Nurses’ decision-making process in cases of physical restraint in acute elderly care: A qualitative study

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Abstract

Background

The increasing vulnerability of patients in acute elderly care requires constant critical reflection in ethically charged situations such as when employing physical restraint. Qualitative evidence concerning nurses’ decision making in cases of physical restraint is limited and fragmented. A thorough understanding of nurses’ decision-making process could be useful to understand how nurses reason and make decisions in ethically laden situations.

Objectives

The aims of this study were to explore and describe nurses’ decision-making process in cases of physical restraint.

Design

We used a qualitative interview design inspired by the Grounded Theory approach. Data analysis was guided by the Qualitative Analysis Guide of Leuven.

Setting

Twelve hospitals geographically spread throughout the five provinces of Flanders, Belgium.

Participants

Twenty-one acute geriatric nurses interviewed between October 2009 and April 2011 were purposively and theoretically selected, with the aim of including nurses having a variety of characteristics and experiences concerning decisions on using physical restraint.

Results

In cases of physical restraint in acute elderly care, nurses’ decision making was never experienced as a fixed decision but rather as a series of decisions. Decision making was mostly reasoned upon and based on rational arguments; however, decisions were also made routinely and intuitively. Some nurses felt very certain about their decisions, while others experienced feelings of uncertainty regarding their decisions.

Conclusions

Nurses’ decision making is an independent process that requires nurses to obtain a good picture of the patient, to be constantly observant, and to assess and reassess the patient's situation. Coming to thoughtful and individualized decisions requires major commitment and constant critical reflection.

Introduction

The ethical dimension of care is an essential part of good nursing practice, and ethical reflection is necessary for nurses to come to thoughtful and balanced decisions (Bishop and Scudder, 1990). The review of Goethals et al. (2010) shows that nurses’ ethical practice is a complex process of reasoning and decision making that involves observing, analyzing, and judging patient-related issues. This decision making is influenced by nurses’ personal qualities. Limited staff and time are context-related elements that impede and complicate nurses’ ethical practice. As a result, more and more nurses prioritize medical technical care and experience the realization of the ethical dimension as a difficult and subordinated task (Milisen et al., 2006a).

Particularly in acute elderly care, where most of the patients have impaired physical and mental abilities and limited capacities to express their personal needs and wishes, the vulnerability of the patients increases. To deal appropriately with this vulnerability, nurses need to be able to critically observe and interpret patients’ signals in order to provide ethical care (Kihlgren and Thorsen, 1996, Randers and Matttiasson, 2000). Critical reflection on what constitutes good care is required in everyday care, but even more so in ethically charged situations such as those requiring physical restraint (Gastmans and Milisen, 2006). Physical restraint is defined as “any device, material, or equipment attached to or near a person's body that cannot be controlled or easily removed by the person and which deliberately prevents or is deliberately intended to prevent a person's free body movement to a position of choice and/or a person's normal access to their body” (Retsas, 1998).

During the last 20 years, awareness has increased about the frequent and unlimited use of restraint in the US, Australia, the UK, and other European countries (Hughes, 2010, Köpke et al., 2010). Based on research and motivated by a philosophy of individualized care, many measures are taken to change this standard of practice (Hughes, 2010). The use of physical restraints, however, is still a common practice (with a prevalence of 33–68%) in acute care settings (Hamers and Huizing, 2005) and remains an international topic of discussion. This discussion relates to several dimensions, including the violation of human rights (Hughes, 2010); the balance of clinical and ethical issues (Gastmans and Milisen, 2006, Gastmans, 2010); and to the question of whether physical restraint can ever be avoided (Flaherty, 2004).

Nurses’ key role in making decisions about the use of physical restraint must be understood in terms of their initiation of restraint use and/or by their intimate involvement in the care of restrained patients (Hamers and Huizing, 2005). A synthesis of qualitative evidence regarding nurses’ decision making in cases of physical restraint characterizes decision making as a complex trajectory that focuses on safety and is guided by ethical principles (Goethals et al., 2012). The different phases—e.g. before, during, and after restraint use—describe the trajectory character of the decision making (Kontio et al., 2010). The “complexity” of this trajectory is attributed to and depends on patient characteristics, such as degree of disruptive behavior (Janelli et al., 1995, Janelli and Kanski, 1996, Chien, 1999, Lee et al., 1999, Hantikainen, 2001, Ludwick et al., 2008); nurse-related factors, such as nurses’ willingness to take risks (Karlsson et al., 2000) and context-related factors, such as the family's viewpoint (Hantikainen and Käppeli, 2000).

While most of the included studies focused on one or more substantive elements of this complexity, only two studies described decision making as a “trajectory” (Ludwick et al., 2008, Kontio et al., 2010). A refined understanding of this trajectory would be helpful in understanding the complexity of nurses’ reasoning process in ethically laden situations. Thus, the aim of this study was to explore nurses’ decision making process in cases of physical restraint in acute elderly care.

Section snippets

Design

We used a qualitative interview design inspired by the Grounded Theory approach (Corbin and Strauss, 2008). The Grounded Theory approach is well suited for discovering complex phenomena such as understanding the underlying social processes of decision-making.

Procedure and sampling

All hospitals in Flanders, Belgium with an acute geriatric ward (n = 63) were contacted by email. Thirty-four hospitals participated in our study. The hospitals completed a questionnaire on hospital characteristics and selected a contact

Discussion of the methods

As far as we know, this is the first qualitative study to examine nurses’ decision-making process during cases of physical restraint in acute elderly care in Flanders, Belgium. This qualitative study provided rich and in-depth insight into nurses’ reasoning and decision making during situations of physical restraint. The strengths of this study are (1) the systematic and cyclic process of data collection and analysis, (2) the heterogeneity of the sample regarding both hospital and nurses

Acknowledgments

The authors would like to thank all the participants for their contribution to this study. We are also thankful to Els Bryon, Yvonne Denier, Corine Tiedtke, and Luc Van Gorp for their participation in the peer-review process.

Conflict of interest: No conflict of interest has been declared by the authors.

Funding: This study is funded by the Flemish Community, Department of Education and the Catholic University College Ghent, Belgium.

Ethical approval: Catholic University of Leuven, Faculty of

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