What if I do? but what if I don't?

Abstract This thesis provides an account of a multi component Action Research study that explored the use of restraint in care homes for people who have Dementia. It draws together the key findings and highlights how the work has added to the wider body of nursing knowledge. Key practice and learning points are distilled for those whose roles encompass the development of policy and practice and who may, in the future, wish to draw on the lessons provided by this study with particular reference to the use of restraint and reducing its use in their organisations. The study entitled ‘What if I do? But what if I don’t?’ examines the use of restraint in residential care environments for older people with mental health problems on the Island of Guernsey, in the Channel Islands. Whilst the topic of restraint was utilized as the area of investigation, the study also illustrates how the process of managing change that was adopted could be applied to other aspects of care in different settings. The study was comprised of three major phases, with a phase being defined here as a ‘distinct stage of development’. Each phase comprised of one or more cycles of activity, with a cycle being described here as a ‘periodically repeated sequence of events’. Each cycle comprised up to five stages, with the stages being those described by Kemmis and McTaggart (1982) as follows: Stage 1. Identification of the problem Stage 2. Problem concepts investigated and the related literature consulted Stage 3. Plan of action to address the problem is designed Stage 4. Implementation of the action plan and monitoring Stage 5. Reflection stage, changes and modifications to the solution continue to be made. Data collection during the above involved the distribution of individual questionnaires, followed by senior staff focus groups, a relatives focus group (in phase one only), a review of client documentation, and finally observations of practice. Later staff also provided case study material to capture the impact of the change process. The initial findings from the study identified a number of ethical and moral dilemmas that staff faced about the use of restraint and suggested that the over-riding reason for its use was the protection of patients and staff. Other challenges involved the emotional aspects of care and the lack of alternative approaches to using restraint. As the study developed it became clear that staff were not as fully engaged as they might have been. This necessitated a re-think of the initial approach to change to ensure greater staff ownership and recognise the influence of organisational culture. Overall the study achieved both an observable reduction in the amount of restraint being used and brought about early changes to the organisational culture around the use of restraint. The key conclusions reached were that whilst staff training and education are important, effective and sustained change requires leadership and commitment. However, whilst leadership is crucial it is also imperative to involve, engage and communicate with all staff at the earliest opportunity. It is clear from the findings that limited staff involvement results in little impact on care practices. Conversely when staff were fully engaged observable changes in practice were seen. Lessons to be drawn from the study that can be applied to other areas of practice are considered and recommendations made.