Step 1: Logic model of the problem
The results of the needs assessment can be found in the logic model of the problem (Figure 2). ‘Quality of life’ (QoL) is the ultimate outcome and formed the starting point of the model. By placing the focus on QoL, the researchers were stimulated to think backwards through the logic model of the problem to identify the problem, the behavior of professional home care providers, the environment and the determinants influencing the behavior and environment. The logic model of the problem helped the researchers to plan, implement and evaluate the program with the end in mind (27).
Quality of life
Physical restraint use has an impact on QoL of the patient, the informal caregiver and the professional home care providers. The patient can experience physical (e.g. urinary incontinence, pressure ulcers, falls,…), psychosocial (e.g. depression, fear,…) and existential consequences (32,33). The use of restraints also comes with negative psychosocial consequences for the informal caregiver (e.g. anger, powerlessness) and professional home care providers (e.g. frustration, moral distress) (1,14).
Due to demographic, epidemiological, social and cultural trends, there is a growing number of older persons living at home (34). These older persons often have chronic conditions, which are associated with restraint use. Consequently, professional home care providers are increasingly confronted with the use of physical restraints (9,33). Findings from the needs assessment indicate that currently physical restraints are being used without analyzing the care context and thoughtful decision-making (1,2,6).
Behavior of professional home care providers and environmental factors
Based on the findings of the literature search, the focus group interview and the expert group meeting, different behavioral and environmental factors leading to a lack of thoughtful decision-making were identified. Not searching for a validated guideline, incorrect use of the guideline and not dealing with conflicting values are behavioral factors at the level of home care providers. The environmental factors are classified into four levels; interpersonal, organization, community and society. The most important environmental factors at interpersonal level are the use of physical restraints by family without thoughtful decision-making and the lack of communication between home care providers, informal caregivers, family and patient. At the organization level, a lack of encouragement from management to use guidelines is a crucial factor. No access to guidelines for all professional home care providers and the absence of financial and non-financial incentives to improve guideline adherence are the most commonly mentioned environmental factors on community and society level.
The most frequently-mentioned determinants are: the feasibility and practicality of the guideline (guideline factors); the knowledge, motivation and awareness of the professional home care providers (individual health professional factors); the burden of informal caregivers and family, no social safety net and the alignment with the life goals of the older person (patient and family factors); communication between home care providers (professional interactions); financial and non-financial incentives (incentives and resources); leadership and organizational priorities (capacity for organizational change); legislation and policy priorities (social, political and legal factors).
Step 2: Logic model of change
Logic model of change
Figure 3 shows the logic model of change. The overall health objective is that home care providers analyze the care context and make a thoughtful decision on the use of physical restraints in home care. The logic model contains 14 behavioral change outcomes. Additionally, the logic model has seven environmental outcomes at interpersonal, organization, community and society level. The main behavioral outcomes focus on the awareness of the problem of physical restraint use, the knowledge of the guideline and the need for clear communication and collaboration between different care providers, patient, informal caregiver and family. The environmental outcomes mainly focus on a clear vision or policy regarding physical restraint use in home care organizations. Above that, the dissemination and the accessibility of the guideline are taken into account. For each behavioral outcome different performance objectives are formulated (Figure 3).
Matrices of change objectives
For each behavioral and environmental outcome a matrix of change objectives was developed. The matrices were constructed by combining performance objectives with determinants and defining specific change objectives. These matrices form a concrete pathway for behavioral and environmental changes (27). An example of a matrix of change objectives can be found in Table 1.
Step 3: Program design
In the third step of IM, the research group and expert panel selected theory- and evidence-based methods to influence the determinants identified in the logic model of change and the different matrices of change objectives. The main theories behind the multicomponent program are the ‘Social Cognitive Theory’ and the ‘Theory of Planned Behavior’ (27,35). From the Social Cognitive Theory the researchers selected ‘modeling’, ‘active learning’ and ‘guided practice’ as evidence-based methods to influence the identified determinants. With modeling we aim to provide the professional home care providers an appropriate role-model, more specifically an ambassador for restraint-free home care. If the home care providers see and observe successful demonstration of behavior by a role model, they can reproduce the same behavior. The ambassadors receive a one-day training, where the trainers use the method ‘active learning’, learning based on goal-driven and activity-based experience. In addition, this training consists of ‘guided practice’. The ambassadors rehearse and repeat behavior various times by means of role play. After the role play, peers discuss the behavior and give feedback. The main evidence-based methods selected from the Theory of Planned Behavior are ‘belief selection’ and ‘resistance to social pressure’. The strategy behind the method ‘belief selection’ is to use messages designed to strengthen positive beliefs and weaken negative beliefs about physical restraint use in home care. With this strategy in mind the researchers developed a flyer and a promo video. For the method ‘resistance to social pressure’, the ambassadors receive a training and peer coaching sessions to build skills for resistance to social pressure. Table 2 gives an overview of all the selected theories, methods, implementation strategies and the practical components of the program.
The developed multicomponent program has three main objectives:  to make the guideline more accessible and to disseminate it,  to increase awareness and knowledge of the problem of physical restraint use in home care, and  to work towards sustained implementation. Based on the theory- and evidence-based methods, the research group and expert panel selected and designed eight practical applications to operationalize those methods; i.e. a website, social media, promo video, flyer, summary of the guideline, physical restraints checklist, tutorials and ambassadors for restraint-free home care. More information on the different components of the program can be found in Figure 4.
Step 4: Producing and testing of program components
In step 4 of IM the multicomponent program (Figure 4) was tested for eight months (February – October 2018) in one primary care district in Flanders, Belgium. In total, 15 professional home care providers received a training for becoming an ambassador for restraint-free home care. One professional home care provider was a self-employed occupational therapist, the other ambassadors worked for various home care organizations, being: home care nursing organizations (n = 8) home care organizations (organization of home health aides; n = 3), a senior and community center (n = 1), an organization that provides assisted living facilities (n = 1) and an adult day care center (n = 1).
After eight months of testing the multicomponent program, a knowledge test was completed by 73 home care providers of the participating organizations, of which 13 were ambassadors and 60 were non-ambassadors (Table 3). The participants were mainly women (n = 71), with a mean age of 41.5 ± 10.6 years. The majority of the participants were certified nursing assistants (n = 23), home health aides (n = 22) and registered nurses (n = 20).
The ambassadors scored noticeably higher on the knowledge test (mean score = 28.9 ± 1.98) than the non-ambassadors (mean score = 22.6 ± 4.36) (table 3). The non-ambassadors scored less on questions about the alternatives for physical restraints and the legislative framework for physical restraint use in home care.
A process evaluation was performed after eight months of delivering the multicomponent program. Ten out of fifteen ambassadors participated in the online survey (results in additional file 5) and nine out of fifteen ambassadors participated in the focus groups. The results of the process evaluation are described in two main topics:  the evaluation of the multicomponent program and  the perceived barriers.
- Multicomponent program
The results of the focus group interviews and the online survey show that the ambassadors acknowledged and appreciated the added value of various components of the program. Several components increased their knowledge and awareness of the problem of physical restraint use.
“The multicomponent program is a valuable framework to support us to achieve a physical restraint-free home care. Otherwise it wasn’t feasible for us.”
“The multicomponent program was very important for awareness. It was the first step to work on a policy within our organization”
The results of the process evaluation show that not all components were evaluated equally positive. During the interpretation of the results of the survey and the focus group interviews, the researchers could identify key components, valuable components and optional components. The key components are those components that are evaluated as the most crucial and useful components of the program. The valuable components are evaluated as useful and helpful, but study results indicate that they are not seen as the most essential components of the multicomponent program. The optional components are deemed valuable to particular professional home care providers, but for the ambassadors these components are less helpful and not appealing.
Key components of the multicomponent program
Based on the results of the online survey and focus group interviews, the ambassadors for restraint-free home care, the tutorials, the physical restraint checklist and the flyer are defined by the researchers as the key components of the multicomponent program. According to the majority of the ambassadors, the training for becoming an ambassador restraint-free home care ensured that they could support their colleagues. All the ambassadors found that this training provided them with the necessary skills to give feedback to colleagues. Nine ambassadors stated that the training helped them to deal with resistance from colleagues. In addition, both the results of the online survey and the focus group interviews showed that peer coaching sessions and the telephone follow-up by the researcher continuously motivated and stimulated them to work on a physical restraint-free home care.
“The peer coaching sessions put the spark back in our work towards physical restraint-free home care”
“In the telephone follow-up, you ask questions "what are you doing, what is your progress?” And then we start to think, how are we going to do it? "
The two peer coaching sessions helped the majority of the ambassadors to understand the legislation relevant to physical restraint use in Belgium and provided them with more insight into the different alternatives for restraint use. In the focus group interviews the ambassadors stipulated that they received information on the alternatives for physical restraint use, but there is still a need to define and provide alternatives.
“Legislation was very important and the alternatives were also important.”
“Can you develop something on the alternatives for physical restraints? Where can you get it? What is the price? Is it covered by the insurance company? Whatare useful tools?”
Participants indicated in the focus group interviews that they used the flyer to communicate with patients, families and caregivers, because it was compact, brief and concise.
“The flyer was also important. Because how do you go to the informal caregiver and discuss the use of physical restraints. The flyer is a useful tool.”
Also the results of the focus group interview and online survey show that the physical restraint checklist was perceived as a helpful tool, since it matched their daily working method and it supported the majority in documenting the care situation and the decision-making process. Other key components of the program are the tutorials on the guideline and on the flowchart. In the focus group interviews the ambassadors evaluated the tutorials as useful and recognizable and it continuously motivated and stimulated them to work on a physical restraint-free home care.
"The tutorials are very useful, the guideline is explained in an amusing way, and the cases appeal to the imagination.”
In the online survey, eight ambassadors found that the tutorial on the guideline raised awareness, supported and motivated them to use the guideline. All the ambassadors that have seen the tutorial on the flowchart believed that the tutorial supported home care providers in their daily practice, motivated them and clarified the use of the flowchart.
Valuable components of the multicomponent program
The results of the online survey and focus group interviews show that the website and the promo video were seen as valuable components. All the ambassadors evaluated the website as logical and clear and it raised their awareness. Nine ambassadors indicated that the website supported them in their daily practice.
“I think the website is very important. We will also use it in the training of our professional home care providers.”
The promo video was well evaluated by the majority of the ambassadors, it increased awareness and it motivated people to work on a physical restraint-free home care. The ambassadors found that due to their education and experience, the professional home care providers already knew the content covered by the promo video. Therefore, the promo video could be more useful for the patient, family and informal caregivers.
“The promo video is for a broader audience, who do not know anything about it. It is important and convenient. If people already know the content, it is difficult to keep their attention.”
Optional components of the multicomponent program
The social media pages and the summary of the guideline are less well evaluated by the ambassadors. The majority of the ambassadors found the social media pages (Facebook and Twitter) less helpful and not appealing. Half of the ambassadors did not visit the social media pages.
“Social media, I am not into social media. I have not been interested in social media and it does not appeal to me at all, maybe for young people.”
The summary of the guideline aimed to support the professional home care providers in the analysis of the care situation and the decision-making process. In the focus group interviews, the ambassadors indicated that the summary of the guideline was not useful and too complex. A minority of the ambassadors used the summary monthly.
“The flowchart, part of the summary of the guideline, is too complex to use especially for home health aides. We have made adaptations.”
2. Perceived barriers to the implementation of the guideline
Several perceived barriers to the implementation of the guideline are identified from the focus group interviews. The ambassadors experienced that, in practice, the term ‘physical restraints’ is being interpreted too narrow; only the most extreme and least acceptable methods (e.g. ropes, belts) were taken into account. Due to the fact that ‘physical restraints’ has a negative connotation and home care providers were not aware of the full meaning of this term, it resulted in limited recognition of the problem. So, the narrow interpretation of ‘physical restraints’ by the ambassadors and other home care providers formed a barrier to fully exploit the added value of the multicomponent program for the implementation of the guideline. The ambassadors found it important to think about a more suitable and uniform terminology and a clear definition for physical restraints, so that confusion could be avoided.
"Locking the door or room, people don't see this as physical restraints … Also if you prevent someone from going upstairs. Not everyone sees this as physical restraints.”
The ambassadors found the fragmented approach in home care a challenge when trying to implement a guideline. They found it difficult to involve and collaborate with different care providers such as self-employed nurses, GPs and physiotherapists. The ambassadors indicated that a common vision, general agreements and uniform documents are important to facilitate this collaboration.
"We want to do it, but if the other care providers are not part of the story, we will remain in the physical restraints circle."
The legislation on physical restraint use was experienced as an important barrier to implement the guideline in home care. In Belgium, only doctors, nurses, certified nursing assistants (if they meet certain conditions such as working in a structured team and under direct supervision of a registered nurse) and informal caregivers (if they meet certain conditions such as training from a nurse or GP, informal caregiver certificate,…) can apply physical restraints (5,10,11). The fact that an informal caregiver can be allowed to apply physical restraints and that certain home care providers (e.g. occupational therapists, home health aides, and physiotherapists) cannot, influenced the self-image and self-confidence of these care providers. In addition, the ambassadors indicated that the current legislation is restrictive for some professional home care providers.
"The legislation is very restrictive for home care. If you apply it strictly, we will give the home health aides the feeling that they are unneeded."
“We have been very careful and have not explained the content of the guideline explicitly to the home health aides.”
The ambassadors experienced a lack of time for facilitating the implementation as an important barrier. The entire process requires effort and time. The implementation process must be well thought out and prepared, before the actual start. With an implementation period of only eight months, all ambassadors perceived the feasibility study as too short.
"It is such a short period of time to realize it. And it takes time to become more aware and to let everything settle. And for an organization you have far too little time to implement something. You solely have time to create awareness."
Another challenge experienced by the ambassadors was the lack of involvement and support of their managers. The ambassadors found it necessary that managers set priorities and develop a common vision and implementation plan related to the use of physical restraints. Not all of the ambassadors had the organizational power to implement a guideline on physical restraint use within their organization, which formed a barrier for the implementation process.
"The management is not yet on board. We need to involve them in order to implement it. We are now working on a vision or policy. That has been the bottleneck, to continue and have a complete concept. Everyone has to go along, including managers. It must be supported by the organization and the management.”