Iniatives to reduce the use of seclusion and restraints on people with developmental disabilities: a systematic review and quantitative synthesis

Contrary to the expectations articulated in public policy, restrictive interventions are commonly used in support services for people with developmental disabilities. This systematic review and quantitative synthesis was undertaken to investigate whether the use of seclusion and restraints on people with developmental disabilities can be reduced. Searches of the Academic Search Complete, CINAHL, MEDLINE, and PsycINFO electronic databases returned 7226 records, of which 11 met the inclusion criteria for this review. A further 3 papers were obtained through scanning the reference lists of those articles included from the initial literature search. All 14 studies were single-subject designs focusing on initiatives to reduce physical or mechanical restraint. Between the baseline and intervention phases, there were mean reductions in the frequency and duration of restraint use of 79% (SD = 21%, n = 13 subjects from 7 studies) and 45% (SD = 58%, n = 10 subjects from 6 studies), respectively. For studies in which restraint use to manage agitation and aggression was targeted, there was a 79% (SD = 21%, n = 13 subjects from 7 studies) decrease in the frequency and a 28% (SD = 67%, n = 6 subjects from 3 studies) reduction in the duration of restraint. With respect to studies in which restraint use to prevent self-harm was targeted, there was a 71% (SD = 34%, n = 4 subjects from 3 studies) reduction in restraint use. Effect sizes were calculable, using non-overlap approaches, for 9 of the 14 studies. The magnitudes of the effect sizes suggest that, on average, the interventions were effective in reducing the use of restraints. The effects generated in studies where restraint use for self-harm was targeted were typically more pronounced than those in which restraint use for agitation and aggression was addressed. There were broad variations, however, in the percentage reductions in restraint use and in the magnitudes of the effect sizes. Although the findings of this review are encouraging, more research is needed, in which greater attention must be paid to rigorous research design, application, and analysis.

A longitudinal evaluation of nursing home care quality in Taiwan

Aging populations worldwide have important implications for elderly care composition and quality, particularly with regard to care provided by nursing homes. Our study investigated quality of nursing home care in Taiwan using resident satisfaction and clinical outcomes as indicators.
We randomly recruited 306 residents in 13 nursing homes and assessed them at initial, 3, 6, and 12-months follow-up. The outcomes of the nursing home care in the 12-month follow-up period showed significant decreases in pressure sores and moderate satisfaction of nursing home care, but increases in physical restraints and psychological loneliness. Study results suggest that longterm nursing home care may improve residents' quality of life. However, to achieve this, nursing homes must provide improved psychological support for residents and decrease the use ofphysical
restraints.

Reviewing the learning organisation model in a child and adolescent mental health service

From 1995 onwards, a child and adolescent mental health service (CAMHS) applied Senge's learning organisation model. This review compared service performance with that of peer services 5 years later and explored whether any differences were associated with the application of this model. The comparison methodology used quantitative analysis of external data from the Department of Human Services, together with qualitative analysis of material including interviews with CAMHS directors and service managers. Results showed high evaluation activity and high quality, efficiency and efficacy of care compared with other services. Several restraints to the optimal application of the model were identified, including inadequate training of new managers, service overload, major external organisational change and limited investment in information systems. Other outcomes are discussed.

Registered and enrolled nurses : experiences of ethical issues in nursing practice

Research aims:
To explore and describe registered and enrolled nurses’ experiences of ethics and human rights issues in nursing practice in the Australian State of Victoria.

Method:
Descriptive survey of 398 Victorian nurses using the Ethical Issues Scale (EIS) survey questionnaire.

Major findings:
The most frequent and most disturbing ethical issues reported by the nurses surveyed included: protecting patients’ rights and human dignity, providing care with possible risk to their own health, informed consent, staffing patterns that limited patient access to nursing care, the use of physical/chemical restraints, prolonging the dying process with inappropriate measures, working with unethical/impaired colleagues, caring for patients/families who are misinformed, not considering a patient’s quality of life, poor working conditions.

Conclusions:
Nurses in Victoria frequently experience disturbing ethical issues in nursing practice that warrant focussed attention by health service managers, educators and policy makers.

Students' experiences using online support sites in NZ tertiary education

Major findings include: students who make use of online learning support sites judge that they do make a useful contribution to their academic success. Students especially value the opportunity to access learning support that is free from the time and space restraints of traditional on-campus support service delivery.

Patient comfort in the intensive care unit : a multicentre, binational point prevalence study of analgesia, sedation and delirium management

Objective: To measure the prevalence of assessment and management practices for analgesia, sedation and delirium in patients in Australian and New Zealand intensive care units.
Materials and Methods: We developed survey items from a modified Delphi panel and included them in a binational, point prevalence study. We used a standard case report form to capture retrospective patient data on management of analgesia, sedation and delirium at the end of a 4-hour period on the study day. Other data were collected during independent assessment of patient status and medication requirements.
Results: Data were collected on 569 patients in 41 ICUs. Pain assessment was documented in the 4 hours before study observation in 46% of patients. Of 319 assessable patients, 16% had moderate pain and 6% had severe pain. Routine sedation assessment using a scale was recorded in 63% of intubated and ventilated patients. When assessed, 38% were alert and calm, or drowsy and rousable, 22% were lightly to moderately sedated, 31% were deeply sedated (66% of these had a documented indication), and 9% were agitated or restless. Sedatives were titrated to a target level in 42% of patients. Routine assessment of delirium occurred in 3%, and at study assessment 9% had delirium. Wrist or arm restraints were used for 7% of patients.
Conclusions: Only two-thirds of sedated patients had their sedation levels formally assessed, half had pain assessed and very few had formal assessment of delirium. Our description of current practices, and other observational data, may help in planning further research in this area.

Limited effect of fly-wheel and spinal mobilization exercise countermeasures on lumbar spine deconditioning during 90 d bed-rest in the Toulouse LTBR study

We examined the effect of high-load fly-wheel (targeting the lower-limb musculature and concurrent loading of the spine via shoulder restraints) and spinal movement countermeasures against lumbar spine muscle atrophy, disc and spinal morphology changes and trunk isokinetic torque loss during prolonged bed-rest. Twenty-four male subjects underwent 90 d head-down tilt bed-rest and performed either fly-wheel (FW) exercises every three days, spinal movement exercises in lying five times daily (SpMob), or no exercise (Ctrl). There was no significant impact of countermeasures on losses of isokinetic trunk flexion/extension (p≥0.65). Muscle volume change by day-89 of bed-rest in the psoas, iliacus, lumbar erector spinae, lumbar multifidus and quadratus lumborum, as measured via magnetic resonance imaging (MRI), was statistically similar in all three groups (p≥0.33). No significant effect on MRI-measures of lumbar intervertebral disc volume, spinal length and lordosis (p≥0.09) were seen either, but there was some impact (p≤0.048) on axial plane disc dimensions (greater reduction than in Ctrl) and disc height (greater increases than in Ctrl). MRI-data from subjects measured 13 and 90-days after bed-rest showed partial recovery of the spinal extensor musculature by day-13 after bed-rest with this process complete by day-90. Some changes in lumbar spine and disc morphology parameters were still persistent 90-days after bed-rest. The present results indicate that the countermeasures tested were not optimal to maintain integrity of the spine and trunk musculature during bed rest. © 2011 Elsevier Ltd.