Use of physical restraints in rehabilitation settings: staff knowledge, attitudes and predictors.

AIM: This paper reports a study examining the knowledge, attitudes and practices of staff with regard to the use of restraints in rehabilitative settings, and quantifying the direct and indirect effects of the factors that influenced these practices. BACKGROUND: Nursing staff hold many misconceptions that support the continued use of physical restraints as a desirable technique in clinical settings to control clients. A number of previous studies measuring the knowledge, attitudes and/or practices of nursing staff towards the use of restraints have been conducted in acute, elder care, or psychiatric settings. However, not many have examined the predictors of staff practices when restraints are applied. In the study reported here, physical restraint was defined as any manual method or physical/mechanical device, material or equipment attached to a client's body so that their free movement was restricted. METHODS: A questionnaire was administered to 168 nursing staff in two rehabilitation centres in Hong Kong. The data were collected in 2002-2003 and the response rate was 80%. FINDINGS: Inadequate knowledge and negative attitudes on the use of restraints were found among staff. Most believed that good alternatives to restraints are not available, or they underestimated the physical and psychological impact of restraints on clients. Path analysis indicated that staff attitudes and their clinical experiences had positive direct effects on restraint use. In addition, level of knowledge and clinical experience had a positive indirect effect on practice by influencing attitudes. CONCLUSION: These data could serve as a basis for re-educating nursing staff on the subject. Staff with more clinical experience could give appropriate guidance to other members of staff on decisions to apply restraints. More effective alternative interventions to restraining clients should be explored. Once the gaps in knowledge are closed, more positive attitudes among staff towards the use of restraints can be cultivated, thus leading to a higher standard of nursing practice.

Percutaneous transluminal renal artery angioplasty: who benefits most?

We set out to assess the long-term benefits of renal percutaneous transluminal angioplasty (PTA) in 107 consecutive hypertensive patients with atheromatous renal artery stenosis. During 12-month follow-up, blood pressure fell to normal levels in 10 (8.8%) patients and improved in 76 (67.3%); renal function improved or remained stable in 74% of patients. In patients with atheromatous disease, renal angioplasty was most successful in those with stenosis in a single functioning kidney, and in nine patients who presented with symptoms and signs of heart failure, in the absence of overt ischaemic or valvular heart disease. In the latter group, renal PTA resulted in a large loss of sodium and water, resolution of the 'apparent' heart failure, and a marked improvement in blood pressure and renal function. It is suggested that all hypertensive patients with haemodynamically significant renal artery stenosis (and/or mild to moderate impairment in renal function), should be considered for renal PTA. Patients with atheromatous stenosis in a single functioning kidney, and those who present with signs of sodium and water retention, are likely to benefit most.

Development of a hierarchical activities of daily living scale for Chinese stroke patients in geriatric day hospitals.

A culture-specific 4-point hierarchical scale covering self-care, household activity and mobility was developed by modifying the Rivermead ADL scale to assess the physical function of Chinese stroke patients. Self-care ability (13 items scored 0/1/2/3 with a maximum of 39) and mobility (8 items scored 0/1/2/3 with a maximum of 24) were routinely assessed by occupational therapists and physiotherapists in stroke patients on admission to and at discharge from two geriatric day hospitals (GDHs). Household activity (6 items scored 0/1/2/3 with a maximum of 18) was assessed by occupational therapists in non-institutionalized patients with self-care scores within 15% of the maximum. The scale was acceptable to patients and staff. Graphical representation in profile format facilitates the identification of items requiring special attention. Internal reliability was high; the Cronbach's alpha for the self-care, household and mobility domains was 0.9732, 0.9530, and 0.9787, respectively. The scale was used to assess the change in physical function of 436 stroke patients discharged from two GDHs in Hong Kong over 18 months. Patients' mean age was 73 years (SD +/- 8.4), and the female/male ratio 1:3. On average, 38 visits (+/- 32) were made over a mean enrollment period of 220 days (+/- 289). Both the self-care and mobility scores showed statistically significant improvements at discharge, and changes in function exceeded 1/4 of the standard deviation of the initial scores. A substudy of 28 stroke patients, in whom household scores were assessed, revealed that for those with better initial physical function, a ceiling effect was apparent with the self-care score but not with the household or mobility scores.(ABSTRACT TRUNCATED AT 250 WORDS)

Predicting urodynamic dysfunction from clinical features in incontinent elderly women.

In a retrospective survey of 296 elderly women referred with urinary incontinence and in whom urodynamic studies were completed, multiple logistic regression was used to determine the optimal set of clinical features to predict the urodynamic dysfunction. Three formulae were obtained expressing the predicted probabilities (p) of the urodynamic dysfunctions as functions of the clinical variables. By choosing the cut-off values of p which gave equal weighting to sensitivity and specificity, we found that clinical features (symptoms, signs, residual volume) are helpful in diagnosing the presence of unstable detrusor and voiding dysfunction, but not incompetent urethra.