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

Research article Open Access Open Peer Review Restraint use in home care: a qualitative study from a nursing perspective Kristien Scheepmans1, 2, Bernadette Dierckx de Casterlé2, Louis Paquay1, Hendrik Van Gansbeke1, Steven Boonen^3, 4 and Koen Milisen2, 3Email author ^Deceased BMC Geriatrics201414:17 https://doi.org/10.1186/1471-2318-14-17 ©  Scheepmans et al.; licensee BioMed Central Ltd. 2014 Received: 27 June 2013Accepted: 4 February 2014Published: 5 February 2014 Open Peer Review reports Abstract 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. Keywords Home carePhysical restraintsNursing Background Despite increasing evidence of negative consequences [1–4], the use of physical restraints is still common practice in many countries. The prevalence ranges between 4% and 85% in nursing homes [4] and between 8% and 68% in hospitals [5]. This wide range partly reflects varying definitions for what constitutes restraint, different populations studied, and different countries with differences in legislation and practice. Due to shifting demographic, economic, and technological trends and the desire of patients to live at home as long as possible, home care is growing in demand. With these trends, an increasing number of frail older persons are living at home despite major cognitive disturbances and functional disabilities [6, 7], conditions known to be associated with an increased use of restraints [4, 5]. As a consequence, healthcare workers are increasingly confronted with restraint use, even in home care. Research on this topic in home care is scarce. One study conducted in the Netherlands suggested that restraint use in home care is common practice [8]. The use of restraints has a large impact on patients (e.g., physical and psychological consequences); family (e.g., anger, worry); and healthcare workers (e.g., mixed emotions such as anger, reassurance) [1, 4, 5, 9]. Furthermore, the decision process to use restraints lies along a complex trajectory that depends on patient characteristics and on the attitude of nurses (e.g., nurses’ perception of patient behavior, their willingness to take risks, or their own comfort). It also depends on context-related factors such as family involvement, which can have a positive or negative impact on nurses’ decision making; insufficient time to discuss restraint use with other staff members like physicians; lack of staff; and the requirement of balancing safety, and ethical and legal aspects [4, 10, 11]. Current understanding about restraint use derives mostly from acute and long-term residential settings. Knowledge about restraint use obtained from residential settings does not easily generalize to the home-care setting, because of the uniqueness of the home-care setting. Moreover, it is unclear how the little research that has been done in home-care settings relates to that done in long-term residential care settings. In the home-care setting, healthcare professionals work in the patient’s personal living environment rather than in a healthcare facility, where they have more control over decisions. Moreover, they see their patients for short visits; thus, they have no opportunity to continuously supervise restrained persons. Also, home-care nurses typically work alone, often leaving them in an unsupported professional position when confronted with decisions about restraints. Patients’ relatives also play a crucial role and may even take the lead in the decision-making process [12, 13]. These factors emphasize the need for research on restraint use in home-care settings. Because of their pivotal role in home care and their intensive interactions with family and other healthcare workers, home-care nurses are in an excellent position to provide relevant information about the use of restraints in home care. The aim of this study was to gain initial insights into the use of restraints in home care in Flanders, Belgium, from the perspective of home nurses. The overarching research question was, “What are nurses’ experiences about restraint use in Flemish home care?” Methods Design A qualitative explorative study was performed to gain more insight into the experiences nurses have with restraint use in the home-care setting [14, 15]. Physical restraint is defined as using “any device, material or equipment attached to or near a person’s body and which cannot be controlled or easily removed by the person and which deliberately prevents or is deliberately intended to prevent a person’s free body movement to a position of choice and/or a person’s normal access to their body” [16]. We extended this definition to include other forms of restraint; e.g., chemical and environmental restraints and any other action applied by someone that restricts another person’s freedom in some way. Setting The study was conducted in the Wit-Gele Kruis, an umbrella organization that provides home nursing in Flanders, Belgium. In Belgium, professional home nursing is provided by a private organization, an agency, or by self-employed nurses. Organizations, such as the Wit-Gele Kruis, have a similar organizational structure to a hospital: nursing director, management head, and nurses. All nurses working at Wit-Gele Kruis are employees and provide care for patients living at home. Professional hom (...truncated)