Restraint use in older adults in home care: A systematic review

OBJECTIVES: To get insight into restraint use in older adults receiving home care and, more specifically, into the definition, prevalence and types of restraint, as well as the reasons for restraint use and the people involved in the decision-making process. DESIGN: Systematic review. DATA SOURCES: Four databases (i.e. Pubmed, CINAHL, Embase, Cochrane Library) were systematically searched from inception to end of April 2017. REVIEW METHODS: The study encompassed qualitative and quantitative research on restraint use in older adults receiving home care that reported definitions of restraint, prevalence of use, types of restraint, reasons for use or the people involved. We considered publications written in English, French, Dutch and German. One reviewer performed the search and made the initial selection based on titles and abstracts. The final selection was made by two reviewers working independently; they also assessed study quality. We used an integrated design to synthesise the findings. RESULTS: Eight studies were reviewed (one qualitative, seven quantitative) ranging in quality from moderate to high. The review indicated there was no single, clear definition of restraint. The prevalence of restraint use ranged from 5% to 24.7%, with various types of restraint being used. Families played an important role in the decision-making process and application of restraints; general practitioners were less involved. Specific reasons, other than safety for using restraints in home care were noted (e.g. delay to nursing home admission; to provide respite for an informal caregiver). CONCLUSIONS: Contrary to the current socio demographical evolutions resulting in an increasing demand of restraint use in home care, research on this subject is still scarce and recent. The limited evidence however points to the challenging complexity and specificity of home care regarding restraint use. Given these serious challenges for clinical practice, more research about restraint use in home care is urgently needed.status: publishe

Reducing physical restraints by older adults in home care: development of an evidence-based guideline

BACKGROUND: Restraint use is a complex and challenging issue in home care. Due to socio-demographic trends, worldwide home healthcare providers are faced with an increasing demand for restraint use from informal caregivers, patients and healthcare providers, resulting in the use of various types of restraints in home care. Awareness and knowledge of restraint use in home care, its implications and the ethical challenges surrounding it are of crucial importance to its reduction. This research aimed to describe the development process of an evidence-based practice guideline to support caregivers to optimize home care. METHOD: The practice guideline was developed according to the framework of the Belgian Centre for Evidence-Based Medicine and AGREE II. The guideline was developed over several stages: (1) determination of the target population and scope, (2) literature search, (3) drafting and (4) validation. A multidisciplinary working group determined the proposed purpose, target group, and six clinical questions for the guideline. A consensus procedure and consultation by experts were used to develop the guideline. RESULTS: The guideline provides an answer to six clinical questions and contains ten key recommendations based on the classification of GRADE, with the objective of increasing healthcare providers' awareness, knowledge and competence to adequately deal with situations or questions related to restraint use. The guideline also includes a flowchart for dealing with complex situations where the use of restraints is requested, already present or considered. CONCLUSIONS: The guideline was validated by the Belgian Centre for Evidence-Based Medicine. Increasing competence, awareness and knowledge related to restraint use are key objectives of the guideline for reducing restraint use in home care. A multicomponent intervention to support healthcare workers in implementing the guideline in clinical practice needs to be developed.status: publishe

De ontwikkeling en evaluatie van een multicomponent-programma voor de implementatie van de praktijkrichtlijn 'Streven naar een fixatiearme thuiszorg'

Achtergrond: Schattingen voor de prevalentie van het gebruik van fysieke fixatie bij patiënten in de thuiszorg variëren van 5% tot 25%. Om zorgverleners te ondersteunen in het omgaan met vragen rond fysieke fixatie, werd de Vlaamse praktijkrichtlijn ‘Streven naar een fixatiearme thuiszorg’ ontwikkeld en vervolgens gevalideerd door CEBAM. Het implementeren van richtlijnen in de thuiszorg is echter een hele uitdaging. Enkel het verspreiden van de praktijkrichtlijn is onvoldoende om deze in de dagelijkse praktijk te krijgen. Daarom werd een multicomponent-programma ontwikkeld om de implementatie van de praktijkrichtlijn ‘Streven naar een fixatiearme thuiszorg’ te faciliteren. Methodologie: Er werd gebruik gemaakt van Intervention Mapping (IM) om het multicomponent-programma te ontwikkelen. Dit raamwerk omvat zes stappen: (a) een logisch model van het probleem, (b) een logisch model van verandering, (c) het selecteren van theorie gebaseerde interventiemethodieken en praktische toepassingen, (d) een programma ontwikkeling, (e) een implementatieplan en (f) een evaluatieplan. Elke stap bestaat uit verschillende taken en draagt bij tot het ontwikkelen van een interventie die theoretisch, empirisch en praktisch is. In het kader van dit project werden de eerste vier stappen genomen om het multicomponent-programma te ontwikkelen. Het ontwikkelde programma werd gedurende acht maanden in een pilootstudie in Vlaanderen uitgetest. Een mixed-methods design werd gebruikt om het multicomponent-programma te evalueren. Resultaten: Het ontwikkelde multicomponent-programma bestaat uit acht componenten: een website, de sociale media, een promofilm, een flyer, een samenvatting van de praktijkrichtlijn, een fysieke fixatiefiche, twee tutorials en een opleiding ‘ambassadeurs fixatiearme thuiszorg’. Zorgverleners die deelnamen aan de pilootstudie hebben de verschillende onderdelen van het programma positief geëvalueerd. Het multicomponent-programma vergrootte hun kennis en bewustzijn. Het ondersteunde zorgverleners in het complexe besluitvormingsproces rond het gebruik van fysieke fixatie in de thuiszorg. Verder was het voor hen belangrijk dat de componenten herkenbaar, compact, kort en bondig waren. Voor een succesvolle implementatie van de praktijkrichtlijn ‘Streven naar een fixatiearme thuiszorg’ in de toekomst, was het volgens zorgverleners echter ook cruciaal om leidinggevenden, directies en beleidsmedewerkers al bij de start van het proces te betrekken, meer tijd te nemen voor het implementatieproces, ‘champions’ te selecteren, verschillende stakeholders te betrekken en meer samen te werken met de verschillende zorgverleners in de thuiszorg. Conclusie: De resultaten van de pilootstudie zijn veelbelovend. Voor verdere implementatie dient onderzoek zich te focussen op de brede uitrol, verankering en evaluatie van het ontwikkelde multicomponent-programma in de volledige Vlaamse thuiszorg.status: publishe

Restraint Use in Older Adults Receiving Home Care

OBJECTIVES: To determine the prevalence, types, frequency, and duration of restraint use in older adults receiving home nursing care, and to determine factors involved in the decision-making process for restraint use and application. DESIGN: Cross-sectional survey of restraint use in older adults receiving home care completed by primary care nurses. SETTING: Homes of older adult patients receiving care from a home nursing organization in Belgium. PARTICIPANTS: Randomized sample of older adults receiving home care (N=6,397; mean age 80.6; 66.8% female). MEASUREMENTS: For each patient, nurses completed an investigator-constructed and -validated questionnaire collecting information demographic, clinical and behavioral characteristics and aspects of restraint use. A broad definition of restraint was used that includes a range of restrictive actions. RESULTS: Restraints were used in 24.7% of the participants, mostly on a daily basis (85%) and often for a long period (54.5%, 24 h/d). The most common reason for restraint use was safety (50.2%). Other reasons were the individual wanted to remain at home longer, which necessitates the use of restraints (18,2%) and to provide respite for the informal caregiver (8.6%). The latter played an important role in the decision and application process. The physician was less involved in the process. In 64.5% of the cases, there was no evaluation after restraint use was initiated. CONCLUSION: Use of restraints is very common in older adults receiving home-care nursing in Belgium. These results contribute to a better understanding of the complexity of use of restraints in home care, a situation that may be even more complex than that in residential and acute hospital settings.status: publishe

De ervaringen van thuisverpleegkundigen bij het toepassen van vrijheidsbeperkende maatregelen: een kwalitatieve studie

SAMENVATTING ‘De ervaringen van thuisverpleegkundigen bij het toepassen van vrijheidsbeperkende maatregelen: een kwalitatieve studie’ Probleemstelling Op basis van de huidige evoluties wordt verwacht dat thuisverpleegkundigen in toenemende mate geconfronteerd zullen worden met de vraag naar het toepassen van vrijheids-beperkende maatregelen. Vergeleken met de residentiële sector is er in de thuiszorg weinig informatie beschikbaar over dit onderwerp. Onderzoeksvraag: Wat zijn de ervaringen van thuisverpleegkundigen bij het toepassen van vrijheidsbeperkende maatregelen? Methode Om de ervaringen van thuisverpleegkundigen te bestuderen is gekozen voor een kwalitatief exploratief onderzoek. De doelgerichte steekproef bestaat uit thuisverpleegkundigen die ervaring hebben met het gebruik van vrijheidsbeperkende maatregelen. De gegevens-verzameling gebeurt a.d.h.v. diepte-interviews (n = 14) en met behulp van een semi-gestruc-tureerde vragenlijst. De uitgeschreven interviews zijn geanalyseerd met behulp van het software programma Nvivo. Het onderzoek is goedgekeurd door de Commissie Medische Ethiek van de Universitaire Ziekenhuizen K.U.Leuven. Resultaten Het toepassen van vrijheidsbeperkende maatregelen wordt door de thuisverpleegkundigen ervaren als een moeilijk, controversieel en ethisch geladen onderwerp, hetgeen de beschrijving ervan niet vergemakkelijkt. Uit de interviews blijkt heel wat onduidelijkheid rond het begrip ‘vrijheidsbeperkende maatregelen’. We merken dat thuisverpleegkundigen geen eenduidige invulling kunnen geven van het begrip vrijheidsbeperkende maatregelen en dat er onduidelijkheid is omtrent de eigen verantwoordelijkheid met betrekking tot deze maat-regelen. Daarnaast merken we dat het toepassen van vrijheidsbeperkende maatregelen in de thuiszorg ervaren wordt als een complex, interactief gebeuren tussen patiënt, familie en verpleegkundigen waarin het streven naar professioneel verantwoord handelen centraal staat. De wens om in vaak moeilijke situaties ‘goede zorg’ te verlenen loopt als een rode draad doorheen alle interviews. De professionaliteit komt vooral tot uiting in de wijze waarop thuisverpleegkundigen met de verschillende situaties trachten om te gaan. Opvallend hierbij is de voortdurende wisselwerking tussen het empatische en doordacht handelen van de thuisverpleegkundigen, dit in samenwerking met het team. De rol van de huisarts is echter minder duidelijk. Tot slot heeft het toepassen van vrijheidsbeperkende maatregelen een grote impact op de verpleegkundigen zelf en gaat het toepassen van deze maatregelen gepaard met heel wat belevingen bij de thuisverpleegkundigen, die al naargelang de situatie, positief of negatief gekleurd kunnen zijn.status: publishe

Factors associated with use of restraints on older adults with home care: A secondary analysis of a cross-sectional survey study.

BACKGROUND: Although there is evidence that use of restraints in home care is increasing, research into the factors associated with restraints in this setting is scarce. OBJECTIVE: To gain insight into the factors associated with restraints in older adults receiving home care. DESIGN: A secondary analysis of a cross-sectional survey about restraint use in home care. SETTINGS: Older adults receiving home care in Belgium. PARTICIPANTS: 8000 subjects were randomly selected from a total of 45,700 older adults. The mean age of the sample (n = 6397) was 80.6 years, 66.8% were women and 46.4% lived alone. METHODS: A cross-sectional survey of restraint use on older adults receiving home care from a nursing organisation in Belgium was completed by the patients' primary care nurses. A binary logistic regression model with generalised estimating equations was used to evaluate factors associated with restraint use. Additional analyses focused on the subgroups with and without an informal caregiver and living alone / with others. Data from 6397 participants were analysed in detail. RESULTS: Multivariate logistic regression indicated that restraint use was associated with supervision [OR = 2.433, 95% CI = 1.948-3.038]; dependency in activities of daily living (i.e. eating [OR = 2.181, 95% CI = 1.212-3.925], transfer [OR = 2.131, 95% CI = 1.191-3.812] and continence [OR = 1.436, 95% CI = 0.925-2.231]; perceived risk of falling in the nurses' clinical judgement [OR = 1.994, 95% CI = 1.710-2.324], daily behavioural problems [OR = 1.935, 95% CI = 1.316-2.846] and less than daily behavioural problems [OR = 1.446, 95% CI = 1.048-1.995]; decreased well-being of the informal caregiver [OR = 1.472, 95% CI = 1.126-1.925], the informal caregiver's dissatisfaction with family support [OR = 1.339, 95% CI = 1.003-1.788]; patient's cognitive impairment [OR = 1.398, 95% CI = 1.290-1.515]; and polypharmacy [OR = 1.415, 95% CI = 1.219-1.641]. The nurses' perception of risk of falling, cognitive impairment (observed with the Cognitive Performance Scale) and supervision are the only variables consistently associated with restraint use across all the analyses. CONCLUSION: The study results provide insight into new and context-specific factors associated with restraint use in home care (e.g. supervision, informal caregiver's decreased well-being and dissatisfaction with family support). These insights could support the development of interventions to reduce restraint use in home care.status: publishe

Restraint use in home care: a qualitative study from a nursing perspective

BACKGROUND: Despite the growing demand for home care and preliminary evidence suggesting that the use of restraint is common practice in home care, research about restraint use in this setting is scarce. METHODS: To gain insight into the use of restraints in home care from the perspective of nurses, we conducted a qualitative explorative study. We conducted semi-structured face-to-face interviews of 14 nurses from Wit-Gele Kruis, a home-care organization in Flanders, Belgium. Interview transcripts were analyzed using the Qualitative Analysis Guide of Leuven. RESULTS: Our findings revealed a lack of clarity among nurses about the concept of restraint in home care. Nurses reported that cognitively impaired older persons, who sometimes lived alone, were restrained or locked up without continuous follow-up. The interviews indicated that the patient's family played a dominant role in the decision to use restraints. Reasons for using restraints included "providing relief to the family" and "keeping the patient at home as long as possible to avoid admission to a nursing home." The nurses stated that general practitioners had no clear role in deciding whether to use restraints. CONCLUSIONS: These findings suggest that the issue of restraint use in home care is even more complex than in long-term residential care settings and acute hospital settings. They raise questions about the ethical and legal responsibilities of home-care providers, nurses, and general practitioners. There is an urgent need for further research to carefully document the use of restraints in home care and to better understand it so that appropriate guidance can be provided to healthcare workers.status: publishe

The experiences, needs and expectations of patients regarding participation at home : an explorative study in Belgium

Background: Patients have an important role in the improvement of their health. Patient participation is a key component to achieving this. Some form of patient participation is already present in home care, but this needs to be optimised. Aim: Gaining insight into the expectations, experiences and needs of patients regarding patient participation in home care. Design: A qualitative design was used. Setting: The study was conducted in the Flemish part of Belgium, in a purposeful sample of patients who have already received nursing care at home for at least 6 weeks. Methods: Semi-structured face-to-face in-depth interviews were conducted and analysed using the Qualitative Analyse Guide of Leuven. Results: Patient participation in home care is a dynamic process. A total of six components, which interact with each other, were identified that explain this process. Conclusion: Patient participation in home care is the interaction of different components of a whole mechanism. Within this mechanism, home nurses play a key role to facilitate participation for patients

The professional self-image of home nurses in Flanders (Belgium): a cross-sectional questionnaire survey

Despite their necessity and relevance, studies examining the professional self-image of nurses and instruments to measure this professional self-image in the homecare setting are scarce. This study highlights both the positive self-image of home nurses and the existence of a delicate balance between the large degree of autonomy that home nurses have and the need to feel supported in their professional role and responsibility. The practice environment, including time pressure, workload, and insufficient support, needs to be addressed to keep it from having a negative impact on the professional self-image of home nurses in the long-term.status: publishe