Information-Motivation-Behavioral Skill model-based physical restraint education program for nursing care providers in long-term care hospitals: A quasi-experimental repeated measures non-equivalent control group design
Article information
Abstract
Purpose
This study aimed to develop a physical restraints education program using the Information-Motivation-Behavioral Skill (IMB) model and examine its effects on physical restraint-related knowledge, attitudes, nursing practices, and person-centered care of nursing care providers in long-term care hospitals.
Methods
A nonequivalent control group repeated measures quasi-experimental design was used. The participants were 54 nursing care providers (intervention group=27, control group=27) in long-term care hospitals from Busan. The IMB model-based education program was developed and implemented once a week for 3 weeks. The program involved brain writing, lectures, poster or slogan creation, writing diary to reduce the use of restraint, and shouting slogans. Data were collected using self-reported questionnaires at pretest, immediately after the program completed (3 weeks after pretest), and 4 weeks after completing the program (7 weeks after pretest). Analysis was conducted using χ2-test, Fisher’s exact test, t-test, Mann-Whitney U-test, and repeated measures ANCOVA with the SPSS/WIN 28.0 program.
Results
The participants consisted of nurses (40.7%), nursing assistants (40.7%), and care workers (18.5%). The education program had statistically significant effects on knowledge (F=46.38, p<.001), attitude (F=42.70, p<.001), nursing practice (F=31.29, p<.001), and person-centered care (F=27.74, p<.001) regarding physical restraints. The intervention’s effects remained for 4 weeks after the completion of the intervention.
Conclusion
This education program effectively enhanced nursing care providers’ knowledge, attitude, nursing practice, and person-centered care concerning physical restraints. Future research is warranted to provide a regularly repeated program and evaluate the direct effects on the frequency of physical restraints for nursing care providers in long-term care hospitals.
INTRODUCTION
1. Background
According to future population projections, the proportion of South Korea’s population aged 65 and older is expected to rise from 15.7% in 2020 to 30.0% by 2035 [1]. With this growing population, caregiving, traditionally seen as a family responsibility, is increasingly shifting towards social and national care systems. As of 2023, there were 1,413 long-term care hospitals [2], and the number of individuals residing in long-term care facilities and hospitals has been steadily increasing. The growth in the number of long-term care hospitals may result in a decline in the quality of medical services, directly and indirectly impacting older adults’ health and quality of life. This makes quality management in long-term care hospitals crucial [3]. In particular, physical restraint management is a significant indicator of patient rights and protection in the accreditation evaluation of long-term care hospitals [4].
According to previous international studies, the application rate of physical restraints to older adults with cognitive impairment in nursing homes was reported to be 38.0% [5], while the application rate in geriatric hospitals was found to be 84.9% [6]. In South Korea, only 8.2% of patients with dementia in nursing homes and long-term care hospitals have experienced physical restraint [7]. However, the international definition of physical restraint for fall prevention [8], which involves attaching or placing restraints on or near the body to limit movement or access, shows a high application rate of 93.8% [9]. The adverse effects of physical restraint include skin abrasions, muscle atrophy, increased agitation, anxiety, delirium, cognitive decline, increased dependency, and even death [10].
According to Article 39-7 of the Enforcement Regulations of the Medical Service Act, the operators of long-term care hospitals are required to provide training to reduce the use of physical restraints [11]. Although most practical nursing care providers receive formal education, they still do not fully understand the hospital’s regulations and guidelines on physical restraints [12]. A previous study found that 76.8% of nursing care providers in long-term care hospital had received education related to physical restraints. While 100.0% of respondents indicated that guidelines were available, only 13.2% actually used alternative methods before applying restraints [13], and only 12.3% engaged in activities to prevent side effects of restraints [9].
Education is a crucial factor in interventions to reduce the use of physical restraints [14]. Factors influencing nursing care related to physical restraint use include knowledge, attitudes [15], and person-centered care [16]. Previous studies have developed and validated educational programs designed to reduce the use of physical restraints among nurses, nursing assistants, and care workers in nursing homes and long-term care hospitals [12,17,18]. However, these programs have primarily involved one-way education on general information, procedures, and alternatives for physical restraint use, lacking person-centered decision-making and participatory elements.
The Information-Motivation-Behavioral Skill (IMB) model posits that for individuals to engage in specific health behaviors, they need relevant information (Information), motivation to engage in the behavior (Motivation), and behavioral skills (Behavioral skill) to perform these behaviors with self-efficacy [19]. Although rare, educational programs based on the IMB model have been effective in improving knowledge, attitudes, use of personal protective equipment (PPE), and hygiene practices among healthcare providers [20] and primary caregivers [21]. Effective elements of IMB model-based interventions include video-based instructions, interviews about personal beliefs, confidence-level sharing, demonstrations of correct practices, peer supervision, and monitoring [20,21].
This study aims to develop and implement an IMB model-based physical restraint education program for nursing care providers (nurses, nursing assistants, and care workers) in long-term care hospitals. The program seeks to enhance their knowledge on decision-making regarding the use of physical restraints, its side effects, person-centered care, and alternative methods, thereby ultimately contributing to reducing the use of physical restraints. In this study, the program was adapted to fit the circumstances of domestic long-term care hospitals based on international evidence-based guidelines [22]. According to research findings [23] that suggest distributed learning at regular intervals is effective for long-term retention of educational content, the program was conducted over three sessions, each spaced 1 week apart. The program’s effectiveness was evaluated at three time points: before the intervention, immediately after, and 4 weeks after the intervention, to assess the educational effect over time. The results are expected to provide foundational data on the effectiveness of physical restraint education and help determine the optimal intervals for its implementation.
2. Aims
This study aimed to develop and implement an IMB model-based physical restraint education program for nursing care providers (nurses, nursing assistants, and care workers) in long-term care hospitals and evaluate its effects on knowledge, attitudes, nursing practices, and person-centered care regarding physical restraint use. The specific objectives were as follows:
1) To develop an IMB model-based physical restraint education program for nursing care providers in long-term care hospitals.
2) To evaluate the effects of the IMB model-based physical restraint education program on the knowledge, attitudes, nursing practices, and person-centered care of nursing care providers in long-term care hospitals.
3. Study Hypotheses
The hypotheses of this study were as follows:
1) The change in knowledge scores regarding physical restraint use differs between the intervention and control groups immediately after the intervention and 4 weeks later.
2) The change in attitude scores regarding physical restraint use differs between the intervention and control groups immediately after the intervention and 4 weeks later.
3) The change in nursing practice scores regarding physical restraint use differs between the intervention and control groups immediately after the intervention and 4 weeks later.
4) The change in person-centered care scores differs between the intervention and control groups immediately after the intervention and 4 weeks later.
METHODS
Ethic statement: This study was approved by the Institutional Review Board (IRB) of Pusan National University (IRB No. PNU/2023-166-HR). Informed consent was obtained from all participants.
1. Study Design
This study utilized a nonequivalent, control-group, repeated-measures, quasi-experimental design to develop and implement an IMB model-based physical restraint education program for nursing care providers and analyze its effects on knowledge, attitudes, nursing practices, and person-centered care regarding physical restraint use (Figure 1). The study was performed in accordance with the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement guidelines (https://www.cdc.gov/trendstatement/).
Flow diagram of the study. IMB=Information-Motivation-Behavioral Skill.
2. Participants
The participants were nurses, nursing assistants, and care workers in long-term care hospitals. Two long-term care hospitals in Busan with similar characteristics (>200 beds, first-grade nursing staff ratio, physical restraint education availability, regular employment status, and accreditation) were selected as the control and intervention groups. Two completely separate institutions were chosen to prevent intervention diffusion; one institution that could adjust work schedules for education participation was assigned to the intervention group and the other to the control group. The specific selection criteria for participants included those who directly provided nursing care to patients, held relevant licenses and qualifications, understood the purpose of the study, agreed to participate, and had at least 3 months of experience working in a long-term care hospital. Heads of nursing departments, patient safety managers, infection managers, and those working in outpatient or oriental medicine departments unrelated to physical restraint use were excluded. Sample size was calculated using G*power 3.1.9.7, with a moderate effect size (f) of .25, a significance level (α) of .05, power (1-β) of .95, considering two groups and three measurements. Correlation coefficient (r) for repeated measures was set at .50, based on prior studies assessing the effect of an educational program on reducing physical restraint use [18,24]. The power analysis determined that at least 22 participants per group were needed. Considering a dropout rate of 20.0% in a previous study [18], 27 participants were recruited for each group, for a total of 54 participants; all of them were included in the final statistical analysis without any dropouts.
3. Measurements
1) General Characteristics
The participants’ general characteristics were surveyed with 11 items, including age, sex, education level, marital status, religion, occupation, work experience, experience using physical restraints, employment status, experience with side effects of physical restraints, and use of alternatives to physical restraints.
2) Knowledge of Physical Restraint Use
Knowledge of physical restraint use was measured using a tool developed by Janelli et al. [25] and translated and modified by Yeo and Park [17], with permission obtained via e-mail. This tool includes 22 items such as “What is the most common reason for using physical restraints?” and “What is expected when a patient is restrained?” Each correct answer was awarded 1 point, while incorrect or unknown responses received 0 points. The total score ranged from 0 to 22, with higher scores indicating higher knowledge of physical restraint use. The tool’s reliability was a Cronbach’s α of .77 in Yeo and Park [17] and a Kuder-Richardson 20 of .61 in Choi and Kim [18], with a Kuder-Richardson 20 of .88 in this study.
3) Attitudes Toward Physical Restraint Use
Attitudes toward physical restraint use were measured using the Attitudes Regarding Use of Restraints tool developed by Janelli et al. [25] and modified by Kim and Oh [26], with permission obtained via e-mail. This tool includes 17 items, such as “Family members have the right to refuse the use of physical restraints” and “Patients have the right to refuse the use of physical restraints.” Responses are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating a more cautious attitude toward the use of physical restraints. The tool’s reliability was a Cronbach’s α of .67 when developed [25], a Cronbach’s α of .70 in Kim and Oh [26], and a Cronbach’s α of .90 in this study.
4) Nursing Practice related to Physical Restraint Use
Nursing practice related to physical restraint use was measured using a tool developed by Janelli et al. [25], modified by Suen et al. [27], and translated by Choi and Kim [18], with permission obtained via e-mail. This tool includes 14 items related to actual nursing activities involving physical restraint use, such as “Explain the reason for applying physical restraints to the patient” and “Frequently assess the need for removal of physical restraints.” Each item was rated on a 3-point Likert scale ranging from 1 (never) to 3 (always), with total scores ranging from 14 to 42 and higher scores indicating more appropriate practices regarding physical restraints. The tool’s reliability was a Cronbach’s α of .73 in Choi and Kim [18], and a Cronbach’s α of .87 in this study.
5) Person-Centered Care
Person-centered care was measured using the Person-centered Care Assessment Tool (P-CAT) developed by Edvardsson et al. [28] and translated and validated into Korean by Tak et al. [29]. This tool consists of 13 items divided into two subdomains: individualized care (seven items) and organizational and environmental support (six items), including five negatively worded items. Each item was rated on a 5-point scale from 1 (not at all) to 5 (very much), with higher scores indicating a higher tendency to provide person-centered care. The tool’s reliability was a Cronbach’s α of .84 when developed, a Cronbach’s α of .86 in Tak et al. [29], and a Cronbach’s α of .87 in this study.
4. Research Procedure
1) Development of the IMB Model-Based Physical Restraint Education Program for Nursing Care Providers in Long-Term Care Hospitals
The IMB model-based physical restraint education program for nursing care providers in long-term care hospitals was developed using the Analysis, Design, Development, Implementation, Evaluation (ADDIE) model. First, during the analysis phase, studies were reviewed such as Köpke et al.’s “Evidence-based practice guideline; Avoidance of physical restraints in long-term geriatric care” [22], and Ha’s “Development and evaluation of an educational program for reducing the use of physical restraints among nurses and nursing assistants in long-term care hospitals” [12]. The researcher’s own experience working in long-term care hospitals and interviews with three head nurses were used to understand the current state of physical restraint use, alternatives, and educational needs of nursing care providers. This led to selecting general information about physical restraints, decision-making protocols for their use, expected side effects, person-centered care, and alternatives to physical restraints as educational topics.
Second, during the design phase, lectures were chosen to convey knowledge about physical restraints, while brain writing, poster/slogan creation, and small group discussions were selected as motivation strategies to reduce the use of physical restraints. Each small group consisted of 4~5 members. To enhance behavioral skills, shouting slogans and writing and sharing performance diaries on reducing physical restraint use were employed to boost self-efficacy through the public declaration effect.
Third, during the development phase, the final educational plan consisted of three 1-hour sessions, based on providing three 1-hour educational interventions to nurses [17] and IMB model-based interventions to primary caregivers [21]. A panel of 10 experts, including a professor specializing in gerontological nursing, a clinical specialist, three nurses with over 10 years of experience in long-term care hospitals, and five master’s students in a gerontological nurse practitioner program, validated the content of the IMB model-based physical restraint education program. Content validity was assessed using a five-item 4-point Likert scale, with average scores ranging from 3.50 to 3.90 and an overall average of 3.66. Based on subjective comments from the expert panel, a feedback-sharing activity was incorporated into the final educational program.
Fourth, during the implementation phase, the researcher explained the study’s purpose, necessity, and methods to the hospital directors and nursing department heads of the two selected long-term care hospitals in Busan and obtained their consent for participation. Recruitment notices were posted, and 27 voluntary participants each for the intervention and control groups were recruited. The researcher provided the intervention group with the educational program once a week for 3 weeks, using various methods, such as booklets, PowerPoint presentations, and visual materials.
Fifth, during the evaluation phase, structured questionnaires on knowledge, attitudes, person-centered care, and nursing practices related to physical restraint use were administered to both groups at the pretest (before the intervention), immediately after the intervention (3 weeks after the pretest), and 4 weeks after completing the program (7 weeks after the pretest) to evaluate the effects of the IMB model-based physical restraint education program.
2) Composition of the IMB Model-Based Physical Restraint Education Program for Nursing Care Providers in Long-Term Care Hospitals
The intervention program in this study is an IMB model-based physical restraint education program focusing on providing information related to physical restraints (Information, IF), motivating to reduce the use of physical restraints (Motivation, MT), and the acquisition of behavioral skills to enhance self-efficacy (Behavioral skills, BS). The principal investigator (SJ) designed and conducted the program. Lectures for providing information (IF) were simultaneously provided to all 27 participants. After the lecture, participants were divided into six small groups of 4~5 people by ward to engage in group activities for motivation (MT). Slogan shouting and writing and sharing performance diaries were conducted to acquire behavioral skills (BS). The education program was structured into introduction (10 minutes), deployment (40 minutes), and conclusion (10 minutes), all conducted over three sessions and each lasting 60 minutes (Table 1).
Contents of the IMB Model-Based PR Education Program for Nursing Care Providers in Long-Term Care Hospitals
The introduction phase included watching a video related to the side effects of using physical restraints to motivate (MT) participants, followed by brain writing, where participants expressed their thoughts and feelings in writing, and slogan shouting to enhance behavioral skills (BS) such as “We can reduce the use of physical restraints” and “The dignity of my patient’s life is in my hands.” Participants also shared performance diaries on reducing physical restraint use written over the past week. The deployment phase included a 20-minute lecture to provide information (IF) and a 20-minute group activity for motivation (MT). In Session 1, the information (IF) covered general aspects of physical restraints, decision-making protocols for their use, and their side effects. Session 2 focused on the definition, components, and methods of person-centered care, while Session 3 addressed alternatives to physical restraints. The group activity for motivation (MT) involved designing (session 1), creating (session 2), and presenting (session 3) posters or slogans on reducing the use of physical restraints in groups. The ending phase included brain writing activities (MT) and shouting slogans (BS). At the end of the educational program, participants shared their reflections (MT) on the changes observed after completing the 3-week program.
5. Data Collection
This study was conducted over 7 weeks, from September 25, 2023 to November 8, 2023. The researcher explained the study purpose, necessity, and methods to the directors of the two selected long-term care hospitals in Busan, obtained their consent, and posted recruitment notices. After confirming the eligibility of those who voluntarily expressed interest, the researcher recruited 27 participants each for the control and intervention groups. Data were collected using self-reported structured questionnaires on general characteristics, knowledge, attitudes, nursing practices, and person-centered care related to physical restraint use.
The principal investigator (SJ) conducted the data collection and educational program. The pretest was conducted on September 27, 2023, before the start of education at the designated educational locations or auditoriums of each hospital, and the survey took approximately 20 minutes. During the pretest, the intervention and control groups were unaware of their group assignments; however, as education progressed, participants in the intervention group became aware of their inclusion in the intervention group. After the pretest, the IMB model-based physical restraint education program for nursing care providers in long-term care hospitals was provided to the 27 participants in the intervention group on October 4 and 11, 2023. The first posttest was conducted immediately after the 3-week education program (3 weeks after the pre-test) using structured questionnaires to assess the knowledge, attitudes, nursing practices, and person-centered care related to physical restraints in both the intervention and control groups. The second posttest was conducted 4 weeks after the completion of the educational program (7 weeks after the pretest) on November 8, 2023, using the same method as the first posttest. Upon completion of the second posttest, all participants were given a small gift certificate as a token of appreciation for participating in the study.
6. Data Analysis
The collected data were analyzed using SPSS WIN 28.0 Program (IBM Corp.). Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to analyze the participants’ general characteristics. Homogeneity tests between the control and intervention groups were conducted using the chi-square test, Fisher’s exact test, independent t-test, or Mann-Whitney U-test. Repeated-measures analysis of covariance (ANCOVA) was used to analyze the changes in outcome variables over time, controlling for covariates that were not homogeneous at baseline (age and working period in long-term care hospitals) and outcome variables (nursing practice related to physical restraint use). Mauchly’s test of sphericity was used to test sphericity. If the interaction between group and time was significant, the simple main effects of group and time were analyzed using paired comparisons and univariate tests in SPSS WIN 28.0 (IBM Corp.).
7. Ethical Considerations
This study was conducted with the approval of the Pusan National University Institutional Review Board (IRB) (PNU IRB/2023_166_HR). Voluntary participation was solicited, and informed consent was obtained from all participants. Participants were assured of the anonymity and confidentiality of the data, the right to withdraw from the study, and details on how the collected data would be stored and disposed of. The collected survey responses were stored in a secure location, and the coded data files were kept on the principal investigator’s (SJ) password-protected personal computer. These files would be stored for 3 years after study completion and then permanently deleted to ensure that the data could not be recovered. All research-related documents, except for the thesis, would be shredded. After data collection was completed, the educational program content was condensed and provided once to the control group considering the ethical aspects. The participants reported no adverse effects during this study.
RESULTS
1. Homogeneity Test of the Intervention and Control Groups
The intervention and control groups were homogeneous in terms of occupation, sex, education level, religion, current job, work experience, employment status, experience using physical restraints, experience with side effects, and use of physical restraints (Table 2). However, significant differences existed between the two groups in terms of age (t=-2.77, p=.008) and working period in long-term care hospitals (t=-2.39, p=.020). No statistically significant differences existed between the intervention and control groups in terms of knowledge, attitudes, and person-centered care regarding physical restraint use before the intervention. However, a significant difference in nursing practice related to physical restraint use was observed (t=-2.79, p=.008).
Characteristics of the Institutes and the Participants and the Levels of Main Outcome Variables
2. Hypothesis Testing
1) Hypothesis 1
Hypothesis 1, “The change in knowledge scores regarding physical restraint use differs between the intervention and control groups,” was supported by repeated-measures ANCOVA, showing a significant interaction between group and time (F=46.38, p<.001) (Table 3, Figure 2). Simple main effects analysis revealed that the intervention group had significantly higher knowledge scores compared to the control group, both immediately after the intervention (F=101.82, p<.001) and 4 weeks later (F=71.98, p<.001). In the intervention group, knowledge scores significantly increased from the pretest to immediately after the intervention (mean difference [MD]=8.61, p<.001) and 4 weeks later (MD=6.35, p<.001). However, scores significantly decreased 4 weeks after the intervention compared to immediately after (MD=-2.26, p=.002).
Effect of IMB Education Program on Outcome Variables (N=54)
Changes in main outcomes* between groups over time. (A) Knowledge about physical restraints; (B) Attitude about physical restraints; (C) Nursing practice about physical restraints; (D) Person-centered care (PCC). *Significant interaction effects observed for all outcomes (p< .05); *Estimated marginal means adjusted for covariates (age, length of employment in long-term care hospital, knowledge about physical restraints at pretest); Pre=Pretest; 3wks=Posttest 1; 7wks=Posttest 2.
2) Hypothesis 2
Hypothesis 2, “The change in attitude scores regarding physical restraint use differs between the intervention and control groups,” was supported by repeated-measures ANCOVA, showing a significant interaction between group and time (F=42.70, p<.001) (Table 3, Figure 2). Simple main effects analysis revealed that the intervention group had significantly higher attitude scores compared to the control group, both immediately after the intervention (F=102.00, p<.001) and 4 weeks later (F=74.02, p<.001). In the intervention group, attitude scores significantly increased from the pretest to immediately after the intervention (MD=8.30, p<.001) and 4 weeks later (MD=6.44, p<.001), while in the control group, scores significantly decreased from the pretest to immediately after the intervention (MD=-3.26, p=.004) and 4 weeks later (MD=-3.55, p<.001).
3) Hypothesis 3
Hypothesis 3, “The change in nursing practice scores regarding physical restraint use differs between the intervention and control groups,” was supported by repeated-measures ANCOVA, showing a significant interaction between group and time (F=31.29, p<.001) (Table 3, Figure 2). Simple main effects analysis revealed that the intervention group had significantly higher nursing practice scores compared to the control group at the pretest (F=8.86, p=.004), immediately after the intervention (F=8.84, p=.005), and 4 weeks later (F=24.89, p<.001). In the intervention group, nursing practice scores significantly increased from the pretest to immediately after the intervention (MD=5.39, p<.001) and 4 weeks later (MD=5.57, p<.001), whereas in the control group, scores significantly decreased 4 weeks after the intervention (MD=-2.91, p=.001).
4) Hypothesis 4
Hypothesis 4, “The change in person-centered care scores differs between the intervention and control groups,” was supported by repeated-measures ANCOVA, showing a significant interaction between group and time (F=27.74, p<.001) (Table 3, Figure 2). Simple main effects analysis revealed that the intervention group had significantly higher person-centered care scores compared to the control group, both immediately after the intervention (F=66.99, p<.001) and 4 weeks later (F=52.21, p<.001). In the intervention group, person-centered care scores significantly increased from the pretest to immediately after the intervention (MD=6.90, p<.001) and 4 weeks later (MD=5.61, p<.001), whereas in the control group, scores significantly decreased from the pretest to immediately after the intervention (MD=-2.98, p=.009) and 4 weeks later (MD=-3.43, p=.009).
DISCUSSION
This study aimed to develop and implement an IMB model-based physical restraint education program for nursing care providers in long-term care hospitals and examine its effects over time. Education on physical restraint use is effective in ensuring appropriate use and reducing its frequency [14]. However, existing educational programs aimed at reducing physical restraint use have been limited to knowledge transfer about procedures, methods, and side effects [12,17,18]. The educational program developed in this study aimed not only to impart knowledge about physical restraints but also to motivate participants to reduce their use and teach behavioral skills that enhance self-efficacy in implementing these changes. The program included activities such as brain writing, lectures, poster/slogan creation, slogan shouting, and diary writing. The goal was to enhance knowledge, attitudes, nursing practices, and person-centered care related to physical restraints, ultimately reducing their use. The application of the educational program in this study resulted in considerable differences in knowledge, attitudes, and person-centered care between the intervention and control groups, with the effects maintained 4 weeks after the intervention. Based on these results, the effectiveness of the IMB model-based physical restraint education program is discussed.
In this study, the knowledge scores regarding the use of physical restraints showed significant differences between the two groups over time, with substantial differences observed between the groups at both posttest 1 and posttest 2, which indicates the sustained effect of education in the intervention group. Previous studies have also shown that physical restraint reduction programs for older adults in long-term care hospitals increased the knowledge of nursing care providers related to reducing physical restraints, and at least 3 weeks were required to improve the knowledge of nursing care providers [17,18,30]. This study effectively increased such knowledge through a 3-week intervention. Although knowledge about physical restraints tended to decrease 4 weeks after the intervention, it remained significantly higher than the knowledge scores in the control group, despite being lower than the posttest 1 scores of the intervention group. The educational program in this study was highly effective in encouraging participation and learning through repetition and recall by distributing booklets containing educational content. However, it also suggests the need for continuous and repeated intellectual stimulation to maintain the effects. The knowledge of nursing care providers about the application of physical restraints affects their knowledge and behavior, making it crucial to assess and improve their knowledge to reduce the use of physical restraints [30]. Therefore, the application of regular and repetitive educational programs and the periodic monitoring of knowledge levels appear to be necessary.
Attitude scores toward the use of physical restraints showed a significant interaction between groups and over time, with significant differences observed between the groups at both posttests 1 and 2, which indicates that the effect of education in the intervention group was evident and sustained. However, contrary to our results, a previous study that provided a 6-week educational program consisting of lectures, demonstrations, discussions, and case studies aimed at reducing the use of physical restraints did not significantly change the attitudes of nursing care providers toward physical restraint use [18]. The IMB model-based educational program in this study effectively utilized motivational strategies, such as brain writing, poster/slogan creation, and small-group discussions, as well as strategies to enhance self-efficacy in reducing physical restraint use, such as slogan shouting and writing performance diaries. These strategies appear to have been effective in changing the attitudes of nursing care providers toward physical restraints, including their right to refuse and the negative impacts of physical restraints. Therefore, to improve the knowledge and attitudes of nursing care providers regarding physical restraint use, it is essential to implement participatory educational programs that utilize motivational and self-efficacy enhancement strategies.
The nursing practice scores related to physical restraint use showed significant differences in homogeneity at the pretest stage; therefore, the pretest scores were controlled as covariates in the analysis. The results indicated a significant interaction between group and time, with significant differences between the groups at all time points. Educational programs on physical restraint use were found to be effective in improving the nursing practice scores of nursing care providers [17], and the use of physical restraints decreased by 0.55 times [14]. Physical restraints can deteriorate a patient’s health status and physical functions; cause psychological issues such as anger, anxiety, and depression; and increase the risk of falls and death [14]. Therefore, nursing care providers should strive to apply alternative methods to protect the safety and health of older patients in long-term care hospitals instead of using physical restraints. In the pretest homogeneity check, participants in the control group were older, had longer employment in long-term care facilities, and had higher nursing practice scores related to physical restraints compared to the intervention group. This finding is consistent with previous studies indicating that higher nursing practice scores related to physical restraints were associated with older age, higher position, and more clinical experience [18]. However, at posttest 1 and posttest 2, the nursing practice scores of the control group tended to decrease, while those of the intervention group tended to increase, aligning with previous research suggesting the need for ongoing education to improve nursing practices related to physical restraints [15]. Therefore, regular and continuous education is necessary to reduce the use of physical restraints.
Last, the person-centered care scores showed a statistically significant interaction between group and time, with significant differences observed between the groups at both posttests 1 and 2. Thus, the effect of the education was evident and sustained in the intervention group. Few previous studies have analyzed the effect of educational programs aimed at reducing physical restraint use on person-centered care, making direct comparison difficult. However, the significance of this study lies in the fact that it introduced the concept and methods of person-centered care for the first time in physical restraint education research. In this study, activities such as brain writing, where participants wrote down their feelings after watching a video about the side effects of physical restraints, allowed participants to empathize with each other. Creating posters or slogans and discussing person-centered care helped foster a collaborative environment within the organization, which demonstrates the positive impact of this education.
1. Limitations
The limitations of this study are as follows. First, this study was conducted with nursing care providers from two conveniently sampled long-term care hospitals in one region; therefore, caution should be exercised when generalizing the findings. Second, the direct outcome variables, such as the reduction in the use of physical restraints, were not included as part of the educational intervention’s measured effects in this study. Future research should measure the effects of educational interventions on direct outcome variables. Third, nursing care providers self-reported the outcome variables (knowledge of physical restraint use, attitudes, nursing practices, and person-centered care), which may have led to underestimation or overestimation in responses. Therefore, caution in interpreting the results is needed. Fourth, based on previous studies [17,21], this study provided three 1-hour intervention sessions, and while the effects on knowledge, attitudes, nursing practices, and person-centered care after the educational intervention were immediate, knowledge significantly decreased, and attitudes and person-centered care tended to decline at the follow-up test 4 weeks after the intervention ended (Figure 2). Ongoing and repeated programs are necessary to induce changes in nursing philosophy, such as reducing the use of physical restraints.
Based on the results of this study, we make the following recommendations. First, this study targeted nursing care providers from long-term care hospitals conveniently sampled from one region; therefore, conducting repeated studies with randomized sampling across multiple regions is recommended. Second, as the intervention in this study did not consider the differences in job roles, intervention studies that are more sensitive to the roles and responsibilities of different job categories should be conducted. Third, future research should include direct outcome variables, such as the reduction in the use of physical restraints.
CONCLUSION
This research was a nonequivalent, control-group, repeated-measures, quasi-experimental study conducted to develop and implement an IMB model-based physical restraint education program for nursing care providers in long-term care hospitals and evaluate its effects on their knowledge, attitudes, nursing practices, and person-centered care regarding physical restraint use. The results showed that the intervention group had higher scores in knowledge, attitudes, and person-centered care immediately after the intervention and 4 weeks later compared to the control group, which confirms both the effect and sustained effect of the intervention. Based on these findings, it is recommended to implement regular and continuous education on the use of physical restraints for nursing care providers in long-term care hospitals and verify the effectiveness of such education on direct outcome variables, such as the frequency of physical restraint use and the incidence of adverse effects.
Notes
Authors' contribution
Conceptualization or/and methodology - SJ and HL; Data curation or/and analysis - SJ and HL; Investigation - SJ; Project administration or/and supervision - HL; Resources or/and software - SJ; Validation - HL; Visualization - SJ; Writing–original draft or/and review & editing - SJ and HL
Conflict of interest
No existing or potential conflict of interest relevant to this article was reported.
Funding
None.
Data availability
Please contact the corresponding author for data availability.
Acknowledgements
We appreciate Dr. Gaeun Park for her assistance in statistical analysis and scholarly support.