Use of restraint with hospitalized children: A survey of nurses' perceptions of practices

[Measuring the intensity of restraint during care in children: Validation of the Pric scale]

Restraint is used relatively often during pediatric care. However, no scale has yet been validated to assess its intensity. The study presented here did this for the Procedural Restraint Intensity in Children tool in metrological terms (with some limitations). In the absence of a reference scale in this area, the reliability of this tool was studied under experimental conditions. It is nevertheless the first scale with metrological validation, measuring the intensity of physical constraint. Other work is underway to validate it in real clinical situations.

[Using restraint during treatment: Definitions, contexts and benchmarks]

The clinical practice of nursing sometimes leads to physically restraining the patient while carrying out a therapeutic or diagnostic procedure. This laconic observation says little about the many questions raised by the use of restraint on a person during treatment. The questions are professional, institutional, philosophical, ethical, legal and deontological. The role of the nurse in the decision to use coercion to provide care is preponderant, and the moral dilemmas that this decision provokes are most often carried out individually by the professionals.

The parent, child and young person experience of difficult venous access and recommendations for clinical practice: A qualitative descriptive study

AIMS AND OBJECTIVES

Explore the parent and child/young person experience of difficult venous access and identify ideas and preferences for changes to clinical practice.

BACKGROUND

Peripheral intravenous catheter insertion is one of the most common invasive procedures in hospitalised paediatric patients. Multiple insertion attempts in paediatric patients are common and associated with pain and distress. Little research has explored the parent and child/young person experience of difficult venous access nor sought to identify their suggestions to improve clinical practice.

DESIGN

Qualitative description.

METHODS

A purposive sampling approach was used to identify children and young people with experience of difficult venous access and their parents. Semi-structured interviews were conducted, with sample size based on data saturation. Transcripts were analysed using thematic analysis.

RESULTS

There were 12 participants, seven parents and five children/young people (five parent/child dyads and two individual parents). Analysis of the data revealed three main themes: (1) Distress-before, during and after (2) Families navigating the system: the challenging journey from general clinician to specialist and (3) Difficult venous access impacts both treatment and life outside the hospital A pre-determined theme, (4) Recommendations for good clinical practice is also described.

CONCLUSIONS

Multiple attempts to insert a peripheral intravenous catheter are a source of substantial distress for children/young people, leading to treatment avoidance. Effective interpersonal skills, providing choice and avoiding frightening language are important to minimise distress. Clinicians without specialist training should assess each child's venous access experience and consider immediate referral to a specialist if they have a history of difficult venous access. Cultural change is required so clinicians and healthcare services recognise that repeated cannulation may be a source of psychological distress for children/young people.

A cross-sectional survey of moral distress and ethical climate - Situations in paediatric oncology care that involve children's voices

Aim

To assess experiences of morally distressing situations and perceptions of ethical climate in paediatric oncology care, with a focus on situations that involve children's voices.

Design

Cross‐sectional survey.

Methods

Registered Nurses at all four paediatric oncology centres in Denmark were asked to complete a web‐based questionnaire with Danish translations of the Swedish Moral Distress Scale‐Revised (MDS‐R) and the Swedish Hospital Ethical Climate Survey‐Shortened (HECS‐S). Data analysis included descriptive statistics and non‐parametric correlation tests.

Results

Nurses (n = 65) perceived morally distressing situations as rather uncommon, except for those that involved shortage of time, poor continuity of care and unsafe staffing levels. Most nurses (83%) found it disturbing to perform procedures on school‐aged children against their will, and 20% reported that they do this often. Perceptions of ethical climate were positive and healthcare professionals were perceived to be attentive to children's wishes.

Physician Perspectives on Severe Behavior and Restraint Use in a Hospital Setting for Patients with Autism Spectrum Disorder

Hospitals, with many features that can evoke severe behavior in patients with autism spectrum disorder (ASD), often use restraint as a behavior management strategy. Prior research on restraint in patients with ASD has primarily focused on children or specific departments. Twenty-five physicians and medical trainees from an urban teaching hospital participated in discussions about experiences managing severe behavior in patients with ASD across the lifespan. Twenty themes emerged from thematic analysis of participant transcripts. The five most salient themes included: lack of procedural knowledge with restraint implemented by other hospital professionals; alternative strategies to manage severe behavior; negative perceptions of restraint; helpful role of caregivers; and limited experience treating patients with ASD, and critical need for training in function-based management.

Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis

Physical restraint is regularly used in children and adolescent mental health care, often as a reactive behaviour management strategy. Physical restraint has been associated with physical injury, but psychological consequences are poorly understood. The aim of this systematic review was to examine physical restraint of children and adolescents in inpatient mental healthcare services. Healthcare databases were searched to identify English language publications discussing anyone aged ≤18 years who had experienced physical restraint as a mental health inpatient. No date restrictions were applied. Sixteen quantitative studies are included within this review. Most studies are retrospective in nature. Publications were appraised using the Critical Appraisal Skills Programme quality assessment tool. Common characteristics associated with children and adolescents who experience physical restraint include age, gender, diagnosis, and history. Most studies associate physical restraint with the management of aggression. Findings suggest that it may be a combination of patient (intrinsic) and environmental (extrinsic) factors which ultimately lead to children and adolescents experiencing restraint. This review confirms that little is known about children and adolescents' first-hand experiences of physical restraint. Future research should address children and adolescents' perceptions and first-hand experiences of physical restraint.

A practical and ethical toolkit for last-minute refusal of anesthetic in children

Children's fear of a procedure, including the anesthetic, is a common issue that operating theatre staff face. This fear is generally mitigated by preesthetic preparation and information sharing. Last-minute refusal of a procedure creates unique difficulties for the anesthetist and proceduralist. Refusal for a procedure raises issues of whether the dissent is binding, and if not, how best to get the child to theatre without creating moral injury. In this case review of a young adolescent who refuses to go to the operating theatre, we explore practical and ethical options to resolve the situation. We discuss respect for persons (including assent and consent), best interests, truth-telling, harm minimization, and restraint. The importance of a postevent debrief is discussed. We also assess the value of a clinical ethics service with team members embedded in clinical teams.

Children's Co-Determination During Challenging Procedures: Nurses and Parents Experiences of Caring Under Short-Term Hospital Stays in Norway

BACKGROUND

Medical and clinical procedures can cause varying levels of discomfort to children.

PURPOSE

This study is to deepen the understanding of the lived experiences of parents and nurses related to challenging medical and clinical procedures performed on children during short-term hospital stays.

DESIGN AND METHODS

This qualitative study, which comprises part of a larger study, adopted a hermeneutic phenomenological approach. The data were obtained through a combination of in-depth interviews and observations of twelve parents of eleven children and seventeen nurses. A narrative re-analysis was conducted of four challenging medical and clinical procedures. Four stories were written and subsequently analyzed as one narrative that represents the findings.

RESULTS

The form of nurses' and parents' care for the children ranged from encouraging the children's consent and receptiveness to the procedures, to coercion. The analysis indicates that promoting the children's co-determination and participation in the procedures encouraged their consent and receptiveness and facilitated a successful outcome. In contrast, an absence of efforts to involve the children in the procedures contributed to the need for coercion to be employed by parents and nurses. Moreover, parental influence and the responsibilities of nurses had an impact on children's co-determination and participation.

CONCLUSIONS

Preparing parents and children before and during a procedure was important to minimize the degree of coercion of the children.

PRACTICE IMPLICATIONS

The findings of this study are relevant to clinical practice because they suggest preparing parents and children before and during a procedure situation.

'The mean mummy way' - experiences of parents instilling eye drops to their young children as described in online forums and blogs

BACKGROUND

Adults often have difficulty instilling eye drops in their own eyes, but little has been documented about the difficulties experienced by parents when administering eye drops to their young children, where the challenges of instillation are accentuated by their inability to cooperate. This qualitative study explores parents' experiences of administering eye drops to their children as described in online forum discussions and blog posts.

METHODS

This was an exploratory study using qualitative methods. We thematically analysed the written exchanges between parents participating in online forum discussions and blog posts about the administration of eye drops to their young children.

RESULTS

We found 64 forum discussion threads and 4 blog posts, representing 464 unique contributors expressing their experiences of eye drop administration to young children. Three major themes were identified - administration challenges, administration methods and role of health care professionals. Besides describing their children's distress, parents discussed their own discomfort and anxiety when administering eye drops. Parents used a variety of techniques to facilitate adherence with medication, including restraining the child, role-play, reassurance, distraction, or reward. The ideas exchanged about eye drop administration occasionally included reiteration of professional advice, but were dominated by parents' own ideas/suggestions; interestingly health care professionals were considered diagnosticians and prescribers, rather than sources of practical advice on administration.

CONCLUSIONS

Parents struggling to deliver eye drops to their young children may seek advice on how to administer treatment from parental on-line discussion forums. The distress experienced by the young child and their parents is a powerful reminder to clinicians that procedures common and routine in health care may be challenging to parents. The advice given to parents needs to go beyond the instillation of the eye drops, and include advice on child restraint, distraction techniques and allaying distress. Forewarned of the potential difficulties and provided with coping strategies parents can employ when the child resists, could alleviate their own and their child's distress.

Restraint in paediatrics: A delicate balance

Patient restraint in health care is currently under intense review. There are two disparate groups that should be considered. First, infants and young children are commonly restrained while undergoing simple medical procedures such as venepuncture or immunisation, and this practice may be better framed as 'hugging' not 'holding'. Second, there is a distinct but significant group of children and adolescents with serious psychiatric or organic illness with behavioural disturbances necessitating restraint, who are the primary focus of this paper. Nevertheless, the balance between restraining any young person in health care and causing preventable harm is delicate: any form of child restraint, whether physical, chemical or seclusion, merits ethical reflection and should be undertaken judiciously. All clinicians should prioritise the dignity and privacy of the young person while weighing the vulnerability of this cohort of patients.

A simple tool to measure procedural restraint intensity in children: validation of the PRIC (Procedural Restraint Intensity in Children) scale

Purpose

Restraint is often used when administering procedures to children. However, no metrologically scale to measure the restraint intensity had yet been validated. This study validated the metrological criteria of a scale measuring the restraint intensity, Procedural Restraint Intensity in Children (PRIC), used during procedures in children.

Design and methods

The PRIC scale performance was measured by a group of 7 health professionals working in a children's hospital, by watching 20 videos of health care procedures. This group included 2 physicians, 1 pediatric resident, and 4 nurses. The intra-class correlation coefficients were calculated to evaluate the inter-rater and test-retest reliability and the construct validity with the correlation between PRIC scale and a numerical rating scale.

Results

One hundred and forty measurements were made. Inter-rater and test-retest correlation coefficients were 0.98 and 0.98, respectively. The 2 scales were positively correlated with a Spearman coefficient of 0.93.

Conclusions

This study validated the Procedural Restraint Intensity in Children (PRIC) scale in metrological terms with some limitation. However, there is not gold standard scale to precisely validate the reliability of this tool and this study has been conducted in “experimental” conditions. Nevertheless, this is the first scale measuring the intensity of physical restraint with a metrological validation. The next step will be to validate it in real clinical situations.

Australasian radiographers' choices of immobilisation strategies for paediatric radiological examinations

INTRODUCTION

Immobilisation may be necessary to ensure patient safety and examination success in paediatric medical imaging. Little guidance exists regarding the selection of different immobilisation methods. The purpose of this study was to explore radiographers' selection of immobilisation methods in paediatric medical imaging and the influences on their choices.

METHODS

Ethical approval was obtained. A mixed methods approach consisting of online questionnaire distribution followed by individual interviews was used to explore Australasian radiographers' self-reported patterns of immobilisation use and the underlying reasons and beliefs. Quantitative data were described using frequency data, with a Fisher's Exact test used to determine any association between demographic variables and immobilisation methods. Qualitative data were evaluated using content analysis.

RESULTS

Sixty-five radiographers returned completed questionnaires, with seven participating in interviews. Psychological immobilisation methods were preferred to minimise patient pain and distress, but physical methods were considered more effective, with parental holding the most likely method to be used (63/65, 96.9%). Participants assumed certain methods to be more appropriate based on patient age and examination type, but adapted their choices based on many other factors, seeking to provide personalised care. Further training was strongly desired (48/64, 75.0%). Participants disagreed on whether introducing written guidance would be beneficial (33/62, 53.2%).

CONCLUSION

Choosing an immobilisation method appears to be a case-by-case activity requiring critical assessment of multiple factors in order to balance patient care with examination success.

IMPLICATIONS FOR PRACTICE

Improvements in quality and quantity of education are recommended to enhance radiographers' ability to make choices based on all relevant factors.

Caregivers blinded by the care: A qualitative study of physical restraint in pediatric care

BACKGROUND

The phenomenon of forceful physical restraint in pediatric care is an ethical issue because it confronts professionals with the dilemma of using force for the child's best interest. This is a paradox. The perspective of healthcare professional working in pediatric wards needs further in-depth investigations.

PURPOSE

To explore the perspectives and behaviors of healthcare professionals toward forceful physical restraint in pediatric care.

METHODS

This qualitative ethnographic study used focus groups with purposeful sampling. Thirty volunteer healthcare professionals (nurses, hospital aids, physiotherapists, and health educators) were recruited in five pediatric facilities in four hospitals around Paris, France, from March to June 2013. The data were processed using NVIVO software (QSR International Ltd. 1999-2013). The data analysis followed a qualitative methodological process.

ETHICAL CONSIDERATIONS

The research was conducted in compliance with the Declaration of Helsinki. Written informed consent was collected systematically from participants.

FINDINGS

This study provides elements to help understand why restraint remains common despite its contradiction with the duty to protect the child and the child's rights. All participants considered the use of forceful physical restraint to be a frequent difficulty in pediatrics. Greater interest in the child's health was systematically used to justify the use of force, with little consideration for contradictory or ethical aspects. Raising the issue of forceful restraint always triggered discomfort, unease and an outpour of emotions among healthcare professionals. The findings have highlighted a form of hierarchy of duties that give priority to the execution of the technical procedure and legitimize the use of restraint. Professionals seemed to temporarily suspend their ability to empathize in order to apply restraint to carry out a technical procedure. This observation has allowed us to suggest the concept of "transient empathic blindness."

CONCLUSION

Using physical restraint during pediatric care was considered a common problem by participants. This practice must be questioned, and professionals must have access to training to find alternatives to strong restraint. Conceptualizing this phenomenon with the concept of "transient empathic blindness" could help professionals understand what happens in their minds when using forceful restraint.

Professionals' experiences with paediatric colonoscopy: an interview study

Background

Colonoscopy plays a crucial role in the diagnosis of paediatric inflammatory bowel disease (IBD), adolescents comprise 25% of all cases of IBD. Several studies have found that a safe, informative, and effective colonoscopy, performed in a child-friendly atmosphere with minimal distress to the child, is difficult to achieve.

The aim of this study was to describe nurse’s experiences of the pre-colonoscopy procedure prior in children.

Methods

A qualitative design with a thematic content analysis approach was used. Fifteen nurses at a children’s hospital participated in interviews regarding their experiences of the bowel cleansing procedure with PEG in children.

Results

Four key themes were extracted from the nurses’ experiences; lack of knowledge, challenges surrounding information, responsibility without control and assembly line- like procedure..

Conclusions

This study shows that nurses feel that they need more time and education opportunities before involved in paediatric colonoscopies.

A qualitative study of health professionals' views on the holding of children for clinical procedures: Constructing a balanced approach

Children undergoing clinical procedures can experience fear, uncertainty, and anxiety which can cause them to become upset and resist procedures. This study aimed to capture an international perspective of how health professionals report they would act if a child was upset and resisted a procedure. An online questionnaire, distributed through network sampling, used three vignettes to elicit qualitative open text responses from health professionals. Seven hundred and twelve professionals participated, resulting in 2072 pieces of text across the three vignettes. Many professionals reported that they would use distraction and spend time to inform and engage children in making choices about their procedure. However, most professionals indicated that if a child became uncooperative they would hold or instruct the holding of the child in order to get the procedure done 'as quickly as possible'. The findings demonstrate that professionals experience difficulty in balancing the different agendas, rights and priorities within the momentum which can build during a clinical procedure, often resulting in the child's voice and rights being undermined. A more balanced approach could be facilitated by a 'clinical pause' that would equip professionals with the time to consider children's expressed wishes and explore alternative approaches to holding.

Exploring perspectives on restraint during medical procedures in paediatric care: a qualitative interview study with nurses and physicians

The aim of this study was to explore nurses’ and physicians’ perspectives on and reasoning about the use of restraint during medical procedures on newly admitted preschoolers in somatic hospital care.

We analysed qualitative data from individual interviews with a video recall session at the end with seven physicians and eight nurses. They had earlier participated in video recorded peripheral vein cannulations on preschool children. The data were collected between May 2012 and May 2013 at a paediatric hospital unit in Norway.

The analysis resulted in three main themes: (1) disparate views on the concept of restraint and restraint use (2), ways to limit the use of physical restraint and its negative consequences, and (3) experience with the role of parents and their influence on restraint. Perspectives from both healthcare professions were represented in all the main themes and had many similarities.

The results of this study may facilitate more informed and reflective discussions of restraint and contribute to higher awareness of restraint in clinical practice. Lack of guidance and scientific attention to restraint combined with conflicting interests and values among healthcare providers may result in insecurity, individual dogmatism, and a lack of shared discussions, language, and terminology.

Holding children for procedures: An international survey of health professionals

Children undergoing clinical procedures can experience pain and/or anxiety. This may result in them being unwilling to cooperate and being held still by parents or health professionals. This study aimed to capture an international perspective of health professionals' reported practices of holding children still for clinical procedures. An online questionnaire was distributed through network sampling to health professionals working with children aged under 16 years of age. A total of 872 responses were obtained from Australia ( n = 477), New Zealand ( n = 237) and the United Kingdom ( n = 158). Responses were from nurses ( n = 651), doctors ( n = 159) and other professionals ( n = 53). Health professionals reported children as held still for clinical procedures quite often (48%) or very often (33%). Levels of holding varied significantly according to country of practice, profession, student status, length of time working within a clinical setting, training received and the availability of resources in the workplace. Health professionals who gained permissions (assent from children and/or consent from parents) before procedures were less likely to hold children still for a clinical procedure than those who did not. Holding children still for procedures is an international practice, which is influenced by training, access to guidance, country of practice and profession. Children's permission and parental consent is often not sought before a child is held for a procedure to be completed.