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Knowledge Attitude and Practice of Nursing Home Staff Towards


									December 1999                                                                                              SUEN

           Knowledge, Attitude and Practice of Nursing
            Home Staff Towards Physical Restraints in
                  Hong Kong Nursing Homes

                                           Lorna K.P. SUEN

          Abstract        The purpose of this paper is to determine the knowledge levc~ attitudes
          and practice of nurSing staff toward restramt use in nursing homes In Ho ng Kong.
          A convenience sample of 253 nurSing staff from five nursing homes was mcluded.
          Many misconceptions eXIst among staff, for example, most nurses believe either that
          good alternatives to restramts do not eXIst, or else they underestimate the phYSIcal
          and psychologtcal effects of restraints applied to clients. However destrable practice
          was reported, with nurses in a more senior position and staff with longer years of
          experience tending to have a better knowledge level, more appropriate attirudes and
          better practice in relation to restraint use. The results of this study provide mSlghts
          to consider when p lannmg an InserVlce program on restraint use so that a higher
          standard of care can be achieved.

INTRODUCTION                                                Physical restraint is usually the first approach
                                                            considered as well as the last resort adopted
Though it is widely believed that physical                  to manage the problems of the above clients.
restraints can impose many adverse effects                  Moreover, when one restraint is ineffective,
on the clients , this practice is still commonly            nurses tend to add another, thus it is not
adopted in many heahh care sett ings .                      unusual lO find a client ending up with
According to Strumpf and Evans (1992,                       multiple restraints (Evans & Strumpf 1990;
p.4), "thousands of older adults are                        Magee et al. 1993; Varone et al. 1992). In
restrained in some way on a daily basis".                   this smdy, physical restraints are defined as
The most frequent reasons stated by nurses                  mechanical devices such as vests, belts or
for using restraints are to prevent falls (Evans            ties applied to the resident's body or
& Strumpf 1990; Mion & Mercurio 1992) ,                     wheelchair to restrict movement.
to stop patients from wandering about (Mion
& Mercurio 1992; Rader 1991) , protect the                  Many myths and misconceptions exist among
residents from harming themselves or others                 nurses that support the continued use of
(Magee et a1. 1993 ; Varone et al. 1992),                   restraints as a desired technique to control
maintain treatment plans (Hard in et al. 1994;              clients . However , in real situations, these
Rader 1991), or lO cOOlrol confused or                      statements can seldom be justified. For
agitated residents (Hard in et al. 1994 ; Magee             example,some nurse s believe that applying
et al. 1993).                                               restraints is for the benefit of the client .

Lorna K.P. SUEN, The Hong Kong Polytechruc Umversity
(Rtqlmt for reprint! can bt addwHd 10 MJ urna Slim, AniJtant Pro/mor, Departmmt of NllrJing & f-ltalth 5 cimm,
The Hong Kong Po!Jttchnic Unillmity, Hung Hom, Kowloon, Hong Ktmg.)

                                                                                               Vol.5 No.2

According to Brower (1991), restraints are viewed    findings that will be relevant to our clients in
by nurses as a necessary evil to be used only when   Hong Kong .
needed. In reality, the hazards of restraining
deVK:eS appear to outweigh any perceived benefits.
Applications of restraints have both physiological   METHODOLOGY
and psychological consequences for the client
(Brower 1991; McHutchion & Morse 1989).              A convenience sample was oblained from the staff
                                                     (registered nurses, enrolled nurses, and personal
As Evans and Strumpf (1990, p.127)                   care workers) working in five subsidized nursing
emphasize, "myths are powerful determinants          homes in Hong Kong in 1998. The selected
of behaviour, even in professional practice" .       nursing homes have 126 to 250 residents under
Therefore it is worthwhile exploring the usual       the 'Care and Attention' sec tion. which
practice of nursing home slaff who play a direct     accommodates re s idents that are relatively
and central role in the care of the elderly.         dependent and require much nursing care. A
Furthermore , the knowledge level about              questionnaire which consists of three sections were
restraints and underlying attirudes of the slaff     u sed in order to collect data relating 10 the
toward them sho uld also be in ves tigated           knowledge level, attitudes and practice of the staff
because knowledge and attitudes can directly         towards physical restraints. The items for the
affect their practice.                               questionnaire were originally developed to srudy
                                                     nursing personnel who worked in nursing homes
Nowadays. the overseas trend is toward tighter       in the United States (Janelli et al . 1991 , Scherer et
regulation of restraint usage . as set out in the    al. 1993). The questionnaire was adapted for the
Omnibus Budget Reconciliation Act of 1987            staff in nursing homes for the current srudy by
(OBRA) which prohibits Ihe use of physical           revising some of the items that were more relevant
restraints in nur si ng homes (Mion &                to the settings of nursing homes in Hong Kong.
Mc Hutch ion 1991; Phillips et at. 1993) . In        For example, the term ' resident' instead of 'patient '
the United States, the desire to reduce or           was used in many items. Translation of the
eliminate the use of restraints has increased        questionnaire into Chinese was validated by an
and beco me part of a national movement to           experienced translator of the university. Three
"untie the elderly " (Phillips et al. 1993). In      nursing staff who have rich experiences in geriatric
view of thi s current trend to advocate the          settings were invited to examine the questionnaires
freedom of the resident, more effort should be        for content validity . The panel was made up of
made to achieve a genuine "' re s traint~free "      two geriatric nurse specialists, and one Department
environment in nurs ing homes.                       Operations Manager of a geriatric unit. The
                                                     content validity index of 86% was achieved after
Stud ies that relate 10 the use of restraints are     a minor adjustment was made. The entire
relatively recent and are dominated by overseas      questionnaire consists of four sections. Section 1
literature, particularly from North America .         deals with the staffs knowledge level toward the
The operational differences in health care            use of restraints ( 11 items). Section 2 contains of
seltings such as the beliefs, practice and            items measuring the altitudes of staff toward the
knowledge levels in Hong Kong 1vhen                   use of restraints (12 items) . The items in section
compared with other countries, may result in          3 pertains to nursing practice issues (14 items) .
the findings of overseas studies being                Personal data and education level in relation to
inappropriate to the lo ca l environment.             restraint use were collected in the last section of
Therefore a local srudy is necessary to produce       the questionnaire .

                                                                              .. ' .., • "-; y
December 1999                                                                                      SUEN
                                                                     _' . 1       .~   j   .1 :;

The test-retest reliability coefficients for       8.4% were registered nurses, 24% enrolled
indi vidual sections (sect ion I, 2 and 3) of      nurses, and 67.6% personal care workers.
the questionnaire were examined by
administering the same instrument repeatedly       Knowledge about th e use of physical
to 12 subjects from two nursing homes at a         restraints:
2-week interval. The reliability coefficients      In this section , correct responses were given a
for the knowledge, attitudes and pract ice         score of 1 and incorrect responses a score of 0,
scales used in this study were 0.65, 0.61 and      with "undecided " an swers included in the
0 .94 respectively . The questionnaires were       incorrect category. Thus, a sco re of II
distributed by the researcher to different         represented 100% correct responses . However,
nur s ing homes . Each questionnaire was           the mean knowledge score of subjects was below
accompanied by an information sheet that           average (mean = 5.3, SD = 1.67), with a range
described the purpose of the study, and            from 2 to 10 (potential range 0- 11) (Diagram I).
explained that the participation was               Most subjects answered incorrectly to items
voluntary. The questionnaires were                 espec ially related to the risk factors or possible
anonymous and subjects were assured that           outcomes of the use of restraints (item 7, 9 and
their responses were to be kept confident ial .    1 I). Moreover , only 9% of the responses
                                                   indicated that good alternatives to restraints do
                                                   exist (Table I). Analysis of variance (ANOVA)
DATA ANALYSIS                                      illustrated that there was a significant difference
                                                   in knowledge level about restraints among staff
The quantitative data was analysed by SPSS         holding different posit ion (F 2 • 159 = 10.48 , P
version 9.0 . Descriptive statis tic s we re        < O.IXKH), and a post-hoc test further illustrated
performed on the responses to the knowledge,       that registered nurses have a higher knowledge
attitudes and practice item s indi viduall y .     score than enrolled nurses (p=0.017). who in
Parametric te sts such as {-tests or Analysis of   turn have a higher sco re than personal ca re
variance (ANOY A) were used to see whether          workers (p=0.021). On the other hand,
the demographic and professional characteristics    significant differences in the knowledge level
(training, staff position , years of experience)   could be found in nurses with different years of
will have any effect on the knowledge, attitudes   experience (F1. I SI = 8.59, p<O .OOOl). nurses
or practice scores. Chi-square analysis was         with 7 or more years of expe rience gained a
conducted when the impact of staff position or      higher score than those with less than 3 years
the years of experience on individual items were    of experience (p<O.OOOI) or those with 3-6
exa mined . Additional analysis with the            years experience (p = O.Ol1) .
Pearson's product moment correlation was
conducted to examine whether there was any         Altitudes toward the use of physical
inte rrelation ship among knowledge le vel,        restraints:
attitudes and practice.                            Respondents were asked to respond on a four-
                                                   point Likert Scale as to whether they "strongly
                                                   agree", "agree", " disagree " , or "strongly
 RESULTS                                           disagree" with the 12 statements . Positively
                                                   phrased attitude items were scored with a four
                                                   for "strongly agree", to a one for "strongly
 The sample in this study represented 73 % of
                                                   disagree". Thus high scores reflected positive
 the total nursing staff of the five selected
                                                   attitudes and low scores reflected negative
 nursing homes. Among the 253 respondents ,

AJNS              <<5l iIII:l!llI! 'l!fflilt>>                                                                                              Vol.5 No.2

         Table I: Knowledge towards the use of physical restraints

                                                                                        Ag«<t             DiSlgrttt                     Incorrect!
                                                                                                                              C.,"""    Undec.'tded
             1.     Ph)Sical restraints are safety ,'CStS        I)"    garments
                    designed to (ttVCIlt injury. (n"'248)                                232 '                  16             93.5        6.'

          2. Restraints should be used \\h01 me: cannot "aim
                    the resident closely. (n=-246)                                            152           94 '               38.2        6 1.8

     ,    1         Residents arc alloo'Cd to refuse to be in a
                    restraint (n=-248)                                                   160 '                  88             ...,        35.S

             4. A Jt!ysical restraint ($lfety '           ....
                                                       & =1
                requires a cooscnt fam from lhe family member.
                                                                                         236'                   12             95.2         4.8

          5. A. restraint        ~ould be released every 2 hOlfi, if
                    the resident is awdke. (rF20l)                                        141 •                 60             70. 1       29.9

          6         Restraints mould be put on snugly so that there is
                    no space bct~ the rc:suainl and !he resident's                            68            179 '              72.5        27.5
                    """. (0-247)

             7.     When a resident is re:strainal skin brt:akdIMn
                    mayina-case. (n~5 1 )                                                 42'                                   1 ~.7      83.3

             8. When a resident is rc:srrainoi in bed. the restraint
                should not be altached to the side rail. (rF244)                          99'                   145            40.6        59.4

             9. A resident !ihoold never be restrained .... hile lying
                flat in bed because of the dangcr of choking.                             40 '                                  \6.1       83.9

         10. Good a1ttmatives             to restraints do nOl exist.
                    (0-245)                                                                   223               22 '            9.0        91.0

         11.        Deaths have been linked to the use of ve!.1
                    restraints. (n=247)                                                       39 '              208             I S.8      842

                    - CaTcct response
         t         'UndccidccJ" rcspooscs may be included if it is an maned rcspoosc 10 that itc:m.


                                          • ,.
                                          "   ..
                                          , "                                                                   ,. ,."., '"
                                                     ~o   ' .0         ' .0   .0   10   1.0     10   .0   '00

                                                   TOTAL KNOW LEDGE SCORES (M u_" . Mln _O)

                                Dilgllm \    The knowledge $Cores ofnuning home .ta« ,oward s phy. inl.u.uin.s

December 1999                                                                                SUEN

attirudes. Items 4 , 9, 10 and 12 were negative    (skewness: - 1.64), a loga rithmic transform-
ite ms and their scores were reversed. The         atio n of data wa s p e rfor med . The
maximum possible score was 48.                     transformed data rather than the raw data
                                                   were used in subsequent parametric analysis .
The attitude of some respondents towards the
use of resrraints was relatively neutral. Scores   Impact of seniority or length of experience
ranged from 20 to 39 (potentia) range 12-48);      of staff on the use of restraints:
the mean sco re was 29 .7 with a standard          Chi-square analysis demonstrated that staff of
deviation of 3.11 (Diagram 2). It was found        different grades o r wi th var iou s years of
that over 70% of the respondents "disagree " or    experience show significant difference s in
"strongly disagree" with hav ing guilty feelings   response on some of the items related to their
when plac ing a res ident in restraints, nor do    knowledge level, attitudes or practice towards
they feel embarrassed when the family enters       rest raint use. For example, lice nsed nurses
the roo m of a reside nt who is re strained        (registered nurses and enrolled nurses) lended
(Table 2) .                                        to have a higher knowledge level of the effect
                                                   of restraints than did personal care workers,
Nursing practice performance toward the            regarding risks such as breakdown (XZ = 19.
use of restraints:                                 25, df = l , p<O.OOOI), and the danger of
This questionnaire addre ssed issues relating      choking (X' = 19.40, df= I, p<O.OOOI). Many
to the use of alternative measures before          of them realized that a resident suffers a loss of
restraining , how to care for a client receiving   dignity when restrai nts are applied (X2=9 .94 ,
restraints and the level of staffing. Nurses       df= 3, p=0.019) (Table 4). On the other hand,
were asked 10 re spond to each of the ite ms       staff with 7 or more years of geriatric experience
on a three-point Likerl Scale as to whether        had a bener knowledge about the need to release
they "always" , "sometimes", o r " ne ve r "       the restraints every two hours than those with
used these practices. Most of the items were       fewer years of experience ()(l=7 .69, d f = I ,
refl ective of more positive practices toward      p =O.OO6); and were more inclined to tell family
car ing for restrained c lients, with a score of    members the reason for restraining the resident
3 for " always", to a score of 1 for " nev er"      than were junior sta ff (XZ = 9.76 , df = 2,
adopted s uch pr ac ti ces. Item 10 was a          p =0.008) (Table 5).
negati ve item and needed to be reverse
sco red . Thu s a score of 14 indicated th e       Other variables:
most undesirable practice, and a score of 42       Analysis using t-tests de mo nstrated th at
the best practice in terms o f restraint use.      attitude scores between staff who had or had
The score s o n the use of restraints ranged       not received training on the use of restraims
 from 20 to 42 (po tential range 14-42), with      in the past differed sig nificant ly (t!99 = -2.58,
a mean of 38.7 and a standard deviation o f        p = O.OII), but no significant relationship
 3.68 (Diagram 3). The majority (88%) of           could be found between training and the
 respondents said that they answer the call of     knowledge score (p=0 .062) o r the practice
 the resident in restraints as soon as possible;   sco re (p=0.48) . · Mo reover , no association
 and 78 % of th e re s pondents fre quently        could be observed between the knowledge ,
 eva luate and record the effect of ph ys ica l    attitude or practice sco re and the other
 re straint. Res pon ses to the practice item s    variables, such as gender, or (he size of hostel
 are listed in Table 3. Since the sco re s on      (i.e. number of beds and staff).
 the use of re straints are skewed to the left

                                                                                                                         Vol.5 NO.2

     Table 2: Atticudes toward the use of physical restraints

                                                                                      Frequency (Ptrunt)

                                                                    Slrongly         Ag~          Disagru     Strongly

     I.     I fccl that fami ly members have the right to            ""=
                                                                       28             169            46
            refuse tnc use of restnl.ints.                           (11.3)          (6s.4)        (18.6)      (1.6)

     2.     If I \o\oCfC the resi!lcnt. I feci I should have the
            righ t 10 rcrusc or resist ""hen restraints are
            placed on me.
                                                                                     (69.5)          "

     1      I feci guilty placing a resident in restraints.             4              30            1S3         29
                                                                      ( 1.6)         (12.2)         (74.4)     (11.8)

     4.     1 fee! that the main reason that restraints ..e             ,              29            149         '9
            used is that the nursi ng home is short staffed.          (2 I)          (12.0)         (61.6)     (24 4)

     ,      I feel embarrassed ~m the family enlCfS the                 3             28             180         ))
            room of a resident who is restrained.                     (1.2)          (IU)           (73.8)     (13.5)

     6.     It makes me feci bad if the residents gets more             10             103           120         13
            upset after restraints ..e applied.                       (4.1)          (4 1.9)        (48.8)      (5 .3)

     1.     11 makes me feci bad v.fIm residents bc:oome                12             89            129         12
            more: disoriented after Ihc: rcsuaints have bcc:n         (5.0)          (36.8)         (53 .3)     (5.0)

     8.     A residcnl: suffers a loss of di~ily \.\.hen placed         6              100           132          8
            in restraints.                                            (2.4)          (40.7)         (53.7)      (3.3)

     9.     It ;s important to appl y restraints 10 i\SS~e legal        12             86            106         35
            protectioo for m)'sel f and my m.sing horne.              (5.0)          (36.0)         (44.4)     (14.6)

            1 foel that placing a residenl in restraints can                           35            148
            deacasc: n~sing care time:.
                                                                      ( 1.6)         (14.3)         (60.7)       "

     11 .   [ believe tha! rC5traints increase the risk of             4               4)            162         32
            strangulation.                                            (17)            (17.8)        (67.2)     (133)

     12.    [ believe that restramts dcacasc the n\fllber of            11             155               13       2
            residents ~o fall.                                        (3 1.2)         (62.8)         (5.)       (O.S)

                                     a     "
                                     ,     .
                                     ,                                                           0 ...   ~"

                                                                                    __".,1, · ZlS '"

                                               TOTAL ATTlTUOE SCORES ("" .. . . 8. l,I,n . 12)

                          Diasum 2 ' The altitude SCOIU of nUl sins home stafftowa . ds physlcat Iutralnu

December 1999                                                                                                                              SUEN

        Table 3: Nursing practice performance toward the use of physical restraints

                                                                                                     Frfqu~n(y (P~rc~nt )

                                                                                        Alw.~             Somr lim es            N~ ,

                  J try altrrnati"" nursing me,uures bef(1fe restraining the
                  resident. (n-2SOj                                                     (680)                      "

         2.       'MIen I reStrain" residenl, I make this da::i5ion only
                  ...ith a phystcian's adcr. (n" 249)                                   (84 3)                 (96)
                                                                                                                                 (6 .0)

        ,          When I fccl that the resident does na. need to be
                   rCSO"ained. I make this $UggeS1ion 10 Ihe doclor. (n a246)             '"
                                                                                        (69.5)                (20.3)"             "

                   J answtT Ihe call for the residml is fe$ID;ined         3$       218                   25                 5
                   soon as possible. (n ~248)                                           (87.9)                (10 I)             (2.0)

         5.        1 oheck the reSlraint$ 3t leaS! c,~ two hour5 to make                  m                         B               ,
                   $Ure they are in the proper pOSItion. (n~HI)                         (86 .5)                (13 I)            (04)

       I'          [ inspect the skin of the reSIdent for abrasIons or skm                245                       ,              0
                   tears If[ bath the residmt who IS festtamc<i . (n - 2S1)              (97 .6)                   (2 .4)        (00)

       I, ,          tdl family membef$ why the resident is be,ng
                   restraintd . (n_249)
                                                                                         (8S S)                     "
                                                                                                                   (9.6)           "
                                                                                                                                 (4 .8)

       I',         I explain to the resident ...hy the restraint is being
                   ~pplled (n ; 249)
                                                                                         (87 .1)
                                                                                                               (11.6)            (1 .2)

                   1 tell the reSIdent \<-hen the re.sttaint(s) will be removed .
                   (n - 246)                                                             (Hl)''''                B
                                                                                                               (21S)              (5.3)

                   More ... t. arc rC$1Jained ..." ... ~ arc short of staff
                   than ","m wc arc fully staffed. (n ~147)
                                                                                         (9.1)                      "
                                                                                                               (26.1)             '"
                                                                                                                                 (63 .6)

         "         In !)lIr nursing home. staff members work together to
                   discover ways to cootrol residents' bchlVloor W.ef than
                   the use of ph)'SlI:al rcsttaints. (n" 243)
                                                                                         (72 0)                     "
                                                                                                                                  (2 .1)

                   I frfquentl)' assess if the restraint should Ix removed.
                   (n"245)                                                                   '"
                                                                                         (6'10)                     "
                                                                                                               (26.9)              "
                                                                                                                                  (4 .1)

            U.     When phY'ical restraint is applied. I re<:Qfd 00 th e
                   cackts the type of .rstraint used, the r... son for adopting
                   it, the time "hen the applicallon C<)mmc",:,,~, ..,d the
                                                                                         (8S.I)                      "
                                                                                                                   (9 ,S)

                   related nursing care .cQU1fed. (n 142)

            "      I frequently evaluate ..,d re<:Qfd the eff"c<:t of phys;cal
                   re:$ttaint v.ttcn it IS applied to a residmt . (n ~ 243)
                                                                                         (78 .2)               {16.S)"            (5 ,3)

                                ,      ...
                                ,       .

                                 "      ..
                                 ,      ..
                                 ,      "
                                              200          2S 0            ,00         .SO          <00
                                                    22S           27 , S          HS          lIS         42 . S

                                             TOTAL PRACTtCE SCORES ( M . . . (2, M,n o l( )

                 Oiagram 3 : The Proetice scores of nursing home st aff towards physical re s s.

                                                                                                                               VoL5 No.2

     Table 4:

     Re:su11S of chi-sqwre anaIy.;is f(T ilClTl'i \\;th significant differCllce> arrmg staff ~th different JXX>iticns.

                              Items                            Licensed nunes •           Personal care \\oWkers         o-vaJue
     Knowl.:                                                        %ccma
     A rcstraint shwJd be rek:asod C\uy 2 hcus, if                      81                                                0.026
     the rcsidalt is awake.

     When a resident is restrained, skin IJ"cakdo\\n                    32                             9                 <O.OOJ I
     may inmase.
     A resident shruId never tx: restrained v.hile                      32                             9                 <O.00J1
     lying nat in bed bealuc;c of the danger of
     Good a1tcrna1ive5 to restraints do not cOst.                       I'                             7                  0.0<4

     D.::aths have been linked to the use of vest                       27                             13                 0.015

                                                              Strmgly Awee (%)               Stroogly AfJO! (%)
                                                                  Agrct:.(%)                     /If!!ee(%)
                                                                 Disagree (%)                   Disagree (%)
                                                             Stroogly Disagree (%)          Stroogly Disaguc (%)
     A n:sidc.:nl suffers a loos of digtity ....hen placed               7                             I                  0.019
     in TCSfJaints.                                                     <IQ                           38
                                                                        44                             '9
                                                                         3                             2

     I relieve that restraints inaease the risk of                       3                              I                <tUXX)!
     Slrangula1ion.                                                     J6                             9
                                                                        "8                             I'
                                                                   Alv.ay.; (0/0)                AI\\ays (%)
                                                                  Scmetirms (%)                 Scmctimes (0/0)
                                                                    Never (0/0)                   Never (%)
     I try a1lcrnative meastrcs befere                          78                            6J                 0.035
     reslTaining the resident.                                           22

     I tell fwni ly membcts v.hy the resjdalt is being                  100                            82                 0.001
     restrained.                                                                                       12
      J explain to the resident \\hy the rcsrainl is                     ~                             82                 0006
      being applied.                                                     3                             17

      1 frequently   <NiCSS   if the restraint shwId re                  81                            6J                 0.010
      """,,".                                                            19                            JO

      When phy.;ical restraint is allllial. 1 recad 00                   93                            81                 0.024
      the cadets the t)pe of restraint used. the reason                   7                            11
      f(T adqIting iL the lime whal the appiicatioo                                                     8
      canmenc:cs. and the rcla1ed nla'Sing care
      I frequently e\'alua1e and rc:cad dov.n the effect                 ss                            75                  0.031
      of Jily.;ical restraint ....hen it is applied 10 a
                                                                         I'                            16

      • Licen..o;cd mrses - rt:giSlered mrses and enrolled nurses

December 1999                                                                                                        SUEN

  Table 5:

  Results of chi-square analysis for items with signi fica nt differences among staff with
  different years of experience.

                        [terns                                :ii 6 years             7 or mnre years      p-value

  Knowledge:                                                   % correct                % correct

  A restrai nt should be re leased every 2 hours. if              64                        83              0.006
  lIl e resident is awa ke

  When a res iden t is restrained, skin breakdown                 13                        25              0,032
  may increase.

  A resident should never be restrained wh ile                    11                        26              0.003
  lying no< ;,      because of the danger of
  choking         ""
  Death s have
  restraints.    "'"    linked to the use of vest                 12
                                                                                            "               0.012

  Attitudes :                                             Str Ollg ty Agree (%)     Strongly Agree (%)
                                                               Agree (%)                Agree (%)
                                                              Disagree (%)             Disagree (%)
                                                         Strongly Disagree (%)     Strongly Disagree (%)

  A resi dent suffers a loss of di gn ity when plact:d
  in res tr aints

                                                                  ---                        ,

  I believe tha t restraints increase lIle risk of                 2                         3              0002
  strangul at ion.                                                 10                       30
                                                                   I.                       "8

   Practice :                                                Always (%)                Always ("le)
                                                            Snmetimes (%)             Sometimes ("le)
                                                              Never (%)                 Never (0/ )

   r tell family members why the resident is bein g                82                       96              0.008
   restrained.                                                     12                        I
                                                                   6                         3

                                                                   81                                       0,010
   I upla in to th e res ident why the restraint is
   being applied.                                                  18

Th e Pearson' s product moment correlat ion                             DISCUSSION
showed a signifi cant positi ve re lation ship
between know ledge and attitudes (r=0 .385 ,                            It was found that the knowledge level of the
p <O.OOOl) ; while a weak relationship cou ld                           staff of nursing homes towards restraints was
be observed between attitudes and practice                              inadequate . Most of th em underestimated
( r= 0.189 , p = O. 00 7 ), and between                                 the effect of re straint s app lied to clie nts .
knowledge and practice (r = 0. 150, p =0 .054 ).                        Phys icall y, the limitation of movements in

                                                                                        VoL5 No.2

the client resulted in mu sc le wasting and         members said that the y do not feel guilt y
weakness (Strumpf et al. 1990), unsteadiness        when placing a resident in restraints, nor do
and eve ntually inability to walk (Eig sti &        they feel embarrassed when the fa mily enters
Vrooman 1992; Strumpf et al. 1990), bone            the room of a resident who is restrained .
resorption due to demineralization (Brower          Ove r half of the re spondents (57%) al so
199 1; Conely & Campbell 1991), abrasion            "disagree " or "stron gly disagree" with the
and skin tear s (Press 1991), and decreased         view that a re sident will suffer a lo ss of
appet ite and intak:e (Strumpf & Evans 1991 ).      dignity when placed in restraints . The se
Some authors (Cutchins 1991 ; Lofgren et al.        findings also accord wi th the findings in a
 1989) report that the use of res tra ints can      paper published by Scherer, et al. (1993) who
increase the number of nosocomial infections.       also state that nurses in their study did not
In more serious cases, the misuse of restraints     appear guilt ridden or embarrassed with
may also result in a re sident 's death through     regard to the use of re straints . The
asphyxiation or strangulation (Conely &             assumption appear s to be that physical
Campbell 1991 ). Some res ident s have even         protection is more important than the negati ve
d ied in fires when the y tried to free             psyc hological effect imposed on the resident.
themselves by burning the vests restraining         Strumpf and Evans (1991) report the result
them (Blakeslee et a!. 1991 ).                      of inte rviews with re si dents of nur s in g
                                                    homes, the y found th at many re siden ts
As in many other studie s (Hardin 1994 ;            revealed anger. fear, humiliation , resistance
Mc Hutch ion & Mor se 1991 , Press 1991 ;           and dem oralisation when being restrained.
Slilwell 1991) . parti c ipant s in thi s stud y    A patient who had the experience of being
showe d little awareness of alternatives.           re strained had the following grievances: " '
Current literature (Browe r 1991; Conely &           felt like a dog and c ried all night. It hurts
Campbell 1991 ; Ka llmann et al. 1991 ;             me 10 have to be tied up . I felt like I was
St rump f & Evans 1992) suggests that many           nobody, that I was dirt . It makes me cry to
alternatives to phys ical restra ints do exisl.      talk about it (tears) . The hospita l is worse
Eva ns and Strumpf organise the alternatives         than a jail" (Strumpf & Evans 1988, p.134) .
into five main categories - "companionship           Pre ss (1991, p .30) also s tre ss es that
and supervision , changing treatment, physical       "restraints dehumanise the cari ng process for
and diversional activities, psyc ho socia l          both the client and the caregiver, and ma y
interventions and environmental                      be a violation of the cli ent 's human rights".
man ipul ation " (Koch 1993, p.IO). Some            The vast majority of respondents (77%) in
conc rete sugge stion s have been made by            the pre se nt study believed that if they we re
Janelli e t al. (1 994 ), such as ensuring easy      the res idents, they shou ld have the right to
reac h of a ca ll light , using a calm and 000-      refuse or to resist when restra ints are placed
threatening voice to talk: to the client, playing    o n th e m . Thi s res ponse sugge sts that
soft background mu sic, providing reorient-          re spondents may have nega tiv e thoughts
alion for a patient who is di so riented ,           regarding the use of restrai nts of which they
eva luating the effect of drug s which may           are unaware.
contribute to agitation, and the use of care
plans to meet individua l needs of clients.         Another misapprehension is that many nurses
                                                    believed that restraints could dec rease the
Awareness of the psychological impact of a          number of resident s who fall. Yet , in 10%
re straint on the client was low . Many staff       to 47% of the cases of patients who had fall s,

Dece mber 1999                                                                                  SUEN

physical re stra int s were in place (Ginter &        staff in a more senior position or with longer
Mion 1992). Using restraints in the elderly           yea rs of experience ma y ha ve a hener
decreases muscular strength and there for e           awareness of th e impli ca ti ons of re straint
increases the potentia l for falls (Koch 1993).       usage. Therefore they are in an ideal position
Strumpf & Evans (1988) also sta le that               to act as role models for other staff membe rs
re st raint use often precipitated falls, as          and can prov ide appropriate guidance about
patients attempted to untie restraints. Some          deci sions to apply restra int s, and when to
authors (Blakeslee, Goldman, Popougenis               remove il. Moreover. Werner et al. ( 1994)
and Torell 1991 ) eve n notice that non -             also not ice that registered nurses or licensed
res training fa c ilities cause fewer injuries        prac ti ca l nurses who had more years of
from falls th an fa ci lities that use rest raints.   experience and more sen iority at work more
Therefore the use of re straint s doe s not           easily had their perce ptions changed in the
necessa ril y ensure residents in nursing homes       desired direc tion following the implement -
remain sec ure .                                      ation of a re straint -reduction program.

Though the knowledge level and animdes of             Education rece ived by the staff in the past
the respondents toward s restraints were not          seems still to affect thei r pre se nt attitudes
fa vourable in this study, de sirable practice        towards the use of restrai nts. The majority
was freq uently reported by staff when the            of the respondents (71.7%) stated that the y
resident was restrained . Despite their               have attended an restraint in-service program
favourable scores, ce rtain respon ses are in         of some form in th e past. However, the
co ntra s t to so me o f the items in the             intenSity and the content of the courses were
.. Knowledg e n measurement sec tion and              not exp lored in this study. Accord ing to
needed to be noted. For example, 68 % of              Stilwell (199 1), education about th e use of
respondents stated that they try alternative          re strai nts for nursing staff is often restricted
nursing measure s before res training the             to an hour or less during the orientation in
res id e nt, howeve r man y of them said that         the nurSing homes. Therefore the way to
good alternatives to res traints do not ex ist        impl e me nt the program , and tran s mit
(item 10 in Table I) ; over 97 % of the staff         knowledge into dail y practice have to be
mentioned that they always inspect the skin           monitored and eva lu ated . More vivid and
of the re sident for abrasions or skin tears if       creative teaching methods about restraints
they bath the re sident who is restrained , but       could be considered, such as role playing,
83% indicated that the y do not follow this           case studies, demo nstration s, simulations.
procedure o r do not know that skin                   debates, or involving family members in the
breakdown may be on e of the poss ible                di scuss ion s on restraint use could even be
outcomes when a resident is restrained . This         considered .
 finding may indicate that what the st aff
 believe and what they do may not always be           The s ignificant inte rrel a ti onship among
 the same. As one might anticipate , staff in a       knowledge le ve l , att itud es and practice
 hi ghe r positio n ( reg iste red nur ses and        related to restraints further illustrates that it
 enrolled nurses) and staff with longe r yea rs       is important to co nsider the knowledge level
 of experience in geriatric nursi ng tended to        an d th e powe r one's beliefs bave on one's
 have a bette r knowledge level , the more            practice. It is expected that the higher the
 appropriate attitudes and better pract ice in        knowl e dge level , the more positive th e
 relate to the use of restraints. It may be that      attitudes, and the better the practice .

                                                                                          Vol.5 No.2

Strengthening the know ledge base regarding        negative attitudes evident from data obtained
the use of restraints among staff is the first     for this study could se rve as a basis for the
step to improve the quality of care for the        re-education of nurses in regard to the use
clients. It is hoped that once the knowledge       of restraints and the implications of such use.
gaps are closed, more positive attitude s          More favourable auitudes and better practice
a mon g s taff towards re s train ts can be        towards restraints could be achieved once the
cultivated , thu s leading to more desirable and   knowledge gaps are ·c1osed. Moreover, staff
appropriate practice when re st raints are         in higher po sition s or with more years of
considered .                                       experience could act as role models for other
                                                   staff members so as to prov ide appro priate
                                                   gu idance fo r making decision about applying
LIMITATIONS                                        restraints.

Information for this study was elicited from       The finding s from thi s study could provide
a se lf-se lected sample, therefore information    so me in s i ght for th e nur sing home
from the no n -re spond en ts ca nno t be          administrators on the planning of an inservice
collected. It may be possible that those who       program on rest ra int use for thei r work in g
did not participate may ha ve responded            staff. It is ho pe d that mo re effe c ti ve
differently to the items in this questionnaire .   alternative interventions to restraining clients
To minimi ze bias , second letters with the        could also be explored. If physical restraint
same set of questionnaire were sent to the         is to be employed, it should be used properly.
nursi ng home staff to try to obtain a higher      Staff mu st understand not on ly how to use it
return rate.                                       properly, but also need to know its negative
                                                   consequences so as to limit th e frequen cy
The statements on the que stionnaire were          with which it is used.
frequently worded towards the positive side
on pract ice performance . Consequently,           As Stru mpf. Evans, Wagne r and Patterson
some respondents might tend to answer the se       (1992) emphasize that res tri ct ion s of
s tatem e nt s th e way they believe the           movement by physical restraint generally
researche r would like them to answer rather       symbolize a poor Quality of care, therefore
than the actua l way they perform.                 only when the use of th is harmful practice is
                                                   reduced, or eve n eliminated , can the standard
                                                   of ca re for the re sidents in nursing homes
CONCLUSION AND                                     ultimatel y be improved.

Many myths and mi sconcept ions related to                      ACKNOWLEDGMENT
the use of restraints ex ist among s taff
wo rking in nursing homes in Hong Kong.             This study was funded by a Departmental Research
                                                    Grant fr om the Department of Nursing & Health
The overall knowledge level regardin g              Sciences, the Ho ng Kong Polytechnic Universi ty.
restraint usage is low , and the attitudes are      Special thanks arc due to Or. L.M. lanelli and her
                                                    resea rc h tcam who pe rmi llcd the use o f their
less favou rable. Howeve r, nursing practice        instruments on physical restrainlS in this study.
regar din g restraint u se in dica te s that        Appreciatio n is also ex te nded to the nursi ng
                                                    personnel who participated in tflis project and to
respondenls use restraints in accordance with       Mc. Sa mue l T sa ng who ha s offered his kind
acceptab le practice. Th e misconceptions and       assistance during the data collection process.

December 1999                                                                               SUEN

                                                    Janelli. L.M., Scherer, Y.K., Kuhn, M.M.
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Blakeslee, J.A., Goldman, B.D., Papougenis,         development. Journal of Nursing Staff
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Gerontological Nursing. 17(2),4-8.                  Kallmann, S.L., Denine-Flynn, M. &
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Brower. H.T. (1991). The alternatives to            independen ce: restraint release and its
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restraints in the nursing homes: it can be done.    Magee, R., Hyau, E.C., Hardin . S.B.,
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                                                    Releasing restrainls: a nursing dilemma.
Gimer, S.F. & Mien, L.C. (1992). Falls in           Journal of Gerontological Nursing. 15(2),16-
the nursing home: preventable or inevitable?        21.
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43-48.                                              Mion, L.C. & Mercurio, A.T. (1992).
                                                    Methods to reduce restraints: a nursing
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Neary, M.A. (1991). What nursing staff              Phillips. C.D., Hawe s. C. & Fries, B.E.
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Rehabilitation Nursing. 16(6).345-348.              in nursing homes: will it increase costs?
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                                                                                               Vol.5 NO.2

Press, M.M. (1991) Restraints : protection or            Slrumpf, N.E . & Evans , LK. (199 1) The
abuse? The Canadian Nurse. December, 29-                 ethical problems of prolonged physical restraint.
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Scherer, V.K. , Janelli, L.M ., Wu , Y.B . &
Kuhn , M. M. ( 1993) Restrained patients: an             Strumpf, N. E. , Evans, L.K ., Wagner , J . &
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Stilwell , E . M. (1991) Nurses' education               27.
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                                                         Gonzales, I. & Gluss man, B . (1992). To
Slrumpf, N.E. & Evans, LX (1988) Physical                restrain or not to restrain? The decision-making
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(3), 132-137.
                                                         Werner. P., Cohen-Mansfield , J .. Koroknay.
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( 1990) Restraint-free care: from dream to               impact on s taff attitudes. Journa l 0/
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124 .

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