How to avoid and prevent coercion in nursing homes

Abstract

In many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia. This article examines what kinds of strategies or alternative interventions nursing staff in Norway used when patients resist care and treatment and what conditions the staff considered as necessary to succeed in avoiding the use of coercion. The data are based on interdisciplinary focus group interviews with nursing home staff. The study revealed that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion. The most common strategies were deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care. According to the staff, their opportunities to use alternative strategies effectively are greatly affected by the nursing home’s resources, by the organization of care and by the staff’s competence.

Keywords

Coercion dementia ethics introduction nursing homes power

Introduction

In Norway, as in other Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially with patients suffering from dementia who need frequent help in the activities of daily living or who behave in a challenging way.¹ Types of coercion vary from the most obvious ones, such as different kinds of physical restraints, for example, bedrails or belts to protect patients from falling out of bed,² to more hidden or indirect forms of coercion, such as covert medication in the patients’ food or beverages.³ In Norway, use of coercion in somatic health care has basically been illegal. However, from January 2009, the Patients’ and Users’ Rights Act was supplemented with a new chapter (Chapter 4A), regulating the possibilities for providing somatic health care against the patient’s will. The main criterion is that the patient lacks the competence to give consent. Other key criteria are that failure to provide health care may lead to significant harm to the patient’s health, the health care is regarded as necessary, and that measures to build confidence have to be tried before coercion is used.⁴ The new legal regulation has two main objectives. The first is to ensure that necessary health care is provided to prevent significant harm. The second is to prevent and limit the use of coercion.

The use of physical restraints and other kinds of coercion involves professional, legal and ethical challenges, which are important to illuminate. To gain more knowledge about how nursing staff understand and practice different kinds of coercion in the light of the recent changes in the law, we carried out a focus group study in Norwegian nursing homes in 2009/2010. In an earlier published article based on these empirical data, we found that the distinction between coercion and voluntariness can be blurred and that situations can change quickly from voluntariness to coercion and vice versa.⁵ In the extension of this, in this article, we want to examine how the nursing staff handle challenging situations where patients resist care and treatment: (a) what kinds of strategies or alternative interventions are used and (b) what conditions are considered necessary to prevent or avoid the use of coercion?

In order to understand the use of coercion among the nursing home population, we first describe the Norwegian nursing home context. Then, we present a summary of previous studies on coercion in nursing homes and a theoretical frame of reference, before presenting the method and the results.

Norwegian nursing homes and the nursing home population

Most Norwegian nursing homes are publicly funded and operated by Norwegian municipal authorities. There are about 41,300 beds in nursing homes,⁶ most of them for long-term care, serving a population of approximately 5 million inhabitants. In 2010, more than two-fifths of all deaths in Norway occurred in nursing homes, and nursing home residents lived in average about 2 years in nursing homes before they died.

As in other Western countries,⁷ most residents have multiple chronic diseases⁸ with dementia as the most frequent diagnosis.⁹ The majority of patients with dementia have severe functional impairments and complex needs, and agitation and other behavioural changes are highly prevalent. They can develop anxiety, become confused and suspicious, and thus have the feeling of losing control over their own situation. This can provoke resistance and aggression in situations where the caregivers help them with daily care.¹⁰ In a study of the use of constraints in Norwegian nursing homes, it was found that 82% of nursing home residents were subjected to some constraint during 1 week.¹¹ Force or pressure related to activities of daily living was reported most frequently.

Patients with cognitive impairments are particularly dependent on the ability of service providers to understand their individual needs. Thus, the quality of the service depends on the professional knowledge, skills and attitudes of the people working face-to-face with the patients, and also adequate resources and good organizational solutions. In Norway about one-third of those working face-to-face with patients lack formal qualifications, and only one-fourth of them have college education.¹² Furthermore, there is a lack of doctors,¹² which means that only the most urgent medical needs can be met.¹³ In a study from 2007, we found that the nursing home staff reported more ethical dilemmas related to patient autonomy when the number of hours the doctor spent with the patients decreased.¹⁴

Previous studies

In order to identify relevant literature for our study, we searched systematically in PubMed and CINAHL. The search was carried out at the end of 2011 and limited to empirical studies of different kinds of coercion in nursing homes from 1995 to 2011. Here, the term ‘coercion’ includes all kinds of physical restraints that are defined as activities by which the physical activity/mobility of older people is restricted either directly or indirectly by physical or mechanical means,¹⁵ covert medication (chemical restraints) and other methods such as locking in a room,¹⁶ electronic surveillance, force or pressure in medical examination or treatment, and force or pressure in activities of daily living.¹⁷ There was no limitation regarding study design. The first and second authors independently screened the title and abstract of the identified references (in total 634) for potentially relevant articles; 103 studies met the inclusion criteria and were reviewed in full text, and 69 were found to be relevant. The search was supplemented with an examination of the reference lists of the retrieved articles and the authors’ knowledge of other literature, from which two studies were included.

Most studies used a cross-sectional design, examining the prevalence of different kinds of coercion in nursing homes,^{2,18

–23} factors associated with the use of coercion,^10,24
–26 the consequences of using coercion^27,28 and the staff’s reasons for using coercion. For example, a number of studies have shown that nursing home staff justify their use of restraint as a way to improve the patient’s safety,^1,29 although there is a growing body of evidence that physical restraints are associated with many adverse effects.³⁰ Other types of motivation for using coercion are to be able to carry out care procedures¹ and resource constraints within the care setting.¹⁴

Research on alternatives to the use of coercion is of special relevance to our study.^{15,31

–35} The systematic review of Enmarker et al.,³⁶ which looked at alternative approaches to the management of dementia-related aggression to avoid the use of restraints, found that the optimal management of aggressive actions was a person-centred approach. Such interpersonal approaches focus on verbal diversion of an aggressive resident’s attention and through such distraction causing the resident to be calm. This is illustrated by Foley et al.³¹ who found that a variety of interpersonal approaches, such as redirection, one-to-one care, validation, using a calm voice and flexibility, were frequently used when the management of aggressive behaviour was characterized as successful. Skovdahl et al.³⁵ also focus on how the caregivers use their position. They claim that the caregivers may use their power in both positive and negative ways, differentiating between using their power to involve the patient in the situation and using their power over the patient in order to exercise control and make decisions for the patient.

To increase person-centred approaches and possibly reduce the use of coercion, Enmarker et al.³⁶ suggest implementing educational programmes, aimed at increasing knowledge about this kind of behaviour. In fact, several studies have examined different kinds of educational interventions used to prevent or reduce behavioural problems and the use of restraints in nursing homes.^{37

–45} The recent systematic review of Möhler et al.⁴⁴ concluded that there is insufficient evidence supporting the effectiveness of educational interventions, but that ongoing and unpublished research may alter the results.

To sum up, there is a significant body of research on different aspects of the use of coercion in nursing homes. The ideal seems to be restraint-free care, but the literature is not clear when it comes to the best and most effective educational approaches. The importance of person-centred or interpersonal approaches is emphasized in several studies.

Theoretical frame of reference

During the last few decades, in most Western countries, the power of health professions has been reduced through legislation and government policy, while users’ rights have been strengthened.⁴ Respect for patient autonomy and the right to self-determination to a certain extent have replaced older more paternalistic ideals in medical ethics and health-care legislation.

During the last decade, the Norwegian debate on the decreasing power of health-care professions has focused on how regulations and structural changes in health care in general affect those working face-to-face with patients.⁴⁶ Several studies describe a care sector under pressure, where staff working close to patients experience a mismatch between welfare ambitions and resources.^46,47 Vike et al.⁴⁶ argue that powerlessness more than power characterizes those who work close to patients.

Due to demographic changes and improved opportunities for diagnosis and treatment, there is an increased demand for care services. Most municipalities have high welfare ambitions, while often complaining of inadequate resources to fulfil their ambitions.⁴⁷ This mismatch causes constant demands for more efficient care. The power to determine the terms and conditions for providing care is centralized, while the responsibility for the proper conduct of care is distributed downwards in the system, that is, decentralized to the care workers, resulting in a continuous feeling of inadequacy. There is a kind of privatization of inadequacy – the care workers are the carriers of the ‘conscience of power’.⁴⁶

However, in analysing the dynamics of power in the daily relationships between patients and staff in nursing homes, Juritzen and Heggen⁴⁸ criticize the impression that it is primarily powerlessness that characterizes nursing home staff, arguing that only looking at power in structural terms may prevent us from exploring how power is carried out, experienced and spoken about. Thus, we have to study how power is exercised at the relational level. Although the relationship between patients and health-care workers has become more equal, there is still an asymmetry built into the relationship. This asymmetry of power is obvious in nursing homes, where most patients are very ill, cognitively impaired and totally dependent on the staff.⁴⁹ The staff still have a great deal of power to define the patients’ needs, what kind of help to provide, and how and when to provide it. The risk of violating the patient’s integrity increases with the patient’s vulnerability and is particularly present when the patient has cognitive impairments. The ambiguity of care is obvious when it turns into control, oppression and coercion.⁵⁰

In line with a Foucauldian perspective on power, Juritzen and Heggen^48,51 have examined how power is exercised in social practices in the caring sector. According to Foucault, the conditions of power cannot be explained in terms of structures or institutions only, but are seen as being generated at the point of interaction. Rather than seeing power as something that is possessed by certain persons or groups, power is characterized as part of the processes of interaction.^52,53

How nursing staff exercise their power is crucial to avoid violating the patient’s human dignity, that is, the dignity attached to the property of being human,⁵⁴ regardless of their levels of competence, consciousness or autonomy.⁵⁵ This means using all their competence, including relational skills, to find creative solutions to difficult situations or as alternatives to the use of coercion. This is in line with how Skovdahl et al.³⁵ use the term power to, in contrast to power over. Power to is a positive kind of power, described as the power to enable others to accomplish things and to help someone through one’s own competence, inviting involvement, while power over is a negative kind of power, exerting control over others, which excludes involvement.

Our starting point is that the caring services are developed in interplay between structural conditions and social practice, that is, there are two main sources of power.⁴⁸ Structural conditions are the economic, legal, professional and organizational conditions for care, while social practice is something that happens between the caregiver and the care receiver, and the power exercised in the clinical encounter should be viewed in the light of the structural conditions.

Methodology

To gain more knowledge and understanding of these issues, we decided to use a focus group design.⁵⁶ The participants were recruited to the study via the managers of the nursing homes. We first asked the manager of five nursing homes in the southern part of Norway to participate in the study and then asked them to find respondents who worked face-to-face with residents and who could be interested in discussing questions regarding behaviourally challenging residents and different kinds of coercion.

We conducted 11 interdisciplinary focus group interviews consisting of nurses, auxiliary nurses and some members of staff without formal qualifications, altogether 60 participants. Some worked in ordinary units and others in special care units. The interviews lasted about 2 h. All interviews were taped and then transcribed.

The interviews were based on an interview guide, which was thematically organized. The interview guide focused on what kinds of coercion the staff had recently experienced in their work, their understanding of coercion and patients’ self-determination and what kind of situations often triggered the use of pressure or some kind of coercion. Last but not least, we asked them about their experience with strategies that could prevent the use of force, that is, alternative strategies aimed at preventing a situation that could provoke the patient’s resistance and aggression with the subsequent need to use coercion.

Analysis

The analysis was conducted in several phases.⁵⁷ First, all interviews were taped and then transcribed without moving or adding anything. Then, all the authors independently read and assessed all the transcripts. The transcripts were discussed both during the process and after all the interviews were finished. Through discussions of the transcripts, we agreed upon the most common types of coercion, pressure or manipulation described; what kind of situations had triggered different kinds of coercion and alternative strategies used. This process ensured an intersubjective understanding between us.⁵⁸ The material was also structured according to different kinds of situations where coercion was used. Our approach in analysing the text may be described as ‘bricolage’;⁵⁹ that is, we moved freely back and forth in the text without using a particular technique for analysis, an eclectic way of creating meaning in the material. Our aim with this study was explorative: we wanted to describe important aspects of what the focus group participants told us. The purpose was to present new descriptions of the phenomenon of coercion, what had triggered the use of coercion and alternatives to coercion. Thus, our analysis is inspired by the themes that emerged in the process, and they are grounded in the data material.⁵⁸

Ethical considerations

Written informed consent for the interviews was obtained before the interviews. The focus group participants were asked to ensure that they did not reveal the identity of the patients when they described challenging situations. Full anonymity was ensured for the staff by removing all identifiable details from the written material. The study was approved by the Norwegian Social Science Data Services.

Results

General findings

The interviews revealed that the staff usually spent a lot of time, trying a wide range of approaches, to prevent the use of coercion. Using coercion was considered a last resort. Most of the staff seemed to have their own ‘repertoire’ of strategies, which they tried to implement when the patients resisted what the staff wanted them to do. A variety of approaches for coping with patient resistance were mentioned in the interviews, most of them of interpersonal characters. Sometimes they succeeded, that is, the patient agreed to take a shower, to take the medicine and so on. Other times the staff did not succeed and felt that they had to use pressure or force to complete an intervention judged as ‘necessary health care’.

In the following section, we first describe the different kinds of approaches or strategies that the nursing home staff used most often to prevent the need for pressure or other kinds of coercion. Second, we present what is described as important conditions to avoid using coercion.

Strategies to prevent and avoid the use of coercion

Deflecting and persuasive strategies

In all the interviews, the expression ‘to coax and lure’ was a frequently occurring description of techniques used to get the patient to do what the staff wanted them to do. By focusing on something positive, for example, by telling the patient that she had pretty hair or by talking about their family or the weather, they tried to turn attention away from what was provoking anxiety, thus distracting the patient:

It can be an eating situation, I talk about … talk about the weather, anything, and then I sit there and feed her, and the patient opens her mouth … we sit and talk a bit. It’s a way of coaxing. I do that to prevent using ‘tremendous’ force.

Some said explicitly that they felt like an actor, playing different roles and using various techniques to distract the residents.

Limiting choices by conscious use of language

The staff’s attempts to explain, persuade and coax imply a more or less conscious use of language. Some are very conscious of how they express themselves; for example, they do not ask the patient what she or he wants, rather they inform them about what is happening:

Instead of asking: do you want to take a shower today, I say; now you are going to take a shower and I will help you.

Language is thus used consciously in a way that avoids explicit questioning and reduces the patients’ options.

Flexibility

Three different kinds of flexibility are described: trying later, change of personnel and one-to-one care.

Trying later

According to the staff, a common strategy to prevent provoking the patient’s resistance is to postpone what they intend to do with or for the patient. For example, if the patient shows some form of resistance, they wait an hour or two and then they try to implement the action once more. The staff often experienced that the patient’s mood and the situation could change quickly, and when trying to carry out the action somewhat later, they often succeeded:

The point is to see that you can avoid … and this is the case with many of those who don’t understand what is happening. If I bring the medicine, and they say: ‘I don’t want to take it!’ If I’m a bit smart, I’ll come back in three minutes and say: ‘Here is your medicine’, – then it is ok.

This quote illustrates that the staff do not give up right away. There are also stories about how they compromise, for example, by only washing a part of the patient’s body or by letting the patient have her coffee and breakfast before the washing session.

Change of personnel

To entrust the task to another member of staff is another related strategy. Although the member of staff usually has a good relationship with the patient, the situation may suddenly change and become difficult. Therefore, it is nice to have the opportunity to ask someone else to take over the task:

If the patient spits out the medicine, how far will you go? Then you have to consult someone else. Or if you see that you cannot handle the situation, then someone else may try. It may work better. Then the situation can be solved by changing people.

One-to-one care – Following the ‘wandering’ patients

Persistent and repetitive walking behaviour among cognitively impaired patients is often a cause of concern for the nursing home staff, because the patients may fall, fail to return or be at risk of accidents. According to the new act, nursing homes in reality have very limited rights to use any barriers to prevent patients from leaving the nursing home. To prevent the unintended and negative consequences of wandering, the staff tried to dissuade the patients from walking away, but when they did not succeed with this strategy, they very often tried to follow the patient either by joining him/her or by following at a distance:

In a situation where he jumped over the fence, I followed him, but I had to go around. I decided to join him, taking my phone. He wanted to go to his home, which is a long distance away. I thought he would soon be tired, but he was not. … After an hour and a half, it started to rain, and I asked him if he wanted to go back by car. He refused, and then I understood that he could manage to go back home where his wife lives, and she is very afraid of him … I had to call the police to pick us up. They did, and I joined him. He was furious, but in spite of that we had a sort of alliance because we were arrested together, and were subjected to the same sort of injustice. Then he allowed me to give him his medicine and help him to bed.

Most staff had experienced that accompanying the patient had value beyond the physical aspect; it inspired confidence and reduced resistance and aggression in the patient.

Seclusion

Isolation or seclusion was often described in relation to agitated patients, for example, when the patient acts in a way that is perceived as threatening to other patients or members of staff. To calm down the patient to ensure that the situation does not escalate, they described situations where they had to gain control, but at the same time use their relationship to the patient in one-to-one-care:

… we isolated him, we locked the doors and then I was left alone with him. I stood in the background for a while, and then I approached him. I got him to go into his room, and then we talked a bit, or he talked the most. I just sat there, listening. He was very frustrated. … There were a lot of things he needed to tell me. You don’t always have to do anything special – maybe just be there.

Thus, in an attempt to create confidence, they consciously use their relationship to the patient. The alternative might be forced medication or isolating the patient in a locked room:

In relation to restlessness, like yelling and acting out, we may have tried other things, for example better, closer follow-up, or one-to-one care. But … we also have many other patients who need assistance.

Prerequisites

Some of quotes mentioned in ‘Strategies to prevent and avoid the use of coercion’ section indicate that different kinds of nursing home resources may affect how the staff handle challenging situations. In all the interviews, the staff expressed more or less explicitly that certain conditions have to be present in order to succeed in carrying out alternative strategies. The conditions described to prevent coercion consist of knowing the patient and having sufficient resources on an organizational level, including having nursing staff with the relevant qualifications. In line with what we found in the interviews, we focus mostly on the conditions related to resources.

Knowing the patient

The importance of being familiar with the patient’s history was emphasized in all the interviews. This made it easier to know and understand the patient’s preferences regarding food, hygiene and so on. Moreover, to have personal knowledge of their family made it easier to talk about their history. Most staff emphasized the importance of understanding whether there was something in the patient’s history that could explain their resistance and certainly how their behaviour could be understood in the light of their medical condition. Understanding the patient’s situation may facilitate the establishment of a good relationship and thus lead to less anxiety in caring situations. Although expressed in different terms, creating a trusting relationship was thus emphasized in all focus groups, as a prerequisite to preventing the use of coercion.

Resources

The interviews also revealed that the above techniques or strategies cannot be viewed separately, but must be seen in the light of the resources the nursing home has and how they organize their daily work. Resources were a recurring topic throughout most of the interviews, either as an underlying theme or expressed more explicitly. For example, when a patient resists being cared for by the member of staff who usually takes care of her, there has to be a certain number of staff at work to enable the tasks to be left to another person. Moreover, the delay of carrying out care of a patient who is resisting it presupposes both consciousness and experience of how to avoid using coercion and flexibility in the organization of the tasks. We use the term resources as a collective term referring both to the staff’s qualifications and their experience, as well as the number of staff at work.

Adequate staffing

The terms ‘sufficient time’ and ‘adequate number of staff at work’ were repeatedly mentioned as prerequisites to avoid the use of coercion. The terms are strongly interconnected and were used interchangeably by the staff. For example, having an adequate number of staff at work means that they have more time to carry out the tasks properly, compared to a situation where one or several members of staff are away from work for different reasons. According to the staff, a shortage of staff may cause unnecessary use of coercion, for example, the patient may have to wear an incontinence pad instead of the nurse spending time to take the patient to the toilet, which is time-consuming. Or patients may be given medication when it could be avoided, as illustrated by the following quotations:

… they don’t choose it themselves, they don’t ask for medicine. … We have observed it several times; we can sit and talk to them, walk with them, or sit down and hold their hands, and then they don’t need the extra medicine. But when we don’t have the money or the resources, then it is ok to … we can afford some extra medicine.

However, as one of the members of staff said, ‘we are not only in need of more hands, but the hands must be skilled too … Then, we might become competent enough to avoid most of the coercion’.

Competence

Using chairs with a fixed tray or table prevents patients from standing up and falling out of the chair. The tray is primarily for meals. The interviews revealed that these trays were frequently used between meals and that unqualified staff used this type of restraint more often than qualified nursing staff:

It is an easy solution. You take the patient, place him in the chair with the tray in front of him, and then you are done with the patient … Not everyone sees that this as wrong, perhaps. We have discussed it, but there is always someone who does not have the competence.

Several informants reported that the staff’s consciousness about using coercion varied with their level of formal education:

The unit employs several care assistants, who have no formal training. There really is a difference in awareness of using coercion … But as skilled workers, we are responsible for raising their awareness too.

By guiding less competent staff to choose alternative measures, for example, sitting with the patient or moving the patient to a safe place, unnecessary use of trays can be avoided.

Discussion

Using data from 11 focus group interviews in five Norwegian nursing homes, this study demonstrates that nursing home staff use a variety of strategies to avoid the use of coercion. However, most of the staff also emphasized that certain conditions had to be present in order to succeed in avoiding the use of coercion.

In general, the use of coercion was experienced as unpleasant and as a last resort when other strategies failed. The reform seems to have raised awareness about the use of coercion, but the data provide no basis for claiming that the reform has affected the variety of strategies used to avoid coercion or the frequency with which they are used.

One limitation of the study is that we have only interviewed nursing home staff. The descriptions of challenging situations and the strategies to prevent the use of coercion are assessed through the eyes of those who have the power to define the patients’ needs and to decide what care to provide, when to provide it and how to carry it out. Interviews with patients and/or their relatives and observations of staff–patient interactions in various challenging situations would have provided more information. The fact that most of the strategies were described in all the focus groups strengthens the study and makes the results more transferable.⁵⁷

Our discussion is limited to two main topics: (1) the use of alternative strategies to coercion as a positive exercise of power and (2) how the use of alternative strategies is affected by structural conditions.

The use of alternative strategies to avoid coercion

A basic requirement in the Patient’s and Users’ Rights Act is that measures to build confidence have to be tried before coercion is used. According to the Ministry of Health and Care Services, this means that the staff must try to get the patient to understand that it is in her/his interest to receive care and treatment. The interviews revealed an impressive amount of creativity in finding strategies to cope with the patients’ resistance. Thus, as far as we can see, most of the alternative strategies described by the staff in this study may be interpreted as different kinds of confidence-building interventions, that is, strategies that according to the legislation have to be carried out before it is decided to use coercion. However, it may be discussed whether limiting the patients’ choice in different ways can be regarded as confidence building.

The kinds of strategy described are in line with the variety of person-centred approaches that are frequently used in successful management of aggressive behaviour among people with dementia.^31,35 For example, Skovdahl et al.³⁵ describe situations of patients who resist being showered and how their resistance is met in different ways. When the staff succeed in playing down the patient’s resistance to being showered, the staff use their competence in order to meet the patient’s wishes and demands, demonstrating their power to accomplish the task, in contrast to situations where they may use their power over the patient, making decisions without trying to involve the patient.

Situations in which the patients do not want to cooperate, or in which they resist the caring activities assessed as necessary, are challenging to the nursing staff. According to Juritzen and Heggen,⁵¹ success in managing such challenging situations necessarily implies exercising their power in a positive way in their interaction with the patients. The interviews revealed that the nursing staff made many attempts to create flexible interaction, in spite of recurrent resistance, using their relationship to the patient. By using strategies that are less focused on the task and more focused on the patient while conducting the care, the staff tried to support the patient’s self-respect. Our impression is that the nursing staff who succeed in this use a wide range of skills, consisting of professional knowledge, relational competence and knowledge of the patient.

The nursing staff only occasionally talked about their power explicitly. However, some of them were very aware of how they expressed themselves when they wanted the patient to cooperate, for example, by informing or instructing instead of asking the patient to do something. Power is thus exerted through language to avoid explicit questioning, reducing the patients’ options and possible resistance.⁶⁰

Structural conditions and organization of care

The Patients’ and Users’ Rights Act clearly states that coercion should not be used because of lack of resources or because of lack of competence. However, as many of the respondents describe their working situation, their opportunities to effectively use alternative strategies are greatly affected by the nursing home’s resources, by the organization of care and by the staff’s competence and knowledge of the patient. Examples of resources mentioned most often were enough time, sufficient numbers of nursing staff at work and sufficient numbers of staff with necessary competence.

Insight into the relationship between operating conditions and the use of coercion is necessary in order to illuminate the discussion and to improve efforts to reduce the use of coercion. We know from other studies that characteristics of the residents are highly associated with the use of physical restraints^10,24 and that the attitudes of the nursing staff may affect the use of coercion.¹⁶ However, there are fewer studies that have looked at how working conditions and organization of work may affect the use of coercion.^61,62

Many nursing homes operate with what is called suboptimal staffing characteristics, which include low professional staff mix, high use of temporary staff, low staff levels and high turnover. Several studies propose that such characteristics may influence the quality of care, for example, the use of coercion. However, as far as we can see from the literature, there is no evidence that simply increasing the number of staff is an adequate measure to reduce the use of restraints. In a survey of American nursing homes, Castle and Engberg⁶³ found that a high professional staff mix was associated with a low level of use of restraint, but not adding more staff per se.

The importance of enough qualified staff is consistent with the experiences of our respondents. Several respondents told us that coercion was used more during the weekends than during the rest of the week, and they explicitly related this to the frequent use of temporary and inexperienced staff. These staff are less familiar with the residents and the ordinary practice on the ward. In particular, people with dementia may be more anxious and restless when they meet people they do not recognize, and these feelings may easily escalate into aggressive behaviour.

Norwegian nursing homes are also facing great challenges related to a high percentage of nursing home staff without formal health-care education. In order for less qualified and inexperienced staff to develop professionally, it is necessary to have a certain level of qualified staff on the ward, who can guide them and thus create a working environment with possibilities for carrying out alternatives to coercion. Another challenge is the high number of part-time staff, especially auxiliary nurses and care assistants, which means less continuity in the patient–staff relationship.

Conclusion

The basis for this article was to examine the kinds of alternative strategies and framework conditions that health-care professionals consider important to prevent coercion. As we have shown, health-care professionals attempt to prevent and limit the use of coercion and actively use their ‘repertoire’ of alternative strategies. However, the results also clearly demonstrate that certain conditions are needed, such as enough people at work, a high professional staff mix with relevant competence and continuity among the staff. The study indicates a mismatch between the ambitions of the legislation and the resources provided, affecting the staff’s possibilities to use their power in a productive way. The results illustrate that there is no objective situation where things just happen, but a moral space where both structural conditions and individual clinical encounters are critical to how the situation develops. Denying the influence of structural conditions, for example, through idealistic legal standards, is probably only to bury one’s head in the sand.

Footnotes

Acknowledgements

The authors would like to thank the nursing staff who participated in the focus group interviews and shared their experiences with us. The authors also thank Bert Molewijk for valuable comments on an earlier version of this article and the two reviewers who offered constructive comments on this article.

Funding

This research received funding from the Norwegian Ministry of Health and Care.

Conflict of interest

The authors declare that there is no conflict of interest.

References

Kirkevold

Engedal

. A study into the use of restraint in nursing homes in Norway. Br J Nurs 2004; 13(15): 902–905.

Kirkevold

Laake

Engedal

. Use of constraints and surveillance in Norwegian wards for the elderly. Int J Geriatr Psychiatry 2003; 18(6): 491–497.

Kirkevold

Engedal

. Concealment of drugs in food and beverages in nursing homes: cross sectional study. BMJ 2005; 330(7481): 20.

The Patients Rights Act . Oslo: Ministry of Health and Care Services, 2010.

Hem

Gjerberg

Pedersen

Pleie og omsorg i grenselandet mellom frivillighet og tvang [Nursing and care at the boundary between voluntariness and coercion]. Sykepl Forsk 2010; 5(4): 294–301.

Statistics Norway. Institutions for the aged and disabled 1996–2011, http://www.ssb.no/pleie_en/tab-2012-07-04-01-en.html2012

Wetle

Shield

Teno

Family perspectives on end-of-life care experiences in nursing homes. Gerontologist 2005; 45(5): 643–650.

Nygaard

. Nursing home as a medical institution – a fata morgana? Tidsskr Nor Laegeforen 2002; 122(8): 823–825.

Engedal

. Assessment of dementia and use of anti-dementia drugs in nursing homes. Tidsskr Nor Laegeforen 2005; 125(9): 1188–1190.

10.

Kirkevold

Sandvik

Engedal

. Use of constraints and their correlates in Norwegian nursing homes. Int J Geriatr Psychiatry 2004; 19(10): 980–988.

11.

Kirkevold

Engedal

. Prevalence of patients subjected to constraint in Norwegian nursing homes. Scand J Caring Sci 2004; 18(3): 281–286.

12.

Norwegian Directorate of Health. Årsrapport 2010. Omsorgsplan 2015 [Annual Report 2010. Care Plan 2015]. Oslo: Norwegian Directorate of Health, 2011.

13.

Pedersen

Nortvedt

Nordhaug

In quest of justice? Clinical prioritisation in healthcare for the aged. J Med Ethics 2008; 34(4): 230–235.

14.

Gjerberg

Forde

Pedersen

Ethical challenges in the provision of end of life care in Norwegian nursing homes. Soc Sci Med 2010; 71: 677–684.

15.

Saarnio

Isola

Laukkala

. The use of physical restraint in institutional care of older people in Finland: nurses’ individual, communal and alternative modes of action. J Clin Nurs 2009; 18(1): 132–140.

16.

Moore

Haralambous

. Barriers to reducing the use of restraints in residential elder care facilities. J Adv Nurs 2007; 58(6): 532–540.

17.

Gastmans

Milisen

. Use of physical restraint in nursing homes: clinical-ethical considerations. J Med Ethics 2006; 32(3): 148–152.

18.

Karlsson

Bucht

Eriksson

Physical restraints in geriatric care in Sweden: prevalence and patient characteristics. J Am Geriatr Soc 1996; 44(11): 1348–1354.

19.

Gruneir

Miller

Lapane

Hospice care in the nursing home: changes in visit volume from enrollment to discharge among longer-stay residents. J Pain Symptom Manage 2006; 32(5): 478–487.

20.

Meyer

Kopke

Haastert

Restraint use among nursing home residents: cross-sectional study and prospective cohort study. J Clin Nurs 2009; 18(7): 981–990.

21.

Milke

Kendall

Neumann

A longitudinal evaluation of restraint reduction within a multi-site, multi-model Canadian continuing care organization. Can J Aging 2008; 27(1): 35–43.

22.

Phillips

Spry

Sloane

Use of physical restraints and psychotropic medications in Alzheimer special care units in nursing homes. Am J Public Health 2000; 90(1): 92–96.

23.

Feng

Hirdes

Smith

Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study. Int J Geriatr Psychiatry 2009; 24(10): 1110–1118.

24.

Karlsson

Bucht

Eriksson

Factors relating to the use of physical restraints in geriatric care settings. J Am Geriatr Soc 2001; 49(12): 1722–1728.

25.

Talerico

Evans

Strumpf

. Mental health correlates of aggression in nursing home residents with dementia. Gerontologist 2002; 42(2): 169–177.

26.

Weiner

Tabak

Bergman

. The use of physical restraints for patients suffering from dementia. Nurs Ethics 2003; 10(5): 512–525.

27.

Engberg

Castle

McCaffrey

. Physical restraint initiation in nursing homes and subsequent resident health. Gerontologist 2008; 48(4): 442–452.

28.

Castle

. Mental health outcomes and physical restraint use in nursing homes {private}. Adm Policy Ment Health 2006; 33(6): 696–704.

29.

Saarnio

Isola

. Nursing staff perceptions of the use of physical restraint in institutional care of older people in Finland. J Clin Nurs 2010; 19 (21–22): 3197–3207.

30.

Capezuti

Brush

Won

Least restrictive or least understood? Waist restraints, provider practices, and risk of harm. J Aging Soc Policy 2008; 20(3): 305–322.

31.

Foley

Sudha

Sloane

Staff perceptions of successful management of severe behavioral problems in dementia special care units. Dementia 2003; 2(1): 105–124.

32.

Neufeld

Libow

Foley

Restraint reduction reduces serious injuries among nursing home residents. J Am Geriatr Soc 1999; 47(10): 1202–1207.

33.

Slettebo

Bunch

. Solving ethically difficult care situations in nursing homes. Nurs Ethics 2004; 11(6): 543–552.

34.

Pulsford

Duxbury

Hadi

. A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings. J Psychiatr Ment Health Nurs 2011; 18(2): 97–104.

35.

Skovdahl

Kihlgren

. Dementia and aggressiveness: video recorded morning care from different care units. J Clin Nurs 2003; 12(6): 888–898.

36.

Enmarker

Olsen

Hellzen

. Management of person with dementia with aggressive and violent behaviour: a systematic literature review. Int J Older People Nurs 2010; 6(2): 153–162.

37.

Testad

Aasland

Aarsland

. The effect of staff training on the use of restraint in dementia: a single-blind randomised controlled trial. Int J Geriatr Psychiatry 2005; 20(6): 587–590.

38.

Testad

Ballard

Bronnick

The effect of staff training on agitation and use of restraint in nursing home residents with dementia: a single-blind, randomized controlled trial. J Clin Psychiatry 2010; 71(1): 80–86.

39.

Koch

Lyon

. Case study approach to removing physical restraint. Int J Nurs Pract 2001; 7(3): 156–161.

40.

Evans

Strumpf

Allen-Taylor

A clinical trial to reduce restraints in nursing homes. J Am Geriatr Soc 1997; 45(6): 675–681.

41.

Huizing

Hamers

Gulpers

Short-term effects of an educational intervention on physical restraint use: a cluster randomized trial. BMC Geriatr 2006; 6: 17.

42.

Huizing

Hamers

Gulpers

A cluster-randomized trial of an educational intervention to reduce the use of physical restraints with psychogeriatric nursing home residents. J Am Geriatr Soc 2009; 57(7): 1139–1148.

43.

Godkin

Onyskiw

. A systematic overview of interventions to reduce physical restraint use in long-term care settings. Online J Knowl Synth Nurs 1999; 6: 6.

44.

Möhler

Richter

Kopke

Interventions for preventing and reducing the use of physical restraints in long-term geriatric care. Cochrane Database Syst Rev 2011. Issue 2. Art. No.: CD007546. DOI: 10.1002/14651858.CD007546.pub2.

45.

Koczy

Becker

Rapp

Effectiveness of a multifactorial intervention to reduce physical restraints in nursing home residents. J Am Geriatr Soc 2011; 59(2): 333–339.

46.

Vike

Bakken

Brinchman

Maktens samvittighet: Om politikk, styring og dilemmaer i velferdsstaten [The conscience of power: on politics, management and dilemmas in the welfare state]. Oslo: Gyldendal Akademiske, 2002.

47.

Vabø

. Forbrukermakt i omsorgstjenesten – til hjelp for de svakeste? [Consumer power in the health care sector]. In: Widding Isaksen

(ed.) Omsorgens pris. Kjønn, makt og marked i velferdsstaten [Gender, power and market in the welfare state]. Oslo: Gyldendal Akademiske, 2003, pp. 102–127.

48.

Juritzen

Heggen

Produktive maktpraksiser i sykehjem. En Foucault-inspirert analyse av pleiefaglig handlekraft [Power relations in care. A Foucauldian analysis of productive power in a nursing home]. Tidsskr for Velferdsforskning 2009; 12(2): 94–104.

49.

McLean

. Power in the nursing home: the case of a special care unit. Med Anthropol 2001; 19(3): 223–257.

50.

Ruyter

Wetlesen

. Omsorgens tvetydighet [The ambiguity of care]. Oslo: Gyldendal Akademisk, 2001.

51.

Juritzen

Heggen

Omsorgsmakt. Relasjonsnære sonderinger mellom makt og avmakt [Power relations in care. Looking into the close relationships between power and powerlessness]. Sosiol i dag 2006; 36(3): 61–80.

52.

Porter

. Contra-Foucault: soldiers, nurses and power. Sociology 1996; 30(1): 59–78.

53.

Sandmo

Foucault som maktteoretiker [Foucault as a theoretician of power]. In: Engelstad

(ed.) Om makt. Teori og kritikk [On Power. Theory and Criticism]. Oslo: Ad Notam Gyldendal, 1999, pp. 79–96.

54.

Nordenfelt

. Dignity and the care of the elderly. Med Health Care Philos 2003; 6(2): 103–110.

55.

Pullman

. The ethics of autonomy and dignity in long-term care. Can J Aging 1999; 18(1): 26–46.

56.

Krueger

Casey

. Focus groups: a practical guide for applied research. 4th ed. Los Angeles, CA: Sage, 2009.

57.

Malterud

. Qualitative methods in medical research. An introduction. 3rd ed. Oslo: Universitetsforlaget, 2011.

58.

Malterud

. Fokusgrupper som forskningsmetode for medisin og helsefag [Focus groups as a research method in medicine and health sciences]. Oslo: Universitetsforlaget, 2012.

59.

Kvale

Brinkmann

. Interviews: learning the craft of research interviewing. 2nd ed. Thousand Oaks, CA: Sage, 2008.

60.

Hewison

. Nurses’ power in interactions with patients. J Adv Nurs 1995; 21(1): 75–82.

61.

Huizing

Hamers

De Jonge

Organisational determinants of the use of physical restraints: a multilevel approach. Soc Sci Med 2007; 65(5): 924–933.

62.

Pekkarinen

Elovainio

Sinervo

Nursing working conditions in relation to restraint practices in long-term care units. Med Care 2006; 44(12): 1114–1120.

63.

Castle

Engberg

. Further examination of the influence of caregiver staffing levels on nursing home quality. Gerontologist 2008; 48(4): 464–476.