Physical restraint use within long term care settings for older persons in Malta

Fenech, Maria Aurora (2016) Physical restraint use within long term care settings for older persons in Malta. PhD thesis, University of Nottingham.

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Purpose: To study this locally unexplored scenario and provide a platform of knowledge base and information on physical restraint use, securing relevant information of essence to the older person, care provider and policy makers within care homes.

Aims and objectives: This dissertation focuses on care providers’ observations and perceptions concerning (a) the types of restraint devices used in government and privately managed long term care homes for older persons in Malta, (b) their mode and extent of application, (c) older person characteristics which may be conducive to physical restraint use, (d) older persons’ reactions to restraint use (e) care providers’ perceptions to physical restraint use within the context of work, environmental and safety concerns, and (f) how the effects of physical restraint use could influence the older person’s rights, autonomy and integrity.

Relevance: The demand for long term care for older persons increases as the population ages. This, coupled with an increasing demand for human resources, aggravates the risk for less humane care for frail and vulnerable older persons. Person centred care is the fulcrum for the quality of service delivery in the care of older persons. It recognises the distinctiveness of each and every person irrespective of mental and functional capabilities, and moves away from the routine-driven, task-oriented and depersonalised services to focus on specific personal needs.

Although there is an increasing international body of literature, exploring the concept of physical restraint use in care homes, there is a lack of research-based evidence exploring care providers’ holistic approach to physical restraint use in long term care settings in Malta. More importantly, published papers fail to captivate the human and humane elements of the physically restrained older person. The relevance of physical restraint use is central within care home environments. The knowledge of the framework within which this use operates is necessary for the establishment of a paradigm that places the older person within the hubs of her/his care.

Study design: A questionnaire booklet incorporating quantitative and qualitative components was developed, designed and adopted. The questionnaire was anonymous and self-administered by care providers within all Maltese care homes (n=13), managed by the government and private sectors. All care providers within these care homes were eligible for study participation, (medical, allied health, nursing, and nursing support staff). Care providers have direct contact with the older persons, and are therefore in a position to provide first-hand information about the use of physical restraints. Participants were requested to complete and return ‘Physical Restraint Use’ (PRU) questionnaire booklet developed for this study. Four hundred and thirty four questionnaire booklets were distributed and 180 booklets were returned over a 3 month time frame, providing a response rate of 41.5%.

Findings: A high observed incidence of physical restraint devices particularly for bed rails and harnesses was registered within both the government and privately managed care homes. Moreover, respondents acknowledged the use of 16 different types of devices, which raised questions as to multiple use of restraining. Privately managed care homes reported a slightly higher incidence of observed devices in use. The observed total duration of restraints in excess of 2 hours by far exceeded durations less than 2 hours in both government and privately managed care homes. Data pertaining to the private care homes points to the existence of potential continual application of restraint.

With respect to observations of modalities of physical restraint use (person recommending, explaining, monitoring and deciding, and documentation), within government and privately managed care homes, a consistent statistically higher involvement of management staff in all of the procedures related to the use of restraining was reported. This was however not evident with respect to documenting restraint use within the private sector. Additionally family members/substitute decision makers had a greater influence on recommending restraint use and its removal within privately managed care homes. Nursing support staff offered a greater contribution to monitoring, documenting restraint use in private than in government managed care homes, whilst nurses in government homes contributed more to monitoring restraint use than their professional counterparts within private homes.

Care providers’ attitudes on the use of restraining were reported to be the strongest advocators for using physical restraints within care homes, rather than issues related to older persons themselves such as mobility and physical limitations, cognitive problems, continence issues, problems with communication/hearing/vision and activity participation and pharmacological treatment.

Respondents also acknowledged observing adverse reactions to restraint use. Care providers reported restlessness to be the most observed reaction from older persons to physical restraint use (87.9%), followed by physical and cognitive consequences (66.7%) and apathy (30.3%).

Participants were uncertain that there would be no serious concerns related to work, environment, safety, and caring, should restraints be reduced, scoring between 3.0 and 4.0 on a 5-point Likert scale, with high scores expressing high concerns. Further analysis revealed that both care home sectors tended to favour least restraint use but were reluctant to remove restraint completely. Similarly, private care home respondents disagreed more than government care home respondents with the statement that the majority of physical restraints in use are necessary while nursing and nursing support staff showed a higher agreement with physical restraining being an invasion of a human right than did managers.

Training did not impact on the use of restraining within the care homes.


Conclusion: This study highlighted the sensitivity surrounding physical restraint use. It substantiated published data and also offered novel contributions to the body of knowledge pertaining to the physical restraints and their use. Primarily, the study indicated that training had no impact to effecting restraint minimisation approaches within the care homes. Secondly, respondents acknowledged the use of 16 different types of restraining devices. Also, arguments that bed rail use was not considered a restraining device, having become unconditionally and unquestionably the accepted norm within care homes was corroborated through the high reported observed incidence of use. The study also offered a fresh insight into the modalities of physical restraint use, (recommendation to, explaining on, and monitoring/removing restraint device).

Few insights into the impact of physical restraining on the human and humane aspects of older person care were captivated in this study, more so as the sensitivity surrounding physical restraining required that the investigation be carried out through care providers’ observations. This situation, within this project, was perhaps the biggest contribution yet, moreover when the study was indicative that care providers’ attitudes towards restraint use were reported to be the strongest advocator for their use.

At its most basic level, physical restraining is tantamount to blocking or limiting a person’s free ability to move as she/he pleases, thus infringing on the older person’s human rights. Indeed, physical restraining is the inability of care providers’ to identify and address the needs of the older persons and provide innovative paradigms of care. Restraining implies a failure in people relationships and consequently in the system of care delivery.

The message in the bottle must address the urgent provision for personalised services that enable the older person to make full decisions about her/his care through the support of care providers when called for and at later stages through advocates. It is only through these approaches that policies and guidelines could be put in place and managed effectively and efficiently.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Hall, Ian Philip
Gladman, John
Keywords: physical restraint, long-term care, care home, older person, autonomy
Subjects: W Medicine and related subjects (NLM Classification) > WT Geriatrics. Chronic disease
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 38980
Depositing User: Fenech, Maria
Date Deposited: 16 Feb 2017 14:18
Last Modified: 08 Feb 2019 08:01

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