A. Write a critical appraisal that demonstrates comprehension of TWO QUALITATIVE RESEARCH STUDIES. Use the “Research Critique Guidelines – Part 1” document to organize your essay. Successful completion of this assignment requires that you provide a RATIONALE, INCLUDE EXAMPLES, and REFERENCE CONTENTS FROM THE STUDIES IN YOUR RESPONSES.

B. Use the practice problem and two qualitative, peer-reviewed research articles you identified in the Topic 1 assignment to complete this assignment.

C. In a 1,000–1,250 word essay, summarize two qualitative studies, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

ResearchCritique Guidelines – Part I

Use this document to organize your essay. Successful completion of this assignment requires that you provide a rationale, include examples, and reference content from the studies in your responses.

Qualitative Studies

Background of Study

1. Summary of studies. Include problem, significance to nursing, purpose, objective, and research question.

How do these two articles support the nurse practice issue you chose?

1. Discuss how these two articles will be used to answer your PICOT question.

2

. Describe how the interventions and comparison groups in the articles compare to those identified in your PICOT question.

Method of Study:

1. State the methods of the two articles you are comparing and describe how they are different.

2. Consider the methods you identified in your chosen articles and state one benefit and one limitation of each method.

Results of Study

1. Summarize the key findings of each study in one or two comprehensive paragraphs.

2. What are the implications of the two studies in nursing practice?

Ethical Considerations

1. Discuss two ethical considerations in conducting research.

2. Describe how the researchers in the two articles you choose took these ethical considerations into account while performing their research.

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2

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Format

5.0%

N/A

15.0%

15.0%

Ethical Considerations 15.0%

15.0%

5.0%

5.0%

5.0%

Format 10.0%

5.0%

5.0%

Course Code	Class Code	Assignment Title	Total Points
NRS-433V	NRS-433V-O500	Rough Draft Qualitative Research Critique and	Ethical Considerations	190.0
Criteria	Percentage	1: Unsatisfactory (0.00%)	2: Less Than Satisfactory (75.00%)	3: Satisfactory (83.00%)	4: Good (94.00%)	5: Excellent (100.00%)	Comments	Points Earned
Content	7						5.0%
Qualitative Studies	Only one article is presented. Neither of the articles presented use qualitative research.	Two articles are presented. Of the articles presented, only one article is based on qualitative research.		N/A	Two articles are presented. Both articles are based on qualitative research.
Background of Study		10.0%	Background of study, including problem, significance to nursing, purpose, objective, and research questions, is incomplete.	Background of study, including problem, significance to nursing, purpose, objective, and research questions, is included but lacks relevant details and explanation.	Background of study, including problem, significance to nursing, purpose, objective, and research questions, is partially complete and includes some relevant details and explanation.	Background of study, including problem, significance to nursing, purpose, objective, and research questions, is complete and includes relevant details and explanation.	Background of study, including problem, significance to nursing, purpose, objective, and research questions, is thorough with substantial relevant details and extensive explanation.
Article Support of Nursing Practice Issue					15.0%	Discussion on how articles support the PICOT question is incomplete.	A summary of how articles support the PICOT question is presented. It is unclear how the articles can be used to answer the proposed PICOT question. Significant information and detail are required.	A general discussion on how articles support the PICOT question is presented. The articles demonstrate general support in answering the proposed PICOT question. It is unclear how the interventions and comparison groups in the articles compare to those identified in the PICOT question. Some rational or information is needed.	A discussion on how articles support the PICOT question is presented. The articles demonstrate support in answering the proposed PICOT question. The interventions and comparison groups in the articles compare to those identified in the PICOT question. Minor detail or rational is needed for clarity or support.	A clear discussion on how articles support the PICOT question is presented. The articles demonstrate strong support in answering the proposed PICOT question. The interventions and comparison groups in the articles strongly compare to those identified in the PICOT question.
Method of Study	Discussion on the method of study for each article is omitted. The comparison of study methods is omitted or incomplete.	A partial summary of the method of study for each article is presented. The comparison of study methods is incomplete. A benefit and a limitation of each method are omitted or incomplete. There are significant inaccuracies.	A general discussion on the method of study for each article is presented. The comparison of study methods is summarized. A benefit and a limitation of each method are summarized. There some inaccuracies or partial omissions. More information is needed.	A discussion on the method of study for each article is presented. The comparison of study methods is generally described. A benefit and a limitation of each method are presented. There minor are inaccuracies. Some detail is required for accuracy or clarity.	A thorough discussion on the method of study for each article is presented. The comparison of study methods is described in detail. A benefit and a limitation of each method are presented. The discussion demonstrates a solid understanding of research methods.
Results of Study	Discussion of study results, including findings and implications for nursing practice, is incomplete.	A summary of the study results includes findings and implications for nursing practice but lacks relevant details and explanation. There are some omissions or inaccuracies.	Discussion of study results, including findings and implications for nursing practice, is generally presented. Overall, the discussion includes some relevant details and explanation.	Discussion of study results, including findings and implications for nursing practice, is complete and includes relevant details and explanation.	Discussion of study results, including findings and implications for nursing practice, is thorough with substantial relevant details and extensive explanation.
Discussion of ethical considerations when conducting nursing research is incomplete. A discussion on ethical considerations of the two articles presented in the essay is incomplete.	Discussion of ethical considerations when conducting nursing research is included but lacks relevant details and explanation. A discussion on ethical considerations of the two articles used in the essay is summarized but there are significant inaccuracies or omissions.	Discussion of ethical considerations when conducting nursing research is partially complete and includes some relevant details and explanation. A discussion on ethical considerations of the two articles used in the essay is discussed but there are some inaccuracies, or some information is needed.	Discussion of ethical considerations when conducting nursing research is complete and includes relevant details and explanation. A discussion on ethical considerations of the two articles used in the essay is presented; some detail in needed for accuracy or clarity.	Discussion of ethical considerations associated with the conduct of nursing research is thorough with substantial relevant details and extensive explanation. A detailed discussion on ethical considerations of the two articles used in the essay is presented.
Organization and Effectiveness
Thesis Development and Purpose	Paper lacks any discernible overall purpose or organizing claim.	Thesis is insufficiently developed or vague. Purpose is not clear.	Thesis is apparent and appropriate to purpose.	Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.	Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.
Argument Logic and Construction	Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.	Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.	Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.	Argument shows logical progressions. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.	Argument is clear and convincing and presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.
Mechanics of Writing (includes spelling, punctuation, grammar, language use)	Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.	Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, or word choice are present.	Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.	Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.	Writer is clearly in command of standard, written, academic English.
Paper Format (use of appropriate style for the major and assignment)	Template is not used appropriately or documentation format is rarely followed correctly.	Template is used, but some elements are missing or mistaken; lack of control with formatting is apparent.	Template is used, and formatting is correct, although some minor errors may be present.	Template is fully used; There are virtually no errors in formatting style.	All format elements are correct.
Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)	Sources are not documented.	Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.	Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.	Sources are documented, as appropriate to assignment and style, and format is mostly correct.	Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.
Total Weightage	100%

Copyright © eContent Management Pty Ltd. Intemational foumal of Multiple Reseawh Approaches (2007) 1: 52-71.

Psychiatric nurses’ knowledge and
attitudes toward the use of physical

restraint on older patients in
psychiatric wards

WAI-TONG CHIEN
Associate Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong,
Hong Kong SAR

ISABELLA YM LEE
Ward Manager, Department of Geriatrics and Medicine, Tuen Mun Hospital, Hong Kong SAR

ABSTRACT
Background: There is still an ongoing debate concerning whether or not to use physical restraint
with confused or frail older patients in various elderly care settings. Nurses’ views and attitudes
toward the use of physical restraints in controlling patients’ behavior and ensuring patient safety
may create conflicts with patients’ rights, including their autonomy in making decisions for their
own care.

Aims of the study: The purposes of this study were to identify registered psychiatric nurses’ knowl-
edge, attitudes and practice issues regarding the use of physical restraints in Hong Kong, and to
examine the factors influencing nurses’ decisions to use restraints on their patients. The findings on
the nurses’ knowledge, attitudes and practice issues were compared with those found in the USA.

Methods: This descriptive exploratory study was conducted in two psycho-geriatric wards of one of
the two mental hospitals in Hong Kong, using a mixed research design. The study consisted of two •
phases: first, 42 registered psychiatric nurses completed a self administered questionnaire to exam-
ine their practice, knowledge and attitudes towards restraint use; and second, data were collected
from semi-structured interviews of 15 of them, from observations of their restraint practices, and
from an examination of clinical records which were then content analyzed to explore what deter-
mined nurses’ decisions to use restraints on the older patients.

Results: Results from the questionnaires and semi-structured interviews indicated that about two-
thirds of nurses believed that patients should be restrained for their own safety and to ensure treat-
ment compliance, even if being restrained meant loss of dignity and was resisted by patients and/or
their family members. Overall, the nurses in this study demonstrated only a modest level of knowl-
edge of restraint use and slightly negative attitudes toward this practice.

Four major themes relating to nurses’ decisions about restraint use were identified from the qual-
itative data, showing considerable similarities and thus conftrming the quantitative ftndings.

5 2 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

Psychiatric nurses’ knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

These included attitudes towards the use of a safety measure and effective intervention for patients,
insufficient consideration of alternative measures and/or adverse consequences, ethical dilemmas,
and psychological reactions towards restraint use.

Conclusion: The mixed research methods and cross-cultural comparison of research findings used
in this study reveals apparent relationships between psychiatric nurses’ knowledge, perceptions, atti-
tudes, and practice issues concerning the application of physical restraints to older hospitalized
patients in psychiatric care. The findings demonstrate that continuing education about restraint
use is important for psychiatric nurses. Further research using an action research method to evalu-
ate the effectiveness of educational interventions on nurses’ decisions regarding restraint use is rec-
ommended for improvement of nursing practice.

Keywords: physical restraint; knowledge; attitude; nursing practice; psychiatric nursing; elderly patients

INTRODUCTION

The use of physical restraints has been a con-troversial yet frequently used nursing inter-
vention for confused and hospitalized frail elderly
and patients with severe mental disorders over the
past two decades. In many Western countries
there were between 3.4% and 30% of acute eld-
erly care and rehabilitation patients subjected to
some form of physical restraint during their hos-
pitalization (Evans & FitzGerald 2002). In some
countries such as Denmark and Japan, not more
than 5% of older patients in hospital and residen-
tial homes were restrained (Ljunggren, Philips &
Sgadari 1997). However, in Hong Kong, there
was very little epidemiological research data on
the use of physical restraints to older patient pop-
ulations.

Patient safety has always been a priority in eld-
erly care. In health care institutions of Hong
Kong, there is no regulation like that offered by
the Joint Commission on Accreditation on
Healthcare Organizations (1998) in the United
States or the European Committee for the Pre-
vention of Torture and Inhuman or Degrading
Treatment of Punishment (2004). The practice of
physical restraint on patients remains widespread
and appears to be accepted as inevitable.

Nurses are most intimately involved in the
decision to restrain and in its implementation.
However, few studies are found which explore

nurses’ attitudes towards, or issues relating to the
practice of, physical restraints in different clinical
settings. Janelli et al. (1992) conducted a descrip-
tive survey on general nurses’ attitudes, knowl-
edge and practice issues regarding the use of
physical restraints in acute medical units in the
US, using a self-developed 71-item Restraint
Study Questionnaire. The results indicated that
the nurses obtained a satisfactory level of knowl-
edge score, but that some areas of misconception,
(e.g. that staffing shortages were the main reason
for restraint use, and that patients were not
allowed to refuse to be placed under restraint),
were evident. Recently, Janelli, Stamps & Delles
(2006) conducted a similar descriptive study in
216 medical nurses in New York, using the same
questionnaire. Despite the fact that nurses’
knowledge scores were similar to those found in
the early 1990s, they indicated significant
changes in their attitudes towards, and their nurs-
ing practices relating to, the use of physical
restraints; for example, there was a higher level of
agreement on statements such as ‘nurses have the
right to refuse to place patients in restraints’, and
on the importance of ‘considering and trying to
use alternative nursing measures before restraint
use’. As suggested by Janelli et al. (2006), these
changes in nurses’ attitudes and practices might
be influenced by the recent development of regu-
latory standards and nursing education related to

Volume 1, Issue 1, October 2007 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES 53

Wai-Tong Chien and Isabella YM Lee

restraint use in acute settings, and they varied a
great deal in diverse clinical settings such as gen-
eral and psychiatric units, and across countries. In
addition, an understanding of nurses’ attitudes
towards restraint use should be considered when
a department or hospital intends to improve
nursing practice. Therefore, as recommended by
Janelli et al., the aim of this study was to examine
the current knowledge, practice and attitudes of
nurses regarding the use of physical restraints
among Chinese psychiatric nurses in Hong Kong.
In addition, it was thought that the findings of
this study would allow a useful comparison of
these important characteristics of nurses across
cultures (i.e., between the nurses in Hong Kong
and in the US).

Moreover, few studies are found which explore
the factors influencing nurses’ decision-making in
restraint use (Sailas & Fenton 2003), particularly
in Hong Kong where restraint use can often be
seen in psychiatric and non-psychiatric settings.
Understanding these factors is essential for an
adequate interpretation of nurses’ perceptions
and attitudes, as well as their practices, regarding
restraint use. To fill in these knowledge gaps, a
mixed method research identifying psychiatric
nurses’ knowledge, attitudes and practices in rela-
tion to the use of physical restraints in Hong
Kong, as well as an examination of the factors
infiuencing their decisions in restraint use, is
essential.

LITERATURE REVIEW

Concept of physical restraints

A review of the literature suggests that physical
restraints can be viewed differently by nurses. A
physical restraint refers to the use of belts, hand-
cuffs and the like, which either partially or totally
restrict the patient’s movements (Currier & Far-
ley-Toombs 2002; Sailas & Wahlbeck 2005). It
can be described by reference to the mechanical
devices used, including various cloth or leather
devices, and the methods of application such as to
the patient’s body or wheelchair (Magee, Hyatt,

Hardin, Stratmann, Vinson &C Owen 1993), or
even by using bedside rails (Ludwick & O’Toole
1996). These variations depend largely on the
users’ justification of the need for restraint (Chien,
Chan, Lam & Kam 2005; Park & Lee 1997).

Use of physical restraints in hospital is often
considered to be an accepted and perhaps
unquestioned practice related to patient safety. In
the elderly care settings, prevention of injury to
patients themselves or others (Choi & Song
2003), and prevention of patient falls (Haber,
Fagan-Pryor & Allen 1997), are the most fre-
quently cited rationales given by nursing profes-
sionals. Physical restraint may be also considered
by nurses to make care-giving more efficient and
less worrisome, and prevent lawsuits (Fradkin,
Kidron & Hendel 1999). Whether restraint use is
in the best interests, and for the greatest benefit,
of patients or of the nurses is an open question.

Effects of restraint use and
alternative measures
In spite of a range of practice myths among nurses
that the use of physical restraints can protect
patients from any harm or injury, a range of seri-
ous adverse effects and consequences, such as
physical problems (Minnick, Mion, Leipzig,
Lamb & Palmar 1998) and even accidental death
by strangulation (Sailas & Wahlbeck 2005), have
been reported in previous studies. There are also
psychosocial effects on patients who had one or
more restraint experiences, such as low social func-
tioning, increasing confusion and adverse emo-
tional reactions (Thomas, Redfern & John 1995).

It is commonly agreed by health professionals
in the literature that physical restraint should not
be the first choice among methods intended to
ensure patient safety or treatment compliance
(Macpherson, Lofgren, Granieri & Myllenbeck
1990; Sailas & Wahlbeck 2005). However,
research evidence and clinical reports indicate
that physical restraints have been considered and
used by the nurses for various reasons, particularly
during emergency situations, to manage the
patients’ disturbed emotions and behaviors in a

5 4 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

Psychiatric nurses’ knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

variety of clinical settings (Evans & FitzGerald
2002). Some conclusive evidence on minimiza-
tion of restraint use has been identified in general
care settings. For example, Johnson & Beneda
(1998) suggested that increasing nurses’ knowl-
edge of restraint use is one of the effective alter-
native measures to the use of physical restraints.
Janelli, Scherer & Kuhn (1994) also reported that
promotion of a secure and comfortable environ-
ment for agitated or confused older patients may
also help in reducing restraint use. Nevertheless,
there is limited research and few suggestions on
reduction of restraint use for patients in psychi-
atric care settings.

Ethical consideration of restraint use
Whenever nurses have to make decisions regard-
ing the use of restraints, they may find themselves
in the midst of conflicts between their profession-
al obligation to care for a patient’s well-being and
concerns about a patient’s right to make an
informed choice (Mayhew, Christy, Berkebile,
Miller & Farrish 1999). There is no consensus
among nurses as to whether the benefits of its use
outweigh the physical and psychosocial risks in
elderly care (Johnson & Beneda 1998).

Although some nurses have attempted to use
physical restraint as an intervention to safeguard
older patients in wards from any harm, accidents,
physical disability and emotional distress among
patients do occur (Kanak 1992; Sailas & Fenton
2003). Therefore, criticisms and arguments are
raised among nurses, as well as other health pro-
fessionals, about whether this is an effective and
first-line intervention for older patients who
appear to face higher risks of falls or of violence.
It is also questioned whether nurses have been
well prepared in developing the knowledge, tech-
niques, attitudes, and moral values to deal appro-
priately and effectively with complex patient
situations (Johnstone 1994).

Guidelines & policy of restraint use
While there are nursing guidelines or protocols
for performing the procedure of using physical

restraints, few institutional guidelines or policy
statements have been drawn to help individual
nurses determine what they should consider in
order to make an ethically appropriate decision.
The hospital policy-makers also do little to support
their nurses in making such decisions and to
implement them. Schieb, Protas and Hasson
(1996) have suggested that the difficulty in making
decisions, and the subsequent inappropriate use of
physical restraints, might be due to the absence of
a clear and supportive institutional policy and a
well-defined assessment framework dealing with
patients with unwanted or harmful behaviors. The
use of restraints may also be associated with nurses’
knowledge about its relevant hospital policy and
guidelines. This notion is supported by research
evidence, such as the study by Magee et al. (1993),
which highlighted that in over half of the restraint
procedures, the nurses themselves queried their
adherence to the institution’s policy.

Aims of the study
Evidence from the literature on physical restraint
suggests that the use of restraints on older
patients with physical and/or mental health prob-
lems is a common practice, and that nurses’ deci-
sions in their use have not been adequately
explored. Therefore, the purpose of this study was
to investigate the knowledge, attitude and per-
ceptions of registered psychiatric nurses about the
use of physical restraint on older inpatients with
mental health problems in one regional mental
hospital in Hong Kong. The objectives of the
study were to:
1. Identify psychiatric nurses’ levels of knowl-

edge and their attitudes towards the use of
physical restraints on hospitalized older
patients in two psycho-geriatric wards in
Hong Kong;

2. Explore the nurses’ perspectives concerning
what the use of physical restraints means to
them; and

3. Identify the factors infiuencing the nurses’
decisions to use physical restraints on their
older patients.

Volume 1, Issue 1, October 2007 INTERNATIONALJOURNAL OF MULTIPLE RESEARCH APPROACHES 55

Wai-Tong Chien and Isabella YM Lee

METHODS

Study design

This was an exploratory descriptive study with
mixed research designs. The study consisted of
two phases. In Phase 1, a small-scale survey of
psychiatric nurses’ knowledge, practice issues and
attitudes regarding the use of physical restraint in
one pair (male and female) of 56-bed psycho-
geriatric wards in a regional mental hospital in
Hong Kong was undertaken. The characteristics
of the two wards in relation to restraint use are
summarized in Table 1. The common psychiatric
diagnoses of the patients within the two wards
included dementia, acute psychosis and chronic
schizophrenia. All 46 registered nurses in the two
wards, including two ward managers, one nurse
specialist, one advanced practice nurse, three
nursing officers, and 39 registered nurses, were
invited to complete a self-administered question-
naire regarding their practice, knowledge and
attitudes towards the use of restraints.

In Phase 2, data were collected from the semi-
structured interviews of 15 nurses who participated
in Phase 1 and who had indicated their willingness
to participate in this second phase. Observation
and cli.nical record examination on the use of
restraints were also conducted. The data collected
from the three sources (interviews, observations
and documentation) were content analyzed in
order to explore what influenced the nurses’ deci-

sions to use restraint on older patients. Use of mul-
tiple data sources in this study can provide a holistic
overview of the social context and the phenomena
under study (Kimchi, Polivka & Stevenson 1991).

Sampling
A convenience sample drawn from two psycho-
geriatric wards in a regional mental hospital was
used. All 46 registered psychiatric nurses in the
two wards were invited to be respondents for a
self-administered questionnaire and 15 of them (

7

or 8 from each ward) were conveniently selected
as key informants for semi-structured interviews.
This sampling method was able to include most of
the accessible and appropriate informants and it
was also time and cost saving (Polit &C Hungler
1999). Inclusion criteria for the sample in the two
phases of the study were the registered psychiatric
nurses who had worked in the psycho-geriatric
wards for not less than three months, had previous
experience(s) of restraint use, and who had agreed
to participate voluntarily in the study.

A total of 42 psychiatric nurses responded to
the questionnaire and their socio-demographic
characteristics are summarized in Table 2. The
response rate was 87.0% and the respondents
were mainly female (71.4%), married (76.2%)
and registered psychiatric nurses (85.7%). Their
ages ranged from 22 to 45 years, with a mean of
31.2 years (SD = 5.2). Most of them (n = 35;
83.3%) had obtained a Bachelor of Nursing

TABLE 1: M A I N CHARACTERISTICS OF TWO PSYCHO-GERIATRIC WARDS

Ward Characteristics Male Ward

45.

5

5 6 – 7

1

4.2

2.5

5.7

(12.5%)
Safety vests,
triangular
bandages,
geriatric chairs
with tables

Female Ward

43.2
5 5 – 7

8

4.8

N/A

6.1

(14.1%)
Safety vests,
limb holders,
bed-side rails,
geriatric chairs
with tables

Average number of patients in ward*
Age range of the patients (years old)
Average nurse strength per duty shift (including student nurses)
Average number of male nurses per shift (including male student nurses)
Average number of patients being restrained per duty shift

Major types of restraint device used

Note. * Average number of patients within the eight observation sessions.

5 6 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

Psychiatric nurses’ knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

TABLE 2: DEMOGRAPHIC CHARACTERISTICS OF PSYCHIATRIC NURSES W H O RESPONDED TO THE
OUESTIONNAIRE ( N = 4 2 )

Characteristics Frequency Percent

Gender
Male
Female

Job position
Registered psychiatric nurse
Nursing officer
Advanced practice nurse/nurse specialist

Age range (years)
22-2

9

30-

39

40-45

Educational level
Diploma in Nursing
Bachelor of Nursing
Master degree or above

Religion
Christianity
Catholicism
Buddhism
No reported religious belief

Experience in psycho-geriatric nursing (years)
1-3
4-

6

7-9
10 or above

12

30

36
4
2

16

20

6

9
26

7

16
13
6
7

10

16
10
6

28.6

71.4

85.7
9.5
4.8

38.1

47.6

14.3

21.4

61.9
16.6

38.1
30.9
14.3

16.7

23.8

38.1
23.8
14.3

degree and had been working in the psycho-geri-
atric ward for an average of nine years (M = 8.8
years, SD = 4.9; range = 2 – 1 5 years). The inter-
viewees consisted of 14 registered nurses and one
nurse specialist, were aged from 26 to 35 years
(M = 28.1 years, SD = 5.1) and were mainly
female (n= 11,73.3%).

Instruments

Restraint Study Questionnaire

This questionnaire consisted of 71 items and was
developed by Janelli, Kanski, Scherer and Neary
(1992) based on an extensive literature review on
physical restraint and comments by gerontologi-
cal nursing experts. It included four parts:

• Part 1, a 23-item demographic data sheet
dealing with information such as age, educa-
tional level, and years of working in geriatric
nursing;

• Part 2, an 18-item knowledge questionnaire
including statements about physical restraint
using a 3-point Likert rating scale on which 1 =
‘true’, 2 = ‘false’, and 3 = ‘not sure’, and with a
total score (i.e. total number of items answered
correctly) ranging from 0 to 18;

• Part 3, 18 statements regarding the issues in
nursing care for patients immediately before or
during restraint such as ‘I check on patients who
are restrained at least every two hours to make
sure they are okay,’ rated on a 3-point Likert
scale on which 1 = ‘always’, 2 = ‘sometimes’, and

Volume 1, Issue 1, October 2007 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES 57

Wai-Tong Chien and Isabella YM Lee

3 = ‘never’, and on which the percentage of each reviewing prevailing policies of restraint use in

response could be calculated; and the study setting and relevant issues discussed

•Part 4, 12-item questionnaire on attitudes in the recent published literature. The questions

regarding the use of physical restraint, rated on a were reviewed and agreed upon by an expert

5-point Likert scale on which 1 = ‘strongly agree’ panel, including three psychiatrists, two psychi-

to 5 = ‘strongly disagree’ and with a total score atric nurse specialists and one occupational

ranging from 12 to 60 (the higher the score, the therapist,

more positive was the nurses’ attitude).

Observation schedule
The Cronbach’s alpha coefficients of Parts 2-4 There were eight 2-hour observation sessions on

were .73, .78 and .67 respectively (Janelli et al. consecutive days comprising general and

1992; Scherer, Janelli, Kanski, Neary & Morth focused observations of restraint use by the

15

1991). psychiatric nurses (interviewees), covering dif-

ferent time spans. An observation schedule,

Semi-Structured interview agenda which was designed according to ward situation

A tentative agenda for semi-structured inter- and pilot tested in one ward, facilitated the

views, as shown in Table 3, was devised by observations.

TABLE 3: SEMI-STRUCTURED INTERVIEW GUIDE

During the interviews, you can refer to the following questions or areas relevant to the background of
the interviewees’their use of physical restraints:

A. Socio-demographic background of the informant
• Ask about years of experience in ward, psycho-geriatric nursing education level.
• Have you attended any courses or workshops about the use of physical restraint? What/when?
• Describe the ward characteristics, current practice of restraint use, exploring their recognition/under-

standing of existing policy/guidelines regarding restraint use in ward.

6. Definitions of physical restraint
• What would you consider a ‘physical restraint’?
• Which devices are commonly used in your ward for application of physical restraint?
• Would you consider using some devices, such as side-rails or chairs with a front table, to be a kind of

restraint? Why or why not?

C. Factors infiuencing the nurses’ decision in restraint use
• Can you recall one of the current impressive experiences of applying restraint to patient?
• What considerations you had made when applying the restraint?

Probing: Tell about the patient or his/her condition, about other people such as family, nurse colleagues
and other staff, about the ward situation or the institution policy, about yourself, any similar experience.

• Which factor(s) is/are the most important one(s) which you considered?
• Have you considered any alternatives? What are they? Why or why are they not being used?

D. Difficulties/feelings in making restraint use decisions
• Have you met any difficulties when making the decision?
• If yes, what are they? How difficult? How did you overcome then?
• Besides the above mentioned difficulties, have you experienced any conflicts with your own values? If

yes, please describe the conflicts. Then, how would you settle it?
• What did you feel about the incident, in the moment of/after your decision making?

Probing: Why did you get these feelings? Rate the levels of emotional responses which you have men-
tioned? How long did you take to settle this emotional distress?

58 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

Psychiatric nurses’ knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

Procedure & data analysis
Permission to access the study site and ethical
approvals were sought from the Ethics Commit-
tees of the study hospital and the University.
Nurses were informed about the purpose and
procedure of the study and their written consent
to participate in it was obtained before their
inclusion. Anonymity, right to withdraw from
the study at any time, and confidentiality of data
collected were assured, and an undertaking not to
discuss the content of the interviews with any
ward staff was given.

In Phase 1, data were collected over a period of
two months from the psycho-geriatric wards.
Eligible psychiatric nurses were invited by a
research assistant to participate in the study when
they were on duty. After full explanation of the
study had been given, written consent was
obtained and each psychiatric nurse completed a
self-report questionnaire which was returned in a
sealed envelope to the research assistant.

In Phase 2, 15 psychiatric nurses who had indi-
cated in the returned questionnaire their willing-
ness to participate in the second study phase were
invited to attend an interview at their earliest con-
venience. Data about the psychiatric nurses’ most
recent or impressive experience of the use of physi-
cal restraint were gathered through the semi-struc-
tured interviews and an examination of relevant
clinical records. The 45-minute interviews were
conducted by the principal researcher in an inter-
view room within the wards; they were audio-taped
and field-notes were taken. Follow-up interviews
were conducted with five of them in order to clari-
fy points that had arisen during the first interview.

Information about their experiences of restraint
use was obtained from clinical records, including
patients’ medical and psychiatric backgrounds,
conditions relating to restraint use, details of med-
ical and nursing interventions used, and the docu-
mentation recorded on the restraint form.

Eight observation sessions in each setting were
scheduled at different times, including all the
days in a week from 7:00am to 9:00pm. A
research assistant was trained by the researcher to

perform the observation with the observation
schedule and to write down field-notes after each
observation. Inter-rater reliability testing of data
collected from the observation was ensured by
cross-checking the data from three pilot observa-
tions in one ward, by the research assistant and
the principal researcher. Only minor differences
between their observation data were found and
these were clarified. The research assistant took
the position of passive participant in ward activi-
ties during observation, being only involved in
basic bedside care for the restrained patients if
needed; and he left the ward for a few minutes’
event introspection during each session. Field-
notes were recorded and reviewed on a daily basis.

A total of 20 interviews were conducted with
15 participants by one researcher. The research
assistant and the researcher independently under-
took transcription and translation of the inter-
view data. One expert (nurse) in qualitative
research compared the two sets of transcribed
interview scripts and suggested amendments. The
researchers then identified themes from the tran-
scribed interview data independently and checked
the coding reliability (>90% of agreement in cod-
ing of data) prior to categorizing the data into
themes (Morse, Penrod & Hcpcey 2000). The
data from observation notes and the clinical doc-
umentation of the use of restraints were also tran-
scribed and translated by the research assistant
and then underwent a similar coding and reliabil-
ity checking process as that for the interview data.

The interview data were then used as the start-
ing point and main source to perform theme
matching and condensing. As recommended by
Miles and Huberman (1994), this method of
content analysis aimed to identify the in-depth
information gathered from each informant and
source of data, and accommodated the wide
diversity of informants’ experience and the social
context of the wards. This method consisted of
six main stages of analysis as follows:
(a) becoming familiar with the diversity of the

verbatim data collected and affixing codes
and remarks to each transcript;

Volume 1, Issue 1, October 2007 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES 59

Wai-Tong Chien and Isabella YM Lee

(b) sorting and sifting through the codes and
interview data to identify inter-relationships
and recurrence of themes;

(c) generalizing the consistencies discerned in
the interview data and field notes;

(d) isolating the patterns and clustering com-
monalities and differences between the
themes and creating a thematic index of all
transcripts;

(e) comparing, contrasting, condensing and
mapping between the categories and themes
identified, making interpretations, and pro-
viding explanations; and

(f) summarizing the results and re-examining
the data where necessary.

RESULTS

Restraint use in two psycho-geriatric
wards

During each observation session, at least one
period of physical restraint was used by each of
the interviewees (i.e., about 1.6 times of restraint
per participant in each two-hour observation). As
shown in Table 1, an average of six patients
(12.5% and 14.1%) was being restrained per
duty shift in both wards during each of the eight
observation sessions. Different types of restraint
device were applied; for instance, safety vests were
used in two-thirds of the restrained patients and
triangular bandages or limb holders were some-
times used for controlling violent or confused
behavior.

Level of knowledge of psychiatric
nurses
The percentages of correct and incorrect respons-
es for the 42 psychiatric nurses to each of the 18
questions are presented in Table 4. Their knowl-
edge scores ranged from 3 to 18 (M = 12.5, SD =
4.5). Percentages of correct responses to the 18
questions ranged from 31.0% to 8 8 . 1 % . Sixty-
two percent of them (n = 26) had 7 to 12 correct
responses and 21.4% (n = 9) had 13 to 18 correct
responses. More than half of them (n = 24,

57.1%) disagreed with the statements that
‘Patients are allowed to refuse to be placed in a
restraint’ and A patient should never be restrained
while lying flat in bed because of the danger of
choking’. Nevertheless, 24 (42.9%) believed that
‘Good alternatives to restraints do not exist’ and
13 (31.0%) believed that ‘In an emergency, you
(nurses) can legally restrain a patient without a
physician’s order’.

Attitudes towards use of restraints
The attitude scores of the 42 psychiatric nurses
ranged from 30 to 56 (M = 48.2, SD = 6.3).
Thirty-six percent of them (n = 15) had a total
score of less than 36, indicating relatively negative
attitude towards the use of physical restraint.
Over half of the nurses (n = 23, 54.8%) felt that
‘The hospital is legally responsible to use
restraints to keep the patient safe’ and about two-
thirds of them (n = 28, 66.7%) disagreed with
the statements that ‘The nurses have the right to
refuse to place patients in restraints’ (38.1%), that
‘Family members have the right to refuse the use
of restraints'(33.3%), or that ‘A patient suffers a
loss of dignity when placed in restraints’ (38.1%).
In general, more than two-thirds of the nurses (n
= 29, 69.1%) felt that they were ‘knowledgeable
about caring for a restrained patient’.

Nursing care of patients immediately
before or during restraint
The frequencies and percentages of the responses
to the 18 statements regarding the nursing care
provided for patients immediately before or during
physical restraint are summarized in Table 5. More
than half of the nurses (n = 23 to 24, 54.8% to
57.1%) indicated that they would ‘always … try
alternative nursing measures before restraining the
patient’ and, where restraint was used, would ‘tell
the patient why the restraint is being applied’ or
‘tell family members/visitors why the patient is
restrained’. Most of the nurses indicated that
‘Before I restrain a patient, I find out the reason for
the restraint’ (n = 37, 88.1%) and ‘I have read the
hospital policy on the use of restraints’ (n = 38,

6 0 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

Psychiatric nurses’ knowledge and atxiaides toward the use of physical restraint on older patients in psychiatric wards

TABLE 4 : NURSES’ LEVEL OF KNOWLEDGE REGARDING THE USE OF PHYSICAL RESTRAINTS ( N = 42)

Item

1. Physical restraints are safety vest or garments
designed to prevent injury.

2. A restraint is legal only if it is necessary to protect the
patients or others from harm.

3. Restraints should be used when one cannot watch
the patient closely.

4. Patients are allowed to refuse to be placed in a restraint.

5. A physical restraint requires a physician’s order.

6. Confusion or disorientation is the main reason for
using a restraint.

7. A restraint should be released every 2 hours if the
patient is awake.

8. Restraints should be put on snugly.

9. A patient should never be restrained while lying flat
in bed because of the danger of choking.

10. When a patient is restrained, skin can break down or
restlessness can increase.

11. When a patient is restrained in a bed, the restraint
should not be attached to the side rails.

12. Sheet restraints may be necessary at times.

13. A nurse can be charged with assault if he/she applies
restraints when they are not needed.

14. A record should be kept on every shift of a patient
in restraints.

15. A physician’s order to restrain must be specific.

16. In an emergency, a nurse can legally restrain a
patient without a physician’s order.

17. Good alternatives to restraints do not exist.

18. Deaths have been linked to the use of vest restraints.

Note. * refers to the correct response to each question.

rue

30*

31*

7

18*

34*

False

12

11

35*

24

8

Percent
Correct

71.4

73.8

83.3

42.9

80.9

Percent
Incorrect

28.6

26.2

16.7

57.1

19.1

17

35*

25* 59.5

83.3

40.5

22*

20
18*

37*

33*

20
20
22*
24
5
9
22*

52.4

47.6
42.9

88.1

78.6

52.4
47.6
52.4
57.1

11.9

21.4
47.6
16.7

32*

30*

13*

24

28*

10
12

29

18*

14

76.2

71.4

31.0

42.9

66.7

23.8
28.6

69.0

57.1

33.3

90.5%). However, only a few indicated that they
would ‘… tell family members/visitors when the
restraints will be removed’ (n = 15, 35.7% rated
‘always’ or ‘sometimes’) and agreed with the state-
ment that ‘All confused patients and those with
arterial or venous lines should be restrained’ (n =
19, 45.2% rated ‘always’ or ‘sometimes’).

Major themes emerging from
comparison of the data sources
The themes which emerged from the interview
data were confirmed or refuted with the data
from observations and clinical records, as well as
those from the responses to the questionnaire.

Finally, four main themes identified from the
data included:
• a safety measure and effective intervention for

patients;
• insufficient consideration for alternative meas-

ures and/or adverse consequences;
• psychological reactions towards restraint use;

and
• ethical considerations.

A safety measure and effective
intervention for patients
Different interpretations of physical restraint
were used by the nurses in the psycho-geriatric

Volume 1, Issue 1, October 2007 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES 61

23

37

15
16
23
39

24
23
18
6

(54.8)

(88.1)

(35.7)

(38.1)

(54.8)

(92.9)

(57.1)
(54.8)
(42.9)
(14.3)

13(31.0)
4 (9.5)

19(45.2)

17(40.5)

10(23.8)

2 (4.8)

10(23.8)

8(19.0)

14(33.3)

9(21.4)

6(14.3)
1 (2.4)

8(19.0)
9(21.4)
9(21.4)
1

8(19.0)
11 (26.2)
10(23.8)
27 (64.3)

Wai-Tong Chien and Isabella YM Lee

TABLE 5: RESULTS OF 18 STATEMENTS ON NURSES’ OPINIONS ABOUT CARING FOR PATIENTS UNDER
RESTRAINT ( N = 4 2 )

Statement Always Sometimes Never

1. I try alternative nursing measures before restraining the patient.
2. Before I restrain a patient, I find out the reason for the

patients unacceptable behaviour.
3. When I feel that the patient does not need to be restrained,

I make this suggestion to the person in charge or the doctor.
4. I answer the call light or calls for ‘help’ for the patient who is

restrained as soon as possible.
5. I check the restraints at least every 2 hours to make sure

they are OK.

6. When giving personal care (bathing or dressing) to a patient
who is restrained, I check their skin for reddened areas/bruises.

7. I tell the patient why the restraint is being applied.
8. I tell family members/visitors why the patient is restrained.
9. I tell the patient when the restraint will be removed.

10. I tell family members/visitors when the restraints will be
removed.

11. The application of physical restraints is necessary in an acute 28(66.7) 10(23.8) 4(9.5)
care setting to prevent a patient from injuring him/herself.

12. All disoriented acute care patients should be restrained.
13. All confused patients’those with arterial or venous lines

should be restrained.
14. I have read the hospital’s policy on the use of restraints.
15. More patients are restrained when we are working ‘short’

than when we have a full staff.
16. In the unit in which I work, staff members work together to 16 (38.1) 12 (28.6) 14 (33.3)

discover ways to control patients’ behavior other than the
use of physical restraints.

17. When I need to restrain a patient, a restraint is available 20(47.6) 16(38.1) 6(14.3)
on my unit.

18. I would rather sedate a patient with prescriptive medication 10(23.8) 6(14.3) 26(61.9)
than physically restrain them.

Note. * Percentage of nurses’ responses on each statement is put in the parentheses.

wards. They mainly perceived physical restraint nursing staff to care for the restrained patient as
in terms of the functional perspective; for exam- well as other patients in ward’,
pie, one experienced nurse said that physical Four main reasons of restraint use were indicat-
restraint was ‘any mechanical device used to ed by the majority of the nurses during the inter-
restrict the individual from doing things that view, including ‘prevention of patient from any
would be harmful to self or other people’, injury’,’maintenance of treatment regimen’,’pre-
Another perception was related to the nurses’ vention of disturbance to other people’, and ‘nurs-
personal beliefs about restraint use. Most of the es’ accountability and role responsibility in caring
nurses stated that they used physical restraint as for their patients’. This can be illustrated by what
an intervention which was solely ‘for the benefit the nurses’ said during interviews or observations:
of patients’. Physical restraint was considered to
be the only effective measure to establish ‘a safe Some patients, especially the violent patients,
ward environment’ or a means of ‘saving time for had to be separated and restrained temporarily

6 2 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

16(38.1)
10(23.8)

38 (90.5)
20 (47.6)

14
9

12

(33.3)
(21.4)

2 (4.8)
(28.6)

12
23

10

(28.6)
(54.8)

2 (4.8)
(23.8)

Psychiatric nurses’ knowledge and attitudes toward the use of physical restraint on older padents in psychiatric wards

to avoid any conflicts from their disturbing
behavior. (Interview C, para. 28)

We (nurses) are responsible to take care of
older patient’s daily living … and their safety
in ward. When they show any physical and/or
mental problems such as confusion and risk of
fall, we have to intervene … by using physical
restraints. (Observation D, para. 39)

Consistent with the questionnaire results,
these nurses strongly agreed that the use of physi-
cal restraints is legally right when it is necessary
to protect the older patients or others from harm,
and the patients should not have the right to
refuse to be placed in a restraint. These nurses
also shared the attitude that the hospital was
legally responsible for using restraints to keep
patients safe, and that patients would not suffer a
loss of dignity when placed in restraints.

Insufficient consideration for
alternative measures and/or adverse
consequences
An important finding from the interview and
observation data was the lack of consideration of
alternative measures to physical restraint by the
majority of the psychiatric nurses. Whilst most
nurses indicated in the interview and the ques-
tionnaire that they did consider the use of avail-
able alternative measures before restraint use,
they could identify only a few such as assigning
one staff member to observe the patient closely
and regularly. From the observation data, most of
the alternatives identified were not used by the
nurses prior to applying physical restraints and
most nurses often restrained the patients imme-
diately after they manifested aggression or prob-
lem behaviors. Six of the 15 interviewees
indicated that location of the patients was
important for reducing the use of physical
restraints, and that patients needing continuous
observation should be put near the nurses’ sta-
tion. This suggestion was consistent with the
observation data, in which confused older

patients were not restrained when sitting near the
nurses’ station.

Some reasons were given by the nurses for
only having a few alternatives. One important
reason was the nurses’ perception of the short-
age of staff and other resources in wards. For
example, over two-thirds of the nurses thought
that ‘there was a lack of nurses to provide con-
tinuous observation’ and ‘insufficient facilities
to provide a safe environment for patients,
instead of applying restraints’. Nine of them
also indicated that there were not enough beds
with adjustable height to prevent falls, and an
absence of wedge-shaped pillows to assist
patients to sit properly.

These results were consistent with the nurses’
knowledge and attitude scores from the ques-
tionnaire. From the knowledge measure, over
half of the nurses indicated that ‘Restraints
should be used when you cannot watch the
patient closely’ and ‘Good alternatives to
restraints do not exist’. From the attitude and
nursing practice measures, more than two-thirds
felt that ‘the main reason that restraints are used
is that the hospital is short staffed’ and they did
not agree that they felt’… embarrassed when the
family enters the room of a patient who is
restrained’.

The analysis of the interview data also
demonstrated that the nurses were generally not
aware of the adverse consequences of restraint
on their patients, especially psychosocial effects.
The majority of them in the two wards admitted
that there were some short-term physical effects
on patients such as temporary obstruction of
blood circulation, skin abrasions and bruising.
However, in contrast with the questionnaire
results and the interview data, nurses attended
to restrained patients on only a few occasions
and had little verbal interaction during the per-
formance of nursing tasks. Only five nurses
identified one or two types of psychological
effects of physical restraint on patients under
their care, including embarrassment, social isola-
tion and humiliation.

Volume 1, Issue 1, October 2007 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES 6 3

Wai-Tong Chien and Isabella YM Lee

Ethical considerations of restraint use
From the interview data, more than one-half of
the nurses (n = 8) identified no ethical dilemma
in applying physical restraints, and they rational-
ized that this intervention was ‘for the interests
and safety of the patients’. As indicated from the
knowledge and attitude scores, most of them
thought that the restraint was legal as it was nec-
essary to protect the patient or others from harm,
with a doctor’s prescription. They also indicated
in the questionnaire that physical restraint was
also the best choice of intervention in an emer-
gency, even without a doctor’s prescription. How-
ever, from the interview and questionnaire data,
most of the nurses understood that ‘Deaths have
been linked to the use of vest restraints’ and
agreed that ‘In general, I feel knowledgeable
about caring for a restrained patient’. Therefore,
during the interviews, they indicated that ‘nurses
have the right and responsibility to place patients
in restraints, in order to protect the best interests
of those under their care’ (Interview H, para. 40).

There were two ethical concerns identified
among the remaining nurses (n = 7). The first was
the appropriateness of limiting patients’ autonomy
and rights in order to prevent harm to themselves
or other people. From the interview data, a few of
them justified the use of restraint for this purpose
by telling themselves that ‘the use of restraint was
the best choice for preventing harm to a patient’s
life’. The second concern was the patients’ mental
competency in making health care decision for
themselves. These seven nurses thought that ‘the
restrained older patients were always incompetent’
and ‘could not understand their own problems
and the staff’s advice to them’. On the contrary,
during the observations some patients wearing
safety vests and sitting in the geriatric chairs talked
with the nurses clearly and consciously, without
any signs of confusion or of disturbed behavior. In
addition, there were not any records revealing
consistent assessment of patients’ mental condi-
tion identified during data collection. Therefore, it
was doubtful whether the nurses’ decisions on
restraint use, which should have been based on

regular assessment results of patients’ mental com-
petence, were justified by the subjective experi-
ences and reasoning given by the nurses.

Moreover, the majority of the psychiatric nurs-
es emphasized the necessity of having specific
policy and guidelines in the hospital. As indicated
by six nurses during the observations and inter-
views, they had to ‘make decisions on restraint
use according to the clear guidelines provided by
the hospital’; otherwise, the intervention would
be ‘illegal or unethical’. From the observations,
most nurses referred to a nursing procedure book
developed by the ward nurses themselves when
they had questions about the procedure of
restraint use. There was not any specific guideline
for handling different situations regarding
restraint use. Nevertheless, the documentation of
restraint use on half of the restrained patients was
written clearly and systematically on the patient
progress sheets and nurses’ notes.

Psychological reactions towards
restraint use
While the majority of the nurses reported ‘dislike’
and sometimes ‘feeling badly’ at applying
restraints, especially ‘if the patient got more upset
after restraints were applied’, the results from the
interview data indicated that the nurses only had
low levels of emotional reactions towards restraint
use. During the observations and interviews,
most of them stated that they felt that their appli-
cations of the restraints were ‘alright’ or ‘reason-
able’ unless they found that the restraints were
used longer than necessary, or without justifica-
tion. As indicated from the attitude scores, most
of them felt neither embarrassed not guilty about
placing the patients in restraints. The restraints
would be released temporarily or every two
hours, if the patients were awake.

These results confirmed the interview data
that the nurses’ emotional reactions associated
with restraint use was closely related to how the
nurses understood and viewed the purpose of
restraint use, and their legal and ethical consider-
ations. It was observed during interviews that

6 4 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

Psychiatric nurses’ knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

about 12 nurses (who defined restraint function-
ally and as of the highest priority in terms of pro-
tecting the patients from harm) asserted that they
handled the situation well. Therefore, in this
study, most of the psychiatric nurses did not
show any intense emotional reactions towards
restraint use.

DISCUSSION
The findings of this study, using the multiple
approaches of quantitative and qualitative
research, provided comprehensive and detailed
information about the nurses’ knowledge and
attitudes toward the use of physical restraints in
older psychiatric patients in a Hong Kong Chi-
nese population.

Four main themes concerning the nurses’ per-
ceptions towards restraint use were identified
from the interview data and confirmed or refuted
by the data from multiple sources, including
observations, clinical records and questionnaires.
These highlight the function and significance of
mixed research methods on a topic such as this.
For instance, without the data from the inter-
views and observation sessions which revealed a
lack of consideration of alternative measures to
restraints by the nurses in the two wards, it would
have been hard to explain why the nurses per-
ceived that good alternatives to restraints did not
exist and that only half of them had sometimes or
never tried alternative nursing measures before
restraining the patients.

Knowledge and attitude of nurses:
Hong Kong versus United States
Overall, the 42 psychiatric nurses in this study
performed fairly well on the questions of knowl-
edge about restraint use (mean score= 12.5 out of
18) and only a few of them obtained a very low
score. When compared with the results of a
recent survey study conducted by Janelli et al.
(2006) using the same questionnaire on a sample
of 216 registered nurses in New York, the per-
centages of correct responses to each of the 18
questions (range from 52.3% to 98.6%) were

higher than those in this study. However, similar
areas of misconception were evident in both this
study and Janelli et al.’s. About half of the nurses
indicated that restraints should be applied snugly
and disagreed with the statement that a restraint
should be released every two hours if the patient
was awake. The current standard of psychiatric
care in Hong Kong is to review and decide upon
release or continuation of a restraint every two
hours (Chien et al. 2005). In contrast with regis-
tered nurses in the United States, less than half of
the psychiatric nurses in Hong Kong were aware
that patients are allowed to refuse to be placed in
a restraint (42.1% vs. 56.0% for the New York
nurses), and that they should never be restrained
while lying flat in bed, in order to prevent chok-
ing (42.9% vs. 56.5%). Despite the fact that the
Hong Kong nurses generally showed a lower level
of knowledge regarding restraint use than the US
nurses, they were more aware that a written
record of patients in restraint should be kept on
every shift (76.2% vs. 47.2%). This finding was
confirmed with the data from observations and
clinical records in this study.

In addition, the Hong Kong psychiatric nurs-
es’ attitudes regarding restraint use were more
negative than those of the US nurses. While only
one-third of the Hong Kong nurses in this study
agreed that family members (33.3%) or the nurs-
es themselves (38.1%) have the right to refuse the
use of restraints, more registered nurses in the US
believed that the family and they themselves have
such a right (46.0% and 70.8%). There were also
more US nurses than the Hong Kong psychiatric
nurses who indicated that they were knowledge-
able about caring for patients in restraints.
(83.8% vs. 69.1%)

A lack of information might contribute to
lower levels of knowledge and more uncertainty
and negative attitudes among nurses regarding
restraint use. This notion is supported by Janelli,
Scherer and Kuhn (1994), who indicated that
65.6% of the 235 acute care nurses felt uncertain
about nursing practice issues in caring for the
restrained patients in wards. McCue, Urcuyo,

Volume 1, Issue 1, October 2007 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES 65

Wai-Tong Chien and Isabella YM Lee

Lilu, Tobias and Chambers (2004) also suggested
that misinformation or misconceptions about
restraint use can be lessened by continuing educa-
tion and by using a reward system for reduction
of restraint use. Bryant and Fernald (1997) indi-
cated that a more insightful and appropriate use
of restraints was found among nurses who had
taken continuing education courses on caring for
older patients in acute care settings.

The influence of nurses’ knowledge
and attitudes on psycho-geriatric
nursing practice in Hong Kong
In this study, the questionnaire, interview and
observation data from the psychiatric nurses in
the psycho-geriatric wards highlight that in Hong
Kong the justification of restraint use on their
older patients was mainly that of fulfilling their
role responsibility in protecting the patients
under their care from any physical harm. The
nurses’ perceptions and attitudes toward restraint
use were highly consistent with the fmding in the
relevant literature that the use of physical
restraints is of a higher priority in maintaining
patient safety and preventing disturbance to the
treatment or other patients in the ward (Evans
and FitzCerald 2002; Haber et al. 1997; Quinn
1993). This may possibly explain why there have
been frequent uses of physical restraints on older
patients in acute care settings, especially when the
nurses believed that the ward was short staffed
and that they had to be very busy carrying out
other nursing procedures. As observed in this
study, the amount of restraint use (i.e., 13% of
male patients and 14% of female patients per
duty shift) was much higher than that in some
developed countries (about 5%) such as the UK,
Denmark and Japan (Evans & FitzGerald 2002;
Ljunggren et al. 1997).

For the above reasons. Hong Kong psychiattic
nurses appear not to treat the patients as individ-
uals with a high level of self-determination over
the care they receive. As suggested by Quinn
(1993) and Currier and Farley-Toombs (2002),
assessment and satisfaction of patients’ psychoso-

cial needs may not figure prominently in nurses’
considerations concerning the application of
physical restraints in both acute and rehabilita-
tion care settings in the US. Both Macpherson et
al. (1990) and Selekman and Snyder (1996) sug-
gested that nurses should always assess the clinical
situation from the perspective of the patients and
the meanings of their disturbed behaviors, as well
as their individual needs. For minimizing
restraint use, it is important for psychiatric nurses
in Hong Kong, as well as in other countries, to
understand and meet patients’ immediate health
needs and anticipate the occurrence of their prob-
lem behaviors (Chien 1999).

The results based on the psychiatric nurses’
knowledge, attitudes and issues relating to nurs-
ing practice regarding restraint use also indicated
that more than half of the psychiatric nurses in
Hong Kong had either never, or only sometimes,
tried alternative nursing measures, or had made
suggestions to the physician not to restrain the
patient. These further confirm that the psychi-
atric nurses might not have adequate knowledge
and/or skills in minimizing restraint use, and thus
maintained their ‘safety first’ belief by using phys-
ical restraints frequently to prevent their patients
from falls and injuries in the ward. As the use of
physical restraints becomes routine practice in
psychiatric wards. Currier and Farley-Toombs
(2002) indicated that nurses are often convinced
of the efficacy of their beliefs and do not question
this intervention in the same way as they ques-
tion other interventions such as administration of
medication and memory training programs.

However, as pointed out by Bryant and Fer-
nald (1997), the provision of a therapeutic envi-
ronment for elderly patients that promotes their
bio-psychosocial well-being is a challenge facing
by all nurses. As an alternative, Stolley (1995)
also suggests that psychiatric nurses should main-
tain regular observation of the elderly patients
and ask their family, friends or the volunteers to
stay with the patients during confused or unsta-
ble mood swings in order to provide companion-
ship and to satisfy the need for one-to-one

66 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

Psychiatric nurses’ knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

attention. The fmdings also highlight the impli-
cations for nurses in terms of being aware of
patients’ adaptive behaviors and thus attempting
to make adjustments of the ward environment
according to patients’ individualized bio-psy-
chosocial needs (Tammello 1997; Winston,
Morelli, Bramble, Friday & Sanders 1999), such
as by reducing loud and irritating noises and
avoiding an overcrowded environment in ward. A
multi-disciplinary approach of care can be used
in the process of creating and maintaining the
least restrictive environment for older patients, in
which each discipline brings its area of expertise
to improve patient management in the ward
(McCue et al. 2004).

Areas of misconception, such as a shortage of
resources and staff and lack of good alternatives
to restraints identified among the psychiatric
nurses in this study, were common among nurses
in general and psychiatric care settings and nurs-
ing homes in the United States and some Euro-
pean countries (Champagne & Stromberg 2004;
Sailas & Fenton 2000). Mandatory education
programs on restraint reduction should be con-
sidered for psychiatric nurses in Hong Kong to
highlight their myths and incorrect concepts
regarding restraint use in a ward. Recent reports
on effective, innovative programs to reduce
episodes of restraints in psychiatric care include:

• the early identification and management of
problematic behaviors;

•complex interventions consisting of interview-
ing patients to determine their stress triggers
and personal crisis-management strategies;

• training staff in crisis escalation and non-vio-
lent intervention, and

• an incentive system for staff on restraint mini-
mization (D’Orio, Purselle, Stevens & Carlow
2004; McCue et al. 2004).

Ethical considerations of restraint use
Consistent with the suggestion by Sailas and
Wahlbeck (2005), the fmdings of this study
demonstrated that psychiatric patients, in partic-
ular demented, frail older patients, may have lim-

ited opportunity to make their views, needs and
dislikes known before being restrained. This
again highlights the need for psychiatric nurses to
assess and understand the perceptions and feel-
ings of patients about being restrained, before
restraints are administered. As recommended by
previous literature (Johnstone 1994; Dawkins
1998; Sailas & Fenton 2000), the majority of the
psychiatric nurses in this study expressed little
conflict between the patients’ right to self-deter-
mination and their role responsibility to do the
best fot their patients. Johnstone (1994) suggest-
ed that registered nurses sometimes may be
‘morally blind’ to patients’ needs as they have sel-
dom seen the effects of their inaccurate and sub-
jective nursing assessments on their patients’
physical and emotional needs, and therefore do
not see subsequent decision making as a moral
problem. The use of physical restraints on
patients was perceived by the psychiatric nurses
in this study as a ‘beneficial’ and an ‘effective’
nursing intervention, with little consideration
being given to patients’ feelings, to a loss of digni-
ty and a denial of informed consent. They expe-
rienced only limited feelings of guilt on placing a
patient in restraint. Chien et al. (2005) and John-
stone (1994) questioned whether or not the nurs-
es are well prepared in managing ethical and legal
situations in elderly care.

In this study, the nurses showed a lack of suffi-
cient knowledge in bio-ethics and mental health
legislation such as the patients’ (and families’)
right to informed consent and choices for their
own health care and treatment. In the past few
years, the recurring message in all of the new leg-
islations, recommendations (e.g., the Final Rules
of Patients’ rights and Centers for Medicare and
Medicaid Services 2006), professional guidelines
(e.g.. Ten Basic Principles of Mental Health Care;
World Health Organization 1996), and some
court cases in psychiatry, has been the need to
practice caution when applying restraints or
when using other coercive measures. There is
some evidence that these documents and meas-
ures can reduce the use of restraints. However, a

Volume 1, Issue 1, October 2007 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES 67

Wai-Tong Chien and Isabella YM Lee

lack of comprehensive and accurate knowledge of
mental health legislation and ethical issues con-
cerning restraint use among nurses in different
clinical settings, such as the psychiatric nurses in
this study, has been shown to exist (D’Orio et al.
2004). Therefore, in Hong Kong and other coun-
tries nurses should continue to be educated and
updated in order to appreciate the ethical and
legal dimensions of restraint use.

Limitations of the study
There were some limitations to this study. First,
there was still room for improvement of the
research instruments used. It is difficult for a
researcher who acts as both an interviewer and an
observer in the wards to maintain objectivity
when collecting and analyzing data from nurses
but while avoiding becoming involved in the
social (patient) situation in the psycho-geriatric
wards. The researcher’s role as a ‘passive partici-
pant observer’ during the observations in the
wards increased the difficulty of remaining an
‘objective’ observer when exploring the meaning
of the social behaviors presented by the nurses. In
addition, the presence of the researcher in the
wards and during interviews might also have had
a Hawthorne effect on the behaviors of the study
participants (nurses). In addition, further testing
and improvement of the interview guide, with
more informants from different professional
backgrounds and clinical settings being used,
would have clarified its usefulness in guiding the
interviews of psychiatric nurses.

Second, only 15 (33%) of the 46 psychiatric
nurses were interviewed in the psycho-geriatric
wards. The perceptions and attitudes of the non-
participants and other people involved in the use
of physical restraints, such as nursing administra-
tors, medical staff, patients, and their families,
were not examined. These people should play
important roles and exert influence in arriving at
decisions in restraint use.

Finally, a few additional research methods cotild
have been considered to elicit a more complete pic-
ture and provide a more adequate theoretical expla-

nation of the nurses’ decision making process on
restraint use. An ethnographic approach might
have been used to explore the meaning of physical
restraint and the nurses’ decision to use restraint
within the complex social context of the rwo psy-
cho-geriatric wards. A more in-depth and ground-
ed theory approach could also have been
considered to develop a model to explain the deci-
sion processes of psychiatric nurses in the use of
physical restraints on older patients with mental
health problems such as hallucination, delusion
and/or emotional fluctuation. In addition, mixed
methods of research, using both the above men-
tioned qualitative approaches and the relevant
quantitative research methods with a variety of
psychosocial measures on the nurses such as anxi-
ety and critical thinking scales, may increase the
understanding of the research topic and thus the
reliability and validity of the study findings.

IMPLICATIONS AND CONCLUSION
This study highlights several issues for clinical
practice and research, which include the follow-
ing:
• the need for nurses to question the established

pre-conceptions and myths about the use of
physical restraints on elderly patients with
mental health problems in order to improve
the standard of legal and ethical practice;

• the nature and importance of nurses’ awareness
and consideration of the important factors,
including the personal meaning of physical
restraints, possible use of alternative measures to
restraint, adverse consequences of restraint use,
staffmg and resources, and ethical dilemmas,
which influence their decisions and which cotild
lead to a consequent reduction of restraint use;

• the extent to which continuing education
among health professionals may be one means
of ensuring more appropriate use of physical
restraints;

• the use multi-disciplinary approaches, and
adequate staffing and other resources, to
encourage nurses to create the least restrictive
environment for older patients in wards; and

6 8 INTERNATIONAL JOURNAL OF MULTIPLE RESEARCH APPROACHES Volume 1, Issue 1, October 2007

Psychiatric nurses’ knowledge and attitudes toward the use of physical restraint on older patients in psychiatric wards

• the use of multiple approaches to data collec-
tion and the integration of data analyses in
research in order to increase the comprehen-
siveness, credibility and depth of understand-
ing of the research topic.

In conclusion, few studies have been found in
Hong Kong or elsewhere that explored nurses’
knowledge, attitudes and decision making regard-
ing the use of physical restraints in older patients
in acute psychiatric units. This study highlights
the importance of cognitive preparation of psy-
chiatric nurses in terms of knowledge and psy-
chological and ethical issues in order to achieve
the appropriate use of physical restraints as an
intervention of last resort.

This study used a mixed methods research
design, in which the researcher could collect rich
and in-depth data from both quantitative (struc-
tured questionnaire) and qualitative (semi-struc-
tured interview and observation session) methods
of data collection, resulting in a more insightful
data analysis and interpretation. In this study, the
multiple data collection methods revealed the
relationships between the knowledge, attitudes,
perceptions, and important issues in nursing
practice concerning the use of physical restraints.
The findings reveal several important factors
infiuencing nurses’ attitudes and practice con-
cerning restraint use; these include their beliefs,
their attempts to implement alternatives to
restraint (which are safe, effective and easy to
employ), their understanding of the ethical and
legal implications of this practice, and their
knowledge, personal beliefs and misconceptions
concerning restraint use. When compared with
the findings of Janelli et al.’s (2006) study in the
US, this research highlights several characteristics
of psychiatric nurses in Hong Kong concerning
restraint use, including a lower level of knowl-
edge, more negative attitudes, more awareness of
the importance of clear documentation, and the
presence of areas of misconception about restraint
use. In the light of these factors, further research
using an action research method is recommended

to evaluate the effects of an educational interven-
tion on psychiatric nurses’ attitudes and decisions
regarding restraint use in Hong Kong and other
countries.

Different methods of study and a larger sam-
ple size are also recommended to develop a more
comprehensive meaning of physical restraints
among nurses, who are the key professionals
responsible for making such decisions in caring
for their patients. Future research on the perspec-
tives of other people involved is also recommend-
ed, in order to obtain a more complete picture of
the use of physical restraints.

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Received 5 February 2007
Accepted 20 September 2007

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Article

Africa Journal of Nursing and Midwifery https://doi.org/10.25159/2520-5293/619

2

https://upjournals.co.za/index.php/AJNM/index ISSN 2520-5293 (Online)
Volume 22 | Number 2 | 2020 | #6192 | 14 pages © The Author(s) 2020

Published by Unisa Press. This is an Open Access article distributed under the terms of the

Creative Commons Attribution-ShareAlike 4.0 International License

(https://creativecommons.org/licenses/by-sa/4.0/)

Caring for Children Diagnosed with Autism
Spectrum Disorder: Caregivers’ Experiences

Nomfundo Mazibuko

https://orcid.org/0000-0003-3365-5890

University of Venda, South Africa

Nomfundo.Mazibuko@gmail.com

Hilda N. Shilubane

https://orcid.org/0000-0002-6121-048

8

University of Venda, South Africa

hilda.shilubane@univen.ac.za

Solomon B. Manganye

https://orcid.org/0000-0002-4060-471X

University of Venda, South Africa

bumani.manganye@univen.ac.za

Abstract

Although awareness about autism has increased in developed countries, more

so than in developing countries, autism spectrum disorder (ASD) remains

poorly understood by most South Africans, especially those in remote areas and

in areas where research is limited. Furthermore, intervention services are often

scarce or not available due to lack of knowledge amongst healthcare

professionals. The current study aimed to explore caregivers’ experiences of

children with ASD in the Ehlanzeni District, Mpumalanga, South Africa. The

study adopted a qualitative approach, and data was collected using semi-

structured interviews, in which an interview guide was used. Twelve

participants were selected purposively from the three different schools in the

Ehlanzeni District and interviewed for the study. The data was analysed using

thematic content analysis. The study adhered to ethical considerations. The

findings of the study indicated that caregivers of children diagnosed with ASD

experienced psychological stress; social stress; financial burden; lack of family

support; and reported unavailability and accessibility of services. Therefore,

information regarding a range of inexpensive interventions and educational

programmes should be available for caregivers in order to reduce their

psychological and social stress. Medicines should be available and accessible

within the district to avoid caregivers having to travel long hours to access them,

and to reduce their financial burden. Caregivers’ support groups should also be

established.

https://creativecommons.org/licenses/by-sa/4.0/

https://orcid/

https://orcid.org/0000-0002-6121-0488

mailto:hilda.shilubane@univen.ac.za

https://orcid.org/0000-0002-4060-471X

Mazibuko, Shilubane and Manganye

2

Keywords: autism; autism spectrum disorder; caregivers’ experiences; children

Introduction and Background Information

Autism spectrum disorder (ASD) is a neuro-developmental disorder which is

characterised by impaired communication, repetitive behaviours, impaired social

functioning and restrictive interest (DePape and Lindsay 2015). The number of children

diagnosed with ASD (hereafter children with ASD) is increasing worldwide and South

Africa is no exception (Mthimunye 2014). ASD can be stressful for both the child and

the caregiver, particularly the caregiver. A caregiver can be defined as a person who

looks after a sick, elderly or disabled person on a regular basis, and can be either a

family member or a paid individual (Van Rooyen 2016). In the current study, a caregiver

is an individual who is responsible for providing day-to-day care to a child diagnosed

with ASD. Caregivers’ whole lives change completely and a normal day to them will

comprise of a structured and set routine that they have to adhere to on a day-to-day basis

(Mthimunye 2014). Apart from the stress experienced, caregivers of children with ASD

also have to deal with stigma and public isolation because of the children’s behavioural

problems (DePape and Lindsay 2015).

Caring for children with ASD comes with higher demands, and requires more time,

effort and patience than caring for children who do not have ASD, which at times is

strenuous for caregivers. All these might lead to the caregivers experiencing

psychological and mental health problems, such as stress, anxiety and depression

(Hoefman et al. 2014). Financial problems might also arise, as some of the caregivers

may be unemployed or not earning enough income to sustain the child’s health, which

requires constant treatment from a health specialist. However, knowledge of the

caregivers’ experiences could perhaps result in the development of strategies and

appropriate services that could ease their burden of caring for

a child with ASD

(Hoefman et al. 2014).

Gona et al. (2016) state that although awareness about autism has increased in developed

countries, more than in developing countries, ASD remains poorly understood by most

South Africans, especially those in remote areas and in areas where research is limited.

Mthimunye (2014) reported that since the African community still believes that this

condition occurs among western communities, this could contribute to further isolation

of families with ASD children. Healthcare facilities lack a significant number of trained

professionals to provide care and support to caregivers upon diagnosis. This is a major

problem in public healthcare facilities. Society may also stigmatise the condition

because of poor knowledge, which makes it even more challenging for the caregivers

(Mthimunye 2014).

According to Gona et al. (2016), the prevalence of ASD in African countries is still

unclear. As a result, it is quite difficult to estimate the number of children diagnosed

with ASD in low- and middle-income countries, more especially African countries. This

Mazibuko, Shilubane and Manganye

3

is because knowledge and awareness is still low, leading to late diagnosis (Bakare and

Munir 2011). Chambers et al. (2017) demonstrated that there are no prevalence studies

for ASD in South Africa due to lack of standardised screening and diagnostic tools.

Furthermore, Malcolm-Smith et al. (2013) state that intervention services are often

scarce or not available at all which could further increase the caregivers’ stress levels.

Problem Statement

The researcher (who is the first author) once volunteered as a school counsellor at one

of the schools for children with special needs in the Ehlanzeni District, Mpumalanga,

South Africa. During her tenure as a volunteer, she observed that the teachers who are

trained on how to deal with children with ASD were struggling to cope with them in

class. Furthermore, these children were exhibiting violent behaviour because they could

not express their feelings and needs due to deficits in their communication skills.

According to Prata, Lawson and Coelho (2018) and Roughan, Parker and Mercer

(2019), interventions, such as the psycho-education programme for parents with

children with ASD, are crucial to increasing parents’ understanding of ASD as well as

helping them develop practical strategies to manage their children. Further, the

programme teaches parents how to modify the environment around their children and

implement ASD specific strategies to manage their children’s behaviour which in turn

has a positive impact in reducing aggressive behavioural problems. There is scarcity of

studies on caregivers’ experiences of children with ASD, and the few that are available

have been conducted in developed countries. The school where the researcher

volunteered is in the rural area of the Ehlanzeni District and at the time of the study had

23 children with ASD. The parents of these children were not involved in activities at

the school, which motivated the researcher to explore how caregivers handle these

children.

Aim of the Study

The study aimed to explore and describe caregivers’ experiences of children with ASD

in the Ehlanzeni District, Mpumalanga, South Africa.

Research Methodology

Research Design

A qualitative approach, using explorative, descriptive and contextual designs was

adopted to explore caregivers’ experiences of children with ASD (Creswell and

Creswell 2018). This approach and designs enabled the researcher to gain a deeper

insight into the experiences of caregivers of children with ASD and it also afforded the

researcher the opportunity to probe and observe non-verbal communication cues from

the participants during the interviews.

Mazibuko, Shilubane and Manganye

4

Study Setting

The study was conducted in the Ehlanzeni District, Mpumalanga, South Africa. The

district is one of the three district municipalities located in the North-Eastern part of

Mpumalanga and its capital city is Mbombela, previously known as Nelspruit. It has a

total population of 944 665, and most people in the district speak iSiswati.

Population and Sampling

The study population comprised caregivers of children with ASD. Three schools were

purposefully selected because they were admitting children with special needs including

those with ASD. The researcher used purposive sampling to select 12 female caregivers.

The participants were eligible for inclusion if they were caring for 5–12-year-old

children with ASD, and were residing in the Ehlanzeni District.

Data Collection

The data was collected using face-to-face interviews, with the aid of an interview guide

in order to eliminate unnecessary questions. The interview guide covered the following

key components, namely, biographic information and experience of caring for a child

with ASD. Data saturation was reached with the tenth participant. The interview guide

was developed in English, then translated into iSiswati to accommodate caregivers who

could not understand English. Fortunately, all the caregivers were literate and preferred

to be interviewed in English. The development of the guide was guided by the literature

on ASD. After development, it was pre-tested among caregivers of a similar background

to those participants who did not form part of the final study. Following the pre-test,

some questions were altered. The researcher obtained informed consent from

participants before conducting the interviews. A voice recorder was used to record the

interviews after the participants granted permission and notes were taken. The study

adhered to ethical considerations.

Data Analysis

The recorded data was transcribed verbatim. Thereafter, thematic analysis was

performed. Vaismoradi, Turenen and Bondas (2013) define thematic analysis as a

method for analysing materials of life stories and reporting patterns (themes) within

data. The researcher used the following processes as outlined by Braun and Clarke

(2006) to analyse the data: read the transcribed data several times to gain overall

meaning of the participants’ responses; generated initial codes; searched for themes;

reviewed themes; defined and named themes; and finally produced the report. The sub-

themes were supported by excerpts from the participants’ verbatim expressions.

Mazibuko, Shilubane and Manganye

5

Ethical Considerations

The University of Venda Ethics Committee issued the ethical certificate (Project no.

SHS/18/PH/08/1505). The Mpumalanga Department of Education gave permission to

conduct the study at the three schools and the principals of these schools allowed the

researcher access to the schools. The participants were informed about the study and

their rights as participants before they gave their consent to participate. They were also

assured that any information they shared would not be made readily available to anyone

else as raw data and that their identities would be protected when writing the report and

manuscripts for publication. Further, the participants were made aware that they could

discontinue at any given stage of the interview if they felt uncomfortable without any

penalty.

Trustworthiness

Trustworthiness was maintained throughout the study by using the four concepts posited

by Lincoln and Guba (1985), namely, credibility, transferability, dependability and

confirmability, adapted from Maree (2016). The researcher ensured credibility by

verbally paraphrasing the participants’ responses and having them confirm their

responses. The researcher also built a trusting relationship with the participants and

created a trusting and familiar environment. Further, the researcher asked follow-up

questions and sought clarity from the responses given. The researcher ensured

transferability by giving a brief description of the data collection method that was used.

To ensure dependability, the researcher used a voice recorder to ensure that she did not

miss any information and made use of field notes to ensure that the data was transcribed

verbatim. To ensure confirmability, the researchers compared the findings of the study

with the extant literature.

Results

Twelve female caregivers whose children were between the ages of 5–12 years and with

ASD participated in the study. The sample size was determined by data saturation. Of

the 12 participants, 10 were the biological parents of the children with ASD and were

blacks, while two were whites and had adopted the children. The participants’

demographic information was as follows: their ages ranged between 25–49 years; they

were from low- and middle-income families; six were single, five were married and one

was divorced. They were labelled P1 to P12. The theme and sub-themes that emerged

from the findings are shown in Table 1.

Mazibuko, Shilubane and Manganye

6

Table 1: Theme and sub-themes

Theme Sub-themes

1. Caregivers’ experiences of caring for

a child with ASD

1.1 Psychological stress

1.2 Social isolation and rejection

1.3 Financial burden

1.4 Lack of family support

1.5 Accessibility and availability of

services

Theme 1: Caregivers’ Experiences of Caring for a Child with ASD

Parents experience a number of challenges when caring for a child with ASD (Hoefman

et al. 2014). Caring for a child with such a disorder can be very strenuous thereby

leading to stress and poor psychological well-being for the caregiver. The study findings

demonstrated that caregivers experience a lot of challenges when it comes to caring for

and raising a child with ASD because it requires time, effort and patience. The

participants mentioned that they tend to experience psychological stress, social isolation

and rejection as well as financial burden because children with ASD have a lot of

financial needs to be catered for. Some of the participants mentioned that accessibility

and availability of health care services was a problem, while others indicated that they

did not have any support system. The sub-themes that emerged under Theme 1 are

discussed below.

Sub-theme 1.1: Psychological Stress

The participants mentioned that they experienced psychological stress when it comes to

caring for a child with ASD. Some even stated that they cannot cope with everything; it

becomes so overwhelming that they end up not coping well with their situations. The

following quotes depict how the participants experienced psychological stress:

It’s not easy, it is difficult because even now he still wears pampers and people think

I’m not training him not to wear pampers and I can’t always be explaining his situation.

That really affects me psychologically and I’m not really coping. (P4, 25)

It’s very hard because he’s constantly on my mind, he times me, so I have to rush home,

if I stop somewhere, he knows and he performs, he’s not happy that I’m late. I can’t just

be impulsive and do what I want, also I am the main purpose in his life so if I had to go

away and something happens to me, nobody will want him, nobody will understand him

the way I do, so psychologically it does play on your mind very much and you always

worried if you leave him with people, you can’t just leave him with anybody because

he’s got to be protected. (P3, 48)

In terms of psychological experience, it’s really hard, some days are good some days

are bad, especially with me and my surrounding. (P8, 32)

Mazibuko, Shilubane and Manganye

7

So psychologically I can say that it pains me because of the spectrum … they are not

really teachable, at home you want him to be independent and self-reliant. (P11, 29)

Psychologically sometimes it’s hard for me because I want him to do things like normal

kids, but he won’t even reach that point, that disturbs me a lot. Sometimes I become

very emotional and end up crying, sometimes I become stressed. (P1, 38)

Sub-theme 1.2: Social Isolation and Rejection

During the interviews, some caregivers mentioned that society neither accepts nor

understands their children. Most of the time people stare at their children and as a result

they avoid social interaction. A participant made the following important statement in

regard to this issue:

Socially I prefer staying at home because at first he can speak one or two words that you

can understand but then he starts speaking this other language that you don’t understand

and people will start staring and then they will start asking questions, as a parent you

are still struggling as well because some of the things you don’t understand, he wants

something but you don’t know what he wants and then he will start screaming and

shouting then people think you don’t discipline your child. I can’t take him anywhere

because he easily gets frustrated and people stare, it’s only family that understand … so

it’s not nice. (P5, 32)

The other unsettling issue for caregivers was lack of parental discipline when their

children are mocked and rejected by their peers. One caregiver whose child experienced

being rejected by peers said:

The problem with the children around my neighbourhood is that most of them do not

understand his condition so they ostracise him, he’s more marginalised, they don’t

accept him, they boo him, they laugh at him and that can be very disturbing even to a

parent especially when you look at their parents and see them not doing anything about

it; hence I think the parents they are also encouraging that because they are supposed to

talk to their children and say no he’s just a child, it’s just that he’s differently abled but

he’s a normal child like you … you don’t have to treat him differently. They are not

handling the situation properly so instead of me fighting with them I would rather keep

him to myself or in the house entertain him with toys, he likes phones. (P9, 47)

Sub-theme 1.3: Financial Burden

The participants outlined that children with ASD have a lot of financial needs and at

times they cannot cover all the costs. Most of the participants mentioned that their

children do not eat what other people in the house do and some of the children use

nappies because they cannot talk and do not have a sense of what is happening around

them. The participants indicated that they also spend a lot of money paying for therapists

and buying medication as some of the things are not available in government hospitals

and also their school fees is expensive, as illustrated by the following statements:

Mazibuko, Shilubane and Manganye
8

Financially it’s very taxing because to start with I’m not even happy with him being in

a government school, I feel like I’m being a bad parent, it’s just that I cannot afford to

enrol him at a private school because it’s too expensive and I won’t be able to meet all

the demands of that particular school. So that is why he’s in a government school but

really it is expensive, even the therapy sessions that I take him to, the medical aid cannot

cover all the costs I have to pay the shortfall. (P1, 38)

The thing with them is that there are specific foods that they eat so you cannot just buy

any type of food. They are very choosey and very sensitive in anything, for instance

before my son eats, he will smell whatever you give him to eat. So you need to buy the

things that he wants, you cannot just buy any food; for example, with cereals he only

eats cornflakes so you need to buy cornflakes; he doesn’t like bread and they are saying

bread is not good for them, so all those special foods are expensive and soya milk is

very expensive. So, it is very strenuous when it comes to finances. (P5, 32)

He’s still on nappies, just a pack of 13 cost R160 so that takes four days so how do we

cope financially with that? He eats non-stop everything goes to the mouth of course he’s

got his own likings and preferences so financially it’s a huge burden. (P11, 29)

Financially you really spend a lot when you have a child with autism, school fees are

expensive, there’s specific food, paying for occupational and speech therapists is

expensive, it’s just too much. (P6, 49)

Another participant added that:

Uh special food as well he didn’t eat this and now, he only eats this [gluten-free

products] so it’s costly all these gluten-free products are very expensive. (P4, 25)

Sub-theme 1.4: Lack of Family Support

One participant reported that she does not have support from her family; she mentioned

that her family members are not helping her at all. The following quote supported this

statement:

Another thing is that I’m not coping really well because I don’t get support from my

family. Uh I am neglected by my own family. I’m paying someone to look after my

child so that I can be able to go to work because my sisters want nothing to do with my

child. (P2, 48)

Sub-theme 1.5: Accessibility and Availability of Services

The participants indicated that accessibility and availability of services is a challenge in

the district. Some of the participants mentioned that at times medication for their

children is not available in public hospitals around the province and they have to go as

far as Steve Biko Hospital in Pretoria to access medication. The following quotes depict
how the participants face challenges in terms of accessibility and availability of services:

Mazibuko, Shilubane and Manganye

9

Uh he’s on medication and we fetch the medication at Steve Biko Hospital, and transport

is arranged by the hospital – it’s just that he doesn’t like being in one place for too long.

So, he gets tired travelling a long distance, sometimes he throws tantrums. (P10, 32)

So right now, the government structure overlooked our children’s situation because the

schools for children with mental illnesses are not enough, it’s like they have written

them off because they think they won’t amount to anything in life which is not always

the case. (P1, 38)

… schools … I don’t think the government really understand what autism is because

yes our children are impaired, but it doesn’t mean that we write them off. (P4, 25)

Discussion

The study findings indicate that caregivers’ psychological well-being is affected as they

worry about the ASD children’s temper tantrums, which may distract alternative

caregivers. This is demonstrated by their fear of leaving the child with someone as well

as their crying. In a study on parental care-seeking pathway and challenges for ASD

children, the authors indicated that parents agreed to be experiencing stress as a result

of their children’s diagnoses (Mahapatra et al. 2019). Similarly, the caregivers in the

present study mentioned that they experienced stress as a result of people’s comments

when in public places. In addition, thinking about the future of the child also increased

the stress of some caregivers. This is in line with the findings of Al-Dujaili and Al-

Mossawy (2017), Hoffman (2012) and Lai et al. (2015), who reported that parents of

children with ASD have poorer psychological outcomes and experience higher levels

of psychological stress than parents who are caring for children without ASD.

Furthermore, it is possible that their fear could prevent them from social interaction that

might ease their stress.

The majority of children with ASD stay with family members in their communities. The

parents continue to experience social rejection and financial challenges (economic

injustice) (Bishop-Fitzpatrick et al. 2016; Howling and Magiati 2017). The caregivers

expressed their feelings when in public places with their children with ASD. Some

caregivers were unhappy with the attitude displayed by peers on their children with

ASD, more especially that parents of those children did not do anything to make them

aware that such children are differently abled and should not be criticised nor rejected.

This is in line with DePape and Lindsay (2015) who reported that parents of children

with ASD often received negative criticism from strangers when they were out in public.

Strangers believed that their children were acting out and should be disciplined.

The lack of intervention by parents made some of the participants choose to isolate

themselves and keep their children indoors because of being rejected by peers. As

Alnazly and Abojedi (2019) found and in the present study some caregivers experienced

depression as demonstrated by social withdrawal. According to Shilubane et al. (2014),

Mazibuko, Shilubane and Manganye

10

depression is a mediating factor of suicidal behaviour; therefore, the caregivers’

depressive behaviour requires immediate intervention by health professionals.

Financial difficulties were identified in all the interviews and Hoefman et al. (2014)

mention underemployment and unemployment as the cause of caregivers’ financial

problems. The caregivers mentioned that their children are selective in terms of what

they want to eat. They further indicated that the therapy sessions were very expensive

and they ended up paying the difference since medical schemes paid the approved rate

charged. The current findings are in line with Bashir et al. (2014), and Matenge (2012)

who indicated that ASD causes financial strain on families in several ways, they need

money for therapists and treatment not covered by medical schemes. The findings of

Yingling, Hock and Bell (2018) and Yingling et al. (2017) also highlighted that most

children with ASD do not access needed services due to costs and unavailability. These

authors’ findings are in line with the current findings as some caregivers mentioned that

they wanted to send their children to a better school that has resources for the benefit of

the child, but due to financial constraints they failed. This is supported by Clasquin-

Johnson and Clasquin-Johnson (2018) who indicated in their study that there are limited

options in selecting a school for a child with ASD because they are expensive.

In their study, the results of which are similar to those of the current study, Hoefman et

al. (2014) found that some family members and friends never showed any support in

their children’s situation. Similarly, Madlala (2012) indicated that parents found it hard

to cope with their children because of the poor support they were receiving from their

families. Since the family is regarded as the primary support system, and most

caregivers in the present study were single parents, either because they had never

married or were divorced, it is unsurprising that caregivers experienced psychological

stress as they had no one to lean on. This is in line with O’leimat, Alhussami and Rayan

(2019) who in their study of the correlates of psychological distress among parents of

children with psychiatric disorders, found parental psychological distress to be

significantly correlated with marital status.

The caregivers stated that it is tiring for them and their children to travel a long distance

to Pretoria for treatment. Similar results were obtained in DePape and Lindsay’s (2015)

study which found that parents experienced challenges when trying to access services

for their children with ASD and was perceived as tiring for their children since they are

not used to confined spaces. Unlike in the current study, where caregivers reported

limited government schools that cater for children with disabilities, Mahapatra et al.

(2019) indicated that services were available. Hoffman (2012) and Mthimunye (2014)

further stated that schools that accommodate children with ASD are not enough and the

few schools that are available have certain criteria for admission in which the child may

not be successful in some cases therefore, forcing them to stay at home.

Mazibuko, Shilubane and Manganye

11

Limitations of the Study

The study findings cannot be generalised because they are applicable to a specific

context with a small population and qualitative nature, which is meant only to generate

hypothesis.

Recommendations

Based on the study findings, the authors recommend that medication should be made

available at the district level to avoid caregivers travelling long distances. Furthermore,

tailor-made interventions/strategies to support caregivers should be developed. Support

groups for caregivers of children with ASD should be established. There are no studies

on experiences of caregivers in the Ehlanzeni District, therefore the current study will

provide a reference for future studies on interventions development to make care of

ASD children easier. Development of an instrument to measure caregivers’ experiences,

challenges, perceptions and behaviours or coping strategies could assist in this as a

quantitative comparison.

Conclusion

The study increased the authors’ insight into the experiences of caregivers and the

impact of caring for ASD children on their psychological being. The study reflects that

the education and the health care systems for ASD children in South Africa are not fully

developed. It is evident that community members do not have sufficient knowledge of

ASD. There is a need to conduct public awareness about ASD which could remove the

stigma and enhance acceptance of children with ASD. Furthermore, support of families

and community members could be enhanced. The fact that caregivers are not involved

in activities at schools could mean that teachers do not know what to tell them, therefore,

there is a need to empower teachers and caregivers with information on ASD and

available services. Once caregivers are well informed through counselling and

workshops, fears and anxiety could be removed. In addition, policy makers should

develop policies that will ensure fair distribution and accessibility of services to ASD

children in all the provinces of South Africa. Future studies may determine knowledge

of caregivers in the Ehlanzeni District and explore their coping strategies.

Acknowledgements

The authors are grateful to the University of Venda and the National Research

Foundation for their support. They also give special thanks to the caregivers of children

with ASD for sharing their experiences.

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Mazibuko, Shilubane and Manganye

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Article 1 RESTRAINT references

W”i-Tong Chien, & Lee, I. Y. M. (2007). Psychi”tric nursesʼ knowledge “nd
“ttitudes tow”rd the use of physic”l restr”int on older p”tients in psychi”tric
w”rds. Intern&tion&l Journ&l of Multiple Rese&rch Appro&ches, 1(1), 52–71. https://
doi-org.lopes.idm.oclc.org/10.5172/mr”.455.1.1.52

Article 2 AUTISM references:

M”zibuko, N., M”ng”nye, S. B., & Shilub”ne, H. N. (2020).
C”ring for Children Di”gnosed with Autism Spectrum
Disorder: C”regiversʼ Experiences. Afric& Journ&l of
Nursing & Midwifery, 22(2), 1–14.