District nurses’ attitudes towards involuntary treatment for dementia care at home: A cross-sectional study

One in two persons living with dementia (PLWD) at home receive care which they resist to and/or have not given consent to, defined as involuntary treatment. District nurses play a key role in the use of involuntary treatment. However, little is known how their attitudes and opinions influence the use of involuntary treatment. This cross-sectional study aims to investigate the attitudes of district nurses towards the use of involuntary treatment in dementia care at home, determinants and their opinion about its restrictiveness and discomfort. Results show that district nurses perceive involuntary treatment as regular part of nursing care, having neither positive nor negative attitude towards its appropriateness. They consider involuntary treatment usage as moderately restrictive to PLWD and feel moderately uncomfortable when using it. These findings underscore the need to increase the awareness of district nurses regarding the negative consequences of involuntary treatment use to PLWD at home.


Introduction
This is a summary of the article "District nurses' attitudes towards involuntary treatment in dementia care at home: A cross-sectional study" published in Geriatric Nursing in September 2022. 1 This article presents district nurses' attitudes toward involuntary treatment in dementia care at home, and discusses determinants and opinions about its restrictiveness and discomfort.This topic is gaining more interest because persons living with dementia (PLWD) often wish to stay in their own homes for as long as possible.However, due to cognitive and functional decline, PLWD need extensive support of (in)formal caregivers.When dementia progresses, caregivers can have greater difficulty communicating with PLWD and managing care refusal, referred to as involuntary treatment. 2nvoluntary treatment is defined as care provided without the consent of the person receiving it and/or to which this person resists, including the use of: (1) Physical restraints, defined as any action or procedure that prevents a person's free body movement to a position of choice, and/or normal access to his/her body by the use of any method that is attached or adjacent to a person's body which he/ she cannot control or remove easily; (2) Off label use of psychotropic medication, defined as substances that act directly on the central nervous system, affecting mood, cognition and behaviour; (3) Non-consensual care, defined as any type of care that limits the organization of a person's own life and to which a person resists (e.g.withholding aids or ambulatory supports/devices, hiding prescribed medications, forced hygiene or medication intake, etc.). 1 Recent research shows that involuntary treatment is provided in 50% of PLWD at home. 2,3It is mostly requested and utilized by family caregivers or district nurses. 3,4 tudies show that involuntary treatment has a negative impact on the physical and psychological well-being of PLWD, and its use should be prevented.Since district nurses have a pivotal role in community dementia care and the use of involuntary treatment, they could play a critical role in preventing it.Studies in nursing homes suggest that the attitudes of nursing staff can influence the use of measures defined as involuntary treatment.However, studies regarding the attitudes and opinions of district nurses' toward involuntary treatment are scarce.Therefore, the aim of this study is to explore district nurses' attitudes towards the use of involuntary treatment in dementia care at home and investigate determinants and opinions regarding its perceived restrictiveness and discomfort.

Methods
From May 2021 to June 2021, a cross-sectional study was conducted among 296 district nurses in the eastern part of Belgium with experience in dementia care at home.The participants completed an online questionnaire, the Maastricht Attitude Questionnaire-Home Care (MAQ-HC). 5This questionnaire measures attitudes toward involuntary treatment, and perceptions regarding restrictiveness and discomfort of use.Table 1 shows that the MAQ-HC consists of two sections.The first section measures attitudes and is comprised of four subscales.The second section includes 26 items on opinions regarding different measures of involuntary treatment.Data was analyzed using descriptive analyses, multiple linear regression and multinomial logistic models.
Table 1.Measures and outcome variables used in the study and their results.

Note:
a For all attitude outcomes, a higher average sum of scores indicates higher acceptability of the applied treatment.b For all opinion outcomes towards non-consensual care and physical restraints, a lower sum of scores indicates higher acceptability of the applied treatment.c For all opinion outcomes towards psychotropic medication, a lower score indicates higher acceptability of the applied treatment.d Each statement is rated on a 5-point Likert scale, ranging from "totally disagree (score 1)" to "totally agree (score 5) e Each measure is evaluated on a 3-point scale with regard to their restrictiveness for the person living with dementia (1 = not restrictive, 2 = moderately restrictive, and 3 = highly restrictive) f Each measure is evaluated on a 3-point scale with regard to their restrictiveness for the person living with dementia (1 = no discomfort, 2 = moderate discomfort, and 3 = high discomfort)

Results
Table 1 shows that district nurses had a rather neutral attitude towards the appropriateness of involuntary treatment in general, non-consensual care, psychotropic medication and physical restraints.The results of the multiple linear regression analysis indicate that with more years of experience, district nurses had a more accepting attitudes toward: 1) involuntary treatment in general (p-value .001);2) non-consensual care (p-value .002);3) psychotropic medication (p-value <.001); and 4) physical restraints (p-value <.001).District nurses with a background of greater education were less accepting of the use of involuntary treatment (p-value .037)and psychotropic medication (p-value .012).Finally, we found that district nurses who perceived the care for PLWD as burdensome had more accepting attitudes toward involuntary treatment in general (p-value .008),non-consensual care (p-value .036),and physical restraints (p-value .040).
Table 1 indicates that district nurses perceive non-consensual care, physical restraints, and the use of psychotropic medication as moderately restrictive for PLWD.Moreover, they felt moderately uncomfortable using non-consensual care, psychotropic medication, and/or physical restraints.The results of the multiple linear regression analysis show that with each year of greater experience as district nurses, there was greater discomfort when using non-consensual care (p-value .001)and physical restraints (p-value .015),and the perceived restrictiveness of non-consensual care (p-value .007)and physical restraints (p-value .001)increased.In addition, perceiving the care of dementia patients as burdensome was associated with finding the use of physical restraints (p-value .016)as less restrictive for PLWD.Further, multiple multinomial logistic regression analysis revealed that with each year of increase in experience as a district nurse, there was reduced odds of finding the use of psychotropic medication either moderately (OR: 0.963; 95% CI 0.934-0.993;p-value .015)or highly restrictive (OR: 0.935; 95% CI 0.903-0.968;p-value <.001) for PLWD.

Discussion
The results of this study indicate that district nurses are not outspoken regarding their attitudes toward involuntary treatment in dementia care at home.Furthermore, they perceive the application of involuntary treatment as moderately restrictive for the PLWD and felt moderately uncomfortable using it.Our results indicate, that if we want to prevent involuntary treatment use, it is crucial for all care givers to have greater awareness of the negative consequences and greater knowledge of person-centered alternatives.When training and supporting professional caregivers, we should consider the determinants associated with more accepting attitudes and opinions.Otherwise, these factors could become possible impediments or even barriers to preventing involuntary treatment.