This study reports on the statistically significant reduction in use of restraint in care homes, both prior and during the 7-month intervention periods, in both intervention and control groups. When interpreted within the context of the current climate of educational initiatives to reduce restraint and a greater focus on the importance of person-centered care, the study also highlights the potential success achieved with national training programs for care staff and should be further evaluated to inform future training initiatives both in Norway and internationally.

Our findings confirm the prospective utility of the PARIHS framework for implementation in a non-English context, particularly the notion of implementation processes as dynamic and multifaceted.

BackgroundPeople living with dementia in nursing homes are most likely to be restrained. The primary aim of this mixed-method education intervention study was to investigate which factors hindered or facilitated staff awareness related to confidence building initiatives based on person-centred care, as an alternative to restraint in residents with dementia in nursing homes. The education intervention, consisting of a two-day seminar and monthly coaching sessions for six months, targeted nursing staff in 24 nursing homes in Western Norway. The present article reports on staff-related data from the study.MethodsWe employed a mixed-method design combining quantitative and qualitative methods. The P-CAT (Person-centred Care Assessment Tool) and QPS-Nordic (The General Nordic questionnaire for psychological and social factors at work) instruments were used to measure staff effects in terms of person-centred care and perception of leadership. The qualitative data were collected through ethnographic fieldwork, qualitative interviews and analysis of 84 reflection notes from eight persons in the four teams who facilitated the intervention. The PARIHS (Promoting Action on Research Implementation in Health Services) theoretical framework informed the study design and the data analysis. Six nursing homes were selected for ethnographic study post-intervention.ResultsQualitative data indicated increased staff awareness related to using restraint - or not- in the context of person-centered care. A slight increase in P-CAT supported these findings. Thirteen percent of the P-CAT variation was explained by institutional belonging. Qualitative data indicated that whether shared decisions of alternative measures to restraint were applied was a function of dynamic interplay between facilitation and contextual elements. In this connection, the role of the nursing home leaders appeared to be a pivotal element promoting or hindering person-centered care. However, leadership-staff relations varied substantially across individual institutions, as did staff awareness related to restraint and person-centeredness.ConclusionsLeadership, in interplay with staff culture, turned out to be the most important factor hindering or promoting staff awareness related to confidence building initiatives, based on person-centered care. While quantitative data indicated variations across institutions and the extent of this variation, qualitative data offered insight into the local processes involved. A mixed method approach enabled understanding of dynamic contextual relationships.Trial registrationThe trial is registered at Clinical Trials gov. reg. 2012/304 NCT01715506.Electronic supplementary materialThe online version of this article (10.1186/s12912-017-0244-0) contains supplementary material, which is available to authorized users.

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Educational initiatives targeting staff to reduce restraint must be sensitive towards fluctuating organisational constraints.

Research ethics must be understood in qualitative research as relational, situational, and emerging. That is, that focus on ethical issues and dilemmas has to be paid attention on the spot and not only at the desktop.

Use of restraint in nursing homes is highly controversial and fundamentally transgresses human rights and freedom of movement and choice. While different forms of formal restraint use in nursing homes are broadly delineated, the use of informal restraint is less understood. The aim of this article is to identify different kinds of informal restraint, and how staff use informal restraint under which circumstances. This article illuminates informal restraint use based on an ethnographic study in four nursing homes in the Western part of Norway. We have identified five different forms of informal restraint use which are as follows: (1) diversion of residents' attention; (2) white lies; (3) persuasion and interpersonal pressure; (4) offers and finally (5) threats. These different forms of informal restraint are actions by staff against residents' will, limiting residents' freedom of movement and their personal preferences. In addition, we have identified 'grey-zone restraint' which comprises actions by staff towards residents which lie in-between formal and informal restraint. The use of informal restraint can be explained by institutional circumstances such as location, architecture and institutional collectivist constraints in relation to care work. Moreover, and paradoxically, informal restraint can be explained as a consequence of neo-liberal policies with establishment of extended premises for freedom of movement and practices of resident preferences in nursing homes. Informal restraint practices call into question whether these practices are compatible with fundamental human rights and the preservation of residents' dignity.

Our study indicates, as a minimum, that a leader's presence is necessary to facilitate the internal processes in order more successfully to implement EBP.