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Alostaz Z, Rose L, Mehta S, Johnston L, Dale CM. Interprofessional intensive care unit (ICU) team perspectives on physical restraint practices and minimization strategies in an adult ICU: A qualitative study of contextual influences. Nurs Crit Care 2024; 29:90-98. [PMID: 36443064 DOI: 10.1111/nicc.12864] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/12/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Guidelines advocate for minimization of physical restraint (PR) use in intensive care units (ICU). Interprofessional team perspectives on PR practices can inform the design and implementation of successful PR minimization interventions. AIM To identify ICU staff perspectives of contextual influences on PR practices and minimization strategies. STUDY DESIGN A qualitative descriptive study in a single ICU in Toronto, Canada. One-on-one semi-structured interviews were conducted with 14 ICU staff. A deductive content analysis of interviews was undertaken using the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. RESULTS Five themes were developed: risk-averse culture, leadership, practice monitoring and feedback processes, environmental factors, and facilitation. Participants described a risk-averse culture where prophylactic application of PR for intubated patients was used to prevent unplanned extubation thereby avoiding blame from colleagues. Perceived absence of leadership and interprofessional team involvement situated nurses as the primary decision-maker for restraint application and removal. Insufficient monitoring of restraint practices, lack of access to restraint alternatives, and inability to control environmental contributors to delirium and agitation further increased PR use. Recommendations as to how to minimize restraint use included a nurse facilitator to advance leadership-team collaboration, availability of restraints alternatives, and guidance on situations for applying and removing restraints. CONCLUSIONS This analysis of contextual influences on PR practices and minimization using the i-PARIHS framework revealed potentially modifiable barriers to successful PR minimization, including a lack of leadership involvement, gaps in practice monitoring, and collaborative decision-making processes. A team approach to changing behaviour and culture should be considered for successful implementation and sustainability of PR minimization. RELEVANCE TO PRACTICE The establishment of an interprofessional facilitation team that addresses risk-averse culture and promotes collaboration among ICU stakeholders will be crucial to the success of any approach to restraint minimization.
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Affiliation(s)
- Ziad Alostaz
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sangeeta Mehta
- Medical Surgical Intensive Care Unit, Mount Sinai Hospital, Sinai Health, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Linda Johnston
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
- Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Canada
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Ha SM. [Nursing Students' Experiences of Observing the Use of Physical Restraints: A Qualitative Study]. J Korean Acad Nurs 2023; 53:610-621. [PMID: 38204345 DOI: 10.4040/jkan.23032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/03/2023] [Accepted: 11/10/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE The purpose of this study was to understand the experiences of final-year undergraduate nursing students in observing the use of physical restraints on patients in the course of clinical practice. METHODS Three focus group interviews were conducted with 12 Korean nursing students who could provide sufficient information about their observation of physical restraints. The collected data was analyzed through conventional content analysis. RESULTS The data were classified into four theme clusters, and nine themes. The four theme clusters included 'recognized as an unavoidable means,' 'experienced problems with the use of physical restraints,' 'realized the importance of the nurse's role and efforts,' and 'aspire to learn about correct use of physical restraints.' While nursing students recognized the necessities and problems of using physical restraints in clinical practice, and the importance of nurses' role and effort, the results found that education related to the use of physical restraints should be more systematic within the nursing curriculum. CONCLUSION This study highlights the necessity of educating nursing students to ensure they acquire accurate knowledge and awareness regarding the use of physical restraints, and suggests the inclusion of systematic guidelines through simulation or extracurricular activities.
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Affiliation(s)
- Sun Mi Ha
- Department of Nursing, Gimcheon University, Gimcheon, Korea.
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Alostaz Z, Rose L, Mehta S, Johnston L, Dale C. Physical restraint practices in an adult intensive care unit: A prospective observational study. J Clin Nurs 2023; 32:1163-1172. [PMID: 35194883 DOI: 10.1111/jocn.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
AIM AND OBJECTIVES To conduct a diagnostic evaluation of physical restraint practice using the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. BACKGROUND Evidence indicates that physical restraints are associated with adverse physical, emotional and psychological sequelae and do not consistently prevent intensive care unit (ICU) patient-initiated device removal. Nevertheless, physical restraints continue to be used extensively in ICUs both in Canada and internationally. Implementation science frameworks have not been previously used to diagnose, develop and guide the implementation of restraint minimisation interventions. DESIGN A prospective observational study of restrained patients in a 20-bed, academic ICU in Toronto, Canada. METHODS Data collection methods included patient observation, electronic medical record review, and verbal check with the point-of-care nurses. Data were collected pertaining to framework domains of unit culture (restraint application/removal), evaluation capacity (documentation) and leadership (rounds discussion). The reporting of this study followed the STROBE guidelines. RESULTS A total of 102 restrained patients, 67 (66%) male and mean age 58 years (SD 1.92), were observed. All observed devices were wrist restraints. Restraint application and removal time was verified in 83 and 57 of 102 patients respectively. At application, 96.4% were mechanically ventilated and 71% sedated/unarousable. Nurses confirmed 71% were prophylactically restrained; 7.2% received restraint alternatives. Restraint removal occurred after interprofessional team rounds (87%), during daytime (79%) and following extubation (52.6%). Of the 923 discrete patient observation of physical restraint use, 691 (75%) were not documented. Of the 30 daytime interprofessional team rounds reviewed, physical restraint was discussed at 3 (10%). CONCLUSION In this single-centre study, a culture of prophylactic physical restraint was observed. Future facilitation of restraint minimisation warrants theoretically informed implementation strategies including leadership involvement to advance interprofessional collaboration. RELEVANCE TO CLINICAL PRACTICE The findings draw attention to the importance of a preliminary diagnostic study of the context prior to designing, and implementing, a physical restraint minimisation intervention.
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Affiliation(s)
- Ziad Alostaz
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital, Toronto, Canada
| | - Linda Johnston
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Canada
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Guenna Holmgren A, von Vogelsang AC, Lindblad A, Juth N. Understanding nurses' justification of restraint in a neurosurgical setting: A qualitative interview study. Nurs Ethics 2023; 30:71-85. [PMID: 36266990 PMCID: PMC9902980 DOI: 10.1177/09697330221111447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite its negative impact on patients and nurses, the use of restraint in somatic health care continues in many settings. Understanding the reasons and justifications for the use of restraint among nurses is crucial in order to manage this challenge. AIM To understand nurses' justifications for restraint use in neurosurgical care. RESEARCH DESIGN A qualitative, descriptive design was used. Data were analysed with inductive qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden. ETHICAL CONSIDERATIONS Approved by The Regional Ethics Committee, Stockholm, Sweden. FINDINGS The analysis resulted in three categories. The category Patient factors influencing restraint use describes patient factors that trigger restraint, such as a diminished decision-making competence, restlessness, and need for invasive devices. The category Specific reasons for justifying restraint describes reasons for restraining patients, such as restraint being used for the sake of the patient or for the sake of others. The category General reasoning in justifying restraint describes how nurses reason when using restraint, and the decision to use restraint was often based on a consequentialist approach where the nurses' weighed the pros and cons of different alternatives. DISCUSSION Nurses with experience of restraint use were engaged in a constant process of justifying and balancing different options and actions. Restraint was considered legitimate if the benefit exceeded the suffering, but decisions on which restraint measures to use and when to use them depended on the values of the individual nurse. CONCLUSION How nurses reason when justifying restraint, why they use restraint, and who they use restraint on must be considered when creating programs and guidelines to reduce the use of restraint and to ensure that when it is used it is used carefully, appropriately, and with respect.
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Affiliation(s)
- Amina Guenna Holmgren
- Amina Guenna Holmgren, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18a, Stockholm SE-171 77, Sweden.
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Tsai PC, Cheng CH, Tzeng IS. A cross-sectional study examining the factors affecting nurses' knowledge, attitude, and behavior toward physical restraint use. Perspect Psychiatr Care 2022; 58:1467-1475. [PMID: 34553392 DOI: 10.1111/ppc.12951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE This study aimed to investigate the factors associated with nurses' intent to use physical restraint. DESIGN AND METHODS This cross-sectional study used a questionnaire to survey 403 nurses from a hospital in northern Taiwan. FINDINGS Nurses who participated in a simulation training program had better knowledge and behavioral intent toward physical restraint use. Seniority and workplace significantly influenced the knowledge of physical restraint use, whereas workplace and clinical ladder level significantly shaped nurses' attitude toward it. PRACTICE IMPLICATIONS The results showed that the simulated physical restraint training program was effective. The impact of nurses' workplace, seniority, and clinical ladder level on an educational intervention should be considered before formulating a plan to reduce physical restraint use.
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Affiliation(s)
- Pi-Chueh Tsai
- Department of Nursing, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan (R.O.C.)
| | - Chu-Hsuan Cheng
- Department of Nursing, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan (R.O.C.)
| | - I-Shiang Tzeng
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan (R.O.C.).,Department of Statistics, National Taipei University, Taipei City, Taiwan (R.O.C.)
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Lao Y, Chen X, Zhang Y, Shen L, Wu F, Gong X. Critical care nurses' experiences of physical restraint in intensive care units: A qualitative systematic review and meta-synthesis. J Clin Nurs 2022; 32:2239-2251. [PMID: 36123309 DOI: 10.1111/jocn.16528] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/09/2022] [Accepted: 08/14/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Physical restraint is widely used in intensive care units. Critical care nurses are the primary decision makers and practitioners of physical restraint. However, little is known about the qualitative evidence of their experience of physical restraint. AIMS To aggregate, synthesise and interpret the qualitative evidence of studies that explored critical care nurses' experiences of physical restraint in intensive care units. METHODS A qualitative systematic review and meta-synthesis was conducted following Joanna Briggs Institute methodology and reported following the ENTREQ statement. Qualitative studies published in the English and Chinese were systematically searched in eight databases. PubMed, Web of Science, CINAHL, EMBASE, PsycINFO, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature Database from inception to November 2021. Two reviewers independently assessed the study eligibility and performed the data extraction and the quality appraisal. A meta-aggregative approach was used to synthesise findings. The review protocol was registered prospectively with PROSPERO (CRD42021278671). RESULTS Thirteen studies were included. A total of 48 intact and definite codes were extracted and classified into ten sub-categories. Four themes were finally identified: intention, alternatives, determinants, and reflection. CONCLUSION The intention of critical care nurses to use physical restraint is primarily driven by patient safety. Nurses will consider alternatives; however, many determinants urge nurses to implement physical restraint. Nurses prefer to sacrifice patients' comfort to ensure their safety. When nurses reflect on what they have done, some experience moral distress, but most rationalise their decision making. Further studies should explore the safety of alternatives, reduce the use of physical restraint, and pay more attention to nurses' moral distress through these insights. RELEVANCE TO CLINICAL PRACTICE Developing alternatives, providing relevant training for nurses, physicians, patients, and families to facilitate a restraint-free culture, and developing high-quality guidelines and regulations are essential strategies to reduce the use of physical restraint in ICUs.
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Affiliation(s)
- Yuewen Lao
- Department of Nursing, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
| | - Xiangping Chen
- Department of Nursing, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
| | - Yi Zhang
- Department of Nursing, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
| | - Lanjun Shen
- Department of Nursing, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
| | - Feixia Wu
- Department of Critical Care Medicine, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Xiaoyan Gong
- Department of Nursing, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
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Perez D, Murphy G, Wilkes L, Peters K. Being tied down—The experience of being physically restrained while mechanically ventilated in
ICU. J Adv Nurs 2022; 78:3760-3771. [DOI: 10.1111/jan.15354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/29/2022] [Accepted: 06/14/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Dawn Perez
- School of Nursing and Midwifery Western Sydney University Penrith New South Wales Australia
| | - Gillian Murphy
- School of Nursing and Midwifery/Translational Health Research Institute (THRI) Western Sydney University Penrith New South Wales Australia
| | - Lesley Wilkes
- School of Nursing and Midwifery Western Sydney University Penrith New South Wales Australia
| | - Kath Peters
- School of Nursing and Midwifery/Translational Health Research Institute (THRI) Western Sydney University Penrith New South Wales Australia
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Guenna Holmgren A, Juth N, Lindblad A, von Vogelsang AC. Nurses' experiences of using restraint in neurosurgical care - A qualitative interview study. J Clin Nurs 2021; 31:2259-2270. [PMID: 34514650 DOI: 10.1111/jocn.16044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 11/28/2022]
Abstract
AIM AND OBJECTIVES To describe nurses' experiences of using restraint in neurosurgical care. BACKGROUND Despite reports of negative consequences, and conflicts with key values in healthcare, restraint measures are still practised in somatic healthcare worldwide. When using restraint, basic principles of nursing collide, creating dilemmas known to be perceived as difficult for many nurses. Patients in neurosurgical care are at high risk of being subjected to restraint, but research on nurses' experiences of using restraint in neurosurgical care are scarce. DESIGN A qualitative, descriptive design guided by a naturalistic inquiry was used. METHODS Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden were analysed with inductive qualitative content analysis. COREQ reporting guidelines were used as reporting checklist. RESULTS The analysis resulted in one overarching theme, The struggling professional, and two categories. The category Internal struggle describes nurses' conflicting emotions and internal struggle when engaging in restraint. The category The struggle in clinical practice, describes how nurses struggle with handling restraint in clinical practice, and how the use of restraint is based on individual assessment rather than guidelines. CONCLUSION Nurses' experience restraint in neurosurgical care as a multi-layered struggle, ranging from inner doubts to practical issues. In order to enhance patient safety, there is a need for policies and guidelines regarding the use of restraint, as well as structured discussions and reflections for nurses engaged in the practice. RELEVANCE TO CLINICAL PRACTICE The results highlight the importance of clear guidelines, openness, support and teamwork for nurses working with patients at risk to be subjected to restraint, in order to create a safer care for patients as well as healthcare personnel. When developing guidelines and policies concerning restraint in somatic care, both practical issues such as the decision-making process, and the emotional effect on nurses should be considered.
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Affiliation(s)
- Amina Guenna Holmgren
- Stockholm Centre for Healthcare Ethics (CHE), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas Juth
- Stockholm Centre for Healthcare Ethics (CHE), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Anna Lindblad
- Stockholm Centre for Healthcare Ethics (CHE), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Ann-Christin von Vogelsang
- Department of Neurosurgery, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Cui N, Qiu R, Zhang Y, Jin J. "Patient Comfort Can Be Sacrificed for Patient Safety"-Perception and Practice Reported by Critical Care Nurses Toward Physical Restraints: A Qualitative Descriptive Study. Front Med (Lausanne) 2021; 8:573601. [PMID: 34368171 PMCID: PMC8342939 DOI: 10.3389/fmed.2021.573601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 06/25/2021] [Indexed: 12/30/2022] Open
Abstract
Aim: The aim of the study was to explore the perception and practice of physical restraints used by critical care nurses. Design: A qualitative descriptive design was used. Method: From December 2019 to May 2020, a one-to-one, semi-structured in-depth interview with 10 critical care nurses from two intensive care units in a tertiary general hospital with 3,200 beds in China was conducted using the method of purposeful sampling. The data were analyzed using inductive thematic analysis. Findings: The perception of physical restraints among critical care nurses was that patient comfort can be sacrificed for patient safety. Physical restraints protected patient safety by preventing patients from unplanned extubation but influenced patient comfort. Physical restraints were common practice of critical care nurses. Relative physical restraints provided patients with more freedom of movement and rationalization of physical restraints which were the practical strategies. Conclusion: The study identified problems in critical care nurses' perception and practice on physical restraints. Critical care nurses are confident that physical restraints can protect patient safety, and the influence of physical restraints on patient comfort is just like the side effect. Although physical restraints were common practice, critical care nurses still faced dilemmas in the implementation of physical restraints. Relative physical restraints and rationalization of physical restraints help critical care nurses cope with the “bad feelings,” which may also be the cause of unplanned extubation. It is necessary for the adaptation of clinical practice guidelines about physical restraints for critically ill patients in the Chinese context, to change the perception and practice of critical care nurses and deliver safe and high-quality patient care.
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Affiliation(s)
- Nianqi Cui
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, China
| | - Ruolin Qiu
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuping Zhang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, China
| | - Jingfen Jin
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, China.,Changxing Branch Hospital of SAHZU, Huzhou, China
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