ORIGINAL ARTICLE
An exploration of the practice of restricting a child’s movement in hospital: a factorial survey Maria Brenner, Jonathan Drennan, Margaret Pearl Treacy and Gerard M Fealy
Aims and objectives. To identify the reported predictors of the practice of restricting a child for a clinical procedure in hospital. Background. Previous work in this area is dominated by discussion papers and suggestions for addressing the issue of restriction. This is the first study to explore reported predictors of this practice with a view to implementing change based on research findings. Design. A factorial survey was developed, which incorporated the use of vignettes with various scenarios. The factorial design enabled exploration of the interaction of multiple factors on the practice of restriction. Methods. One hundred and sixty-six nurses caring for children were each sent 10 vignettes and asked to rate their likelihood to restrict a child based on the vignettes. A total of 105 nurses responded to the survey, representing a response rate of 63%. Hierarchical linear regression was used to identify reported predictors of restriction. Results. Nurses were more likely to restrict a child if they had prior instruction on safe holding, if there was no play therapist available, if the nurse was a registered general nurse with no other registration qualification, if the child required cannulation or if the child was less than five years of age. Conclusion. This study identified predictors of restriction from the perspective of practicing nurses; the evidence needs to be used in developing clinical guidelines and in multidisciplinary education. Relevance to clinical practice. There is a need to move from any presumption of restriction towards more critical consideration of the individual requirements of the child. There is a need to increase the numbers of nurses receiving specialist training on the care of a child in hospital. The importance of a well-resourced play therapy service is supported, and there is a need for multidisciplinary work to explore alternatives to restriction.
What does this paper contribute to the wider global clinical community?
• This paper challenges a practice •
•
that is generally implicit in the care of a child in hospital. The use of a factorial design offers an innovative way to explore potentially sensitive issues in practice. Recommendations for improving practice support international discourse on the ongoing need for enhanced care of the child in hospital in accordance with their individual developmental needs.
Key words: children in hospital, clinical procedure, factorial survey, restriction Accepted for publication: 24 May 2014
Authors: Maria Brenner, PhD, RCN, RGN, Lecturer, School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland; Jonathan Drennan, PhD, Dip Statistics, RGN, Professor of Healthcare Research, Centre for Innovation and Leadership in Health Sciences, Faculty of Health Sciences, University of Southampton, Highfield, Southampton, UK; Margaret Pearl Treacy, PhD, RGN, Emeritus Professor of Nursing, School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin; Gerard M
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1189–1198, doi: 10.1111/jocn.12650
Fealy, PhD, RGN, Associate Professor and Associate Dean for Research & Innovation, School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland. Correspondence: Maria Brenner, Lecturer, School of Nursing, Midwifery & Health Systems, Health Sciences Building, Belfield Campus, University College Dublin, Dublin 4, Ireland. Telephone: +353 1 7166470. E-mail: [email protected]
1189
M Brenner et al.
Introduction Traditionally, restriction has been discussed in relation to the care of older people, patients in intensive care, those receiving psychiatric treatment and people with intellectual disability, and presented as a means of preventing interference with treatment, or to cope with confused or aggressive patients (Moran et al. 2009, LeBel et al. 2010). Little is known about the practice of restricting a child for a clinical procedure (Brenner et al. 2007), although parents of children in hospital have expressed concern that this practice occurs when staff view procedures as tasks that need to be completed, rather than seeing the child as an individual (Brenner 2013a,b). In this study, restriction was defined as a child being held for a clinical procedure with varying degrees of force against the child’s resistance (Royal College of Nursing (RCN) 2010).
findings of these studies suggest that the content of preparatory instruction may influence the likelihood of restricting a child for a clinical procedure; a significant reduction in restriction of movement was found when specific instruction enabled staff to understand the social and cognitive influences on patients’ behaviour and thereby to identify and address precipitating events. A skill-based approach, focusing specifically on procedural knowledge, has been traditionally used to train nurses on the safe holding of a child during a clinical procedure. This approach, with specific instruction on acquiring skills to restrict a child for particular procedures, such as nasogastric insertion and insertion of a cannula, suggests a presumption of restriction. As little is known about this practice in the context of children’s nursing, the aim of this study was to explore a range of potentially influencing factors that, individually and in combinations, would constitute reported predictors of the practice of restricting the movement of a child for a clinical procedure.
Background Restricting a child’s movement is at variance with their innate curiosity and need to explore their environment; it is suggested that this practice may have a negative effect on the development of trusting relationships and the child’s developmental progression (Folkes 2005). This is supported by early theorists on emotional development who proposed that negative experiences in childhood may have long-lasting effects on the individual (Erikson 1950, Bowlby 1958, Freud 1971). Collectively, they highlight the need for healthcare professionals to develop a trusting relationship with the child in hospital and the need for appropriate comfort measures during clinical procedures. Physiologically, it is known that emotional regulation, the mechanism responsible for modifying emotional reactions and enhancing a child’s coping ability, is an ongoing process of child development (Hoeksma et al. 2004) suggesting that children are not equipped to cope with the demands of complex interactions such as being restricted for a clinical procedure. Despite this restriction of children’s movements for common clinical procedures is an implicit aspect of the nursing care of the child in hospital (Folkes 2005, Brenner & Noctor 2010, Jeffrey 2010, RCN 2010, Brenner et al. in press). To enhance care for hospitalised children, it is necessary to examine this common practice, with particular reference to the impact of nurses’ professional and personal characteristics on their reported likelihood to restrict a child. For example, some studies have examined the impact of professional training on the likelihood of restricting the movement of children and adults with challenging behaviours (Campbell et al. 2008, Martin et al. 2008, Finn & Sturmey 2009). The
1190
Methods Design The study used a factorial survey design, which has previously been used to explore complex care interactions (Ludwick & Zeller 2001, Taylor et al. 2009). The design involved the administration of vignettes and an associated questionnaire to a random sample of nurses working in a large children’s hospital. The method allowed examination of the interaction of a large number of factors on the dependent variable (DV), identified as the likelihood of the nurse to restrict a child for a clinical procedure. The sample included registered children’s nurses (RCNs) and non-RCNs and excluded nursing students. The sample size was informed by the fact that the unit of analysis in a factorial survey is each vignette, not each participant (Ludwick et al. 2004). Therefore, the decision on the number of respondents was influenced by the number of vignettes to be sent to each respondent and was determined using power analysis (Brenner 2013b). The study sample of 166 nurses, drawn from a sampling frame of 450 using a simple random sampling procedure, was calculated using a moderate effect size of R2 = 013 and was guided by the possibility of nonresponse in a mailed survey (De Vaus 2002). The factorial survey consisted of two sections, vignettes and personal and professional characteristics of the nurses, and was informed by the work of Ludwick et al. (1999, 2004) and Taylor (2006). Seven factors associated with restricting a child, with interchangeable levels, were explored in the vignettes, which were informed by literature © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1189–1198
Original article
Restricting a child’s movement in hospital
and theory, previous interviews with staff and parents (Brenner 2013a, Brenner et al. in press) and clinical experts. The interchangeable level refers to options for representing each factor in the vignettes (Rossi & Nock 1982). A vignette frame was developed with the capacity for interchangeable factors. In the example given here, the interchangeable levels are in italics; for example, the tenyear-old child could be substituted for another age, and the reinsertion of a nasogastric tube could be substituted for another procedure. At the start of your shift a ten year old girl requires reinsertion of a naso-gastric tube. This girl has a cognitive impairment, and this is the second attempt to carry out this procedure. She is refusing to cooperate. Her parents are present, and there is a staff shortage. (Brenner 2013b)
This captures the essence of a factorial design in that the use of such a vignette increases the proportion of surveys and, consequently, the proportion of observations for analysis (Moore 2010). Using a factorial design, the systematic varying of the levels of factors for inclusion means that a large number of different vignettes can be available (Atzmuller & Steiner 2010). For example, using seven factors and levels within them (Table 1), the present study had the potential to yield 8960 cells, and a unique vignette could be produced for each of these cells. Therefore, each participant received just a subset of the overall vignettes.
Table 1 Factors and levels of factors for inclusion in vignettes Independent factors
Levels Value of independent factors
Age of the child Cognitive ability of the child Parental presence during the procedure Child’s refusal or request to stop Environment of care
8 2
Type of clinical procedure
7
Frequency of procedure
4
2
2, 4, 6, 8, 10, 12, 14, 16 Cognitive impairment, no cognitive impairment Yes, No
2
Yes, No
5
Reduced staff numbers, time pressure, order from more senior nurse, order from consultant, play therapist available Nasogastric tube insertion, cannulati on, surgical wound dressing, removal of sutures, administration of an enema, female catheterisation, administration of oral medication 1, 2, 3, 4
Source: The table is reproduced from Brenner M. (2013b).
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1189–1198
There are no definitive guidelines on how many vignettes should be given to each participant, and the exhaustion effects of participating in a study using vignettes have not been examined extensively. In previous studies, up to forty vignettes have been presented to participants, although Muller-Engelmann et al. (2008) suggest that the number of vignettes should exceed the number of factors being examined. Ten vignettes were presented to each participant in this study, based on the fact that the vignette frame was deliberately short to avoid response burden (Ludwick et al. 2004, Taylor et al. 2009) and using a sample size of 166 nurses could yield responses on 1660 unique scenarios. Participants were provided with the operational definition of restriction for this study and asked to rate on a 10-point analogue scale (1–10) their likelihood to restrict a child after reading each vignette; higher scores represent the greater likelihood of the nurse to restrict a child’s movement for a clinical procedure. Respondents also completed a demographic questionnaire, which measured variables related to professional qualifications, highest level of education, age, whether they received instruction in emotional development, training on safe holding and length of experience in children’s nursing. Reliability of the vignettes was tested through the test– retest procedure. Ten per cent of respondents were asked to complete the same vignette two weeks apart prior to the full role out of the study. A significant correlation was found between responses at time one and, two weeks later, at time two with Pearson’s r = 080, and no significant difference was found in the distribution of scores (Anthony 1999). Paired t-test showed no significant difference for scores at time one (M = 561) and time two (M = 552), p = 007. Face and content validity was established through consultation with clinical experts and methodologists who had experience in vignette development. Ethical approval to conduct the study was sought and granted by the hospital’s research ethics committee. Hard copies of the cover letters and vignettes, together with stamped and addressed envelopes, were delivered to the nurses through the hospital’s internal mail. Information was supplied in the cover letter to ensure respondents were fully informed of the study. Return of the factorial survey to the researcher was taken as evidence of consent to participate. Data collection took place over a 12-week period in 2010.
Analysis version 15 (SPSS Inc., Chicago, IL, USA) was used to analyse the data. Frequency distributions and measures of
SPSS
1191
M Brenner et al.
central tendency and variability were calculated to summarise and describe demographic characteristics of the sample. Multiple regression analysis was used to measure and determine the independent variables (IVs) that had the strongest effect on nurses’ likelihood to restrict a child’s movement for a clinical procedure. Multiple regression analysis is the most commonly used method of analysis for factorial survey, as regression allows assessment of the relationship between the IVs, and between the IVs and the DV (Ludwick et al. 2004, Taylor 2006, Taylor et al. 2009). In this study, each nurse rated ten vignettes. To address the potential for similar scoring patterns, a more complex multiple regression analysis, hierarchical regression, was used. IVs at nominal or ordinal level were converted into dummy variables. All k 1 levels of each IV were recoded to k 1 dummy variables, where k refers to the number of levels of the original variable. Prior to using multiple regression, the researchers tested a number of assumptions of regression as follows: adequate sample size; absence of outliers among the IVs and on the DV; absence of multicollinearity and singularity; and normality, linearity and homogeneity of residuals (Tabachnick & Fidell 2007). It is always possible that any independent factor may exert undue influence on the model that emerges. The effect of each single case on the model as a whole was measured using Cook’s distance test, and no negative effect was found for any factor.
Results Characteristics of the nurses A total of 105 nurses responded to the survey, representing a response rate of 6331% (Table 2) and yielding a return of 1050 vignettes. The mean age of staff nurses was 3321 years (SD = 670). The number of years’ experience in children’s nursing ranged from 1–24 years. Almost 15% (n = 15) of respondents held a single registration qualification, which was in general nursing. The remaining 8531% (n = 90) held the registered children’s nurse (RCN) qualification and one other registration qualification in nursing as follows: 6681% (n = 70) were registered general nurses, 1272% (n = 13) were registered nurses in intellectual disability, and 491% (n = 5) were registered psychiatric nurses.
Likelihood to restrict a child for a clinical procedure Data were normally distributed for scores on the 10-point Likert scale for the DV, likelihood to restrict a child for a
1192
Table 2 Professional and demographic profile of the respondents Characteristic
n = 105
Age in years M, (SD), (minimum–maximum) 3321 (670) (24–52) Years’ experience in children’s nursing M, (SD), (median) (IQR) 432 (406) (3) (3) Professional qualification % (n) Registered general nurse 1471 (15) Registered children’s nurse & 8531 (90) registered in any other discipline Academic qualification* % (n) Certificate/diploma 380 (4) Bachelors degree or higher 9622 (101) Education on emotional development in children % (n) Yes 7532 (79) No 2473 (26) Training on safe holding techniques† % (n) Yes 4593 (49) No 5414 (56) *Staff may hold multiple academic qualifications. †Training on methods of keeping a child still for a clinical procedure.
clinical procedure. Scores were split on the likelihood to restrict scale into those who scored less than five and those who scored five and above on the 10-point scale. The decision to split the scores in this manner was based on the fact that 55 is the mean value of this 10-point scale. Therefore, a cut-off point of five was required to ensure scores of 55 and above represented likelihood to restrict. The results showed that 61% (n = 64) of participants scored five or greater, indicating that the majority of those surveyed were likely to restrict a child for a clinical procedure.
Clinical rationale for restricting a child for a procedure Table 3 presents the mean scores when each level of each factor was included in the vignettes, ranked from highest (more likely to restrict) to lowest (less likely to restrict). The four highest-ranked items show that, from the responses given, children were more likely to have their movement restricted if they required cannulation, when there was decreased staff present, if there was a fourth attempt to carry out a procedure and if the child was younger than five years of age. A nurse was less likely to restrict a child if the child was older (between 11– 16 years of age), if they required removal of sutures or if there was a play therapist available to help. An order from a consultant to restrict the child, the absence of a parent, the presence of a cognitive impairment in the child and the child’s request to have the restriction stopped were ranked among the top ten factors (6th, 7th © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1189–1198
Original article
Restricting a child’s movement in hospital
Table 3 Mean scores for each level of each clinical factor ranked according to nurses’ intention to restrict a child* Independent variable Factor
Level
Procedure Environment Frequency Age of child Environment Parents Cognition
Cannulation Decreased staff 4th attempt at procedure Child
An exploration of the practice of restricting a child’s movement in hospital: a factorial survey Maria Brenner, Jonathan Drennan, Margaret Pearl Treacy and Gerard M Fealy
Aims and objectives. To identify the reported predictors of the practice of restricting a child for a clinical procedure in hospital. Background. Previous work in this area is dominated by discussion papers and suggestions for addressing the issue of restriction. This is the first study to explore reported predictors of this practice with a view to implementing change based on research findings. Design. A factorial survey was developed, which incorporated the use of vignettes with various scenarios. The factorial design enabled exploration of the interaction of multiple factors on the practice of restriction. Methods. One hundred and sixty-six nurses caring for children were each sent 10 vignettes and asked to rate their likelihood to restrict a child based on the vignettes. A total of 105 nurses responded to the survey, representing a response rate of 63%. Hierarchical linear regression was used to identify reported predictors of restriction. Results. Nurses were more likely to restrict a child if they had prior instruction on safe holding, if there was no play therapist available, if the nurse was a registered general nurse with no other registration qualification, if the child required cannulation or if the child was less than five years of age. Conclusion. This study identified predictors of restriction from the perspective of practicing nurses; the evidence needs to be used in developing clinical guidelines and in multidisciplinary education. Relevance to clinical practice. There is a need to move from any presumption of restriction towards more critical consideration of the individual requirements of the child. There is a need to increase the numbers of nurses receiving specialist training on the care of a child in hospital. The importance of a well-resourced play therapy service is supported, and there is a need for multidisciplinary work to explore alternatives to restriction.
What does this paper contribute to the wider global clinical community?
• This paper challenges a practice •
•
that is generally implicit in the care of a child in hospital. The use of a factorial design offers an innovative way to explore potentially sensitive issues in practice. Recommendations for improving practice support international discourse on the ongoing need for enhanced care of the child in hospital in accordance with their individual developmental needs.
Key words: children in hospital, clinical procedure, factorial survey, restriction Accepted for publication: 24 May 2014
Authors: Maria Brenner, PhD, RCN, RGN, Lecturer, School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland; Jonathan Drennan, PhD, Dip Statistics, RGN, Professor of Healthcare Research, Centre for Innovation and Leadership in Health Sciences, Faculty of Health Sciences, University of Southampton, Highfield, Southampton, UK; Margaret Pearl Treacy, PhD, RGN, Emeritus Professor of Nursing, School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin; Gerard M
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1189–1198, doi: 10.1111/jocn.12650
Fealy, PhD, RGN, Associate Professor and Associate Dean for Research & Innovation, School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland. Correspondence: Maria Brenner, Lecturer, School of Nursing, Midwifery & Health Systems, Health Sciences Building, Belfield Campus, University College Dublin, Dublin 4, Ireland. Telephone: +353 1 7166470. E-mail: [email protected]
1189
M Brenner et al.
Introduction Traditionally, restriction has been discussed in relation to the care of older people, patients in intensive care, those receiving psychiatric treatment and people with intellectual disability, and presented as a means of preventing interference with treatment, or to cope with confused or aggressive patients (Moran et al. 2009, LeBel et al. 2010). Little is known about the practice of restricting a child for a clinical procedure (Brenner et al. 2007), although parents of children in hospital have expressed concern that this practice occurs when staff view procedures as tasks that need to be completed, rather than seeing the child as an individual (Brenner 2013a,b). In this study, restriction was defined as a child being held for a clinical procedure with varying degrees of force against the child’s resistance (Royal College of Nursing (RCN) 2010).
findings of these studies suggest that the content of preparatory instruction may influence the likelihood of restricting a child for a clinical procedure; a significant reduction in restriction of movement was found when specific instruction enabled staff to understand the social and cognitive influences on patients’ behaviour and thereby to identify and address precipitating events. A skill-based approach, focusing specifically on procedural knowledge, has been traditionally used to train nurses on the safe holding of a child during a clinical procedure. This approach, with specific instruction on acquiring skills to restrict a child for particular procedures, such as nasogastric insertion and insertion of a cannula, suggests a presumption of restriction. As little is known about this practice in the context of children’s nursing, the aim of this study was to explore a range of potentially influencing factors that, individually and in combinations, would constitute reported predictors of the practice of restricting the movement of a child for a clinical procedure.
Background Restricting a child’s movement is at variance with their innate curiosity and need to explore their environment; it is suggested that this practice may have a negative effect on the development of trusting relationships and the child’s developmental progression (Folkes 2005). This is supported by early theorists on emotional development who proposed that negative experiences in childhood may have long-lasting effects on the individual (Erikson 1950, Bowlby 1958, Freud 1971). Collectively, they highlight the need for healthcare professionals to develop a trusting relationship with the child in hospital and the need for appropriate comfort measures during clinical procedures. Physiologically, it is known that emotional regulation, the mechanism responsible for modifying emotional reactions and enhancing a child’s coping ability, is an ongoing process of child development (Hoeksma et al. 2004) suggesting that children are not equipped to cope with the demands of complex interactions such as being restricted for a clinical procedure. Despite this restriction of children’s movements for common clinical procedures is an implicit aspect of the nursing care of the child in hospital (Folkes 2005, Brenner & Noctor 2010, Jeffrey 2010, RCN 2010, Brenner et al. in press). To enhance care for hospitalised children, it is necessary to examine this common practice, with particular reference to the impact of nurses’ professional and personal characteristics on their reported likelihood to restrict a child. For example, some studies have examined the impact of professional training on the likelihood of restricting the movement of children and adults with challenging behaviours (Campbell et al. 2008, Martin et al. 2008, Finn & Sturmey 2009). The
1190
Methods Design The study used a factorial survey design, which has previously been used to explore complex care interactions (Ludwick & Zeller 2001, Taylor et al. 2009). The design involved the administration of vignettes and an associated questionnaire to a random sample of nurses working in a large children’s hospital. The method allowed examination of the interaction of a large number of factors on the dependent variable (DV), identified as the likelihood of the nurse to restrict a child for a clinical procedure. The sample included registered children’s nurses (RCNs) and non-RCNs and excluded nursing students. The sample size was informed by the fact that the unit of analysis in a factorial survey is each vignette, not each participant (Ludwick et al. 2004). Therefore, the decision on the number of respondents was influenced by the number of vignettes to be sent to each respondent and was determined using power analysis (Brenner 2013b). The study sample of 166 nurses, drawn from a sampling frame of 450 using a simple random sampling procedure, was calculated using a moderate effect size of R2 = 013 and was guided by the possibility of nonresponse in a mailed survey (De Vaus 2002). The factorial survey consisted of two sections, vignettes and personal and professional characteristics of the nurses, and was informed by the work of Ludwick et al. (1999, 2004) and Taylor (2006). Seven factors associated with restricting a child, with interchangeable levels, were explored in the vignettes, which were informed by literature © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1189–1198
Original article
Restricting a child’s movement in hospital
and theory, previous interviews with staff and parents (Brenner 2013a, Brenner et al. in press) and clinical experts. The interchangeable level refers to options for representing each factor in the vignettes (Rossi & Nock 1982). A vignette frame was developed with the capacity for interchangeable factors. In the example given here, the interchangeable levels are in italics; for example, the tenyear-old child could be substituted for another age, and the reinsertion of a nasogastric tube could be substituted for another procedure. At the start of your shift a ten year old girl requires reinsertion of a naso-gastric tube. This girl has a cognitive impairment, and this is the second attempt to carry out this procedure. She is refusing to cooperate. Her parents are present, and there is a staff shortage. (Brenner 2013b)
This captures the essence of a factorial design in that the use of such a vignette increases the proportion of surveys and, consequently, the proportion of observations for analysis (Moore 2010). Using a factorial design, the systematic varying of the levels of factors for inclusion means that a large number of different vignettes can be available (Atzmuller & Steiner 2010). For example, using seven factors and levels within them (Table 1), the present study had the potential to yield 8960 cells, and a unique vignette could be produced for each of these cells. Therefore, each participant received just a subset of the overall vignettes.
Table 1 Factors and levels of factors for inclusion in vignettes Independent factors
Levels Value of independent factors
Age of the child Cognitive ability of the child Parental presence during the procedure Child’s refusal or request to stop Environment of care
8 2
Type of clinical procedure
7
Frequency of procedure
4
2
2, 4, 6, 8, 10, 12, 14, 16 Cognitive impairment, no cognitive impairment Yes, No
2
Yes, No
5
Reduced staff numbers, time pressure, order from more senior nurse, order from consultant, play therapist available Nasogastric tube insertion, cannulati on, surgical wound dressing, removal of sutures, administration of an enema, female catheterisation, administration of oral medication 1, 2, 3, 4
Source: The table is reproduced from Brenner M. (2013b).
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1189–1198
There are no definitive guidelines on how many vignettes should be given to each participant, and the exhaustion effects of participating in a study using vignettes have not been examined extensively. In previous studies, up to forty vignettes have been presented to participants, although Muller-Engelmann et al. (2008) suggest that the number of vignettes should exceed the number of factors being examined. Ten vignettes were presented to each participant in this study, based on the fact that the vignette frame was deliberately short to avoid response burden (Ludwick et al. 2004, Taylor et al. 2009) and using a sample size of 166 nurses could yield responses on 1660 unique scenarios. Participants were provided with the operational definition of restriction for this study and asked to rate on a 10-point analogue scale (1–10) their likelihood to restrict a child after reading each vignette; higher scores represent the greater likelihood of the nurse to restrict a child’s movement for a clinical procedure. Respondents also completed a demographic questionnaire, which measured variables related to professional qualifications, highest level of education, age, whether they received instruction in emotional development, training on safe holding and length of experience in children’s nursing. Reliability of the vignettes was tested through the test– retest procedure. Ten per cent of respondents were asked to complete the same vignette two weeks apart prior to the full role out of the study. A significant correlation was found between responses at time one and, two weeks later, at time two with Pearson’s r = 080, and no significant difference was found in the distribution of scores (Anthony 1999). Paired t-test showed no significant difference for scores at time one (M = 561) and time two (M = 552), p = 007. Face and content validity was established through consultation with clinical experts and methodologists who had experience in vignette development. Ethical approval to conduct the study was sought and granted by the hospital’s research ethics committee. Hard copies of the cover letters and vignettes, together with stamped and addressed envelopes, were delivered to the nurses through the hospital’s internal mail. Information was supplied in the cover letter to ensure respondents were fully informed of the study. Return of the factorial survey to the researcher was taken as evidence of consent to participate. Data collection took place over a 12-week period in 2010.
Analysis version 15 (SPSS Inc., Chicago, IL, USA) was used to analyse the data. Frequency distributions and measures of
SPSS
1191
M Brenner et al.
central tendency and variability were calculated to summarise and describe demographic characteristics of the sample. Multiple regression analysis was used to measure and determine the independent variables (IVs) that had the strongest effect on nurses’ likelihood to restrict a child’s movement for a clinical procedure. Multiple regression analysis is the most commonly used method of analysis for factorial survey, as regression allows assessment of the relationship between the IVs, and between the IVs and the DV (Ludwick et al. 2004, Taylor 2006, Taylor et al. 2009). In this study, each nurse rated ten vignettes. To address the potential for similar scoring patterns, a more complex multiple regression analysis, hierarchical regression, was used. IVs at nominal or ordinal level were converted into dummy variables. All k 1 levels of each IV were recoded to k 1 dummy variables, where k refers to the number of levels of the original variable. Prior to using multiple regression, the researchers tested a number of assumptions of regression as follows: adequate sample size; absence of outliers among the IVs and on the DV; absence of multicollinearity and singularity; and normality, linearity and homogeneity of residuals (Tabachnick & Fidell 2007). It is always possible that any independent factor may exert undue influence on the model that emerges. The effect of each single case on the model as a whole was measured using Cook’s distance test, and no negative effect was found for any factor.
Results Characteristics of the nurses A total of 105 nurses responded to the survey, representing a response rate of 6331% (Table 2) and yielding a return of 1050 vignettes. The mean age of staff nurses was 3321 years (SD = 670). The number of years’ experience in children’s nursing ranged from 1–24 years. Almost 15% (n = 15) of respondents held a single registration qualification, which was in general nursing. The remaining 8531% (n = 90) held the registered children’s nurse (RCN) qualification and one other registration qualification in nursing as follows: 6681% (n = 70) were registered general nurses, 1272% (n = 13) were registered nurses in intellectual disability, and 491% (n = 5) were registered psychiatric nurses.
Likelihood to restrict a child for a clinical procedure Data were normally distributed for scores on the 10-point Likert scale for the DV, likelihood to restrict a child for a
1192
Table 2 Professional and demographic profile of the respondents Characteristic
n = 105
Age in years M, (SD), (minimum–maximum) 3321 (670) (24–52) Years’ experience in children’s nursing M, (SD), (median) (IQR) 432 (406) (3) (3) Professional qualification % (n) Registered general nurse 1471 (15) Registered children’s nurse & 8531 (90) registered in any other discipline Academic qualification* % (n) Certificate/diploma 380 (4) Bachelors degree or higher 9622 (101) Education on emotional development in children % (n) Yes 7532 (79) No 2473 (26) Training on safe holding techniques† % (n) Yes 4593 (49) No 5414 (56) *Staff may hold multiple academic qualifications. †Training on methods of keeping a child still for a clinical procedure.
clinical procedure. Scores were split on the likelihood to restrict scale into those who scored less than five and those who scored five and above on the 10-point scale. The decision to split the scores in this manner was based on the fact that 55 is the mean value of this 10-point scale. Therefore, a cut-off point of five was required to ensure scores of 55 and above represented likelihood to restrict. The results showed that 61% (n = 64) of participants scored five or greater, indicating that the majority of those surveyed were likely to restrict a child for a clinical procedure.
Clinical rationale for restricting a child for a procedure Table 3 presents the mean scores when each level of each factor was included in the vignettes, ranked from highest (more likely to restrict) to lowest (less likely to restrict). The four highest-ranked items show that, from the responses given, children were more likely to have their movement restricted if they required cannulation, when there was decreased staff present, if there was a fourth attempt to carry out a procedure and if the child was younger than five years of age. A nurse was less likely to restrict a child if the child was older (between 11– 16 years of age), if they required removal of sutures or if there was a play therapist available to help. An order from a consultant to restrict the child, the absence of a parent, the presence of a cognitive impairment in the child and the child’s request to have the restriction stopped were ranked among the top ten factors (6th, 7th © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1189–1198
Original article
Restricting a child’s movement in hospital
Table 3 Mean scores for each level of each clinical factor ranked according to nurses’ intention to restrict a child* Independent variable Factor
Level
Procedure Environment Frequency Age of child Environment Parents Cognition
Cannulation Decreased staff 4th attempt at procedure Child
