In the public domain The Gemntologist Vol. 32, No. 6, 767-770
This study identifies resident characteristics related to nursing staff failure to provide consistent release from physical restraints as required by regulation. The lengths of intervals during which residents were restrained were measured and correlated with the staff's perception of degree of care burden and resident behavioral characteristics in order to identify risk factors related to the absence of consistent release. Staff perceptions of residents' verbal aggressiveness (multiple R = - .30, p < .01), physical aggressiveness (multiple R = - .25, p < .03) and unpleasantness (multiple R = - .25, p < .03) are the three characteristics most predictive of the length of time residents continuously remain restrained. Key Words: Aggression, Neglect, Staff management
John F. Schnelle, PhD,1 Sandra F. Simmons, MA,1 and Marcia G. Ory, PhD2
The probability of restraint use increases with age and severity of cognitive impairment (Evans & Strumpf, 1989). Most likely, these two predictive factors explain why restraint use is so common in nursing homes. Prevalence of restraint use in nursing homes varies from 25% to 85% of the resident populations, with unsteadiness, disruptive behavior (e.g., aggression), and wandering most often cited as reasons for using restraints (Evans & Strumpf, 1989; Tinetti et al., 1991). The practice of physically restraining residents has been questioned for humane and psychological reasons. Loss of dignity, urinary incontinence, muscle atrophy, and even higher mortality rates have been attributed to restraint use (Werner et al., 1989). The alleged benefits of restraint have also been questioned. For example, critics stress a lack of evidence that restraints reduce falls or decrease resident agitation (Werner et al., 1989). Federal regulation mandates that restrained residents are to be released, exercised, and repositioned every 2 hours to prevent the deleterious side effects of immobility (American Health Care Association, 1986). However, despite federal mandates, a recent study confirmed that nursing staff frequently do not adhere to the guidelines regarding restraint release and repositioning. In that study, more than 60% of residents in two nursing homes were restrained for intervals in excess of 2 hours (Schnelle et al., 1992). The present study identifies resident characteristics that are most predictive of nursing staff failure to consistently release restraints. Since specific resi-
1 Borun Center for Cerontological Research, UCLA School of Medicine, 10833 Le Conte Avenue (CHS 32-144), Los Angeles, CA 90024-1687. 2 National Institute on Aging, Bethesda, MD.
Vol. 32, No. 6,1992
dent behavioral characteristics predict restraint use (Evans & Strumpf, 1989; Tinetti et al., 1991), it was hypothesized that resident characteristics may predict poor restraint management as well. The number of episodes during which residents were restrained for 2 hours or longer was measured. The frequency of these episodes was then correlated with resident characteristics to identify risk factors that may predict excessive restraint intervals. Methods
Participants We studied 64 restrained residents during 1990 in two nursing homes located in the middle Tennessee area (81% female and 19% male). (Because of the disproportionate numbers of men and women, gender was not included in the later regression analysis.) Restraints being used in the two facilities were waist, mitten, wrist, and vest restraints and geri-chairs. Geri-chairs were not monitored during the study; however, only three residents were in geri-chairs without any other restraint device. Bed rails were not counted as restraint devices. All other restraint devices were monitored, thus yielding 61 residents. The use of restraints was confirmed through direct observation by research staff, who made rounds in the nursing homes for 12 continuous hours on 3 separate days prior to the evaluation. This observation also confirmed that all restraints used on the 61 subjects (except mittens) relied on ties that required knots. Residents' functioning skills were assessed in six major areas using the Geriatric Assessment Inventory (GAI), a standardized and validated instrument that utilizes staff ratings of resident functioning, t h e 767
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Michigan on June 28, 2015
Risk Factors That Predict Staff Failure to Release Nursing Home Residents from Restraints
Restraint Monitoring The participants and the restraint monitoring procedures utilized here were part of a larger, previously published intervention study designed to improve staff's management of restraints, which provided an extensive description of all restraint monitoring procedures (Schnelle et al., 1992). A black light measurement system was used to facilitate nonobtrusive observation of how long restraint knots remained tied without loosening. Research staff marked each knot on a restraint with a spot of ink that was visible only if a hand-held black light was shone on the knot. Preliminary research demonstrated that it was not possible to release a restraint and retie it without movement of the dot (Schnelle et al., 1992). After marking restraints, rounds to check all residents were made each hour between 7 a.m. and 7 p.m. During each round, the center of the knot was marked for residents found restrained for the first time or for residents who were found to have been released and re-restrained. A resident was counted as restrained and then released only if the ink mark found on the knot had changed position between hours. For example, if a resident was found 768
restrained at 7 a.m. and the ink mark was missing or had moved at 8 a.m., then a 1-hour restraint interval was counted. This resident's restraint would again be marked and a new restraint interval count would begin. If the marked knot did not change until the 11 a.m. round, then a 3-hour restraint interval for that resident would be calculated. The marking of the restraint intervals for mittens was calculated in an identical fashion except the ink mark was placed on the velcro spot that secured the mittens. An average of 83 different restraint intervals was calculated per day for the 61 residents observed during the study. A total of 1,444 restraint intervals were calculated during a 7-day observation period in Facility 1 and a 14-day observation period in Facility 2. The total number of intervals that each individual resident was found restrained for more than 2 hours was the dependent measure. To ensure interrater reliability, two independent observers examined the same knots on 130 separate occasions and independently recorded whether ink spots had moved. The interrater agreement on the knot-marking system was 91%, indicating high reliability of the restraint monitoring system. Risk Factor Measures Staff perceptions of resident characteristics chosen as potential predictors of staff failure to release residents from restraints were identified by an extensive review of the literature and by the clinical impressions of the research staff. The professional literature that documents resident characteristics that lead caregivers to provide poor care was considered particularly relevant. In addition, the literature that describes resident characteristics that nursing staff find stressful to deal with was reviewed under the assumption that nursing staff might tend to avoid residents who are considered stressful. Research on neglect in community-dwelling elderly indicated that cognitive impairment and the extent of care burden and workload created by the elder are associated with neglect (Fulmer & Ashley, 1989). In addition, specific problem behaviors such as combativeness, verbal belligerence, and incontinence have also been identified as possible precipitating factors for neglect (O'Malley, Everitt, & O'Malley, 1983). Underlying the potential importance of these factors, a recent study reported that nursing home caregivers rate physical and verbal abuse as the most stressproducing behaviors exhibited by nursing home residents, and that resident withdrawal was found distressful nearly two-thirds of the time by nursing home staff (Everitt et al., 1991). Six potential risk factors were chosen for the present study, each related to the degree of caregiver burden posed by the resident, resident combativeness, or resident withdrawal. These risk factors were evaluated for their ability to predict the number of intervals a resident remained restrained for more than 2 hours. Five nursing staff were identified for each of the 61 residents, each having rated herself as knowing the resident extremely well or well. Each of The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Michigan on June 28, 2015
measures included: self-help dressing, self-help general, locomotion, socialization, communication, and cognition. Additionally, the Mini-Mental State Exam (MMSE) was administered to the residents. The residents averaged 84.5 years of age and were severely impaired as documented by the GAI and the MMSE (X = 7.55). Only 18% of the residents were capable of independent ambulation when not restrained, and only 54% of the residents could follow one-step instructions. Both nursing homes (containing 80 and 97 beds, respectively) were staffed with a 10:1 resident-toaide ratio during the 7 a.m. to 3 p.m. shift, and a 15:1 ratio during the 3 p.m. to 11 p.m. shift. One LPN was responsible for approximately 40 residents. The number of residents restrained in the facilities was not significantly different (30 and 31 residents, respectively). Both nursing homes had received excellent state survey reports in the 2 years preceding this evaluation. Neither home was cited for resident care deficiencies, and one home received no deficiencies in any area. All aides and staff were trained according to recommended OBRA guidelines. For the present study each subject was observed continuously during all periods that they were restrained. The number of restraint intervals recorded for each resident was determined by staff behavior. For example, if a resident was restrained at 8 a.m. and not released until 5 p.m., one 9-hour restraint interval was recorded. If a resident was restrained at 8 p.m. and then released every 2 hours until 6 p.m., then five 2-hour restraint intervals were recorded. Both of the residents in this example would be observed for identical periods of time, having been restrained for equally long periods of time; however, the number of intervals recorded differs considerably.
Results
Including all residents monitored, 373 restraint intervals were recorded that lasted more than 2 hours. This represented 26% of all recorded restraint intervals. All 61 residents in this study were found to be restrained each day during the entire period they were out of bed. All residents were continuously monitored during these periods in an identical fashion. For individual residents, the number of restraint intervals that exceeded the 2-hour limit ranged from 0 to 33. Preliminary analysis revealed that the functioning skill areas measured in the CAI and MMSE did not significantly discriminate between residents because all scored very low on all areas measured. Reflecting the homogeneity of the residents in terms of functioning, there were no significant correlations between the functioning scores and the restraint intervals measured. Thus, the functioning scores were not included in further regression analyses. Table 1 illustrates key content areas of the questionnaire items and the distribution of the scores. Since five staff members rated each of the 61 residents, there was a total of 305 responses to each area except for communication ability, where the 5 scores were averaged. Vol. 32, No. 6,1992
A regression analysis was conducted to relate the six resident characteristics identified as potential predictors to the number of restraint intervals of more than 2 hours for each resident. This analysis is illustrated in Table 2. The correlation of each variable with the restraint measure as well as the beta weight and significance level in the multiple regression analysis is indicated. Staff ratings of verbal aggressiveness, physical aggressiveness, and unpleasantness were all correlated with the measure of failure to adhere to the restraint-release guidelines. In the multiple regression analysis only verbal aggression emerged as a significant predictor of failure to release restraints. However, verbal aggression (VA), physical aggression (PA), and unpleasantness (U) were all highly intercorrelated (VA vs. PA = .89; PA vs. U = .76; VAvs. U = .76). Each of these variables emerged as predictive of failure to release restraints Table 1 . Staff Perceptions of Resident Characteristics Hypothesized to Be Predictive of Failure to Release Restraints, by Content Area of Questionnaire
Distribution Content area
Frequency
%
N = 305 Lifting (2) One
(1)Two (0) More than two Excessive demands (0) Yes (DNo Verbally aggressive (0) All/most of the time (1) Sometimes (2) Rarely (3) Never Physically aggressive (0) All/most of the time (1) Sometimes (2) Rarely (3) Never Pleasantness (1) Pleasant (2) Unpleasant Communication ability3 0.0-2.0 2.1-4.0 4.1-6.0 6.1-8.0
80 219 6
26 72 2
41 264
13 87
16 44
5 14
51
17
194
64
15 46 55 189
5 15 18 62
42 263 N = 61 7 8 7 39
14 86 11.5 13 11.5 64
a Each of the five staff members scored communication ability on a 0-8 scale for each resident. The average scores are presented.
Table 2. Value of Resident Characteristics, as Measured by Multiple Regression Analysis, to Predict Staff Failure to Release Restraints
Correlation
Beta
Resident characteristic
coefficient (/?)
weight (B)
Lifting Excessive demands Verbally aggressive Physically aggressive Pleasantness Communication ability
.16 .04 -.30** -.25* -.25* .14
.192108 .108063 - .303794 -.011904 - .047071 .019916
Note. Resident characteristics were measured by staff perceptions of residents they know well. * p < .05; * * p < .01.
769
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Michigan on June 28, 2015
these staff members was then guided through the behavioral interview format and asked to describe the resident's behaviors and relative care burden through answering a series of six questions. Questions 1, 2, and 5 reflected care burden, questions 3 and 4 were measures of resident combativeness, and question 6 was a measure of resident withdrawal. A numerical score for each resident was derived by circling the number associated with the staff rating of that resident. In the case of communication, one overall score was calculated by adding all response alternatives chosen by the staff members. For example, if a resident was rated as verbally communicative, rational, spontaneous, and clear, then his or her total communication score equalled 8. If a resident was reported as not communicating verbally or nonverbally, the score was 0. Operational definitions for each question were read to the staff members during the interviews. For example, in question 2, the interviewer asked the staff member: "Does this resident make excessive demands? For example, constantly use the call light or ask unnecessary questions." If the staff member indicated that the resident made excessive demands, the question would be assigned a score of 0. The average score provided by five different staff raters for each of the items was the independent variable measure used in a regression analysis designed to relate subject characteristics to failure to follow restraint guidelines. Higher scores represented (staff-perceived) low care burden, high communication, high pleasantness, and low aggression. The overall interrater reliability for the five staff members' answers to the six questions was 86%. The interrater reliability for specific questions ranged from 79% to 91%.
in a step-wise multiple regression analysis in which verbal aggression was held out of analysis (multiple R = - . 3 2 , p < .01) and physical aggression was held out of analysis (multiple R = - .34, p < .01). Discussion
t
Annual Midwest Caribbean Geriatric Conference March 5, 6, 7, 1993 at
Caribe Hilton Hotel San Juan, Puerto Rico Jointly Sponsored by: GRECC, St. Louis VA Medical Center and John L. McClellan Memorial Veterans Hospital Saint Louis University School of Medicine Department of Internal Medicine University of Arkansas for Medical Sciences
References
American Health Care Association. (1986). The long-term care survey (Catalog No. 110334/12-87/SM/BAL). Washington, DC: Health Care Financing Administration. Evans, L. K., & Strumpf, N. (1989). Tying down the elderly: A review of the literature on physical restraints, journal of the American Geriatrics Society, 37, 65-74. Everitt, D. E., Fields, D. R., Soumerai, S. S., & Avorn, J. (1991). Resident behavior and staff distress in the nursing home, journal of the American Geriatrics Society, 39, 792-798. Fulmer, T.,& Ashley, J. (1989). Clinical indicators of elder neglect, journal of Applied Nursing Research, 2,161-167. O'Malley, T., Everitt, D., & O'Malley, H. (1983). Identifying and preventing family mediated abuse and neglect of elderly persons. Annals of Internal Medicine, 98, 998-1005. Schnelle, J. F., Newman, D., White, M., Volner, T. ; Burnett, J., Cronquist, A., & Ory, M. (1992). Reducing and managing restraints in long-term care facilities, journal of the American Geriatrics Society, 40, 381-385. Tinetti, M. C , Liu, V., Marottolil, R. A., & Cinter, S. F. (1991). Mechanical restraint use among residents of skilled nursing facilities: Prevalence, patterns and predictors. Journal of the American Medical Association, 265,468-471. Werner, P., Cohen-Mansfield, J., Brown, J., & Marx, M. S. (1989). Physical restraints and agitation in nursing home residents, journal of the American Geriatrics Society, 37, 1122-1126.
Missouri Gateway Geriatric Education Center Universtity of Puerto Rico, School of Medicine For further information, please contact: Sue Wheat Saint Louis University Medical Center 1402 S. Grand Blvd., Room M238 St. Louis, Missouri 63104 Phone: (314) 577-8462
770
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Michigan on June 28, 2015
Three highly intercorrelated risk factors related to residents' physical or verbal aggression and unpleasantness were most predictive of staff failure to consistently release residents from restraints. Resident characteristics related to care burden and workload (e.g., those resulting in lifting or transporting difficulties) and responsiveness or withdrawal were not predictive. The fact that verbal and physical aggression are predictors supplements previous findings that nursing staff rate both of these resident behaviors as highly stressful. The stressful nature of these behaviors apparently leads to staff avoidance of these residents as measured by the absence of restraint release, which constitutes a form of neglect. It would not be surprising if residents who were neglected in restraint management were also exercised, turned, or otherwise cared for less frequently than they should be. Residents who are physically and verbally aggressive and otherwise rated by staff as unpleasant to work with should be particularly monitored by supervisors for evidence of staff inconsistency in applying resident care routines and adhering to related OBRA guidelines. In addition, training systems to sensitize staff to these risk factors could be implemented and evaluated against the type of measures illustrated in this study. Previous research documented that physical and verbal aggression are predictive of staff's decisions to use restraints. This study expands the picture by providing evidence that physical and verbal aggression are also predictive of neglect in the management of the restraints. Thus, further evidence is provided for the imperative need to develop behavior management procedures that can serve as alternatives to restraint use in nursing homes.
This study identifies resident characteristics related to nursing staff failure to provide consistent release from physical restraints as required by regulation. The lengths of intervals during which residents were restrained were measured and correlated with the staff's perception of degree of care burden and resident behavioral characteristics in order to identify risk factors related to the absence of consistent release. Staff perceptions of residents' verbal aggressiveness (multiple R = - .30, p < .01), physical aggressiveness (multiple R = - .25, p < .03) and unpleasantness (multiple R = - .25, p < .03) are the three characteristics most predictive of the length of time residents continuously remain restrained. Key Words: Aggression, Neglect, Staff management
John F. Schnelle, PhD,1 Sandra F. Simmons, MA,1 and Marcia G. Ory, PhD2
The probability of restraint use increases with age and severity of cognitive impairment (Evans & Strumpf, 1989). Most likely, these two predictive factors explain why restraint use is so common in nursing homes. Prevalence of restraint use in nursing homes varies from 25% to 85% of the resident populations, with unsteadiness, disruptive behavior (e.g., aggression), and wandering most often cited as reasons for using restraints (Evans & Strumpf, 1989; Tinetti et al., 1991). The practice of physically restraining residents has been questioned for humane and psychological reasons. Loss of dignity, urinary incontinence, muscle atrophy, and even higher mortality rates have been attributed to restraint use (Werner et al., 1989). The alleged benefits of restraint have also been questioned. For example, critics stress a lack of evidence that restraints reduce falls or decrease resident agitation (Werner et al., 1989). Federal regulation mandates that restrained residents are to be released, exercised, and repositioned every 2 hours to prevent the deleterious side effects of immobility (American Health Care Association, 1986). However, despite federal mandates, a recent study confirmed that nursing staff frequently do not adhere to the guidelines regarding restraint release and repositioning. In that study, more than 60% of residents in two nursing homes were restrained for intervals in excess of 2 hours (Schnelle et al., 1992). The present study identifies resident characteristics that are most predictive of nursing staff failure to consistently release restraints. Since specific resi-
1 Borun Center for Cerontological Research, UCLA School of Medicine, 10833 Le Conte Avenue (CHS 32-144), Los Angeles, CA 90024-1687. 2 National Institute on Aging, Bethesda, MD.
Vol. 32, No. 6,1992
dent behavioral characteristics predict restraint use (Evans & Strumpf, 1989; Tinetti et al., 1991), it was hypothesized that resident characteristics may predict poor restraint management as well. The number of episodes during which residents were restrained for 2 hours or longer was measured. The frequency of these episodes was then correlated with resident characteristics to identify risk factors that may predict excessive restraint intervals. Methods
Participants We studied 64 restrained residents during 1990 in two nursing homes located in the middle Tennessee area (81% female and 19% male). (Because of the disproportionate numbers of men and women, gender was not included in the later regression analysis.) Restraints being used in the two facilities were waist, mitten, wrist, and vest restraints and geri-chairs. Geri-chairs were not monitored during the study; however, only three residents were in geri-chairs without any other restraint device. Bed rails were not counted as restraint devices. All other restraint devices were monitored, thus yielding 61 residents. The use of restraints was confirmed through direct observation by research staff, who made rounds in the nursing homes for 12 continuous hours on 3 separate days prior to the evaluation. This observation also confirmed that all restraints used on the 61 subjects (except mittens) relied on ties that required knots. Residents' functioning skills were assessed in six major areas using the Geriatric Assessment Inventory (GAI), a standardized and validated instrument that utilizes staff ratings of resident functioning, t h e 767
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Michigan on June 28, 2015
Risk Factors That Predict Staff Failure to Release Nursing Home Residents from Restraints
Restraint Monitoring The participants and the restraint monitoring procedures utilized here were part of a larger, previously published intervention study designed to improve staff's management of restraints, which provided an extensive description of all restraint monitoring procedures (Schnelle et al., 1992). A black light measurement system was used to facilitate nonobtrusive observation of how long restraint knots remained tied without loosening. Research staff marked each knot on a restraint with a spot of ink that was visible only if a hand-held black light was shone on the knot. Preliminary research demonstrated that it was not possible to release a restraint and retie it without movement of the dot (Schnelle et al., 1992). After marking restraints, rounds to check all residents were made each hour between 7 a.m. and 7 p.m. During each round, the center of the knot was marked for residents found restrained for the first time or for residents who were found to have been released and re-restrained. A resident was counted as restrained and then released only if the ink mark found on the knot had changed position between hours. For example, if a resident was found 768
restrained at 7 a.m. and the ink mark was missing or had moved at 8 a.m., then a 1-hour restraint interval was counted. This resident's restraint would again be marked and a new restraint interval count would begin. If the marked knot did not change until the 11 a.m. round, then a 3-hour restraint interval for that resident would be calculated. The marking of the restraint intervals for mittens was calculated in an identical fashion except the ink mark was placed on the velcro spot that secured the mittens. An average of 83 different restraint intervals was calculated per day for the 61 residents observed during the study. A total of 1,444 restraint intervals were calculated during a 7-day observation period in Facility 1 and a 14-day observation period in Facility 2. The total number of intervals that each individual resident was found restrained for more than 2 hours was the dependent measure. To ensure interrater reliability, two independent observers examined the same knots on 130 separate occasions and independently recorded whether ink spots had moved. The interrater agreement on the knot-marking system was 91%, indicating high reliability of the restraint monitoring system. Risk Factor Measures Staff perceptions of resident characteristics chosen as potential predictors of staff failure to release residents from restraints were identified by an extensive review of the literature and by the clinical impressions of the research staff. The professional literature that documents resident characteristics that lead caregivers to provide poor care was considered particularly relevant. In addition, the literature that describes resident characteristics that nursing staff find stressful to deal with was reviewed under the assumption that nursing staff might tend to avoid residents who are considered stressful. Research on neglect in community-dwelling elderly indicated that cognitive impairment and the extent of care burden and workload created by the elder are associated with neglect (Fulmer & Ashley, 1989). In addition, specific problem behaviors such as combativeness, verbal belligerence, and incontinence have also been identified as possible precipitating factors for neglect (O'Malley, Everitt, & O'Malley, 1983). Underlying the potential importance of these factors, a recent study reported that nursing home caregivers rate physical and verbal abuse as the most stressproducing behaviors exhibited by nursing home residents, and that resident withdrawal was found distressful nearly two-thirds of the time by nursing home staff (Everitt et al., 1991). Six potential risk factors were chosen for the present study, each related to the degree of caregiver burden posed by the resident, resident combativeness, or resident withdrawal. These risk factors were evaluated for their ability to predict the number of intervals a resident remained restrained for more than 2 hours. Five nursing staff were identified for each of the 61 residents, each having rated herself as knowing the resident extremely well or well. Each of The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Michigan on June 28, 2015
measures included: self-help dressing, self-help general, locomotion, socialization, communication, and cognition. Additionally, the Mini-Mental State Exam (MMSE) was administered to the residents. The residents averaged 84.5 years of age and were severely impaired as documented by the GAI and the MMSE (X = 7.55). Only 18% of the residents were capable of independent ambulation when not restrained, and only 54% of the residents could follow one-step instructions. Both nursing homes (containing 80 and 97 beds, respectively) were staffed with a 10:1 resident-toaide ratio during the 7 a.m. to 3 p.m. shift, and a 15:1 ratio during the 3 p.m. to 11 p.m. shift. One LPN was responsible for approximately 40 residents. The number of residents restrained in the facilities was not significantly different (30 and 31 residents, respectively). Both nursing homes had received excellent state survey reports in the 2 years preceding this evaluation. Neither home was cited for resident care deficiencies, and one home received no deficiencies in any area. All aides and staff were trained according to recommended OBRA guidelines. For the present study each subject was observed continuously during all periods that they were restrained. The number of restraint intervals recorded for each resident was determined by staff behavior. For example, if a resident was restrained at 8 a.m. and not released until 5 p.m., one 9-hour restraint interval was recorded. If a resident was restrained at 8 p.m. and then released every 2 hours until 6 p.m., then five 2-hour restraint intervals were recorded. Both of the residents in this example would be observed for identical periods of time, having been restrained for equally long periods of time; however, the number of intervals recorded differs considerably.
Results
Including all residents monitored, 373 restraint intervals were recorded that lasted more than 2 hours. This represented 26% of all recorded restraint intervals. All 61 residents in this study were found to be restrained each day during the entire period they were out of bed. All residents were continuously monitored during these periods in an identical fashion. For individual residents, the number of restraint intervals that exceeded the 2-hour limit ranged from 0 to 33. Preliminary analysis revealed that the functioning skill areas measured in the CAI and MMSE did not significantly discriminate between residents because all scored very low on all areas measured. Reflecting the homogeneity of the residents in terms of functioning, there were no significant correlations between the functioning scores and the restraint intervals measured. Thus, the functioning scores were not included in further regression analyses. Table 1 illustrates key content areas of the questionnaire items and the distribution of the scores. Since five staff members rated each of the 61 residents, there was a total of 305 responses to each area except for communication ability, where the 5 scores were averaged. Vol. 32, No. 6,1992
A regression analysis was conducted to relate the six resident characteristics identified as potential predictors to the number of restraint intervals of more than 2 hours for each resident. This analysis is illustrated in Table 2. The correlation of each variable with the restraint measure as well as the beta weight and significance level in the multiple regression analysis is indicated. Staff ratings of verbal aggressiveness, physical aggressiveness, and unpleasantness were all correlated with the measure of failure to adhere to the restraint-release guidelines. In the multiple regression analysis only verbal aggression emerged as a significant predictor of failure to release restraints. However, verbal aggression (VA), physical aggression (PA), and unpleasantness (U) were all highly intercorrelated (VA vs. PA = .89; PA vs. U = .76; VAvs. U = .76). Each of these variables emerged as predictive of failure to release restraints Table 1 . Staff Perceptions of Resident Characteristics Hypothesized to Be Predictive of Failure to Release Restraints, by Content Area of Questionnaire
Distribution Content area
Frequency
%
N = 305 Lifting (2) One
(1)Two (0) More than two Excessive demands (0) Yes (DNo Verbally aggressive (0) All/most of the time (1) Sometimes (2) Rarely (3) Never Physically aggressive (0) All/most of the time (1) Sometimes (2) Rarely (3) Never Pleasantness (1) Pleasant (2) Unpleasant Communication ability3 0.0-2.0 2.1-4.0 4.1-6.0 6.1-8.0
80 219 6
26 72 2
41 264
13 87
16 44
5 14
51
17
194
64
15 46 55 189
5 15 18 62
42 263 N = 61 7 8 7 39
14 86 11.5 13 11.5 64
a Each of the five staff members scored communication ability on a 0-8 scale for each resident. The average scores are presented.
Table 2. Value of Resident Characteristics, as Measured by Multiple Regression Analysis, to Predict Staff Failure to Release Restraints
Correlation
Beta
Resident characteristic
coefficient (/?)
weight (B)
Lifting Excessive demands Verbally aggressive Physically aggressive Pleasantness Communication ability
.16 .04 -.30** -.25* -.25* .14
.192108 .108063 - .303794 -.011904 - .047071 .019916
Note. Resident characteristics were measured by staff perceptions of residents they know well. * p < .05; * * p < .01.
769
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Michigan on June 28, 2015
these staff members was then guided through the behavioral interview format and asked to describe the resident's behaviors and relative care burden through answering a series of six questions. Questions 1, 2, and 5 reflected care burden, questions 3 and 4 were measures of resident combativeness, and question 6 was a measure of resident withdrawal. A numerical score for each resident was derived by circling the number associated with the staff rating of that resident. In the case of communication, one overall score was calculated by adding all response alternatives chosen by the staff members. For example, if a resident was rated as verbally communicative, rational, spontaneous, and clear, then his or her total communication score equalled 8. If a resident was reported as not communicating verbally or nonverbally, the score was 0. Operational definitions for each question were read to the staff members during the interviews. For example, in question 2, the interviewer asked the staff member: "Does this resident make excessive demands? For example, constantly use the call light or ask unnecessary questions." If the staff member indicated that the resident made excessive demands, the question would be assigned a score of 0. The average score provided by five different staff raters for each of the items was the independent variable measure used in a regression analysis designed to relate subject characteristics to failure to follow restraint guidelines. Higher scores represented (staff-perceived) low care burden, high communication, high pleasantness, and low aggression. The overall interrater reliability for the five staff members' answers to the six questions was 86%. The interrater reliability for specific questions ranged from 79% to 91%.
in a step-wise multiple regression analysis in which verbal aggression was held out of analysis (multiple R = - . 3 2 , p < .01) and physical aggression was held out of analysis (multiple R = - .34, p < .01). Discussion
t
Annual Midwest Caribbean Geriatric Conference March 5, 6, 7, 1993 at
Caribe Hilton Hotel San Juan, Puerto Rico Jointly Sponsored by: GRECC, St. Louis VA Medical Center and John L. McClellan Memorial Veterans Hospital Saint Louis University School of Medicine Department of Internal Medicine University of Arkansas for Medical Sciences
References
American Health Care Association. (1986). The long-term care survey (Catalog No. 110334/12-87/SM/BAL). Washington, DC: Health Care Financing Administration. Evans, L. K., & Strumpf, N. (1989). Tying down the elderly: A review of the literature on physical restraints, journal of the American Geriatrics Society, 37, 65-74. Everitt, D. E., Fields, D. R., Soumerai, S. S., & Avorn, J. (1991). Resident behavior and staff distress in the nursing home, journal of the American Geriatrics Society, 39, 792-798. Fulmer, T.,& Ashley, J. (1989). Clinical indicators of elder neglect, journal of Applied Nursing Research, 2,161-167. O'Malley, T., Everitt, D., & O'Malley, H. (1983). Identifying and preventing family mediated abuse and neglect of elderly persons. Annals of Internal Medicine, 98, 998-1005. Schnelle, J. F., Newman, D., White, M., Volner, T. ; Burnett, J., Cronquist, A., & Ory, M. (1992). Reducing and managing restraints in long-term care facilities, journal of the American Geriatrics Society, 40, 381-385. Tinetti, M. C , Liu, V., Marottolil, R. A., & Cinter, S. F. (1991). Mechanical restraint use among residents of skilled nursing facilities: Prevalence, patterns and predictors. Journal of the American Medical Association, 265,468-471. Werner, P., Cohen-Mansfield, J., Brown, J., & Marx, M. S. (1989). Physical restraints and agitation in nursing home residents, journal of the American Geriatrics Society, 37, 1122-1126.
Missouri Gateway Geriatric Education Center Universtity of Puerto Rico, School of Medicine For further information, please contact: Sue Wheat Saint Louis University Medical Center 1402 S. Grand Blvd., Room M238 St. Louis, Missouri 63104 Phone: (314) 577-8462
770
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Michigan on June 28, 2015
Three highly intercorrelated risk factors related to residents' physical or verbal aggression and unpleasantness were most predictive of staff failure to consistently release residents from restraints. Resident characteristics related to care burden and workload (e.g., those resulting in lifting or transporting difficulties) and responsiveness or withdrawal were not predictive. The fact that verbal and physical aggression are predictors supplements previous findings that nursing staff rate both of these resident behaviors as highly stressful. The stressful nature of these behaviors apparently leads to staff avoidance of these residents as measured by the absence of restraint release, which constitutes a form of neglect. It would not be surprising if residents who were neglected in restraint management were also exercised, turned, or otherwise cared for less frequently than they should be. Residents who are physically and verbally aggressive and otherwise rated by staff as unpleasant to work with should be particularly monitored by supervisors for evidence of staff inconsistency in applying resident care routines and adhering to related OBRA guidelines. In addition, training systems to sensitize staff to these risk factors could be implemented and evaluated against the type of measures illustrated in this study. Previous research documented that physical and verbal aggression are predictive of staff's decisions to use restraints. This study expands the picture by providing evidence that physical and verbal aggression are also predictive of neglect in the management of the restraints. Thus, further evidence is provided for the imperative need to develop behavior management procedures that can serve as alternatives to restraint use in nursing homes.
