Restraints or alternatives: safety work in care of older persons.

AIM: To examine the factors and complexity that account for physical restraints use and their alternatives as nurses' protect the safety of older adults. BACKGROUND: Research on physical restraints has repeatedly shown the human, financial and work costs associated with their use, but their use continues to be a major quality issue across hospitals and across countries for older persons. METHOD: Interviews with medical surgical nurses in a Midwestern hospital in the United States were recorded and interpreted using grounded theory. RESULTS: Using data that described the complexity of initiating, maintaining, or discontinuing restraints, we captured the density of these processes and showed how nurses made decisions about restraint use. The tasks carried out to protect the older person's safety often involved using restraints or their alternatives and these tasks then set in motion a cascade of other types of tasks or work, e.g., diagnostic, comfort, articulation. CONCLUSIONS: The study extended the work on chronic illness trajectories and formulated a framework for understanding the complexity of the use of restraints and their alternatives. Using a tracing approach we were able to predict the types of situations that would most likely result in the initiation, maintenance and discontinuation of restraints or the use of alternative procedures. RELEVANCE TO PRACTICE: The study has identified a process of 'safety work' that identified the risk associated with the problem, the work to cope with the problem and risk, the conditions that influenced the process and the consequences or outcomes of the work strategies to maintain the older person's safety.

Safety work: initiating, maintaining, and terminating restraints.

PURPOSE: This study examines the variations and complexities in nurses' decision making about the initiation, maintenance, and termination of physical restraints. METHODS: This qualitative research used a semistructured interview of registered nurses on medical-surgical units at a midsized hospital in the Midwest. RESULTS: All the nurse respondents easily recalled caring for a patient in restraints and detailed in their accounts a complex trajectory of care that centered on safety. However, most nurses reported that the trajectory of restraint use was started by other departments, shifts, or nurses. The findings revealed a forceful interplay of patient, nurse, family, healthcare worker, and organizational factors that influence nurses' decision making about restraint use. CONCLUSIONS: This article discusses how a deeper understanding of the intricacies of the decision-making processes related to restraints can help clinical nurse specialists tailor education, impact policy, and serve as role models to reduce the use of restraints in hospitals.

Overreporting and underreporting of child abuse: teachers' use of professional discretion.

OBJECTIVE: According to mandatory reporting laws for professionals, the relationship between initial recognition that a child may have been abused and the subsequent reporting of that suspected case of child abuse to the responsible agency would, at first glance, appear to be clear. However, this relationship has developed into one of the major social policy controversies of the recent past. Our major goal is to present research findings that address this social policy debate concerning the problems of underreporting and overreporting, focusing specifically on teachers. METHOD: A factorial survey design, that combines the advantages of the factorial experiment with those of surveys, was employed in a probability sample of teachers (N=480) who responded to vignettes in which case characteristics were systematically manipulated. Teachers responded with judgments about whether the vignette was child abuse and the likelihood that they would report this suspected case. Characteristics of the teachers and their work setting (school) were also measured. RESULTS: When comparing the teachers' recognition and reporting scores, we found that they gave the same score for 63% of the vignettes they judged, gave higher reporting than recognition scores (overreporting) for 4% of the vignettes, and gave higher recognition than reporting scores (underreporting) for 33% of the vignettes. Discrepancies between recognition and reporting (over and under reporting) were related to characteristics of the case, teacher, and school where the teacher was employed. CONCLUSIONS: Teachers in our Ohio sample evidence the use of professional discretion in making judgments about the recognition and reporting of child abuse and do not appear to make these judgments with equal certainty. Their use of discretion is more likely to result in underreporting than overreporting.