Moving Beyond Resistance to Restraint Minimization: A Case Study of Change Management in Aged Care

Original Article

Moving Beyond Resistance to RestraintMinimization: A Case Study of ChangeManagement in Aged Care

Susan Johnson, RN, BSc, MPH, DipEd, DipAppSc(Nursing), Joan Ostaszkiewicz, RN, MNurs, Beverly O’Connell, RN, MSc, PhD, FRCNA

ABSTRACTAim: This case study describes a quality initiative to minimize restraint in an Australian residential

aged care facility.Approach: The process of improving practice is examined with reference to the literature on im-

plementation of research into practice and change management. The differences between planned andemergent approaches to change management are discussed. The concepts of resistance and attractors areexplored in relation to our experiences of managing the change process in this initiative. The importanceof the interpersonal interactions that were involved in facilitating the change process is highlighted.

Implications: Recommendations are offered for dealing with change management processes in clinicalenvironments, particularly the need to move beyond an individual mind-set to a systems-based approachfor quality initiatives in residential aged care.

KEYWORDS restraint minimization, change management, residential aged care, quality improvement, resis-tance, research integration, emergent approach, facilitation, implementation strategies

Worldviews on Evidence-Based Nursing 2009; 6(4):210–218. Copyright ©2009 Sigma Theta Tau International

BACKGROUND

Despite the legislative requirements for residential agedcare facilities to have restraint use policies in place

and to provide staff education on restraint minimization(Department of Health & Ageing 2005), the use of physicalrestraints is commonplace in the management of a rangeof challenging behaviors in Australian residential care fa-cilities (Australian Society for Geriatric Medicine 2005). Asystematic review conducted by The Joanna Briggs Insti-tute for Evidence Based Nursing and Midwifery indicatedthat globally the proportion of residents who are restrainedin residential aged care settings ranges from 12% to 47%

Susan Johnson, Research Assistant; Joan Ostaszkiewicz, Research Fellow; BeverlyO’Connell, Chair in Nursing; all at Deakin University—Southern Health, DeakinUniversity—Southern Health Nursing Research Centre, Burwood, Victoria, Australia.

Address correspondence to Susan Johnson, Deakin University—Southern HealthNursing Research Centre, School of Nursing, 221 Burwood Hwy., Burwood,Victoria, 3125 Australia; [email protected]

Funding for this project was provided by Victorian Department of Human Servicesunder the Improving Care for Older Persons Projects. The project team would liketo recognize the valuable contribution to the project by Elizabeth Mackay, ChereneOckerby, and staff of the participating units.

Accepted 13 May 2009Copyright ©2009 Sigma Theta Tau International1545-102X1/09

(Evans et al. 2002). Assessment of risks versus benefits isinterpreted differently in different countries. Historically,in the United States of America (USA) restraint use wasmore prevalent compared with much lower rates in withthe United Kingdom (UK) while in Scandinavia, restraintshave rarely been used (Strumpf et al. 1998). Notably, cul-tures that are less litigious in nature have lower rates ofrestraint use (Evans & Strumpf 1989). However, highprevalence rates of restraint use have been found in Aus-tralian facilities (ranging from 15% to 30% of people inAustralian nursing homes) (Whitehead et al. 1997; Retsas1998; Timmins 2008).

Restraint use is commonly initiated, implemented andmonitored by nursing staff. While nurses accept that theuse of restraint infringes patients’ rights, they also perceiverestraint use as being essential to protecting patients fromharm and falling (Chuang & Huang 2007; Curran 2007;Lai 2007). According to the Australian National Ageing andResearch Institute (2004) up to 50% of all residents of agedcare facilities experience one or more falls in a 12-monthperiod. The National Coroner’s Information System cites21 deaths from the use of restraint in individuals overthe age of 65 years in the 12 months from 2000 to 2001(Semmonds 2006) Nurses commonly express the viewthat the safety benefits of restraint use outweigh the risks

210 Fourth Quarter 2009 �Worldviews on Evidence-Based Nursing

Moving Beyond Resistance to Restraint Minimization

(Chuang & Huang 2007; Curran 2007; Lai 2007). Conse-quently, minimizing the use of restraint in these settingsis a challenging task as it often requires a change in staffattitude and beliefs that minimizing restraint use can po-tentially harm residents. While education is an importantfactor in improving staff knowledge and attitudes aboutrestraint use, it does not always result in changes in behav-ior and practice (Mac Dermaid & Byrne 2006). However,when education is combined with other implementationstrategies such as access to expert support, the results aremore positive (Evans et al. 1997; Bourbonniere et al. 2003).Consistent with these principles, we embarked on the fol-lowing quality improvement project.

THE QUALITY IMPROVEMENT PROJECT

The aim of the project was to develop, implement, andevaluate a restraint minimization program that addressedthe care needs of older people with dementia in a residen-tial aged care setting. The program was conducted usingthe following approach:

� A policy on restraint use was developed based oncurrent literature and guidance from the AustralianGovernment Department of Health and AgingDecision-making tool: Responding to issues of re-straint in aged care (2004).

� A survey of attitudes to restraint use was adminis-tered to staff.

� A series of education forums were conducted at avenue and times convenient to staff. Topics coveredincluded (1) impact of restraint use on resident phys-ical and psychological well-being, (2) the resident’sperspective, (3) impact on rates of serious and mi-nor injury falls, (4) adverse consequences of the useof restraint and evidence from the National Coro-ner’s Information System, (5) cultural differences inrestraint use, (6) ambiguity of definitions, (7) hu-man rights, (8) legal and ethical issues, (9) clini-cal decision-making, (10) situations necessitating theuse of restraint, (11) documentation, (12) monitor-ing of restrained residents, and (13) alternatives torestraint.

� Staffs were provided with access to a multidisci-plinary team of experts who provided clinical adviceon strategies for minimizing restraint use in com-plex situations. The multidisciplinary team includedrepresentation from medicine, nursing, allied health,and diversional therapy.

� The project was implemented in three residentialaged care units, two 28-bed general units and one35-bed psychogeriatric unit in a metropolitan healthservice in Australia. Pre- and postdata were collected

on staff attitudes to restraint use, the frequency ofrestraint use and the number of resident falls. Inaddition, a documentation audit was undertaken toidentify the degree to which staff adhered to the newrestraint policy.

Challenges and Key LearningAlthough the restraint minimization policy was developedusing the best available evidence, staff voiced strong con-cerns about its clinical application. Specifically, data fromthe preimplementation survey of attitudes to restraint userevealed staff concerns that the policy and program wouldincrease residents’ risk of harm and falling, which wouldin turn increase their current workload. This impacted ontheir willingness to implement the policy. In an attempt tounderstand staff responses to the recommended changes,the project team explored the research literature on changemanagement and, more specifically, the literature on theconcept of resistance to change and added strategies to theoriginal plan. The additional strategies included:

� Convening small group forums of staff and manage-ment

� Providing an experiential learning exercise in whichstaff were invited to experience being restrained

� Providing staff with opportunities to visit a facilitythat had successfully implemented restraint mini-mization within existing staffing levels

� Providing increased staff education, provided by theAged Psychiatry Nursing Education Team, address-ing the issue of meeting the needs of residents ex-hibiting behavioral and psychological symptoms ofdementia (BPSD)

The situation faced by the project team was not uniqueas research revealed that changing behavior of health careprofessionals in any health setting using traditional im-plementation strategies such as education, audit and feed-back, the use of opinion leaders and tailoring interventionsto overcome identified barriers typically result in mod-est impact (Bero et al. 1998; O’Brien et al. 2001; Cheateret al. 2005; Jamtvedt et al. 2006; Doumit et al. 2007;O’Brien et al. 2007; Grimshaw & Eccles 2008). For ex-ample, a systematic review by Jamtvedt et al. (2006) ofaudit and feedback, a commonly used strategy used to im-prove health care practice, revealed limited impact, i.e., amedian absolute improvement in performance, of only 5%(Grimshaw et al. 2004). This lack of uptake of evidencehas also been noted in nursing homes (Rantz et al. 2001,Rondeau & Wagar 2002; Bates-Jensen et al. 2003;Berlowitz et al. 2003; Schnelle et al. 2004; Wipke-Teviset al. 2004). Kitson et al. (1998) argue that one of thereasons for this lack of impact could be that traditional

Worldviews on Evidence-Based Nursing �Fourth Quarter 2009 211


approaches to changes in practice have largely been basedon the erroneous assumption that providing clinicians withcredible and sound evidence will lead to changes in theirbehavior and practice. This is supported by Dopson et al.(2002) who state that there is still a weak relationshipbetween the strength of the evidence base and clinical be-havior change. The other possible reason for a lack of ad-herence to the policy could have been an overreliance ontraditional implementation strategies that fail to take intoaccount the human dimensions of change (NHS Institutefor Innovation and Improvement 2005). The NHS Instituteof Innovation and Improvement, in its guide Managing theHuman Dimensions of Change (2005), stresses that it is anormal human reaction to resist change, and outlines thedifferent types of help and support that may need to beprovided to people experiencing difficulty with a changeprocess.

According to the Institute of Medicine (2001), mostnursing homes, even those with highly motivated staff,may lack the technical expertise and resources necessary totranslate quality improvement into practice. For example,a survey of 384 nursing home administrators in the UnitedStates concluded that whilst nearly all nursing homes meetthe requirement to have quality assurance committees, keypersonnel lack knowledge on how to manage change pro-cesses that would subsequently lead to sustained perfor-mance improvements (Rehnquist 2003). For this reason,there is a global call for aged care facility managers to havegreater understanding of change management theories andmodels and of the science of research integration in orderfor nursing homes to translate quality improvement sys-tems into practice enhancements (Institute of Medicine2001; Rondeau & Wagar 2002; Rehnquist 2003; Leemanet al. 2007; Shanley 2007a).

Change Management Theories and ModelsRogers’ (1995, 2003) Diffusion of Innovations has beenused extensively to describe the process of change. Aconceptual synthesis of Learning from Diffusion of Innova-tions produced at the Research Unit for Research Utiliza-tion (RURU) in the United Kingdom (Nutley et al. 2002)identified factors affecting the likelihood that a particu-lar innovation will be adopted. These include innovationattributes, adopter characteristics, environmental/contextcharacteristics, the characteristics of those promoting theinnovation and communication channels. “According toRogers (1995) there are five elements of a new or substituteclinical behavior that will each partly determine whetheradoption or diffusion of a new activity will occur: rela-tive advantage, compatibility, complexity, trialability, andobservability.” (Sanson-Fisher 2004, p. S55). The projectteam increased the observability of restraint minimization

by providing staff with opportunities to visit other facilitiesthat had successfully implemented restraint minimizationwithin their existing staffing levels. This appeared to havea positive impact upon staff’s willingness to adopt restraintminimization.

According to Nutley et al. (2002), early research onthe diffusion of innovations concentrated on the adoptionbehavior of individuals based on a linear stage model; over-simplifying what is often a complex process of organiza-tional change. More recent work by Rogers et al. (2005) hasrecognized the complexity of the change process in organi-zations and proposed the use of a co-theoretical model ofDiffusion of Innovation Model (DIM) and Complex Adap-tive Systems (CAS). In complex adaptive systems, changeis not smooth and linear. Unlike linear systems in whichcause and effect occur in proportion to one another (Kiel1995), there is no linear correlation between the size ofthe change in initial conditions and the magnitude of theresponse of the system. Thus, it is not possible to antic-ipate the magnitude of the resultant changes in the sys-tem when initial conditions change. According to Rogerset al. (2005), most real-life situations are complex, “Smallchanges in initial conditions, and later interventions ofwhatever size, can result in disproportionately large ef-fects” (p.3).

Contemporary literature on change management the-ories and models draw attention to the need for organi-zations and individuals involved in change managementprocesses to recognize different approaches to change man-agement (Nutley et al. 2002; Graetz et al. 2006). Tradi-tional approaches (i.e., planned change models) have beenbased on the assumption that the process of change is ra-tional and linear, that it can be planned and controlled andthat it can provide a solution to the problem of how to suc-cessfully manage change and “overcome resistance” (Higgs& Rowland 2005; Shanley 2007a). By contrast, Graetz etal. (2006) recommend a systems-based approach that tack-les change at the level of the organizational system ratherthan focusing on individual behavioral change. Mittonet al. (2008), discussing research integration (using theterm Knowledge Transfer and Exchange [KTE]), said thatin current literature the opinion has been expressed that toconceptualize and implement KTE with an individual-levelmindset is a “folly.” A systems-based approach to changeacknowledges that change in any one area will inevitablyaffect another; i.e., recognizing the interrelationships in or-ganizations (Senge 1990). Using a systems-based approachIPRO, the New York State Quality Improvement Orga-nization, has developed a Restraint Elimination TrainingModule (IPRO 2007) to guide the process of restraint min-imization. IPRO (2007) provides an “Organizational Com-mitment to Restraint Elimination Checklist” and a list of“Systems to Review” to formalize and systematize the role



of management in the process of restraint minimization.The IPRO Restraint Elimination Training Module (IPRO2007) provides a framework for implementing change withregards to restraint minimization that takes into accountthe complexity of the residential aged care environmentand addresses multiple systems factors.

Systems-based approaches to change view organizationsas complex adaptive systems that comprise a set of el-ements, connected together and interrelating to form awhole (Plsek & Wilson 2001; Callaly & Arya 2005). Inso far as the early stages of this project were based on theassumption that education combined with access to expertadvice would result in changes in staff behaviors, it wasunderpinned by a traditional rational, linear planned ap-proach to change that did not take sufficient account of thecomplexity of the interrelated systems factors. One of thesefactors was the level of staff education provided to man-age behavioral and psychological symptoms of dementia inthe absence of restraint. The quality improvement projectwas expanded to include this additional education and wasdelivered by staff educators who were known to the par-ticipants, who were perceived as “credible” and who actedas local opinion leaders.

The Emergent ApproachAccording to Iles and Sutherland (2001, p. 14), there isan important emergent element in organizational changethat is not fixed or linear but is rather spontaneous andunplanned. Contemporary literature on change manage-ment supports this notion that change is a complex andunpredictable phenomenon and that individuals involvedin change management should address contextual systemsfactors and emotional issues (Shanley 2007b). This ap-proach to change, termed the emergent approach, “is rep-resented by a loose coalition of theories rather than atight theoretical school” (Shanley 2007a, p. 541). It re-jects the “rational, linear, non-political, managerialist andshort-term accounts of change” (Shanley 2007a, p. 541).Moreover, emergent approaches are concerned with the so-cial and relational dimensions that are affected by the pro-posed change; with building relationships and a climatethat is conducive to change (Higgs & Rowland, 2005).Senge (1990) describes a climate conducive to change inhis book The Fifth Discipline: The Art and Practice of TheLearning Organisation. The interrelationships between staffand management in a learning organization are charac-terized by everyone communicating and working together(Rowden 2001). Within this project increased involvementof management was initiated by inviting them to attendsmall group forums with clinicians to develop interrela-tionships in which management and staff communicatedand worked together. The project team reflected on staffreactions to the original strategy and adjusted their course

with improvised strategies, in line with Rowden’s (2001)description that reflection and adjustment follow action ina learning organization.

Facilitation of ChangeOur initial approach to introducing change by contrast,focused more on the quality of the evidence than on theneed to understand the social and environmental contextthat would support the proposed changes. To this end, wewere unprepared for the emotional responses of the staffand the degree of resistance encountered. To address thisgap, we engaged the Falls Coordinator and DiversionalTherapist to act as local opinion leaders to encourage andsupport the recommended changes at the point of care.These staff members adopted a facilitative role that in-volved building relationships of trust, and guiding andsupporting staff to adopt the recommended changes inpractice. This role is also consistent with the findings ofDoumit et al. (2007) and also with recommendations forsuccessfully implementing evidence into practice using thePARIHS framework (Rycroft-Malone et al. 2002; Kitsonet al. 2008). This framework posits that evidence, con-text, and facilitation are necessary for successful researchimplementation (Rycroft-Malone et al. 2002). A conceptanalysis conducted by Stetler et al. (2006, p. 1) definedfacilitation as “a deliberate and valued process of inter-active problem solving and support that occurs in thecontext of a recognized need for improvement and a sup-portive interpersonal relationship.” Successful manage-ment of change involves the fostering of relationships so-cially so that staff members are comfortable discussingchange openly (Miles et al. 2002). In this study, a mem-ber of the research team in conjunction with the FallsCoordinator convened small group forums. The Falls Co-ordinator and Diversional Therapist, in their roles thatemerged as facilitators, established a sense of trust withstaff and promoted free discussion. The Falls Coordina-tor acted as a facilitator encouraging the developmentof supportive interpersonal relationships through discus-sion of different perspectives, including the discussion ofvalues and ethical issues associated with restraint use.Specifically, the issues of autonomy, beneficence andnonmaleficence were discussed. This provided the clin-icians with the opportunity to reflect on their practice,convey their nonmanagerial experiences, opinions, andemotions regarding the proposed changes to their prac-tice, and for the project team to identify factors (i.e.,attractors) that would assist staff to adopt best practicerecommendations.

Understanding the Rationality of Others’ Perspectivesand the Role of AttractorsPlsek & Kilo (1999) emphasized the need for individ-uals and organizations involved in change management



processes to focus on building relationships of trust thatwould support effective change management. They pro-pose that exploring the rationality of others’ points of viewis fundamental to understanding “resistance.” Accordingto Plsek & Kilo (1999), what we label as “resistance” arereally factors in the current system that we might not fullyappreciate or understand. Rather than labeling others whenchange fails, Plsek & Kilo (1999) suggest finding out whysome are reluctant to change. Identifying their reasons willoften reveal the most relevant factors: attractors that needto be addressed (Plsek & Kilo 1999). “Attractors are eas-ier to create when working together in cooperative, pos-itive relationships of trust” (Plsek & Kilo 1999, p. 42).The culture of blame most commonly used to explain andunderstand resistance to change has tended to separate so-cially, organizationally, and hierarchically the managers ofchange from those who must carry out the change (Plsek& Kilo 1999). Use of the term attractors places responsi-bility for successfully bringing about the desired changeprocess with those managing the change rather than thosebeing asked to change. The change leader is responsiblefor creating attraction, and failure to bring about change isusually due to their poor performance of this task (Plsek& Kilo 1999).

According to Plsek & Kilo (1999), key features of thechange management process are pilot testing and visit-ing sites that have successfully implemented the proposedchange. This tends to reduce risk and provides a methodfor identifying attractors under controlled conditions. Inthis project, staff visits to other facilities that had success-fully implemented restraint minimization appeared to allaysome anxieties associated with implementing the restraintminimization policy. Staff members were provided withthe opportunity to learn about the psychological impact ofrestraint use through the use of the experiential learningexercise. They were invited to experience what it is liketo be restrained. Experiencing the psychological impactof the use of restraint on themselves raised awareness ofthe potential psychological benefits of restraint minimiza-tion for residents. This raised awareness appeared to be anattractor, positively influencing staff to minimize restraintuse. This possible attractor was not anticipated, or plannedfor, in the original quality improvement project plan.

Project OutcomeThis restraint minimization project took longer than origi-nally anticipated: 6 months instead of the initially planned4 months. However, eventually it resulted in a reductionin the number of residents who were restrained, withno concurrent increase in resident falls, and improvedstaff adherence to documentation requirements of the newpolicy.

DISCUSSION

The aim of this project was to implement an evidence-based restraint minimization policy and procedure inresidential aged care settings. The project team wereoriginally of the view that a sound evidence-based pol-icy accompanied by an education program and access toan expert panel would be sufficient to successfully im-plement the project. They also felt that they fully un-derstood the environment in which the change was pro-posed. However, this strategy proved to be insufficientand the project team experienced difficulties implement-ing the change. A key learning point from this experiencewas that efforts to translate quality improvement initiativesinto practice enhancements need to be informed by changemanagement theory and models, and with reference to thebody of knowledge on successfully integrating researchinto practice (Senge 1990; Plsek & Kilo 1999; Grimshawet al. 2004; Higgs & Rowland 2005; Graetz et al. 2006;Leeman et al. 2007; Shanley 2007a, 2007b; Grimshaw &Eccles 2008; Kitson et al. 2008). Each clinical contextdiffers and all clinical environments are complex. Con-sequently, no particular approach to change managementis likely to be adequate (Shanley 2007a). It would alsohave been useful to have conducted an assessment of thereadiness of the environment to change and the poten-tial impact of change on the clinicians (Eastwood et al.2008).

According to Higgs & Rowland (2005), who com-pared outcomes of 70 change initiatives using differenttechniques, approaches that are based on assumptionsof linearity (i.e., planned approaches) are unsuccessful,whereas those built on assumptions of complexity (i.e.,emergent change) are more successful. Moreover, organi-zations and individuals involved in change managementprocesses need to be in a state of constant readiness, en-gaged in continuous planning, being prepared to impro-vise implementation and to adopt action learning strategies(Rowden 2001).

Our experience has also led us to revise our originalstance on staff resistance to change, and to understand theissue from their perspective and sense of custodial pro-tection for residents (Koch et al. 2006). In reality, thechanges proposed confronted many nurses with an un-spoken ethical dilemma. This ethical dilemma is a ten-sion between the principle of beneficence (the duty todo good) and nonmaleficence (the duty to do no harm)and between ensuring safety and the individual resident’sright to autonomy. Specifically, as staff members wereconcerned that reducing restraint would cause patientsto fall or harm themselves, they were presented with anethical dilemma by the request to minimize the use ofrestraints.



The forums provided opportunities for the project teamto acknowledge the emotional reactions of staff and to ad-dress the relational aspects of the proposed change. Whengiven the opportunity to be heard, staff engaged in moreactive discussion about the facilitators to the reductionin restraint use and identified ways in which managementcould address systems and resource issues that would assistthem to adopt the recommended changes in their practice.

As the project team implemented a number of dif-ferent strategies (i.e., local opinion leaders, small groupsupport, experiential learning opportunities and facili-tation), it is difficult to know which strategy providedthe most effective catalyst. This is consistent with Kitsonet al. (1998) claims that current research does not pro-vide conclusive evidence as to which elements (i.e.,evidence, context, or facilitation) are most crucial for suc-cessful change and hence should be given equal standing,contrary to commonly held clinical effectiveness agendaassumptions that the most important factors for consider-ation are the level and rigor of the evidence (Kitson et al.1998).

CONCLUSIONS

In conclusion, the experience of undertaking this qualityimprovement initiative to minimize the use of restraint inresidential aged care settings and the subsequent reviewof literature on change management theories and modelsidentified a number of areas for improvement. Specificallyfor restraint minimization, these improvements could beinformed by use of the IPRO module (2007) and more gen-erally for all quality initiatives by the PARIHS framework(Kitson et al. 1998; Harvey et al. 2002; McCormack et al.2002; Rycroft-Malone et al. 2002; Rycroft-Malone 2004;Rycroft-Malone et al. 2004; Kitson et al. 2008), the NHSInstitute for Innovation and Improvement (2005) Guideto Managing the Human Dimensions of Change and Manag-ing Change in the NHS: Organisational Change: A review forHealth Care Managers, Professionals and Researchers (Iles& Sutherland 2001). Specifically, managers of residentialaged care facilities and individuals involved in quality ini-tiatives should:

1. Have a greater understanding of change managementtheories and models in order for nursing homes totranslate quality improvement systems into practiceenhancements.

2. Adopt an emergent approach to change managementthat acknowledges the complexity of the environ-ment and the relational aspects of the change process.

3. Adopt flexible, open strategic plans and be preparedto improvise implementation.

4. Adopt management styles that are participatory andfacilitative.

5. Provide opportunities to gain understanding of theconcerns and attractors of the individuals who arerequired to adopt practice changes.

6. Adopt a systems-based approach that tackles changeat the level of the organizational system rather thanfocusing on individual behavioral change.

7. Provide opportunities for those being asked tochange to view the innovation in a facility in whichit has been successfully implemented (increase ob-servability (Rogers 1995).

As the movement toward evidence-based practice inaged care becomes fundamental to delivering quality care,it is important for policy makers, managers, and clini-cians to take into account the above mentioned issuesand to incorporate the evidence from emergent changemanagement theories and knowledge of implementationapproaches into their change management strategies. It isimperative to use a multistrategy approach and not hold onto traditional assumptions of a linear relationship betweenlevels of evidence and extent of uptake in practice.

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Moving Beyond Resistance to Restraint Minimization: A Case Study of Change Management in Aged Care

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