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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.

Le recours aux contentions physiques auprès des personnes âgées hospitalisées demeure une problématique malgré l'abondance d'écrits scientifiques sur la nécessité d'en réduire l'usage pour la sécurité et le maintien de la dignité des patients, notamment par l’utilisation des mesures alternatives. Les infirmières, qui sont parmi les professionnels de la santé qui ont la responsabilité d'en déterminer l'utilisation et la surveillance auprès d'aînés, se perçoivent comme étant peu formées sur le sujet. Bien que diverses interventions éducatives aient été mises en place pour tenter d'en réduire l'utilisation, leur efficacité sur les changements de pratique des infirmières demeure limitée. Par ailleurs, des interventions éducatives actives et engageantes, telle qu'une intervention de pratique réflexive, seraient pertinentes à explorer puisqu'elles semblent soutenir le développement professionnel des infirmières et l'amélioration des pratiques cliniques. Une étude pilote à devis mixte a permis de mettre à l'essai une intervention de pratique réflexive portant sur l’utilisation des contentions physiques auprès de huit infirmières d'un centre hospitalier universitaire et d'en évaluer l'acceptabilité, la faisabilité ainsi que les retombées. Les données collectées au moyen de questionnaires, de journaux réflexifs (infirmières participantes), d’un journal de bord (étudiante-chercheuse) et de groupes de discussion focalisée ont été analysées selon la méthode d’analyse thématique de Paillé et Mucchielli ainsi que de tests de Student. Les résultats de cette étude suggèrent qu’une intervention de pratique réflexive est acceptable et faisable auprès des infirmières, en plus d’améliorer leurs connaissances et favoriser leur réflexion quant à leurs attitudes et leur pratique en lien avec l’utilisation des contentions physiques auprès des personnes âgées hospitalisées. Cette étude a permis de relever les forces et les pistes d’amélioration de l’intervention. De nouvelles études portant sur l’évaluation des effets d’une intervention de pratique réflexive sur l’amélioration des pratiques cliniques des infirmières au regard de l’utilisation de la contention seraient pertinentes à mener. / The use of physical restraints on hospitalized elderly persons remains a concern despite the abundance of scientific literature emphasizing the need to reduce their use for the safety and dignity of patients through the implementation of alternative measures. Nurses, who are among the healthcare professionals responsible for determining the use and monitoring of restraints, perceive themselves as poorly trained on the subject. Although various educational interventions have been implemented to try to reduce their use, their effectiveness in changing nurses' practices remains limited. Moreover, active and engaging educational interventions, such as a reflective practice intervention, would be relevant to explore, as they appear to support nurses' professional development and the improvement of their clinical practices. A mixed-design pilot study was conducted to test a reflective practice intervention on the use of physical restraints with eight nurses from a university hospital and to assess its acceptability, feasibility, and outcomes. Data were collected through questionnaires, reflective journals (from participating nurses), field notes (from the student-researcher) and focused groups, and were analyzed using Paillé and Mucchielli's thematic analysis method as well as Student's t-tests. The results of this study suggest that a reflective practice intervention is acceptable and feasible among nurses, in addition to enhancing their knowledge and encouraging reflection on their attitudes and practices related to the use of physical restraints among hospitalized elderly. This study identified strengths and avenues for improvement in the intervention. Further studies evaluating the effects of a reflective practice intervention would be relevant.

Unplanned extubation is premature removal of endotracheal tube, is an adverse event; which can either, be accidental during a nursing procedure or self deliberate by the patient. The AACN Synergy Model for Patient Care was used as conceptual model for this study. A retrospective descriptive design revealed that over a period of two years, 327 patients admitted to the intensive care unit require intubation of which 40.4% were self-deliberate extubation and 59.4% accidental extubation. Of the accidental extubated patients, 29.8% had physical restrains, 57.6% received sedation, 43.9% had analgesic infusion and 38.9% were on neuromuscular blockade. A means Glasco Coma Scale was 9.4 and 56% of the patients were reported as being. Most patients (89.9%) required re-intubation. The findings also revealed that 49.1% of the nurses who cared for the patients when the extubation occured had one patient at the time. Also, 84.2% of nurses had 0-6 years of nursing experience and 74% of nurses had less than five years of ICU experience. / Health Studies / M.A. (Health Studies)

PURPOSE: Substantial research demonstrates that many nursing homes are not providing adequate quality of care for residents because of inadequate processes of care and insufficient numbers and training of nursing staff. Some residents experience poor-quality outcomes, such as pressure ulcers and unintended weight loss. To address these issues, the long-term care industry has focused on improving quality of care by improving staff education about care processes and reducing nurse turnover rate. The aim of this study was to compare the association between - licensed nurse hours of care and turnover rate to five quality measures—incidence of ADL decline, physical restraints, prevalence of pressure ulcers among residents with risk factors for skin breakdown, and prevalence of unintended weight loss. DESIGN: The study population included 618 freestanding Texas nursing facilities. A cross-sectional multiple regression analysis was conducted using 2007 data to examine the relationship between nurse staffing levels and turnover and resident outcomes with control variables for facility and resident characteristics. RESULTS: The high-risk pressure ulcer variable accounted for 10% of the variation in the regression model. LVN (hprd) was positively associated with an increase in high-risk pressure ulcers. The ADL decline variable accounted for 7.5% of the variation in the regression model, and RN hprd was positively associated with ADL decline. The prevalence of weight loss variable accounted for 3% of the variation in the regression model. RN turnover rate was approaching significance. The physical restraint variable accounted for 2% of the variation in the regression model. LVN contract hprd was significant and positively associated with an increase in physical restraint use although a minimal contribution to the model given the low percentage of LVN contract hprd. The prevalence of low-risk pressure ulcers was not significant. The control variable case mix index was positively associated with ADL decline, high-risk pressure ulcers, and weight loss. CONCLUSIONS: This research will contribute to understanding the relationship of licensed nursing staff to resident outcomes. Additionally, it will contribute to nursing education, research, and policy. While controlling for acuity using case mix index, some negative findings were still noted that requires further research. / text

Diss. (sammanfattning) Umeå : Umeå universitet, 2010. / Härtill 4 uppsatser.

Unplanned extubation is premature removal of endotracheal tube, is an adverse event; which can either, be accidental during a nursing procedure or self deliberate by the patient. The AACN Synergy Model for Patient Care was used as conceptual model for this study. A retrospective descriptive design revealed that over a period of two years, 327 patients admitted to the intensive care unit require intubation of which 40.4% were self-deliberate extubation and 59.4% accidental extubation. Of the accidental extubated patients, 29.8% had physical restrains, 57.6% received sedation, 43.9% had analgesic infusion and 38.9% were on neuromuscular blockade. A means Glasco Coma Scale was 9.4 and 56% of the patients were reported as being. Most patients (89.9%) required re-intubation. The findings also revealed that 49.1% of the nurses who cared for the patients when the extubation occured had one patient at the time. Also, 84.2% of nurses had 0-6 years of nursing experience and 74% of nurses had less than five years of ICU experience. / Health Studies / M.A. (Health Studies)