Evidence-based Practice Of Minimized Physical Restraint Program For Older Adults In Medical-nursing Facilities

Objectives:1.To investigate the current situation of physical restraint(PR)use among older adults in medical-nursing facilities and analyze its influencing factors from characteristics of older adults,nursing staff and facilities,so as to provide clinical basis for minimized PR grogram construction.2.To integrate the best evidence for PR prevention and management among older adults in medical-nursing facilities and provide evidence-based references for minimized PR grogram construction.3.To construct and test the applicability of minimized PR grogram for older adults in medical-nursing facilities.Methods:1.Investigation on PR among older adults in medical-nursing facilities(1)The use of PR and its related risk factors: A total of 1026 older adults from six medical-nursing facilities in Chongqing,selected by cluster sampling method,were investigated using a questionnaire on PR use of older adults in medical-nursing facilities.Direct observation,a review of older adults’ records and interviews with nursing staff were used to complete a data collection.The independent risk factors for PR use were assessed with chi-square test and binary logistic regression.(2)Qualitative study on PR practice of nursing staff: Based on the theory of planned behavior,20 nursing staff from 2 medical-nursing facilities in Chongqing were selected for open-ended questionnaires survey and 12 nursing staff for semi-structured interview.Data were analyzed by Colaizzi’s phenomenological method.(3)Quantitative study on PR practice of nursing staff: A total of 316 nursing staff from medical-nursing facilities in Chongqing was selected via cluster sampling method.PR-TPB questionnaire and the practice subscale of the Chinese version of the Staff Knowledge,Attitudes and Practices Questionnaire regarding PR were used to collect the data.Structural equation modeling(SEM)was used to examine the relationship between variables.2.Evidence synthesis on PR among older adults in medical-nursing facilities(1)Meta-analysis of the effect of PR interventions: We searched databases including Pubmed,CINAHL,EMBASE,Web of Science,Cochrane library(CENTRAL),Psyc INFO,CNKI,Wan Fang Data,VIP and Open Grey.Rev Man 5.3 software was used to conduct meta-analysis.(2)Content analysis of relevant guidelines and systematic reviews: We searched guidelines,best practice,evidence summary,recommended practice,expert consensus and systematic review from relevant guideline website,database between 2000 and 2020,and evaluated,integrated the content.3.Construction of minimized PR program for older adults in medical-nursing facilitiesThe preliminary draft of minimized PR program was constructed based on current situation investigation and evidence summary,and a panel meeting was organized to form the final draft.4.A pilot study of minimized PR program for older adults in medical-nursing facilitiesA single-group pre-post design was conducted to test the applicability of minimized PR program in a medical-nursing facility(n=97)in Chongqing.Qualitative study method was performed to understand the experience of nursing staff during the practice of minimized PR program.Quantitative study method was used to evaluate the changes of relevant outcomes in the older adults and nursing staff before and after intervention.Quantitative data were analyzed using paired t-test,Wilcoxon signed rank test,chi-square test or Fisher precise test before and after the intervention.Results:1.Investigation on PR among older adults in medical-nursing facilities(1)The use of PR and its related risk factors: The prevalence of PR in six medical-nursing facilities in China was 25.83%.Waist belts(55.47%)and wrist restraint(52.83%)were most frequently used.Only 61.51% of physical restraints were signed with informed consent.71.70% of physical restraints were caused by the prevention of falls,89.06% of physical restraints were without nursing documentation,and 13.58% of restrained older adults were observed to have physical complications.Facility type and ownership,older adults per nursing assistant,length of residence,cognitive impairment,care dependency,mobility restriction,fall risk,physical agitation and indwelling tubes emerged as important risk factors for the use of physical restraints(P<0.05).(2)Qualitative study on PR practice of nursing staff: Nursing staff’s behavioral,normative and control beliefs of PR use were identified,including eight themes as following: cognition,attitude,emotional experience,group pressure,moral pressure,responsibility pressure,external facilitators and barriers.(3)Quantitative study on PR practice of nursing staff: The mean total score of the items on nursing practice toward PR was 30.89(SD=4.82).The mean score of the attitude,subjective norms,perceived behavioral control and intention was 5.30(SD=0.62),4.55(SD=0.73),3.99(SD=1.31),5.05(SD=0.88),respectively.Stronger attitude(β=0.536,P<0.001),PBC(β=0.139,P<0.05)were all related to stronger intention.Stronger subjective norms was also related to the stronger intention,however,the path coefficient had no statistical significance(β =0.046,P=0.646).Perceived behavioral control displayed a negative direct effect(β=-0.348,P<0.001)on nursing practice,but intention was not a significant predictor of practice(β =-0.117,P=0.057).2.Evidence synthesis on PR among older adults in medical-nursing facilities(1)Meta-analysis of the effect of PR interventions: Education program[OR=0.68,95%CI(0.28-1.64),P=0.39],education combined with consultation [OR=0.76,95%CI(0.29-1.98),P=0.58] were not statistically significant.The effect of multi-component intervention on reducing PR was statistically significant [OR=0.74,95%CI(0.64-0.86),P<0.001].There was no statistically significant effect of reducing PR intervention on fall[OR=0.89,95%CI(0.64–1.24),P=0.48],fall-related injuries [OR =1.14,95% CI(0.79–1.65),P =0.47] and the use of psychotropic drugs [OR =1.09,95% CI(0.89–1.33),P = 0.41].(2)Content analysis of relevant guidelines and systematic reviews: A total of 17 articles was finally included,containing 1 guideline,2 evidence summaries,2 best practices,1 recommended practice,3 expert consensus,and 8 systematic reviews.25 pieces of evidence summarized,including definition,staff required,evaluation,decision-making,informed consent,preventive measures,implementing,monitoring,recording,reporting,education and organizational policy support.3.Construction of minimized PR program for older adults in medical-nursing facilitiesThe minimized PR program for older adults in medical-nursing facilities included 13 dimensions,29 items: PR use principles,organizational support,personnel requirement,evaluation,decision-making,informed consent,alternatives,implementation,monitoring,removing,recording and reporting,personnel training.The expert authority coefficient is 0.894.4.A pilot study of minimized PR program for older adults in medical-nursing facilities(1)Quantitative results: After educational intervention,a statistically significant increase in the mean knowledge,attitude,and practice scores and a decrease in the mean intention scores of nursing staff toward PR(P<0.001).There was no significant difference in PR use after the 3-month intervention.However,a statistically significant increase in the correct use of PR and a decrease in the daytime of restraint(P<0.05).There was no statistically significant effect of reducing PR intervention on fall and fall-related injuries,psychotropic drugs use(P>0.05).(2)Qualitative results: Seven themes were refined,including deepening theoretical understanding,changing cognition and attitude,improving practical ability,positive experience of program practice,negative experience of program practice,difficult assessment of restraint necessity,and obstacles to the implementation of alternative measures.Conclusion:1.The use of PR among medical-nursing facilities older adults was at a relatively high level and lacking of standardized and regulated practices.It was affected by complicated factors including the characteristics of older adults,nursing staff and facilities.Effective restraints minimization approaches should consider these risk factors,which is of significance for improving long-term care quality and promoting the life quality of older adults.2.The evidence-based construction of minimized PR program in medical-nursing facilities is scientific,comprehensive and specific.Although it couldn’t reduce the PR rate,it improves staff’s knowledge,attitude and practice toward PR,improve the correct use of PR,reduce the daytime of PR and standardize the type of restraint,but the program still needs further research and promotion.