Rough Draft Qualitative Research Critique and Ethical Considerations

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Psychiatric nurses' knowledge and attitudes toward the use of physical

restraint on older patients in psychiatric wards

WAI-TONG CHIEN Associate Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong SAR

ISABELLA YM LEE Ward Manager, Department of Geriatrics and Medicine, Tuen Mun Hospital, Hong Kong SAR

ABSTRACT Background: There is still an ongoing debate concerning whether or not to use physical restraint with confused or frail older patients in various elderly care settings. Nurses' views and attitudes toward the use of physical restraints in controlling patients' behavior and ensuring patient safety may create conflicts with patients' rights, including their autonomy in making decisions for their own care.

Aims of the study: The purposes of this study were to identify registered psychiatric nurses' knowl- edge, attitudes and practice issues regarding the use of physical restraints in Hong Kong, and to examine the factors influencing nurses' decisions to use restraints on their patients. The findings on the nurses' knowledge, attitudes and practice issues were compared with those found in the USA.

Methods: This descriptive exploratory study was conducted in two psycho-geriatric wards of one of the two mental hospitals in Hong Kong, using a mixed research design. The study consisted of two • phases: first, 42 registered psychiatric nurses completed a self administered questionnaire to exam- ine their practice, knowledge and attitudes towards restraint use; and second, data were collected from semi-structured interviews of 15 of them, from observations of their restraint practices, and from an examination of clinical records which were then content analyzed to explore what deter- mined nurses' decisions to use restraints on the older patients.

Results: Results from the questionnaires and semi-structured interviews indicated that about two- thirds of nurses believed that patients should be restrained for their own safety and to ensure treat- ment compliance, even if being restrained meant loss of dignity and was resisted by patients and/or their family members. Overall, the nurses in this study demonstrated only a modest level of knowl- edge of restraint use and slightly negative attitudes toward this practice.

Four major themes relating to nurses' decisions about restraint use were identified from the qual- itative data, showing considerable similarities and thus conftrming the quantitative ftndings.

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Psychiatric nurses' knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

These included attitudes towards the use of a safety measure and effective intervention for patients, insufficient consideration of alternative measures and/or adverse consequences, ethical dilemmas, and psychological reactions towards restraint use.

Conclusion: The mixed research methods and cross-cultural comparison of research findings used in this study reveals apparent relationships between psychiatric nurses' knowledge, perceptions, atti- tudes, and practice issues concerning the application of physical restraints to older hospitalized patients in psychiatric care. The findings demonstrate that continuing education about restraint use is important for psychiatric nurses. Further research using an action research method to evalu- ate the effectiveness of educational interventions on nurses' decisions regarding restraint use is rec- ommended for improvement of nursing practice.

Keywords: physical restraint; knowledge; attitude; nursing practice; psychiatric nursing; elderly patients

INTRODUCTION

The use of physical restraints has been a con-troversial yet frequently used nursing inter- vention for confused and hospitalized frail elderly and patients with severe mental disorders over the past two decades. In many Western countries there were between 3.4% and 30% of acute eld- erly care and rehabilitation patients subjected to some form of physical restraint during their hos- pitalization (Evans & FitzGerald 2002). In some countries such as Denmark and Japan, not more than 5% of older patients in hospital and residen- tial homes were restrained (Ljunggren, Philips & Sgadari 1997). However, in Hong Kong, there was very little epidemiological research data on the use of physical restraints to older patient pop- ulations.

Patient safety has always been a priority in eld- erly care. In health care institutions of Hong Kong, there is no regulation like that offered by the Joint Commission on Accreditation on Healthcare Organizations (1998) in the United States or the European Committee for the Pre- vention of Torture and Inhuman or Degrading Treatment of Punishment (2004). The practice of physical restraint on patients remains widespread and appears to be accepted as inevitable.

Nurses are most intimately involved in the decision to restrain and in its implementation. However, few studies are found which explore

nurses' attitudes towards, or issues relating to the practice of, physical restraints in different clinical settings. Janelli et al. (1992) conducted a descrip- tive survey on general nurses' attitudes, knowl- edge and practice issues regarding the use of physical restraints in acute medical units in the US, using a self-developed 71-item Restraint Study Questionnaire. The results indicated that the nurses obtained a satisfactory level of knowl- edge score, but that some areas of misconception, (e.g. that staffing shortages were the main reason for restraint use, and that patients were not allowed to refuse to be placed under restraint), were evident. Recently, Janelli, Stamps & Delles (2006) conducted a similar descriptive study in 216 medical nurses in New York, using the same questionnaire. Despite the fact that nurses' knowledge scores were similar to those found in the early 1990s, they indicated significant changes in their attitudes towards, and their nurs- ing practices relating to, the use of physical restraints; for example, there was a higher level of agreement on statements such as 'nurses have the right to refuse to place patients in restraints', and on the importance of 'considering and trying to use alternative nursing measures before restraint use'. As suggested by Janelli et al. (2006), these changes in nurses' attitudes and practices might be influenced by the recent development of regu- latory standards and nursing education related to

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restraint use in acute settings, and they varied a great deal in diverse clinical settings such as gen- eral and psychiatric units, and across countries. In addition, an understanding of nurses' attitudes towards restraint use should be considered when a department or hospital intends to improve nursing practice. Therefore, as recommended by Janelli et al., the aim of this study was to examine the current knowledge, practice and attitudes of nurses regarding the use of physical restraints among Chinese psychiatric nurses in Hong Kong. In addition, it was thought that the findings of this study would allow a useful comparison of these important characteristics of nurses across cultures (i.e., between the nurses in Hong Kong and in the US).

Moreover, few studies are found which explore the factors influencing nurses' decision-making in restraint use (Sailas & Fenton 2003), particularly in Hong Kong where restraint use can often be seen in psychiatric and non-psychiatric settings. Understanding these factors is essential for an adequate interpretation of nurses' perceptions and attitudes, as well as their practices, regarding restraint use. To fill in these knowledge gaps, a mixed method research identifying psychiatric nurses' knowledge, attitudes and practices in rela- tion to the use of physical restraints in Hong Kong, as well as an examination of the factors infiuencing their decisions in restraint use, is essential.

LITERATURE REVIEW

Concept of physical restraints

A review of the literature suggests that physical restraints can be viewed differently by nurses. A physical restraint refers to the use of belts, hand- cuffs and the like, which either partially or totally restrict the patient's movements (Currier & Far- ley-Toombs 2002; Sailas & Wahlbeck 2005). It can be described by reference to the mechanical devices used, including various cloth or leather devices, and the methods of application such as to the patient's body or wheelchair (Magee, Hyatt,

Hardin, Stratmann, Vinson &C Owen 1993), or even by using bedside rails (Ludwick & O'Toole 1996). These variations depend largely on the users' justification of the need for restraint (Chien, Chan, Lam & Kam 2005; Park & Lee 1997).

Use of physical restraints in hospital is often considered to be an accepted and perhaps unquestioned practice related to patient safety. In the elderly care settings, prevention of injury to patients themselves or others (Choi & Song 2003), and prevention of patient falls (Haber, Fagan-Pryor & Allen 1997), are the most fre- quently cited rationales given by nursing profes- sionals. Physical restraint may be also considered by nurses to make care-giving more efficient and less worrisome, and prevent lawsuits (Fradkin, Kidron & Hendel 1999). Whether restraint use is in the best interests, and for the greatest benefit, of patients or of the nurses is an open question.

Effects of restraint use and alternative measures In spite of a range of practice myths among nurses that the use of physical restraints can protect patients from any harm or injury, a range of seri- ous adverse effects and consequences, such as physical problems (Minnick, Mion, Leipzig, Lamb & Palmar 1998) and even accidental death by strangulation (Sailas & Wahlbeck 2005), have been reported in previous studies. There are also psychosocial effects on patients who had one or more restraint experiences, such as low social func- tioning, increasing confusion and adverse emo- tional reactions (Thomas, Redfern & John 1995).

It is commonly agreed by health professionals in the literature that physical restraint should not be the first choice among methods intended to ensure patient safety or treatment compliance (Macpherson, Lofgren, Granieri & Myllenbeck 1990; Sailas & Wahlbeck 2005). However, research evidence and clinical reports indicate that physical restraints have been considered and used by the nurses for various reasons, particularly during emergency situations, to manage the patients' disturbed emotions and behaviors in a

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Psychiatric nurses' knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

variety of clinical settings (Evans & FitzGerald 2002). Some conclusive evidence on minimiza- tion of restraint use has been identified in general care settings. For example, Johnson & Beneda (1998) suggested that increasing nurses' knowl- edge of restraint use is one of the effective alter- native measures to the use of physical restraints. Janelli, Scherer & Kuhn (1994) also reported that promotion of a secure and comfortable environ- ment for agitated or confused older patients may also help in reducing restraint use. Nevertheless, there is limited research and few suggestions on reduction of restraint use for patients in psychi- atric care settings.

Ethical consideration of restraint use Whenever nurses have to make decisions regard- ing the use of restraints, they may find themselves in the midst of conflicts between their profession- al obligation to care for a patient's well-being and concerns about a patient's right to make an informed choice (Mayhew, Christy, Berkebile, Miller & Farrish 1999). There is no consensus among nurses as to whether the benefits of its use outweigh the physical and psychosocial risks in elderly care (Johnson & Beneda 1998).

Although some nurses have attempted to use physical restraint as an intervention to safeguard older patients in wards from any harm, accidents, physical disability and emotional distress among patients do occur (Kanak 1992; Sailas & Fenton 2003). Therefore, criticisms and arguments are raised among nurses, as well as other health pro- fessionals, about whether this is an effective and first-line intervention for older patients who appear to face higher risks of falls or of violence. It is also questioned whether nurses have been well prepared in developing the knowledge, tech- niques, attitudes, and moral values to deal appro- priately and effectively with complex patient situations (Johnstone 1994).

Guidelines & policy of restraint use While there are nursing guidelines or protocols for performing the procedure of using physical

restraints, few institutional guidelines or policy statements have been drawn to help individual nurses determine what they should consider in order to make an ethically appropriate decision. The hospital policy-makers also do little to support their nurses in making such decisions and to implement them. Schieb, Protas and Hasson (1996) have suggested that the difficulty in making decisions, and the subsequent inappropriate use of physical restraints, might be due to the absence of a clear and supportive institutional policy and a well-defined assessment framework dealing with patients with unwanted or harmful behaviors. The use of restraints may also be associated with nurses' knowledge about its relevant hospital policy and guidelines. This notion is supported by research evidence, such as the study by Magee et al. (1993), which highlighted that in over half of the restraint procedures, the nurses themselves queried their adherence to the institution's policy.

Aims of the study Evidence from the literature on physical restraint suggests that the use of restraints on older patients with physical and/or mental health prob- lems is a common practice, and that nurses' deci- sions in their use have not been adequately explored. Therefore, the purpose of this study was to investigate the knowledge, attitude and per- ceptions of registered psychiatric nurses about the use of physical restraint on older inpatients with mental health problems in one regional mental hospital in Hong Kong. The objectives of the study were to: 1. Identify psychiatric nurses' levels of knowl-

edge and their attitudes towards the use of physical restraints on hospitalized older patients in two psycho-geriatric wards in Hong Kong;

2. Explore the nurses' perspectives concerning what the use of physical restraints means to them; and

3. Identify the factors infiuencing the nurses' decisions to use physical restraints on their older patients.

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Wai-Tong Chien and Isabella YM Lee

METHODS

Study design

This was an exploratory descriptive study with mixed research designs. The study consisted of two phases. In Phase 1, a small-scale survey of psychiatric nurses' knowledge, practice issues and attitudes regarding the use of physical restraint in one pair (male and female) of 56-bed psycho- geriatric wards in a regional mental hospital in Hong Kong was undertaken. The characteristics of the two wards in relation to restraint use are summarized in Table 1. The common psychiatric diagnoses of the patients within the two wards included dementia, acute psychosis and chronic schizophrenia. All 46 registered nurses in the two wards, including two ward managers, one nurse specialist, one advanced practice nurse, three nursing officers, and 39 registered nurses, were invited to complete a self-administered question- naire regarding their practice, knowledge and attitudes towards the use of restraints.

In Phase 2, data were collected from the semi- structured interviews of 15 nurses who participated in Phase 1 and who had indicated their willingness to participate in this second phase. Observation and cli.nical record examination on the use of restraints were also conducted. The data collected from the three sources (interviews, observations and documentation) were content analyzed in order to explore what influenced the nurses' deci-

sions to use restraint on older patients. Use of mul- tiple data sources in this study can provide a holistic overview of the social context and the phenomena under study (Kimchi, Polivka & Stevenson 1991).

Sampling A convenience sample drawn from two psycho- geriatric wards in a regional mental hospital was used. All 46 registered psychiatric nurses in the two wards were invited to be respondents for a self-administered questionnaire and 15 of them (7 or 8 from each ward) were conveniently selected as key informants for semi-structured interviews. This sampling method was able to include most of the accessible and appropriate informants and it was also time and cost saving (Polit &C Hungler 1999). Inclusion criteria for the sample in the two phases of the study were the registered psychiatric nurses who had worked in the psycho-geriatric wards for not less than three months, had previous experience(s) of restraint use, and who had agreed to participate voluntarily in the study.

A total of 42 psychiatric nurses responded to the questionnaire and their socio-demographic characteristics are summarized in Table 2. The response rate was 87.0% and the respondents were mainly female (71.4%), married (76.2%) and registered psychiatric nurses (85.7%). Their ages ranged from 22 to 45 years, with a mean of 31.2 years (SD = 5.2). Most of them (n = 35; 83.3%) had obtained a Bachelor of Nursing

TABLE 1: M A I N CHARACTERISTICS OF TWO PSYCHO-GERIATRIC WARDS

Ward Characteristics Male Ward

45.5 5 6 - 7 1

4.2

2.5

5.7

(12.5%) Safety vests, triangular bandages, geriatric chairs with tables

Female Ward

43.2 5 5 - 7 8

4.8

N/A

6.1

(14.1%) Safety vests, limb holders, bed-side rails, geriatric chairs with tables

Average number of patients in ward* Age range of the patients (years old) Average nurse strength per duty shift (including student nurses) Average number of male nurses per shift (including male student nurses) Average number of patients being restrained per duty shift

Major types of restraint device used

Note. * Average number of patients within the eight observation sessions.

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Psychiatric nurses' knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

TABLE 2: DEMOGRAPHIC CHARACTERISTICS OF PSYCHIATRIC NURSES W H O RESPONDED TO THE OUESTIONNAIRE ( N = 4 2 )

Characteristics Frequency Percent

Gender Male Female

Job position Registered psychiatric nurse Nursing officer Advanced practice nurse/nurse specialist

Age range (years) 22-29 30-39 40-45

Educational level Diploma in Nursing Bachelor of Nursing Master degree or above

Religion Christianity Catholicism Buddhism No reported religious belief

Experience in psycho-geriatric nursing (years) 1-3 4-6 7-9 10 or above

12 30

36 4 2

16 20

9 26

16 13 6 7

10 16 10 6

28.6 71.4

85.7 9.5 4.8

38.1 47.6 14.3

21.4 61.9 16.6

38.1 30.9 14.3 16.7

23.8 38.1 23.8 14.3

degree and had been working in the psycho-geri- atric ward for an average of nine years (M = 8.8 years, SD = 4.9; range = 2 - 1 5 years). The inter- viewees consisted of 14 registered nurses and one nurse specialist, were aged from 26 to 35 years (M = 28.1 years, SD = 5.1) and were mainly female (n= 11,73.3%).

Instruments

Restraint Study Questionnaire

This questionnaire consisted of 71 items and was developed by Janelli, Kanski, Scherer and Neary (1992) based on an extensive literature review on physical restraint and comments by gerontologi- cal nursing experts. It included four parts:

• Part 1, a 23-item demographic data sheet dealing with information such as age, educa- tional level, and years of working in geriatric nursing;

• Part 2, an 18-item knowledge questionnaire including statements about physical restraint using a 3-point Likert rating scale on which 1 = 'true', 2 = 'false', and 3 = 'not sure', and with a total score (i.e. total number of items answered correctly) ranging from 0 to 18;

• Part 3, 18 statements regarding the issues in nursing care for patients immediately before or during restraint such as 'I check on patients who are restrained at least every two hours to make sure they are okay,' rated on a 3-point Likert scale on which 1 = 'always', 2 = 'sometimes', and

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3 = 'never', and on which the percentage of each reviewing prevailing policies of restraint use in

response could be calculated; and the study setting and relevant issues discussed

•Part 4, 12-item questionnaire on attitudes in the recent published literature. The questions

regarding the use of physical restraint, rated on a were reviewed and agreed upon by an expert

5-point Likert scale on which 1 = 'strongly agree' panel, including three psychiatrists, two psychi-

to 5 = 'strongly disagree' and with a total score atric nurse specialists and one occupational

ranging from 12 to 60 (the higher the score, the therapist,

more positive was the nurses' attitude).

Observation schedule The Cronbach's alpha coefficients of Parts 2-4 There were eight 2-hour observation sessions on

were .73, .78 and .67 respectively (Janelli et al. consecutive days comprising general and

1992; Scherer, Janelli, Kanski, Neary & Morth focused observations of restraint use by the 15

1991). psychiatric nurses (interviewees), covering dif-

ferent time spans. An observation schedule,

Semi-Structured interview agenda which was designed according to ward situation

A tentative agenda for semi-structured inter- and pilot tested in one ward, facilitated the

views, as shown in Table 3, was devised by observations.

TABLE 3: SEMI-STRUCTURED INTERVIEW GUIDE

During the interviews, you can refer to the following questions or areas relevant to the background of the interviewees'their use of physical restraints:

A. Socio-demographic background of the informant • Ask about years of experience in ward, psycho-geriatric nursing education level. • Have you attended any courses or workshops about the use of physical restraint? What/when? • Describe the ward characteristics, current practice of restraint use, exploring their recognition/under-

standing of existing policy/guidelines regarding restraint use in ward.

6. Definitions of physical restraint • What would you consider a 'physical restraint'? • Which devices are commonly used in your ward for application of physical restraint? • Would you consider using some devices, such as side-rails or chairs with a front table, to be a kind of

restraint? Why or why not?

C. Factors infiuencing the nurses' decision in restraint use • Can you recall one of the current impressive experiences of applying restraint to patient? • What considerations you had made when applying the restraint?

Probing: Tell about the patient or his/her condition, about other people such as family, nurse colleagues and other staff, about the ward situation or the institution policy, about yourself, any similar experience.

• Which factor(s) is/are the most important one(s) which you considered? • Have you considered any alternatives? What are they? Why or why are they not being used?

D. Difficulties/feelings in making restraint use decisions • Have you met any difficulties when making the decision? • If yes, what are they? How difficult? How did you overcome then? • Besides the above mentioned difficulties, have you experienced any conflicts with your own values? If

yes, please describe the conflicts. Then, how would you settle it? • What did you feel about the incident, in the moment of/after your decision making?

Probing: Why did you get these feelings? Rate the levels of emotional responses which you have men- tioned? How long did you take to settle this emotional distress?

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Psychiatric nurses' knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

Procedure & data analysis Permission to access the study site and ethical approvals were sought from the Ethics Commit- tees of the study hospital and the University. Nurses were informed about the purpose and procedure of the study and their written consent to participate in it was obtained before their inclusion. Anonymity, right to withdraw from the study at any time, and confidentiality of data collected were assured, and an undertaking not to discuss the content of the interviews with any ward staff was given.

In Phase 1, data were collected over a period of two months from the psycho-geriatric wards. Eligible psychiatric nurses were invited by a research assistant to participate in the study when they were on duty. After full explanation of the study had been given, written consent was obtained and each psychiatric nurse completed a self-report questionnaire which was returned in a sealed envelope to the research assistant.

In Phase 2, 15 psychiatric nurses who had indi- cated in the returned questionnaire their willing- ness to participate in the second study phase were invited to attend an interview at their earliest con- venience. Data about the psychiatric nurses' most recent or impressive experience of the use of physi- cal restraint were gathered through the semi-struc- tured interviews and an examination of relevant clinical records. The 45-minute interviews were conducted by the principal researcher in an inter- view room within the wards; they were audio-taped and field-notes were taken. Follow-up interviews were conducted with five of them in order to clari- fy points that had arisen during the first interview.

Information about their experiences of restraint use was obtained from clinical records, including patients' medical and psychiatric backgrounds, conditions relating to restraint use, details of med- ical and nursing interventions used, and the docu- mentation recorded on the restraint form.

Eight observation sessions in each setting were scheduled at different times, including all the days in a week from 7:00am to 9:00pm. A research assistant was trained by the researcher to

perform the observation with the observation schedule and to write down field-notes after each observation. Inter-rater reliability testing of data collected from the observation was ensured by cross-checking the data from three pilot observa- tions in one ward, by the research assistant and the principal researcher. Only minor differences between their observation data were found and these were clarified. The research assistant took the position of passive participant in ward activi- ties during observation, being only involved in basic bedside care for the restrained patients if needed; and he left the ward for a few minutes' event introspection during each session. Field- notes were recorded and reviewed on a daily basis.

A total of 20 interviews were conducted with 15 participants by one researcher. The research assistant and the researcher independently under- took transcription and translation of the inter- view data. One expert (nurse) in qualitative research compared the two sets of transcribed interview scripts and suggested amendments. The researchers then identified themes from the tran- scribed interview data independently and checked the coding reliability (>90% of agreement in cod- ing of data) prior to categorizing the data into themes (Morse, Penrod & Hcpcey 2000). The data from observation notes and the clinical doc- umentation of the use of restraints were also tran- scribed and translated by the research assistant and then underwent a similar coding and reliabil- ity checking process as that for the interview data.

The interview data were then used as the start- ing point and main source to perform theme matching and condensing. As recommended by Miles and Huberman (1994), this method of content analysis aimed to identify the in-depth information gathered from each informant and source of data, and accommodated the wide diversity of informants' experience and the social context of the wards. This method consisted of six main stages of analysis as follows: (a) becoming familiar with the diversity of the

verbatim data collected and affixing codes and remarks to each transcript;

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Wai-Tong Chien and Isabella YM Lee

(b) sorting and sifting through the codes and interview data to identify inter-relationships and recurrence of themes;

(d) isolating the patterns and clustering com- monalities and differences between the themes and creating a thematic index of all transcripts;

(e) comparing, contrasting, condensing and mapping between the categories and themes identified, making interpretations, and pro- viding explanations; and

(f) summarizing the results and re-examining the data where necessary.

RESULTS

Restraint use in two psycho-geriatric wards

During each observation session, at least one period of physical restraint was used by each of the interviewees (i.e., about 1.6 times of restraint per participant in each two-hour observation). As shown in Table 1, an average of six patients (12.5% and 14.1%) was being restrained per duty shift in both wards during each of the eight observation sessions. Different types of restraint device were applied; for instance, safety vests were used in two-thirds of the restrained patients and triangular bandages or limb holders were some- times used for controlling violent or confused behavior.

Level of knowledge of psychiatric nurses The percentages of correct and incorrect respons- es for the 42 psychiatric nurses to each of the 18 questions are presented in Table 4. Their knowl- edge scores ranged from 3 to 18 (M = 12.5, SD = 4.5). Percentages of correct responses to the 18 questions ranged from 31.0% to 8 8 . 1 % . Sixty- two percent of them (n = 26) had 7 to 12 correct responses and 21.4% (n = 9) had 13 to 18 correct responses. More than half of them (n = 24,

57.1%) disagreed with the statements that 'Patients are allowed to refuse to be placed in a restraint' and A patient should never be restrained while lying flat in bed because of the danger of choking'. Nevertheless, 24 (42.9%) believed that 'Good alternatives to restraints do not exist' and 13 (31.0%) believed that 'In an emergency, you (nurses) can legally restrain a patient without a physician's order'.

Attitudes towards use of restraints The attitude scores of the 42 psychiatric nurses ranged from 30 to 56 (M = 48.2, SD = 6.3). Thirty-six percent of them (n = 15) had a total score of less than 36, indicating relatively negative attitude towards the use of physical restraint. Over half of the nurses (n = 23, 54.8%) felt that 'The hospital is legally responsible to use restraints to keep the patient safe' and about two- thirds of them (n = 28, 66.7%) disagreed with the statements that 'The nurses have the right to refuse to place patients in restraints' (38.1%), that 'Family members have the right to refuse the use of restraints'(33.3%), or that 'A patient suffers a loss of dignity when placed in restraints' (38.1%). In general, more than two-thirds of the nurses (n = 29, 69.1%) felt that they were 'knowledgeable about caring for a restrained patient'.

Nursing care of patients immediately before or during restraint The frequencies and percentages of the responses to the 18 statements regarding the nursing care provided for patients immediately before or during physical restraint are summarized in Table 5. More than half of the nurses (n = 23 to 24, 54.8% to 57.1%) indicated that they would 'always ... try alternative nursing measures before restraining the patient' and, where restraint was used, would 'tell the patient why the restraint is being applied' or 'tell family members/visitors why the patient is restrained'. Most of the nurses indicated that 'Before I restrain a patient, I find out the reason for the restraint' (n = 37, 88.1%) and 'I have read the hospital policy on the use of restraints' (n = 38,

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Psychiatric nurses' knowledge and atxiaides toward the use of physical restraint on older patients in psychiatric wards

TABLE 4 : NURSES' LEVEL OF KNOWLEDGE REGARDING THE USE OF PHYSICAL RESTRAINTS ( N = 42)

Item

1. Physical restraints are safety vest or garments designed to prevent injury.

2. A restraint is legal only if it is necessary to protect the patients or others from harm.

3. Restraints should be used when one cannot watch the patient closely.

4. Patients are allowed to refuse to be placed in a restraint.

5. A physical restraint requires a physician's order.

6. Confusion or disorientation is the main reason for using a restraint.

7. A restraint should be released every 2 hours if the patient is awake.

8. Restraints should be put on snugly.

9. A patient should never be restrained while lying flat in bed because of the danger of choking.

10. When a patient is restrained, skin can break down or restlessness can increase.

11. When a patient is restrained in a bed, the restraint should not be attached to the side rails.

12. Sheet restraints may be necessary at times.

13. A nurse can be charged with assault if he/she applies restraints when they are not needed.

14. A record should be kept on every shift of a patient in restraints.

15. A physician's order to restrain must be specific.

16. In an emergency, a nurse can legally restrain a patient without a physician's order.

17. Good alternatives to restraints do not exist.

18. Deaths have been linked to the use of vest restraints.

Note. * refers to the correct response to each question.

rue

30*

31*

18*

34*

False

35*

Percent Correct

71.4

73.8

83.3

42.9

80.9

Percent Incorrect

28.6

26.2

16.7

57.1

19.1

35*

25* 59.5

83.3

40.5

22*

18*

37*

33*

22*

52.4

47.6

42.9

88.1

78.6

52.4

47.6

52.4

57.1

11.9

21.4

47.6

16.7

32*

30*

13*

28*

18*

76.2

71.4

31.0

42.9

66.7

23.8

28.6

69.0

57.1

33.3

90.5%). However, only a few indicated that they would '... tell family members/visitors when the restraints will be removed' (n = 15, 35.7% rated 'always' or 'sometimes') and agreed with the state- ment that 'All confused patients and those with arterial or venous lines should be restrained' (n = 19, 45.2% rated 'always' or 'sometimes').

Major themes emerging from comparison of the data sources The themes which emerged from the interview data were confirmed or refuted with the data from observations and clinical records, as well as those from the responses to the questionnaire.

Finally, four main themes identified from the data included: • a safety measure and effective intervention for

patients; • insufficient consideration for alternative meas-

ures and/or adverse consequences; • psychological reactions towards restraint use;

and • ethical considerations.

A safety measure and effective intervention for patients Different interpretations of physical restraint were used by the nurses in the psycho-geriatric

Volume 1, Issue 1, October 2007 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES 61

23 37

24 23 18 6

(54.8) (88.1)

(35.7)

(38.1)

(54.8)

(92.9)

(57.1) (54.8) (42.9) (14.3)

13(31.0) 4 (9.5)

19(45.2)

17(40.5)

10(23.8)

2 (4.8)

10(23.8) 8(19.0)

14(33.3) 9(21.4)

6(14.3) 1 (2.4)

8(19.0)

9(21.4)

8(19.0) 11 (26.2) 10(23.8) 27 (64.3)

Wai-Tong Chien and Isabella YM Lee

TABLE 5: RESULTS OF 18 STATEMENTS ON NURSES' OPINIONS ABOUT CARING FOR PATIENTS UNDER RESTRAINT ( N = 4 2 )

Statement Always Sometimes Never

1. I try alternative nursing measures before restraining the patient. 2. Before I restrain a patient, I find out the reason for the

patients unacceptable behaviour. 3. When I feel that the patient does not need to be restrained,

I make this suggestion to the person in charge or the doctor. 4. I answer the call light or calls for 'help' for the patient who is

restrained as soon as possible. 5. I check the restraints at least every 2 hours to make sure

they are OK.

6. When giving personal care (bathing or dressing) to a patient who is restrained, I check their skin for reddened areas/bruises.

7. I tell the patient why the restraint is being applied. 8. I tell family members/visitors why the patient is restrained. 9. I tell the patient when the restraint will be removed.

10. I tell family members/visitors when the restraints will be removed.

11. The application of physical restraints is necessary in an acute 28(66.7) 10(23.8) 4(9.5) care setting to prevent a patient from injuring him/herself.

12. All disoriented acute care patients should be restrained. 13. All confused patients'those with arterial or venous lines

should be restrained. 14. I have read the hospital's policy on the use of restraints. 15. More patients are restrained when we are working 'short'

than when we have a full staff. 16. In the unit in which I work, staff members work together to 16 (38.1) 12 (28.6) 14 (33.3)

discover ways to control patients' behavior other than the use of physical restraints.

17. When I need to restrain a patient, a restraint is available 20(47.6) 16(38.1) 6(14.3) on my unit.

18. I would rather sedate a patient with prescriptive medication 10(23.8) 6(14.3) 26(61.9) than physically restrain them.

Note. * Percentage of nurses' responses on each statement is put in the parentheses.

wards. They mainly perceived physical restraint nursing staff to care for the restrained patient as in terms of the functional perspective; for exam- well as other patients in ward', pie, one experienced nurse said that physical Four main reasons of restraint use were indicat- restraint was 'any mechanical device used to ed by the majority of the nurses during the inter- restrict the individual from doing things that view, including 'prevention of patient from any would be harmful to self or other people', injury','maintenance of treatment regimen','pre- Another perception was related to the nurses' vention of disturbance to other people', and 'nurs- personal beliefs about restraint use. Most of the es' accountability and role responsibility in caring nurses stated that they used physical restraint as for their patients'. This can be illustrated by what an intervention which was solely 'for the benefit the nurses' said during interviews or observations: of patients'. Physical restraint was considered to be the only effective measure to establish 'a safe Some patients, especially the violent patients, ward environment' or a means of 'saving time for had to be separated and restrained temporarily

6 2 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

16(38.1) 10(23.8)

38 (90.5) 20 (47.6)

14 9

(33.3) (21.4)

2 (4.8) (28.6)

12 23

(28.6) (54.8)

2 (4.8) (23.8)

Psychiatric nurses' knowledge and attitudes toward the use of physical restraint on older padents in psychiatric wards

to avoid any conflicts from their disturbing behavior. (Interview C, para. 28)

We (nurses) are responsible to take care of older patient's daily living ... and their safety in ward. When they show any physical and/or mental problems such as confusion and risk of fall, we have to intervene ... by using physical restraints. (Observation D, para. 39)

Consistent with the questionnaire results, these nurses strongly agreed that the use of physi- cal restraints is legally right when it is necessary to protect the older patients or others from harm, and the patients should not have the right to refuse to be placed in a restraint. These nurses also shared the attitude that the hospital was legally responsible for using restraints to keep patients safe, and that patients would not suffer a loss of dignity when placed in restraints.

Insufficient consideration for alternative measures and/or adverse consequences An important finding from the interview and observation data was the lack of consideration of alternative measures to physical restraint by the majority of the psychiatric nurses. Whilst most nurses indicated in the interview and the ques- tionnaire that they did consider the use of avail- able alternative measures before restraint use, they could identify only a few such as assigning one staff member to observe the patient closely and regularly. From the observation data, most of the alternatives identified were not used by the nurses prior to applying physical restraints and most nurses often restrained the patients imme- diately after they manifested aggression or prob- lem behaviors. Six of the 15 interviewees indicated that location of the patients was important for reducing the use of physical restraints, and that patients needing continuous observation should be put near the nurses' sta- tion. This suggestion was consistent with the observation data, in which confused older

patients were not restrained when sitting near the nurses' station.

Some reasons were given by the nurses for only having a few alternatives. One important reason was the nurses' perception of the short- age of staff and other resources in wards. For example, over two-thirds of the nurses thought that 'there was a lack of nurses to provide con- tinuous observation' and 'insufficient facilities to provide a safe environment for patients, instead of applying restraints'. Nine of them also indicated that there were not enough beds with adjustable height to prevent falls, and an absence of wedge-shaped pillows to assist patients to sit properly.

These results were consistent with the nurses' knowledge and attitude scores from the ques- tionnaire. From the knowledge measure, over half of the nurses indicated that 'Restraints should be used when you cannot watch the patient closely' and 'Good alternatives to restraints do not exist'. From the attitude and nursing practice measures, more than two-thirds felt that 'the main reason that restraints are used is that the hospital is short staffed' and they did not agree that they felt'... embarrassed when the family enters the room of a patient who is restrained'.

The analysis of the interview data also demonstrated that the nurses were generally not aware of the adverse consequences of restraint on their patients, especially psychosocial effects. The majority of them in the two wards admitted that there were some short-term physical effects on patients such as temporary obstruction of blood circulation, skin abrasions and bruising. However, in contrast with the questionnaire results and the interview data, nurses attended to restrained patients on only a few occasions and had little verbal interaction during the per- formance of nursing tasks. Only five nurses identified one or two types of psychological effects of physical restraint on patients under their care, including embarrassment, social isola- tion and humiliation.

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Wai-Tong Chien and Isabella YM Lee

Ethical considerations of restraint use From the interview data, more than one-half of the nurses (n = 8) identified no ethical dilemma in applying physical restraints, and they rational- ized that this intervention was 'for the interests and safety of the patients'. As indicated from the knowledge and attitude scores, most of them thought that the restraint was legal as it was nec- essary to protect the patient or others from harm, with a doctor's prescription. They also indicated in the questionnaire that physical restraint was also the best choice of intervention in an emer- gency, even without a doctor's prescription. How- ever, from the interview and questionnaire data, most of the nurses understood that 'Deaths have been linked to the use of vest restraints' and agreed that 'In general, I feel knowledgeable about caring for a restrained patient'. Therefore, during the interviews, they indicated that 'nurses have the right and responsibility to place patients in restraints, in order to protect the best interests of those under their care' (Interview H, para. 40).

There were two ethical concerns identified among the remaining nurses (n = 7). The first was the appropriateness of limiting patients' autonomy and rights in order to prevent harm to themselves or other people. From the interview data, a few of them justified the use of restraint for this purpose by telling themselves that 'the use of restraint was the best choice for preventing harm to a patient's life'. The second concern was the patients' mental competency in making health care decision for themselves. These seven nurses thought that 'the restrained older patients were always incompetent' and 'could not understand their own problems and the staff's advice to them'. On the contrary, during the observations some patients wearing safety vests and sitting in the geriatric chairs talked with the nurses clearly and consciously, without any signs of confusion or of disturbed behavior. In addition, there were not any records revealing consistent assessment of patients' mental condi- tion identified during data collection. Therefore, it was doubtful whether the nurses' decisions on restraint use, which should have been based on

regular assessment results of patients' mental com- petence, were justified by the subjective experi- ences and reasoning given by the nurses.

Moreover, the majority of the psychiatric nurs- es emphasized the necessity of having specific policy and guidelines in the hospital. As indicated by six nurses during the observations and inter- views, they had to 'make decisions on restraint use according to the clear guidelines provided by the hospital'; otherwise, the intervention would be 'illegal or unethical'. From the observations, most nurses referred to a nursing procedure book developed by the ward nurses themselves when they had questions about the procedure of restraint use. There was not any specific guideline for handling different situations regarding restraint use. Nevertheless, the documentation of restraint use on half of the restrained patients was written clearly and systematically on the patient progress sheets and nurses' notes.

Psychological reactions towards restraint use While the majority of the nurses reported 'dislike' and sometimes 'feeling badly' at applying restraints, especially 'if the patient got more upset after restraints were applied', the results from the interview data indicated that the nurses only had low levels of emotional reactions towards restraint use. During the observations and interviews, most of them stated that they felt that their appli- cations of the restraints were 'alright' or 'reason- able' unless they found that the restraints were used longer than necessary, or without justifica- tion. As indicated from the attitude scores, most of them felt neither embarrassed not guilty about placing the patients in restraints. The restraints would be released temporarily or every two hours, if the patients were awake.

These results confirmed the interview data that the nurses' emotional reactions associated with restraint use was closely related to how the nurses understood and viewed the purpose of restraint use, and their legal and ethical consider- ations. It was observed during interviews that

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Psychiatric nurses' knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

about 12 nurses (who defined restraint function- ally and as of the highest priority in terms of pro- tecting the patients from harm) asserted that they handled the situation well. Therefore, in this study, most of the psychiatric nurses did not show any intense emotional reactions towards restraint use.

DISCUSSION The findings of this study, using the multiple approaches of quantitative and qualitative research, provided comprehensive and detailed information about the nurses' knowledge and attitudes toward the use of physical restraints in older psychiatric patients in a Hong Kong Chi- nese population.

Four main themes concerning the nurses' per- ceptions towards restraint use were identified from the interview data and confirmed or refuted by the data from multiple sources, including observations, clinical records and questionnaires. These highlight the function and significance of mixed research methods on a topic such as this. For instance, without the data from the inter- views and observation sessions which revealed a lack of consideration of alternative measures to restraints by the nurses in the two wards, it would have been hard to explain why the nurses per- ceived that good alternatives to restraints did not exist and that only half of them had sometimes or never tried alternative nursing measures before restraining the patients.

Knowledge and attitude of nurses: Hong Kong versus United States Overall, the 42 psychiatric nurses in this study performed fairly well on the questions of knowl- edge about restraint use (mean score= 12.5 out of 18) and only a few of them obtained a very low score. When compared with the results of a recent survey study conducted by Janelli et al. (2006) using the same questionnaire on a sample of 216 registered nurses in New York, the per- centages of correct responses to each of the 18 questions (range from 52.3% to 98.6%) were

higher than those in this study. However, similar areas of misconception were evident in both this study and Janelli et al.'s. About half of the nurses indicated that restraints should be applied snugly and disagreed with the statement that a restraint should be released every two hours if the patient was awake. The current standard of psychiatric care in Hong Kong is to review and decide upon release or continuation of a restraint every two hours (Chien et al. 2005). In contrast with regis- tered nurses in the United States, less than half of the psychiatric nurses in Hong Kong were aware that patients are allowed to refuse to be placed in a restraint (42.1% vs. 56.0% for the New York nurses), and that they should never be restrained while lying flat in bed, in order to prevent chok- ing (42.9% vs. 56.5%). Despite the fact that the Hong Kong nurses generally showed a lower level of knowledge regarding restraint use than the US nurses, they were more aware that a written record of patients in restraint should be kept on every shift (76.2% vs. 47.2%). This finding was confirmed with the data from observations and clinical records in this study.

In addition, the Hong Kong psychiatric nurs- es' attitudes regarding restraint use were more negative than those of the US nurses. While only one-third of the Hong Kong nurses in this study agreed that family members (33.3%) or the nurs- es themselves (38.1%) have the right to refuse the use of restraints, more registered nurses in the US believed that the family and they themselves have such a right (46.0% and 70.8%). There were also more US nurses than the Hong Kong psychiatric nurses who indicated that they were knowledge- able about caring for patients in restraints. (83.8% vs. 69.1%)

A lack of information might contribute to lower levels of knowledge and more uncertainty and negative attitudes among nurses regarding restraint use. This notion is supported by Janelli, Scherer and Kuhn (1994), who indicated that 65.6% of the 235 acute care nurses felt uncertain about nursing practice issues in caring for the restrained patients in wards. McCue, Urcuyo,

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Wai-Tong Chien and Isabella YM Lee

Lilu, Tobias and Chambers (2004) also suggested that misinformation or misconceptions about restraint use can be lessened by continuing educa- tion and by using a reward system for reduction of restraint use. Bryant and Fernald (1997) indi- cated that a more insightful and appropriate use of restraints was found among nurses who had taken continuing education courses on caring for older patients in acute care settings.

The influence of nurses' knowledge and attitudes on psycho-geriatric nursing practice in Hong Kong In this study, the questionnaire, interview and observation data from the psychiatric nurses in the psycho-geriatric wards highlight that in Hong Kong the justification of restraint use on their older patients was mainly that of fulfilling their role responsibility in protecting the patients under their care from any physical harm. The nurses' perceptions and attitudes toward restraint use were highly consistent with the fmding in the relevant literature that the use of physical restraints is of a higher priority in maintaining patient safety and preventing disturbance to the treatment or other patients in the ward (Evans and FitzCerald 2002; Haber et al. 1997; Quinn 1993). This may possibly explain why there have been frequent uses of physical restraints on older patients in acute care settings, especially when the nurses believed that the ward was short staffed and that they had to be very busy carrying out other nursing procedures. As observed in this study, the amount of restraint use (i.e., 13% of male patients and 14% of female patients per duty shift) was much higher than that in some developed countries (about 5%) such as the UK, Denmark and Japan (Evans & FitzGerald 2002; Ljunggren et al. 1997).

For the above reasons. Hong Kong psychiattic nurses appear not to treat the patients as individ- uals with a high level of self-determination over the care they receive. As suggested by Quinn (1993) and Currier and Farley-Toombs (2002), assessment and satisfaction of patients' psychoso-

cial needs may not figure prominently in nurses' considerations concerning the application of physical restraints in both acute and rehabilita- tion care settings in the US. Both Macpherson et al. (1990) and Selekman and Snyder (1996) sug- gested that nurses should always assess the clinical situation from the perspective of the patients and the meanings of their disturbed behaviors, as well as their individual needs. For minimizing restraint use, it is important for psychiatric nurses in Hong Kong, as well as in other countries, to understand and meet patients' immediate health needs and anticipate the occurrence of their prob- lem behaviors (Chien 1999).

The results based on the psychiatric nurses' knowledge, attitudes and issues relating to nurs- ing practice regarding restraint use also indicated that more than half of the psychiatric nurses in Hong Kong had either never, or only sometimes, tried alternative nursing measures, or had made suggestions to the physician not to restrain the patient. These further confirm that the psychi- atric nurses might not have adequate knowledge and/or skills in minimizing restraint use, and thus maintained their 'safety first' belief by using phys- ical restraints frequently to prevent their patients from falls and injuries in the ward. As the use of physical restraints becomes routine practice in psychiatric wards. Currier and Farley-Toombs (2002) indicated that nurses are often convinced of the efficacy of their beliefs and do not question this intervention in the same way as they ques- tion other interventions such as administration of medication and memory training programs.

However, as pointed out by Bryant and Fer- nald (1997), the provision of a therapeutic envi- ronment for elderly patients that promotes their bio-psychosocial well-being is a challenge facing by all nurses. As an alternative, Stolley (1995) also suggests that psychiatric nurses should main- tain regular observation of the elderly patients and ask their family, friends or the volunteers to stay with the patients during confused or unsta- ble mood swings in order to provide companion- ship and to satisfy the need for one-to-one

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Psychiatric nurses' knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

attention. The fmdings also highlight the impli- cations for nurses in terms of being aware of patients' adaptive behaviors and thus attempting to make adjustments of the ward environment according to patients' individualized bio-psy- chosocial needs (Tammello 1997; Winston, Morelli, Bramble, Friday & Sanders 1999), such as by reducing loud and irritating noises and avoiding an overcrowded environment in ward. A multi-disciplinary approach of care can be used in the process of creating and maintaining the least restrictive environment for older patients, in which each discipline brings its area of expertise to improve patient management in the ward (McCue et al. 2004).

Areas of misconception, such as a shortage of resources and staff and lack of good alternatives to restraints identified among the psychiatric nurses in this study, were common among nurses in general and psychiatric care settings and nurs- ing homes in the United States and some Euro- pean countries (Champagne & Stromberg 2004; Sailas & Fenton 2000). Mandatory education programs on restraint reduction should be con- sidered for psychiatric nurses in Hong Kong to highlight their myths and incorrect concepts regarding restraint use in a ward. Recent reports on effective, innovative programs to reduce episodes of restraints in psychiatric care include:

• the early identification and management of problematic behaviors;

•complex interventions consisting of interview- ing patients to determine their stress triggers and personal crisis-management strategies;

• training staff in crisis escalation and non-vio- lent intervention, and

• an incentive system for staff on restraint mini- mization (D'Orio, Purselle, Stevens & Carlow 2004; McCue et al. 2004).

Ethical considerations of restraint use Consistent with the suggestion by Sailas and Wahlbeck (2005), the fmdings of this study demonstrated that psychiatric patients, in partic- ular demented, frail older patients, may have lim-

ited opportunity to make their views, needs and dislikes known before being restrained. This again highlights the need for psychiatric nurses to assess and understand the perceptions and feel- ings of patients about being restrained, before restraints are administered. As recommended by previous literature (Johnstone 1994; Dawkins 1998; Sailas & Fenton 2000), the majority of the psychiatric nurses in this study expressed little conflict between the patients' right to self-deter- mination and their role responsibility to do the best fot their patients. Johnstone (1994) suggest- ed that registered nurses sometimes may be 'morally blind' to patients' needs as they have sel- dom seen the effects of their inaccurate and sub- jective nursing assessments on their patients' physical and emotional needs, and therefore do not see subsequent decision making as a moral problem. The use of physical restraints on patients was perceived by the psychiatric nurses in this study as a 'beneficial' and an 'effective' nursing intervention, with little consideration being given to patients' feelings, to a loss of digni- ty and a denial of informed consent. They expe- rienced only limited feelings of guilt on placing a patient in restraint. Chien et al. (2005) and John- stone (1994) questioned whether or not the nurs- es are well prepared in managing ethical and legal situations in elderly care.

In this study, the nurses showed a lack of suffi- cient knowledge in bio-ethics and mental health legislation such as the patients' (and families') right to informed consent and choices for their own health care and treatment. In the past few years, the recurring message in all of the new leg- islations, recommendations (e.g., the Final Rules of Patients' rights and Centers for Medicare and Medicaid Services 2006), professional guidelines (e.g.. Ten Basic Principles of Mental Health Care; World Health Organization 1996), and some court cases in psychiatry, has been the need to practice caution when applying restraints or when using other coercive measures. There is some evidence that these documents and meas- ures can reduce the use of restraints. However, a

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Wai-Tong Chien and Isabella YM Lee

lack of comprehensive and accurate knowledge of mental health legislation and ethical issues con- cerning restraint use among nurses in different clinical settings, such as the psychiatric nurses in this study, has been shown to exist (D'Orio et al. 2004). Therefore, in Hong Kong and other coun- tries nurses should continue to be educated and updated in order to appreciate the ethical and legal dimensions of restraint use.

Limitations of the study There were some limitations to this study. First, there was still room for improvement of the research instruments used. It is difficult for a researcher who acts as both an interviewer and an observer in the wards to maintain objectivity when collecting and analyzing data from nurses but while avoiding becoming involved in the social (patient) situation in the psycho-geriatric wards. The researcher's role as a 'passive partici- pant observer' during the observations in the wards increased the difficulty of remaining an 'objective' observer when exploring the meaning of the social behaviors presented by the nurses. In addition, the presence of the researcher in the wards and during interviews might also have had a Hawthorne effect on the behaviors of the study participants (nurses). In addition, further testing and improvement of the interview guide, with more informants from different professional backgrounds and clinical settings being used, would have clarified its usefulness in guiding the interviews of psychiatric nurses.

Second, only 15 (33%) of the 46 psychiatric nurses were interviewed in the psycho-geriatric wards. The perceptions and attitudes of the non- participants and other people involved in the use of physical restraints, such as nursing administra- tors, medical staff, patients, and their families, were not examined. These people should play important roles and exert influence in arriving at decisions in restraint use.

Finally, a few additional research methods cotild have been considered to elicit a more complete pic- ture and provide a more adequate theoretical expla-

nation of the nurses' decision making process on restraint use. An ethnographic approach might have been used to explore the meaning of physical restraint and the nurses' decision to use restraint within the complex social context of the rwo psy- cho-geriatric wards. A more in-depth and ground- ed theory approach could also have been considered to develop a model to explain the deci- sion processes of psychiatric nurses in the use of physical restraints on older patients with mental health problems such as hallucination, delusion and/or emotional fluctuation. In addition, mixed methods of research, using both the above men- tioned qualitative approaches and the relevant quantitative research methods with a variety of psychosocial measures on the nurses such as anxi- ety and critical thinking scales, may increase the understanding of the research topic and thus the reliability and validity of the study findings.

IMPLICATIONS AND CONCLUSION This study highlights several issues for clinical practice and research, which include the follow- ing: • the need for nurses to question the established

pre-conceptions and myths about the use of physical restraints on elderly patients with mental health problems in order to improve the standard of legal and ethical practice;

• the nature and importance of nurses' awareness and consideration of the important factors, including the personal meaning of physical restraints, possible use of alternative measures to restraint, adverse consequences of restraint use, staffmg and resources, and ethical dilemmas, which influence their decisions and which cotild lead to a consequent reduction of restraint use;

• the extent to which continuing education among health professionals may be one means of ensuring more appropriate use of physical restraints;

• the use multi-disciplinary approaches, and adequate staffing and other resources, to encourage nurses to create the least restrictive environment for older patients in wards; and

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Psychiatric nurses' knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

• the use of multiple approaches to data collec- tion and the integration of data analyses in research in order to increase the comprehen- siveness, credibility and depth of understand- ing of the research topic.

In conclusion, few studies have been found in Hong Kong or elsewhere that explored nurses' knowledge, attitudes and decision making regard- ing the use of physical restraints in older patients in acute psychiatric units. This study highlights the importance of cognitive preparation of psy- chiatric nurses in terms of knowledge and psy- chological and ethical issues in order to achieve the appropriate use of physical restraints as an intervention of last resort.

This study used a mixed methods research design, in which the researcher could collect rich and in-depth data from both quantitative (struc- tured questionnaire) and qualitative (semi-struc- tured interview and observation session) methods of data collection, resulting in a more insightful data analysis and interpretation. In this study, the multiple data collection methods revealed the relationships between the knowledge, attitudes, perceptions, and important issues in nursing practice concerning the use of physical restraints. The findings reveal several important factors infiuencing nurses' attitudes and practice con- cerning restraint use; these include their beliefs, their attempts to implement alternatives to restraint (which are safe, effective and easy to employ), their understanding of the ethical and legal implications of this practice, and their knowledge, personal beliefs and misconceptions concerning restraint use. When compared with the findings of Janelli et al.'s (2006) study in the US, this research highlights several characteristics of psychiatric nurses in Hong Kong concerning restraint use, including a lower level of knowl- edge, more negative attitudes, more awareness of the importance of clear documentation, and the presence of areas of misconception about restraint use. In the light of these factors, further research using an action research method is recommended

to evaluate the effects of an educational interven- tion on psychiatric nurses' attitudes and decisions regarding restraint use in Hong Kong and other countries.

Different methods of study and a larger sam- ple size are also recommended to develop a more comprehensive meaning of physical restraints among nurses, who are the key professionals responsible for making such decisions in caring for their patients. Future research on the perspec- tives of other people involved is also recommend- ed, in order to obtain a more complete picture of the use of physical restraints.

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Received 5 February 2007 Accepted 20 September 2007

B O O K S : & I S S U E S 6 N C U L t U R E A N I D H E A L T H

Traditional Chinese Medicine: The Human Dimension by Big Leung ISBN 978-0-9775742-2-3 i v - H 88 pages This book invites us to rethink the meaning of medicine and life - which are intertwined together Most significantly, it stimulates our thinking of how to live in a more humane way, and this is the passion that I would like to share with you all. Author Traditional Chinese Medicine (TCM) is a great treasure of China's ancient history and culture. Written for health professionals, researchers, social scientists and educators, this book elaborates the embodiment of TCM in the lifespan and complex human dimensions and meanings in Chinese culture.

Orphaned by the Colour of My Skin: A Stolen Generation Story by Mary Terszak ISBN 978-1 -921348-08-2 viii -H 152 pages / need to emphasise that my time in The Home of the Good Shepherd caused me mental trauma, which I feel destroyed my soul. Author In an invasive, paternalistic, federal public policy environ- ment for Indigenous communities, this book provides an in-depth account of one person's experiences as a 'Stolen Generation' Aboriginal Australian. Told from the heart, the book speaks in the raw voice of a grandmother reflecting on her life, focusing on her child- hood experiences, subsequent perceptions and life stories.

In Our Own Right: Black Australian Nurses' Stories edited by Sally Goold OAM and Kerrynne Uddle ISBN 978-0-9757422-2-8 xiii + 120 pages The intimate, private, and heart wrenching stories told in this book, the first of its kind in Australia, will penetrate the hearts and souls of even the most hardened reader. Told with incredible dignity and humility, each of the individual and deeply personal stories recounted is a powerful testimony to the gross inhumanity and brutal capacity of white people in Australia - colonists who selectively destroy and humiliate, without remorse, the lives and souis of their fellow black Australians. This book provides a powerful catalyst for questioning and calling into question the taken-for-granted humanity of us all.

Advances in Contemporary Transcultural Nursing edited by John Daly and Debra Jackson ISBN 978-0-9750436-1 -5 xiv + 190 pages The articles in this collection provide compelling evidence that culture is fundamental to personhood and can be a crucial variable in human experiences around health, illness, recovery and rehabilitative processes. Within the challenges lie opportunities - opportunities to extend and develop practice, to examine the ways that nursing and health care is delivered, to continue to develop our understandings of spirituality and culture, and their relationship to health and well-being.

Advances in Indigenous Health Care edited by Eileen Willis, Vicki Smye and Maria Rameka ISBN 978-0-9750436-9-1 xii + 204 pages The burden of disease and ill-health in colonised Indigenous populations globally is greater when compared to other groups within their nations. Indigenous health status is linked not only to the deprivation and socio-economic positioning, but to the access and use of health services - shrouded in politics through Indigenous communities to policy and resource decisions in government. This issue explores differential access to essential determinants of health (such as housing, education, income and nutrition) and health services in North America, Australia and New Zealand and seeks to compare lessons learned.

Transcultural Nursing: Pathways of Cultural Awareness (2008) edited by Akram Omeri, Marilyn McFarland and Sandy Lovering ISBN 0-9757710-5-1 viii + 216 pages With a Foreword by Madeleine Leininger, this significant collection addresses the significance of culture-specific care for maintaining the health and well-being of Indigenous people, transcultural nursing leadership & intercultural communication in action, transcultural nursing models (frameworks) for education & practice (combined models, standards, competencies), evidence- based transcultural nursing practice, transcultural nursing ethics, social justice, human rights, and challenges and issues of nursing beyond borders.

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