, BPSD, aged
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
urn:nbn:se:umu:diva-31949 (URN)10.1017/S1041610208007837 (DOI)18834557 (PubMedID)
Available from: 2010-02-24 Created: 2010-02-24 Last updated: 2012-05-30Bibliographically approved
3. Effects of a restraint minimization program on staff knowledge, attitudes, and practice: a cluster randomized trial
Open this publication in new window or tab >>Effects of a restraint minimization program on staff knowledge, attitudes, and practice: a cluster randomized trial
2010 (English)In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 58, no 1, 62-69 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To evaluate the effects of a restraint minimization education program on staff knowledge and attitudes and use of physical restraints.

DESIGN: Cluster-randomized controlled trial with nursing units as the basis for randomization.

SETTING: Forty group dwelling units for people with dementia.

PARTICIPANTS: At baseline, there were 184 staff and 191 residents in the intervention group and 162 staff and 162 residents in the control group. At the 6-month follow-up, there were 156 staff and 185 residents (36 newly admitted) in the intervention group and 133 staff and 165 residents (26 newly admitted) in the control group.

INTERVENTION: A 6-month education program for all nursing staff.

MEASUREMENTS: Staff knowledge and attitudes and physical restraint use were measured before and after the education program.

RESULTS: In the intervention group, staff knowledge about and attitudes toward restraint use changed, and the overall use of physical restraints decreased. A comparison including only residents present during the whole study period showed that the level of use was similar between the groups at baseline, whereas it was significantly lower in the intervention group at follow-up. Adjusted analyses showed that the odds of being restrained at follow-up were lower in the intervention group than in the control group. There was no significant change in the number of falls or use of psychoactive medication.

CONCLUSION: The results indicate that staff education can increase knowledge, change attitudes, and reduce the use of physical restraints without any change in the incidence of falls or use of psychoactive drugs.

Place, publisher, year, edition, pages
United Kindom: Wiley Interscience, 2010
Keyword
physical restraints, cluster-randomized trial, dementia care, staff education, knowledge, attitudes
National Category
Geriatrics
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-31950 (URN)10.1111/j.1532-5415.2009.02629.x (DOI)000273311500009 ()20122041 (PubMedID)
Available from: 2010-02-24 Created: 2010-02-24 Last updated: 2010-08-06Bibliographically approved
4. Effects of a restraint minimization programme on staff’s work environment and the quality of care: a cluster randomized trial
Open this publication in new window or tab >>Effects of a restraint minimization programme on staff’s work environment and the quality of care: a cluster randomized trial
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aims and objectives. The aim of the study was to evaluate the effects of a restraint minimization education programme on staff’s work environment and the quality of care in group dwellings for persons with dementia.

Background. Nursing staff in dementia care frequently face ethically difficult situations and have a challenging work environment. The use of physical restraints is one factor found to be associated with an impaired work environment and to evoke negative feelings such as guilt and sadness among the staff.

Design. Cluster randomized controlled trial.

Methods. The intervention and control groups each consisted of 20 group dwellings for persons with dementia. Staff and resident data were gathered by means of questionnaires one month before and after the 6-month education programme. Staff’s work environment was measured using the Stress of Conscience Questionnaire, the Demand–Control–Social Support model, and an assessment of caring climate, while the quality of care was subjectively rated for each resident by the staff.

Results. Analyses showed that nursing staff’s work environment improved in the intervention group, as well as did the quality of care, while there was no significant change in the control group. Subgroup analysis within the intervention group indicated that the largest effect on staff’s work environment occurred in those group dwellings where the use of physical restraints was reduced or stayed constant.

Conclusions. Staff’s work environment and the quality of care can be improved by the implementation of staff education. The findings also indicate that there was a synergistic effect between the education programme and the change in physical restraints use.

Keyword
Physical restraints, staff education, work environment, dementia care, RCT
National Category
Geriatrics
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-31948 (URN)
Available from: 2010-02-24 Created: 2010-02-24 Last updated: 2010-03-01Bibliographically approved

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