Asian Nursing Research 6 (2012) 173e180

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Research Article

Nursing Staff Views of Barriers to Physical Restraint Reduction in Nursing Homes Eun-Hi Kong, RN, PhD, 1, * Lois K. Evans, RN, PhD, FAAN 2 1 2

Department of Nursing, Gachon University, Seongnam-si, South Korea School of Nursing, University of Pennsylvania, Philadelphia, USA

a r t i c l e i n f o

s u m m a r y

Article history: Received 8 June 2012 Received in revised form 4 October 2012 Accepted 18 October 2012

Purpose: There are few studies globally regarding the barriers to restraint-reduction. The purpose of this study was to describe the views of nursing staff (both nurses and geriatric care assistants) regarding the barriers to reducing physical restraint use in Korean nursing homes. Methods: Forty registered nurse and geriatric care assistant informants participated in the first round of interviews and 16 of them participated in second confirmatory interviews. All interviews were conducted on site, one-on-one and face-to-face, using semi-structured interview protocols. Qualitative descriptive method was used and qualitative content analysis was employed. Results: Six themes were identified: (a) being too busy, (b) lack of resources, (c) beliefs and concerns, (d) lack of education, (e) differences and inconsistencies, and (f) relationship issues. Conclusion: The findings of this study provide a valuable basis for developing restraint reduction education programs. Korean national leaders and nursing homes should develop and employ practice guidelines regarding restraints, support nursing staff to follow the guidelines, provide more practical and professional education, employ alternative equipment, use a multidisciplinary team approach, and engage volunteers in care support as well as employ more nursing staff to achieve restraint-free care. Copyright Ó 2012, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.

Keywords: nursing nursing homes physical restraint qualitative research

Introduction Recently, reports of adverse effects and ethical issues surrounding physical restraint use in nursing homes have been so widely disseminated that restraint reduction has become an important care issue globally. In the last two decades, the United States, followed by European countries (Hughes, 2010), has played a leading role in research, policy, and practice of physical restraint reduction in nursing homes. Since 1990, physical restraint use in American nursing homes has markedly decreased from 35% in 1991 to 3.3% in 2012 (Capezuti, Brush, Won, Wagner, & Lawson, 2008; Department of Health and Human Services, 2012). Physical restraints, however, are still used in American nursing homes, with wide variation across institutions and geographic regions (Capezuti et al., 2008). Likewise, physical restraint prevalence in nursing homes varies among countries around the globe (Feng et al., 2009; Laurin, Voyer, Verreault, & Durand, 2004; Ljunggren, Phillips, & Sgadari, 1997). Recent studies from other western nations show that physical restraints are still commonly used in nursing homes: 59% in the Netherlands (Huizing, Hamers, Gulpers, & Bergers, 2006), 33.7% in Canada (Laurin et al., 2004), 28% in Finland (Feng * Correspondence to: Eun-Hi Kong, RN, PhD, Department of Nursing, Gachon University, Sungnamdaero 1342, Seongnam-si, Gyeonggi-do 461-701, South Korea. E-mail address: [email protected]

et al.), 26.2% in Germany (Meyer, Köpke, Haastert, & M€yhlhauser, 2008), and 6% in Switzerland (Feng et al.). In comparison, there is a dearth of reports regarding physical restraint use in nursing homes in Eastern countries. Feng et al. (2009) have documented a restraint prevalence of 20% in Hong Kong, while others (Chiba, Yamamoto-Mitani, & Kawasaki, 2012; Ljunggren et al., 1997) reported the prevalence to be from 25.5% to less than 4.5% in Japan. Although physical restraints are frequently used in Korea, there exists no reliable epidemiological data on the incidence or prevalence of their use in nursing homes. One survey (Kim et al., 2009) on the prevalence of physical restraint in 13 units in seven Korean long-term care facilities indicated that 84.6% of facilities used wrist restraints. In addition, ankle, limb, chest, and/or belt restraints were used in 15.4% of the facilities (Kim et al.). In Korea, physical restraint use in nursing homes has become viewed as a serious ethical and social issue related to elder abuse. Since the implementation of Long-Term Care Insurance for the Elderly (LTCIE) in 2008, the National Health Insurance Corporation (2012) has inspected all Korean nursing homes every 2 years to improve their quality. One of 98 regulatory standards for inspection is related to physical restraint use. According to the standard, restraint use is allowed only in three situations: life-threatening event, no alternatives to restraint use, and temporary use of restraint to permit care for symptoms of medical conditions. To use restraint, Korean nursing staff is required to provide explanations to

1976-1317/$ e see front matter Copyright Ó 2012, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.


E.-H. Kong, L.K. Evans / Asian Nursing Research 6 (2012) 173e180

and receive written permission from elders and families and also record the reason for and process of restraint use. Therefore, Korean nursing homes are under pressure to reduce restraint use and have started providing restraint reduction education programs for their staff. Despite these efforts, physical restraints remain in common use in Korean nursing homes. Over the past 10 years, some researchers began to explore perceptions of nursing staff about physical restraint use in longterm care facilities. These studies comprise many issues such as beliefs or feelings about restraints, decision-making, factors that contribute to restraint use, and alternatives to or consequences of physical restraint use (Ben Natan, Akrish, Zaltkina, & Noy, 2010; Elsden, Velez Mediavilla, Arana Izuel, Chasco Arroniz, & Espina Diez, 2002; Hantikainen, 2001; Hantikainen & Kappeli, 2000; Kim, Kim, Kim, & Park, 2011; Saarnio & Isola, 2010). There are, however, no studies focused on the barriers to restraint reduction in nursing homes in Korea and a shortage of such studies even globally. Only three qualitative studies regarding barriers were found; these were conducted in the United States and Australia (Hennessy, McNeely, Whittington, Strasser, & Archea, 1997; Moore & Haralambous, 2007; Nay & Koch, 2006). In one, Hennessy et al. explored the perceptions of restraint use and barriers to restraint reduction among nine direct care staff, two administrators, and one director of nursing in the US. In the second, Moore and Haralambous compared the perspectives of Australian staff (nurse, care assistant, activities coordinator, general practitioner, and pharmacist) with those of residents and family members about barriers to reduction of physical, chemical, and environmental restraints. The third study of barriers (Nay & Koch) included managers, academic advocates, consultants, counselors, carers, representatives, therapists, and relatives as well as the direct care staff in Australian care facilities for older adults. The overall body of research regarding physical restraints in Korean nursing homes is still small. Most existing Korean studies used quantitative designs to explore the knowledge, attitudes, and perceptions of nursing staff surrounding physical restraint (An, 2010; Kim, 2002; Kim & Oh, 2006; Kim et al., 2009; Lee & Kweoun, 2001). The sole qualitative study described nursing staff experiences regarding physical restraint use, but not barriers to its reduction (Kim et al., 2011). Nursing staff in Korean nursing homes were reported to show an increasing level of knowledge on the adverse effects of physical restraints and to feel the ethical conflict about their use (Kim et al., 2011; Kim & Oh, 2006). Identifying the barriers to restraint reduction is crucial to the successful design and implementation of restraint reduction programs (Curran, 2007). There are, however, no published qualitative studies related to barriers of physical restraint reduction in Korea or in other Asian countries. Given the large differences in the definition, standard, prevalence, type, and intensity of physical restraint use across countries (Feng et al., 2009; Ljunggren et al., 1997), there may also be different perceived barriers to physical restraint reduction. Therefore, the purpose of this study was to describe the barriers to physical restraint reduction in Korean nursing homes from the perspectives of the direct care nursing staff including registered nurses (RNs) and geriatric care assistants (GCAs). Methods Theory Symbolic interactionism, a major theory in sociology (Denzin, 1992), was used as an overarching framework to guide the study and to understand the data. The core principle in symbolic interactionism is that “human beings act toward things on the basis of

the meanings that the things have for them” (Blumer, 1969, p. 2). The concepts in symbolic interactionism such as self, interaction, role, role conflict and role strain (Stryker, 2002) aided in understanding the experiences of nurses and GCAs. Study design A qualitative descriptive approach (Sandelowski, 2000, 2010) was used. Qualitative description offers a comprehensive summary of an event with data-near analysis and the least interpretation (Sandelowski, 2000, 2010). Qualitative description produces “straight and unadorned answers to questions” (Sandelowski, 2000, p. 337). The qualitative descriptive design was, thus, a good fit with the purpose of this study. Setting and samples The study was conducted in two volunteer nursing homes, each with about 200 beds; the nursing homes were located in the capital city of Seoul and Gyeonggi province in Korea. There are 4,176 nursing homes in Korea and 1,662 (40%) of them are located in Seoul and Gyeonggi province (National Health Insurance Corporation, 2012). The two nursing homes adopted the standard of LTCIE regarding the use of physical restraint. In addition, both facilities were similar in frequency and content of restraint education provided for staff. In each setting, volunteers for interviews were sought from RNs and GCAs. The GCA was a newly created qualification in preparation for the enforcement of LTCIE. Similar to the nursing assistant in other countries, GCAs provide elders with basic care services related to physical care, daily activity support, and emotional support. To become a GCA in Korea requires completion of 240-hours of education and passing a certification examination. Korean nursing homes are required to have at least one RN per 25 residents and one GCA per 2.5 residents. A two-interview process was employed. In the first interview, the informants comprised 24 GCAs, 12 RNs, and 4 head nurses (also RNs) from all three shifts across both nursing homes. Persons interviewed satisfied the following criteria: (a) had provided direct care to older adults for more than 3 months, (b) had used or witnessed use of physical restraint during the last 3 months, and (c) consented to participate in the study. The second confirmatory interview included 16 of the 40 first interview informants: 8 GCAs, 6 RNs, and 2 head nurses. They (a) consented to participate in the second interview, (b) had provided rich information in the first interview, and (c) expressed interest in the results of the first interviews. Informants’ ages ranged from 24 to 60 years (M ¼ 50) and all were women (Table 1). Among all participants, 23 (57.5%) had more than a college education, 10 had a high school education, and 7 had less than middle school education. In total, 70.0% had more than 37 months of work experience in long-term care; 75.0% identified their religion as protestant or catholic. In terms of restraint education, 60.0% informants had received 1e4 restraint education sessions in the last year, whereas 37.5% informants had received none (Table 1). Data collection The study was approved by the Human Subjects Research Review Committee of Gachon University (2010-001). Before beginning, the first author met with directors and staff in charge of education of nurses and GCAs in Korean nursing homes and provided information about this study. Two nursing homes volunteered to participate. With the help of the nursing home staff and directors, the first author met potential informants individually and provided information about the study, its risks and benefits, privacy

E.-H. Kong, L.K. Evans / Asian Nursing Research 6 (2012) 173e180 Table 1 General Characteristics of Informants (N ¼ 40) Characteristics Gender Age (yr)

Education level completed


Work experience (mo)


Work pattern Restraint educationa in the last year

Categories Female 20e29 30e39 40e49 50e59 60e69 Middle School High School College GCA RN HN 1e12 13e36 37e72  73 Protestant Catholic Buddhist None Three shift Others None 1e2 3e4

n (%) 40 (100.0) 3 ( 7.5) 1 ( 2.5) 8 (20.0) 27 (67.5) 1 ( 2.5) 7 (17.5) 10 (25.0) 23 (57.5) 24 (60.0) 12 (30.0) 4 (10.0) 1 ( 2.5) 9 (22.5) 8 (20.0) 20 (50.0) 21 (52.5) 9 (22.5) 6 (15.0) 4 (10.0) 32 (80.0) 8 (20.0) 15 (37.5) 18 (45.0) 6 (15.0)

Note. GCA ¼ geriatric care assistants; RN ¼ registered nurse; HN ¼ head nurse; yr ¼ year; mo ¼ month. a No response is omitted.

and confidentiality, disclaimer/withdrawal, and participant rights. After obtaining verbal and written consent from informants, data were collected between September 2010 and August 2011. Interviews were conducted in the quiet rooms in the nursing homes at each informant’s convenience, usually 30 minutes after finishing or 1 hour before starting a work shift. Using an interview guide, the first author conducted individual interviews in Korean with 40 informants until data were saturated. The interview guide consisted of semi-structured, open-ended, and informal questions. Examples of the first interview questions were as follows: “Tell me about your work.” “Tell me about your experiences related to physical restraint.” “What do you think about physical restraint?” “What are the difficulties you experience regarding restraint reduction?” “What are the barriers to restraint reduction?” “Is there anything else that you would like to add related to physical restraint?” “What has it been like participating in this study?” First interviews lasted from 14 to 43 minutes (M ¼ 28 minutes). To obtain informants’ feedback on data analysis, second voluntary interviews were conducted in Korean with 16 of the 40 informants until data were saturated, totaling 56 interviews for the entire study. These second confirmatory interviews focused on informants’ responses to the initial summaries and analyses of the first interviews. Examples of the second interview questions included “Some participants said that too many chores and severity of illness were barriers to restraint reduction. What do you think about that?” “Some participants mentioned lack of resources as a barrier to restraint reduction. What do you think about that?” and “Other participants cited lack of education as a barrier to restraint reduction. What do you think about that?” Second interviews lasted from 12 to 25 minutes (M ¼ 19 minutes). Informants received the equivalent of US $20 after completing each interview as an honorarium for participation. All interviews were recorded simultaneously using two digital recorders. Field notes were written immediately after each interview to avoid interfering with the interview. Field notes included descriptive summary of the site, informants’ expressed feelings or behaviors, interview, and problems experienced during interview.


Additionally, with staff permission, the first author made four observation visits to the involved units, paying special attention to staff restraint use, restrained elders, the physical environment, and interactions among staff and residents. All interview data, field notes, and observational descriptions were stored in the authors’ password protected computer with backup files in locked filing cabinets. Data analysis Data included 56 interviews, 40 field notes, and 4 observations, all of which were transcribed verbatim in Korean. Data analysis started with data collection and data management. Qualitative content analysis was used, which is “the analysis strategy of choice in qualitative descriptive studies and oriented toward summarizing the informational content of that data” (Sandelowski, 2000, p. 338). Downe-Wamboldt’s (1992) eight processes together with Graneheim and Lundman’s (2004) concepts of content analysis were employed for data analysis. The processes are (a) selecting the unit of analysis; (b) creating and defining the categories; (c) pretesting the category definitions and rules; (d) assessing the trustworthiness; (e) revising the coding rules if necessary; (f) pretesting the revised category schemes; (g) coding all the data and creating themes; and (h) reassessing the trustworthiness. The unit of analysis was each informant’s response to the questions. To get a sense of the whole, the first author read all of the data several times and then wrote memos and reflective notes as the initial step of data analysis. The first author and two qualitative scholars read the first three interviews and related field notes to develop an initial 6 categories and 24 codes. ATLAS.ti 6.2 (ATLAS.ti Scientific Software Development GmbH, Germany) computer software was used in coding, counting frequencies of codes, sorting, organizing, making audit trails, searching, and retrieving data. Counting codes was used to interpret the code pattern (Morgan, 1993). To increase intra-rater reliability, data were coded and categorized four times by the first author until the findings were consistent. Codes, categories, and themes were all modified, added, tested, and revised by the first author and the two qualitative scholars to additionally improve inter-rater reliability. In addition, within-case and across-case approaches were used to analyze data “both through its parts and as a whole” (Ayres, Kavanaugh, & Knafl, 2003, p. 873). Rigor Various strategies (Devers, 1999; Guba, 1981) were employed to increase the rigor with which this study was conducted. For enhancing credibility, member check and peer debriefing were used, that is, initial data analysis was confirmed by informants through the second interviews and all data analyses were checked by the two qualitative scholars as well as the authors. To achieve credibility in the translation of data, two Korean-American nursing professors who were bilingual read the themes, subthemes, and quotations which were translated to English, and then back translated to Korean. Detailed descriptions of the content were made to ensure transferability. To enhance dependability, an audit trail was established and skeptical peer reviews by the two qualitative scholars were employed. Moreover, to obtain confirmability of analysis, skeptical peer review and audit trail were used. Results Data analysis generated six major themes: being too busy, lack of resources, beliefs and concerns, lack of education, differences and inconsistencies, and relationship issues (Table 2). In addition,


E.-H. Kong, L.K. Evans / Asian Nursing Research 6 (2012) 173e180

Table 2 Themes and Subthemes of Barriers to Physical Restraint Reduction Theme Being too busy

Lack of resources

Beliefs and concerns

Lack of education

Differences and inconsistencies

Relationship issues

Subtheme Too many chores Severity of illness Family expectations Lack of nursing staff Lack of volunteers or students Lack of alternative equipment Restraints as protectors Concerns for accidents Concerns about responsibilities Lack of practical education Lack of professional education Lack of family education Differences among elders Differences among staff Inconsistent standards and policies Lack of understanding Lack of respect Communication problems

18 subthemes that were linked with specific major themes were identified: too many chores, severity of illness, family expectations, lack of nursing staff, lack of volunteers or students, lack of alternative equipment, restraints as protectors, concerns for accidents, concerns about responsibilities, lack of practical education, lack of professional education, lack of family education, differences among elders, differences among staff, inconsistent standards and policies, lack of understanding, lack of respect, and communication problems (Table 2). Being too busy Too many chores All GCAs and many nurses mentioned that they were “too busy”. Some GCAs said the following: Wishing to treat elders as my parents, I would like to stay and spend more time with them and take better care of them. I cannot, however, because I have too many chores and not enough time. I would really like to hug them, care for them intimately, and talk to them more, but I cannot [because of my busy schedule]. Most GCAs said that they had to do too many chores such as bathing, feeding, general care, preventing falls and pressure ulcers, documentation, cleaning elders’ rooms, helping elders take medicine, monitoring naso-gastric tubes or Foley catheters, and so on. Severity of illness Many GCAs and nurses pointed out that “there are too many elders who are seriously ill, so that restraint is automatically applied for most elders with a naso-gastric tube or Foley catheter.” Some attributed the growing population of critically ill elders to the implementation of LTCIE: “After the implementation of LTCIE, many who were seriously ill were admitted to nursing homes so that our workload increased and [we were obliged to use restraints].” Family expectations Some GCAs and nurses mentioned that families’ expectations led to increased workloads and physical restraint application: In this nursing home, we cannot provide one-on-one care. We need to take care of a lot of elders, but many family members don’t seem to recognize this load before institutionalization of their elders. When I started working here several years ago, families were not like families now. These days, however,

families tend to demand too many things and easily find fault with our care. Some GCAs and nurses attributed families’ increased demands both to the implementation of LTCIE which went into effect in 2008 and to increased knowledge about the services to which their relative is entitled. Lack of resources Lack of nursing staff Most GCAs attributed high use of physical restraints to understaffing: “We do not have enough GCAs to take care of our many elders. Therefore, although we try not to use physical restraints, we are obliged to [use them].” Some GCAs said that three GCAs took care of 21 elders on the day shift and one GCA took care of 21 elders on the night shift. Several GCAs requested one-on-one assignments in order to avoid physical restraint. Many GCAs and nurses, however, thought that one-on-one care is unrealistic budget-wise and does not guarantee elimination of accidents or avoidance of restraint use. Lack of volunteers or students GCAs believe that presence of students or volunteers could help reduce restraint use. As one GCA described, “Sometimes an elder’s hands are swollen [because of restraints], then I untie the restraint and ask a student to watch over the elder.” Other GCAs mentioned that when there was a volunteer who was observing elders, they were less concerned about the elders’ safety and did not tie them. Some GCAs, however, complained that although volunteers and students were helpful in avoiding restraint use, their commitment was not consistent and, further, there were not enough of them. Lack of alternative equipment A number of GCAs did not even know of the existence of alternative equipment for promoting safety and mobility. Several GCAs described this need: “Isn’t there any person who invents alternative equipment? I wish that some alternative equipment would be invented to let elders stay free and safe.” They mentioned that there were needs for alternative equipment that prevents falls from bed or wheelchair and prevents treatment interference such as pulling out tubes. They thought that with the existence of such devices or tools, education regarding restraint-free care would be more accepted by staff. Beliefs and concerns Restraints as protectors Many GCAs and nurses believed strongly that restraints protected elders from injuries. In addition, they did not feel comfortable with using the term “restraint”; they preferred “protector” as being more appropriate. “We think that it is not a restraint but a ‘protector’. It is used for the purpose of protecting elders, so we call it a ‘protector’.” Moreover, some of them expressed discomfort with the interviewer’s use of the term “restraint” and they tried to correct it, arguing that the term should be changed to “protector”. Several GCAs and nurses, however, admitted that the term “protector” was used from the viewpoint of staff rather than elder. Additionally, some GCAs expressed feelings of conflict regarding restraint use, questioning its potential for beneficial effects for elders. Concerns for accidents Most GCAs said that “Without restraints, accidents happen. To prevent accidents, applying restraint is better. For the safety of

E.-H. Kong, L.K. Evans / Asian Nursing Research 6 (2012) 173e180

elders, I am obliged to apply restraints.” Many GCAs explained that they use physical restraints to protect elders from self-injury such as pulling out naso-gastric tubes or IV lines, hitting themselves and other residents, and eating their own feces. Some GCAs revealed that they felt relieved when applying restraints and they used restraint for staff convenience: “Restraints protect elders so restraints give us relief. I don’t know whether it is right or not to feel relief. Anyway, we feel relief with restraints. We can do our other work [without worry] when we use restraints.” Concerns about responsibilities Many GCAs and nurses described the concerns and burdens of responsibility related to accident or injury: “There is a burden of responsibility. I think that accidents should never happen on my duty, so I am obliged to use restraint.” Some GCAs expressed concerns about families’ complaints and legal litigation following accidents: “Sometimes, an elder might have a very minor injury. Even so, some family members took pictures of their elders with a camera or cell-phone [in order to file a lawsuit or threaten us].” Some nurses sympathized with the feeling of responsibility among GCAs. Lack of education Lack of practical education A number of GCAs emphasized the gap between education and practice. Although they were told not to use restraints, they thought this was impossible in reality. In addition, many GCAs reported that they did not receive any education regarding the practical methods of reducing restraintdthe “what to do”: “We have heard many times that restraints should not be used and using restraints violated human rights. But we have not received any education regarding alternatives to restraint.” Some GCAs expressed their educational needs related to restraints: “I really would like to learn about how to care for and make elders feel more comfortable without tying them.” Most of GCAs and nurses described that effective education regarding alternative interventions might reduce restraint use. Other GCAs thought that observing cases from other countries demonstrating successful care without restraint would be beneficial. Lack of professional education Several GCAs addressed the need for more professional education for themselves: Although GCAs receive education for GCA certificate, I think that the education received is not “professional”. I think that it is important to train GCAs more “professionally” and make them provide individualized care to elders. If so, restraints will not be necessary. Some GCAs also admitted to needing more knowledge regarding the characteristics of dementia, individualized care, and specific conditions of elders: “When I could not communicate with elders with dementia, speech impairment, or hearing impairment, I had difficulties in taking care of them because I didn’t know much about their exact condition.” In addition, several GCAs and nurses reported their educational needs to improve their attitudes and minds as professional staff in caring for elders. Lack of family education Many GCAs stated that family members did not know much about their loved ones’ conditions, which led to complaints about accidents and physical restraint use. Many GCAs mentioned that families expected improvements in their loved ones’ conditions after institutionalization and did not anticipate or comprehend the ongoing


deterioration of health due to aging combined with chronic disease. In addition, GCAs reported family members’ lack of knowledge about behavioral symptoms of dementia and their relationship to accidents: The family member who had taken care of the elder at home before institutionalization really understood the situation well when there were some minor accidents. But, some families who had not lived with the loved ones before institutionalization could not understand the strange behaviors of their elders with dementia. They never understood the minor accidents that were caused by behavioral symptoms of dementia. The GCAs noted that they were so concerned about family’s complaints that they were obliged to use restraints for the safety of elders with dementia. Thus, many of them insisted that families of elders should also receive education regarding restraint reduction.

Differences and inconsistencies Differences among elders Many GCAs reported that every elder differed in her or his personality and behavioral pattern. They also mentioned that each elder with dementia showed different behavioral and psychological symptoms. In addition, some GCAs pointed out inconsistent patterns in behaviors of elders over time: “Some elders show variation in their behaviors. Usually they are calm, but intermittently they are at a loss with their anger; then there is nothing we can do.” GCAs revealed, however, that they could not provide individualized care to the elders whose individual characteristics were not well known. GCAs were also too busy; therefore, they usually applied physical restraints to control the behaviors. Differences among staff Inconsistencies among nurses’ expectations related to physical restraint use were mentioned by some GCAs: “Sometimes there is no consistency among nurses’ orders related to restraint use, so we are confused.” Other GCAs and nurses also reported differences among GCAs in terms of restraint use. They noted that a GCA’s character, sense of responsibility, work satisfaction, educational background, and skill quality might be more important in affecting frequency, duration, tying method, or release of restraints. Differing perspectives between nurses and GCAs were described by many GCAs and nurses: “Nurses think that restraint should not be used if possible, whereas GCAs think that not using restraint is impossible and wonder who will control [the elder’s behavior or treatment interference].” Nurses also thought that GCAs were more likely to use restraint because of concerns about accidents and as a substitute for observation. Inconsistent standards and policies A number of GCAs and nurses emphasized inconsistent standards or policies related to physical restraint use. Many GCAs complained that they are asked by the government not to use physical restraint, but that it is impossible not to restrain. Thus, restraints are used frequently in most Korean nursing homes. Staff expressed confusion and conflicts about their facility’s inconsistent policies regarding restraint. They described as being incongruous that “the facility asked us both to prevent falls and not to use restraints.” Some GCAs revealed that when government inspection officials visited the nursing home, they were asked by their facilities to temporarily untie elders. Many GCAs also criticized the lack of detailed practice guidelines regarding restraint use and demanded that they be developed to include examples of when restraint should and should not be applied, and when staff’s nonrestraint practices would be protected by law.


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Relationship issues Lack of understanding Some GCAs and nurses stressed the importance of understanding an elder’s mind and thinking about restraint use from the elder’s viewpoint. One nurse mentioned that she usually said to GCAs, “If you were tied like this, wouldn’t you think that it was torture?” Two GCAs described that when they gave elders more attention and love, restraints were not necessary. Several staff mentioned that it was also important to understand the families’ feelings, demands, and complaints related to restraint use. Lack of respect Many GCAs complained that although most families were very nice, some showed disrespect, demeaned, and tried to find fault with them. In addition, some GCAs requested that nurses also should respect GCAs and listen to them: I would like to suggest that nurses respect us and listen carefully to our opinions. Some nurses just order us, which offends us. I want nurses to listen carefully to our opinion, try to understand our stance, and then tell us what they want to say.. Sometimes some nurses do not respect us and treat us contemptuously which hurts our pride. GCAs thought that sometimes nurses’ lack of respect and lack of listening to their opinions resulted in the use of restraints for selfprotection. A couple of nurses also stressed the importance of the GCA’s role and the cooperative relationship between nurses and GCAs to reduce use of restraint. They argued that they should regard GCAs as partners rather than workers at a lower level. Communication problems Several nurses reported that some GCAs did not understand nurses’ orders because of their lower educational background or lack of professional knowledge. The nurses also mentioned that some GCAs did not communicate well with other GCAs on the next shift, thus, preventing continuous and consistent care to elders. A few nurses added that some GCAs were not good at communicating with families regarding restraint use. One nurse also stressed the importance of good communication and cooperation among nurses, GCAs and families in reducing restraint: For example, when we take care of elders with dementia, the nurse, GCA and family should cooperate, collect data, and discuss [the situation] together. Based on the communication among the three persons, the final decision [regarding restraint] should be made. Nurses should listen to the GCAs’ report and family’s description and then the three persons should communicate together about [restraint use].

Discussion Given that there are few studies globally regarding the barriers to restraint-reduction, a dearth of restraint research conducted in Asia, and limitations of existing research, this study provides valuable information regarding barriers to physical restraintreduction in nursing homes and suggests content for educational programs on restraint-free care. The findings indicate that Korean nursing staff is aware of the many barriers to physical restraint reduction and their need for help in overcoming them. Meanwhile, they continue using restraints, albeit reluctantly. In symbolic interactionism, the self is constructed by the relationships with others in a social process and the expectations of

others are crucial to construct the self (Stryker, 2002). Symbols are used to indicate positions that guide and influence behaviors (Stryker). Holding a “position” makes a person come up to the expectations or roles that are attached to the position and which are learned in social interaction (Stryker). Nursing staff in this study had to meet institutional expectations, peer and supervisor expectations, elders’ expectations, and family expectations regarding restraint use, which were sometimes incompatible. In the situation, nursing staff felt role strain and role conflicts through their interactions with peers, supervisors, elders, and families. In addition, nursing staff in this study held positive meanings or beliefs about restraint such as “protector,” and these beliefs served as a barrier to restraint reduction. The barriers found in this study had some similarities to those reported in earlier studies conducted in the United States and Australia (Hennessy et al., 1997; Moore & Haralambous, 2007; Nay & Koch, 2006). Five of the subthemes in this study, however, have not been reported in previous research: too many chores, differences among elders, lack of volunteers and students, lack of understanding, and lack of respect. Further, several themes reported in previous studies (Hennessy et al.; Moore & Haralambous; Nay & Koch) were not found in this study: existing organization culture, institutional routine, environmental constraints, management issues, and inadequate review practices. The themes of being too busy and lack of resources were mentioned as barriers to reducing physical restraint use in both this study and the previous research conducted in the United States and Australia (Hennessy et al., 1997; Moore & Haralambous, 2007). In addition, in a systematic review, compensating for understaffing was identified as one of the common reasons given for using physical restraint (Evans & Fitzgerald, 2002a). Korean nursing homes are required by the LTCIE to have one nurse per 25 residents and one GCA per 2.5 residents. Many Korean nursing homes, however, do not meet these requirements because of budgetary constraints. Korean nursing homes might benefit, as identified by informants, from a multidisciplinary team approach, employment of alternative equipment, and engagement of volunteers as well as hiring more nursing staff to achieve restraint-free care. The theme of beliefs/concerns was very similar to the myths about restraint use in the United States (Evans & Strumpf, 1990; Strumpf, Robinson, Wagner, & Evans, 1998) and situations in which restraint use was justified in Switzerland (Hantikainen & Kappeli, 2000). In this study, some nursing staff expressed conflicted feelings regarding restraint use, which was similar to the findings of previous studies conducted in New Zealand, Korea, Finland, and the United States (Bigwood & Crowe, 2008; Kim et al., 2011; Saarnio & Isola, 2010; Strumpf et al., 1998). In order to change the false beliefs held by staff and eliminate their conflicted feelings, nursing homes need to provide continuing education about the harmful effects of restraint, support staff efforts to take “reasonable risks” in reducing restraint use, and encourage and reward efforts, successes, and positive experiences related to restraint-reduction. The theme, lack of education, indicated that Korean nursing staff desired more practical and professional knowledge regarding restraint-reduction. Lack of education was also reported as a barrier in Australian studies (Moore & Haralambous, 2007; Nay & Koch, 2006). Given that Korean GCAs were more inclined than nurses to use restraints to prevent accidents, education and examination for GCA certification should include methods to assure safe mobility and treatment together with restraint-free care. In addition, GCAs specifically requested education regarding dementia care, individualized care, and ways to reduce restraint use. Given that elders with dementia are more vulnerable than others to restraint application, continuing education regarding dementia will be essential to reduce restraint use. Individualized care is identified

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as an important component of restraint reduction education in earlier studies (Capezuti et al., 2007; Huizing, Hamers, Gulpers, & Berger, 2009); it is widely becoming the best practice intervention for elders. Additionally, more education regarding ways to understand and meet residents’ needs as an alternative to restraint should be provided to Korean nursing staff. In terms of educational methods, considerations should be made regarding nursing staff’s time constraints in attending training sessions because of duty schedules (Moore & Haralambous). With the high use of internet and smart phone in Korea, future studies should also consider multimedia educational programs on restraint-free care and test the effects among nursing home staff. In this study, Korean nursing staff attributed the current high prevalence of restraint use to families’ expectations, lack of knowledge, complaints, and threatened legal litigation over their loved ones’ accidents. Therefore, staff requested restraint-free care education for families as well. According to findings from earlier research conducted in several countries (Evans & Fitzgerald, 2002b; Kim et al., 2011; Saarnio & Isola, 2010), families of elders had many negative feelings such as anger, discomfort, and guilt related to restraint use, but they requested restraints for the safety of their elders. Given that family request is one of the main factors contributing to restraint use (Hantikainen & Kappeli, 2000; Moore & Haralambous, 2007; Saarnio & Isola, 2009), providing education to families can be very important in reducing restraint use. In addition, students and volunteers need to be educated about restraint-free care. Korean nursing staff identified inconsistent standards and lack of detailed practice guidelines as barriers against restraint reduction. This finding was consistent with that of the studies conducted in Switzerland and Finland (Hantikainen & Kappeli, 2000; Saarnio & Isola, 2010) which reported inconsistent use of restraint among staff and lack of legislation. In one Australian study (Moore & Haralambous, 2007), issues with restraint policy was also identified as a barrier; the investigators pointed out, however, that the policy was implemented in a top-down approach with limited input from direct care staff. Although there is a national regulatory standard regarding restraint use in Korea, practice guidelines regarding restraint do not yet exist and therefore, nursing staff think that not using restraint is impossible. This study also showed that the lack of practice guidelines resulted in inconsistent restraint use among Korean nursing staff. Both the Korean government and nursing homes need to develop and adopt practice guidelines regarding restraints, support nursing staff to follow the guidelines, and provide access to successful case examples of restraint-free care in other countries or other nursing homes. In addition, Korean nursing homes need to evaluate and modify their philosophy and standard regarding restraint use (Park, Tang, Adams, & Titler, 2007). Many nursing staff stressed the importance of understanding, respect, and communication among elders, GCAs, nurses and families for successful restraint reduction. A similar theme of establishing partnerships was identified in an Australian study (Nay & Koch, 2006) which reported the importance of collaboration among nursing staff, family, other health professionals, and institutions for avoiding restraint use. In addition, lack of respect was one of the reasons given for the high turnover rate among nursing assistants, and turnover interrupted restraint-free care (Goldman, 2008). To achieve restraint-free care, teaching ways to improve relationships and communication among nursing staff, elders, and their families should accompany restraint-reduction education. Considering Korean family caregivers’ strong feelings of guilt, stigma, and conflict regarding institutionalization (Lee, Kim, & Kim, 2010) that lead to complaints about accidents and demands to use physical restraints, future studies need to develop and test nursing


interventions to ensure better relationships and communication among families, elders, and nursing staff. The transferability of these findings might be limited because of the study’s sampling bias in terms of recruitment area and facilities: only two nursing homes located in Seoul and Gyeonggi province in Korea. Conclusion Despite being limited to nursing staff in two nursing homes, this study provides valuable information and suggestions for restraintreduction in Korean nursing homes in terms of practice, education, policy, and research. Korean nursing staff is aware of many barriers to physical restraint reduction and acknowledge their needs for help in overcoming them. Korean nursing staff requested more practical and professional education regarding dementia care, individualized care, and ways to reduce restraint use. In addition, they requested restraint-free care education for families. Many nursing staff stressed the importance of understanding, respect, and communication among elders, GCAs, nurses and families for successful restraint reduction. Korean nursing homes and national leaders will need to develop practice guidelines regarding restraints, support nursing staff to follow the guidelines, use a multidisciplinary team approach, employ alternative equipment, engage volunteers, and hire more nursing staff to achieve restraintfree care. Given the busy schedules and the high prevalence of internet and smart phone technology among Korean staff , future research should test effectiveness of multimedia educational programs on restraint-free care. Conflict of interest The authors declare no conflicts of interest with respect to the authorship and/or publication of this article. Acknowledgment We thank our participants for their invaluable contributions to the study. The research was supported by the Basic Science Research Program through the National Research Foundation of Korea, Ministry of Education, Science, and Technology (20100021483) and Gachon University research fund. The abstract of this paper was presented at the 8th International Nursing Conference, Seoul, South Korea on October 27, 2011. References An, D. (2010). Knowledge and attitudes of caregivers about using restraints in elderly care facilities. Pusan, Korea: Catholic University of Pusan (Unpublished master's thesis). Ayres, L., Kavanaugh, K., & Knafl, K. A. (2003). Within-case and across-case approaches to qualitative data analysis. Qualitative Health Research, 13, 871e883. Ben Natan, M., Akrish, O., Zaltkina, B., & Noy, R. H. (2010). Physically restraining elder residents of long-term care facilities from a nurses’ perspective. International Journal of Nursing Practice, 16, 499e507. Bigwood, S., & Crowe, M. (2008). Its part of the job, but it spoils the job: a phenomenological study of physical restraint. International Journal of Mental Health Nursing, 17, 215e222. Blumer, H. (1969). Symbolic interactionism. Englewood Cliffs, New Jersey: PrenticeHall. Capezuti, E., Brush, B. L., Won, R. M., Wagner, L. M., & Lawson, W. T. (2008). Least restrictive or least understood? Waist restraints, provider practices, and risk of harm. Journal of Aging and Social Policy, 20, 305e322. Capezuti, E., Wagner, L. M., Brush, B. L., Boltz, M., Renz, S., & Talerico, K. A. (2007). Consequences of an intervention to reduce restrictive side rail use in nursing homes. Journal of American Geriatrics Society, 55, 334e341. Chiba, Y., Yamamoto-Mitani, N., & Kawasaki, M. (2012). A national survey of the use of physical restraint in long-term care hospitals in Japan. Journal of Clinical Nursing, 21, 1314e1326.


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Nursing staff views of barriers to physical restraint reduction in nursing homes.

There are few studies globally regarding the barriers to restraint-reduction. The purpose of this study was to describe the views of nursing staff (bo...
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