A mixed-methods systematic review protocol to examine the use of physical restraint with critically ill adults and strategies for minimizing their use

Organizational factors associated with less use of restraints in older adults with dementia in acute care hospitals: A scoping review

OBJECTIVE

Dementia affects more than 55 million people worldwide. Use of restraints for hospitalized older adults with dementia is a social issue that should be addressed systematically and should not depend on the characteristics of nurses. This study reviewed the literature on organizational factors associated with reducing use of restraints in older adults with dementia admitted to acute care hospitals.

METHODS

A scoping review was performed. Three databases were searched for papers that met our eligibility criteria. Factors related to restraint reduction were extracted, and results were deduced. Through inductive analysis, subthemes were categorized according to similarities and differences, which were then integrated into broader themes.

RESULTS

Sixteen studies were eligible for inclusion. The prevalence of restraints ranged from 5.1% to 80.0% depending on how the meaning of restraint was interpreted. The most common indications for restraints were history of falls and fall risk. Interdisciplinary screening for restraints was associated with reduced prevalence of restraints, with a 0.18-fold (confidence interval [CI]: 0.12-0.24) reduction through use of a restraint decision flowchart and a 0.76-fold (CI: 0.63-0.92) reduction through consultation with a psychiatrist. Interdisciplinary members included nurses, physicians, clinical psychologists, pharmacists, respiratory therapists, and therapists.

CONCLUSIONS

Research is needed to introduce and develop an interdisciplinary restraint decision-making system and to test its effectiveness. Important factors in implementing alternatives to restraints are the harmful effects of restraints, expertise in dementia, regular education on alternative methods, an inpatient environment that ensures patient safety, and the development of human resources.

Restrictive use of Restraints and Delirium Duration in the Intensive Care Unit (R2D2-ICU): protocol for a French multicentre parallel-group open-label randomised controlled trial

INTRODUCTION

Physical restraint (PR) is prescribed in patients receiving invasive mechanical ventilation in the intensive care unit (ICU) to avoid unplanned removal of medical devices. However, it is associated with an increased risk of delirium. We hypothesise that a restrictive use of PR, as compared with a systematic use, could reduce the duration of delirium in ICU patients receiving invasive mechanical ventilation.

METHODS AND ANALYSIS

The Restrictive use of Restraints and Delirium Duration in ICU (R2D2-ICU) study is a national multicentric, parallel-group, randomised (1:1) open-label, controlled, superiority trial, which will be conducted in 10 ICUs. A total of 422 adult patients requiring invasive mechanical ventilation for an expected duration of at least 48 hours and eligible for prescription of PR will be randomly allocated within 6 hours from intubation to either the restrictive PR use group or the systematic PR use group, until day 14, ICU discharge or death, whichever comes first. In both groups, PR will consist of the use of wrist straps. The primary endpoint will be delirium or coma-free days, defined as the number of days spent alive in the ICU without coma or delirium within the first 14 days after randomisation. Delirium will be assessed using the Confusion Assessment Method-ICU twice daily. Key secondary endpoints will encompass agitation episodes, opioid, propofol, benzodiazepine and antipsychotic drug exposure during the 14-day intervention period, along with a core outcome set of measures evaluated 90 days postrandomisation.

ETHICS AND DISSEMINATION

The R2D2-ICU study has been approved by the Comité de Protection des Personnes (CPP) ILE DE FRANCE III-PARIS (CPP19.09.06.37521) on June 10th, 2019). Participant recruitment started on 25 January 2021. Results will be published in international peer-reviewed medical journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT04273360.

Factors affecting nursing practice of patient physical restraint among nurses

BACKGROUND

This study was aimed to identify perception, knowledge, attitude and nursing practice toward use of physical restraints among clinical nurses.

METHODS

The research participants were 180 nurses from general hospitals located in Korea. Data were collected using self-report questionnaires regarding perception, attitude, knowledge, and nursing practice on application of physical restraints and analyzed using t-test, ANOVA, Pearson correlation coefficients, and multiple regression.

RESULTS

There were significant negative relationships attitudes towards the use of physical restraints with knowledge (r = -.32, p < .001). Knowledge showed a positive correlation with nursing practice (r = .28, p < .001). Factors affecting nursing practice of clinical nurses were identified as knowledge (β = .23), education experiences on physical restraints (Yes) (β = .18), and work unit (ICU) (β = .43). The explanation power of this regression model was 22% and it was statistically significant (F = 7.45, p < .001).

CONCLUSION

This study suggests that knowledge, education experiences on physical restraints, and work unit were the strongest predictor on nursing practice toward use of patient physical restraints. Therefore, developing and applying evidence-based educational intervention programs by work unit to reduce the inappropriate use of physical restraints in hospitals are required.

Health Effects of Policing in Hospitals: a Narrative Review

IMPORTANCE

Law enforcement activity, in the form of outside agencies or hospital security forces, is increasingly common in American healthcare. Little is known about the potential effects of this prevalent, modifiable exposure on hospital staff and patient health. This narrative review characterizes existing evidence on the direct and indirect health effects of law enforcement activity in hospitals.

OBSERVATIONS

Law enforcement activity in hospitals can affect health outcomes through four mechanisms: (1) physical health effects related to workplace violence, restraint use, excessive force, and weapon use; (2) mental health effects involving perceptions of safety and psychological distress; (3) social effects related to the patient-provider relationship, mistrust, and bias and discrimination; and (4) legal and ethical considerations affecting overall well-being.

CONCLUSIONS AND RELEVANCE

Unchecked law enforcement activity in hospitals may risk patient physical and mental health, reduce patient trust, result in bias and discrimination, and contribute to legal and ethical rights violations. Importantly, law enforcement activity in hospitals may also contribute to staff perceptions of safety. To fill knowledge gaps on the measurable impact of law enforcement activity in the hospital on staff and patients, hospitals should collect and publicly share robust data on law enforcement activity in their facilities, create and adopt patient-centered policies to ensure safety and protect patient health and privacy, and implement evidence-based interventions that safely reduce law enforcement involvement with patients.

Coercion in intensive care, an insufficiently explored issue-a scoping review of qualitative narratives of patient's experiences

Purpose

The use of coercion, in a clinical context as imposing a measure against a patient's opposition or declared will, can occur in various forms in intensive care units (ICU). One prime example of a formal coercive measure in the ICU is the use of restraints, which are applied for patients' own safety. Through a database search, we sought to evaluate patient experiences related to coercive measures.

Results

For this scoping review, clinical databases were searched for qualitative studies. A total of nine were identified that fulfilled the inclusion and the CASP criteria. Common themes emerging from the studies on patient experiences included communication issues, delirium, and emotional reactions. Statements from patients revealed feelings of compromised autonomy and dignity that came with a loss of control. Physical restraints were only one concrete manifestation of formal coercion as perceived by patients in the ICU setting.

Conclusion

There are few qualitative studies focusing on patient experiences of formal coercive measures in the ICU. In addition to the experience of restricted physical movement, the perception of loss of control, loss of dignity, and loss of autonomy suggests that restraining measures are just one element in a setting that may be perceived as informal coercion.

The patient and their family's perspectives on agitation and its management in adult critical care: A qualitative study

BACKGROUND

Agitation is frequently experienced by patients during critical illness, this is distressing for both the patient and their family. In addition, an acute episode of agitation can create management dilemmas for clinical teams. What is not understood is the patient and family's perspective of agitation and any subsequent management strategies employed.

OBJECTIVE

To understand the perspectives of patients and family members on the experience of agitation in adult critical care.

METHOD

An interpretive qualitative study using semi-structured interviews was undertaken with 13 participants, patient participants (n = 7) with the mean critical care length of stay 59 days (±70.88 days). Family members (n = 6) all opted to be interviewed with the patient present.

FINDINGS

Three themes generated from the data: 1) The recollection of sensations and delusions. 2) Communication and its impact. 3) Managing agitation, what helped and what did not.

CONCLUSION

The presence of family members has a positive effect on the patient during episodes of agitation. Their involvement in care requires promotion.

Protocol for a mixed-method systematic review on challenges perceived by final-year undergraduate nursing students in a clinical learning environment

Aims

To determine the challenges perceived by final‐year nursing students in the clinical learning environment.

Design

Data‐based convergent mixed‐method systematic review.

Methods

Three electronic databases (Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature) will be used in the identification stage. The first search will use the search string for each database to identify relevant studies. The articles retrieved will be screened by year of publication, article type and language. Abstracts and full‐text of selected studies will be screened for eligibility independently by a minimum of two reviewers. The reference lists will be manually screened to identify additional publications. The quality assessment will be conducted by two reviewers using the Mixed Methods Appraisal Tools. Quantitative and mixed‐method studies will be transformed into qualitative. A thematic approach will be used to synthesize and report the data. Ethics approval and funding have been approved in April 2020.

Discussion

This study will synthesize the types of challenges perceived by final‐year undergraduate nursing students in different clinical learning environments across the country.

Impact

The proposed study findings will help nursing education stakeholders and faculty provide assistance to final‐year nursing students in their transition year to become registered nurses.

The principles of physical restraint use for hospitalized elderly people: an integrated literature review

BACKGROUND

Physical restraint (PR) is a routine care measure in many hospital wards to ensure patient safety. However, it is associated with many different professional, legal, and ethical challenges. Some guidelines and principles have been developed in some countries for appropriate PR use. The present study aimed to explore the principles of PR use for hospitalized elderly people.

METHODS

This was an integrative review. For data collection, a literature search was conducted in Persian and English databases, namely Magiran, Scientific Information Database (SID), Scopus, Google Scholar, Web of Science, and PubMed as well as the websites of healthcare organizations and associations. Eligibility criteria were publication in English or Persian between January 1, 2010, and January 1, 2021, and description of the principles of PR use for hospitalized elderly people. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for document screening and selection, while the critical appraisal tools of the Joanna Briggs Institute (JBI) and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument were used for quality appraisal. The data were analyzed through constant comparison.

RESULTS

Primarily, 772 records were retrieved, while only twenty were eligible for the study. The principles of PR use for hospitalized elderly people were categorized into six main categories, namely principles of education for PR use, principles of decision making for PR use, principles of implementing the PR procedure, principles of monitoring patients with PR, principles of PR use documentation, and principles of PR management.

CONCLUSION

PR should be used only by trained healthcare providers, with the consent of patient or his/her family members, with standard devices and safe techniques, based on clear guidelines, and under close managerial supervision. Moreover, elderly people with PR should continuously be monitored for any PR-related complications. The findings of the present study can be used for developing clear PR-related guidelines.

Factors associated with the use of physical restraint in intensive care patients

OBJECTIVE

To verify the frequency of physical restraint in patients and the factors associated with its use in the intensive care unit.

METHOD

An observational and prospective study on the use of restraint in patients observed over two days, considering the variables: age and gender, personal and clinical characteristics, devices, adverse event and restraint use. The frequency was verified in three groups of patients with different conditions by applying the Chi-Squared, Likelihood Ratio or Kruskal-Wallis tests. The association of the variables was verified with the Multinomial Logistic Regression.

RESULTS

Eighty-four (84) patients participated. Restraint was observed in 77.4% of the 84 analyzed patients, and was more frequent in the presence of sedation, agitation and invasive devices. The chance of being restrained was at least five times higher in sedation conditions, whether in weaning or daily awakening, mechanical ventilation weaning, agitation or the presence of invasive devices.

CONCLUSION

Restraint use was high and was associated with female gender, sedation, agitation and invasive airway. It is emphasized and important to apply policies to reduce restraint use in intensive care.

Iranian nurses' perceptions about using physical restraint for hospitalized elderly people: a cross-sectional descriptive-correlational study

BACKGROUND

Using physical restraint (PR) for hospitalized elderly people is a major nursing challenge. It is associated with different physical and mental complications and ethical dilemmas, though many nurses still use it to ensure patient safety. Nurses' perceptions are one of the most important factors affecting PR use. This study aimed to evaluate Iranian nurses' perceptions about PR use for hospitalized elderly people.

METHODS

This cross-sectional descriptive-correlational study was conducted from July to December 2019. Participants were 270 hospital nurses who were purposively recruited from intensive care units and medical and surgical wards of three teaching hospitals in Kermanshah, Iran. Data were collected using a demographic questionnaire and the Perceptions of Restraint Use Questionnaire (PRUQ). The SPSS software (v. 23.0) was used for data analysis through the independent-sample t test, the one-way analysis of variance, and the multiple regression analysis.

RESULTS

The total mean score of PRUQ was 4.08 ± 0.12 in the possible range of 1-5. The most important reasons for PR use were to prevent patients from falling out of bed and to prevent them from pulling out catheters. The total mean score of PRUQ had significant relationship with participants' age, work experience, and history of receiving PR-related educations (P < 0.05), but had no significant relationship with their gender, educational degree, and affiliated hospital ward (P > 0.05).

CONCLUSION

This study suggests that nurses attach high importance to PR use for hospitalized elderly people. Healthcare policy-makers at national and hospital levels are recommended to provide nurses with PR-related educations in order to reduce the rate of PR-related complications.

Nurses' Knowledge, Attitude, and Influencing Factors regarding Physical Restraint Use in the Intensive Care Unit: A Multicenter Cross-Sectional Study

Background

Physical restraint is a common practice in the intensive care units which often result in frequent skin laceration at restraint site, limb edema, restricted circulation, and worsening of agitation that may even end in death. Despite the sensitivity of the problem, however, it is felt that there are nurses' evidence-based practice gaps in Ethiopia. To emphasize the importance of this subject, relevant evidence is required to develop protocols and to raise evidence-based practices of health professionals. So, this study aimed to assess the knowledge, attitude, and influencing factors of nurses regarding physical restraint use in the intensive care units in northwest Ethiopia.

Methods

An institution-based cross-sectional study was maintained from March to September 2019 at Amhara regional state referral hospitals, northwest Ethiopia. A total of 260 nurses in the intensive care units were invited to take part in the study by a convenience sampling technique. The Level of Knowledge, Attitudes, and Practices of Staff regarding Physical Restraints Questionnaire was used to assess the nurses' knowledge and attitude. Linear regression analysis was employed to examine the influencing factors of knowledge and attitude. Adjusted unstandardized beta (β) coefficient with a 95% confidence interval was used to report the result of association with a p value < 0.05 statistical significance level.

Result

The mean scores of nurses' knowledge and attitude regarding physical restraint use among critically ill patients were 7.81 ± 1.89 and 33.75 ± 6.50, respectively. These mean scores are above the scale midpoint nearer to the higher ranges which imply a moderate level of knowledge and a good attitude regarding physical restraint. Lower academic qualification and short (<2 years) work experience were associated with lower-level of knowledge, and reading about restraint from any source and taken training regarding restraints were factors associated with a higher knowledge. Diploma and bachelor's in academic qualification were significantly associated with a negative attitude regarding restraint. Besides, there was a more positive attitude among nurses with a higher level of knowledge and who received training regarding physical restraint use.

Conclusion

The nurses working in the intensive care unit had a moderate level of knowledge and a good attitude regarding physical restraint use. So, developing and providing educational and in-service training to the nurses regarding physical restraint are necessary to strengthen the quality of care for critically ill patients.

Physical and Pharmacological Restraints in Hospital Care: Protocol for a Systematic Review

BACKGROUND

Physical and pharmacological restraints, defined as all measures limiting a person in his or her freedom, are extensively used to handle unsafe or problematic behavior in hospital care. There are increasing concerns as to the extent with which these restraints are being used in hospitals, and whether their benefits outweigh their potential harm. There is currently no comprehensive literature overview on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in the hospital setting.

METHODS

A systematic review of the existing literature will be performed on the beneficial and/or adverse effects of physical and pharmacological restraints in the hospital setting. Relevant databases will be systematically searched. A dedicated search strategy was composed. A visualization of similarities (VOS) analysis was used to further specify the search. Observational studies, and if available, randomized controlled trials reporting on beneficial and/or adverse effects of physical and/or pharmacological restraints in the general hospital setting will be included. Data from included articles will be extracted and analyzed. If the data is suitable for quantitative analysis, meta-analysis will be applied.

DISCUSSION

This review will provide data on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in hospital care. With this review we aim to guide health professionals by providing a critique of the available evidence regarding their choice to either apply or withhold from using restraints. A limitation of the current review will be that we will not specifically address ethical aspects of restraint use. Nevertheless, the outcomes of our systematic review can be used in the composition of a multidisciplinary guideline. Furthermore, our systematic review might determine knowledge gaps in the evidence, and recommendations on how to target these gaps with future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42019116186.

The effect of physical restraint on neurovascular complications in intensive care units

BACKGROUND

To reduce the neurovascular complications caused by physical restraint in intensive care patients, there is a need to examine the occurrence of neurovascular complications and their rate.

OBJECTIVES

The objective of this research was to investigate the effect of physical restraint on the occurrence of neurovascular complications and their rate.

METHODS

A prospective observational cohort study was carried out. A total of 90 patients from anaesthesia and internal intensive care units participated in this study. Patients were assessed at intervals of 24 h for 4 days using the following instruments: Individual Characteristics Form, Richmond Agitation-Sedation Scale (RASS), Behavioral Pain Scale, and Complication Diagnostic Diary.

RESULTS

Redness (p < 0.001), limb movement (p < 0.001), oedema (p < 0.001), and colour complication (p < 0.001) increased, whereas pulse strength (p < 0.001) decreased in physically restrained sites on the arm from day 1 to day 4. Redness was increased in patients physically restrained with all types of materials (p < 0.001; p < 0.001; p = 0.020). Although there was a statistically significant difference in terms of movement (p = 0.006; p = 0.003) and oedema (p < 0.001; p < 0.001), both with a roll of gauze and tough cuff, these complications were not significantly different in patients restrained with green foam tie (p > 0.05). According to logistic regression analysis, material type, position of the limb, space between the physical restraint and limb, age, RASS, and pain were independent risk factors for neurovascular complications. RASS and pain were independent protective factors against movement complications.

CONCLUSIONS

The duration of physical restraint increases neurovascular complications. This study revealed that nurses did not regularly check the restrained wrist and did not focus on the peripheral circulation. It is necessary to develop training programs, standards, and appropriate follow-up strategies in intensive care units in Turkey.

Two-hit model of postintensive care syndrome induced by lipopolysaccharide challenge and subsequent chronic unpredictable stress in mice

Postintensive care syndrome (PICS) is defined as a new or worsening impairment in cognition, mental health, and physical function after critical illness. However, there is still a lack of a clinically relevant animal model. Thus, development of a PICS model is essential for understanding the mechanism underlying PICS and screening treatment methods for this neuropsychiatric disorder. The purpose of this study was to establish a clinically relevant PICS model based on the two-hit concept, in which lipopolysaccharide (LPS, 3 mg/kg) injection was served as the first hit and subsequent modified chronic unpredictable stress as the second hit. In order to pharmacologically verify the proposed model of PICS, we studied the effectiveness of fluoxetine to reverse the behavioral and molecular abnormalities in this model. In the present study, body- and adrenal weight changes proved our model was effective, as reflected by body weight loss, increased adrenals weight, and a significantly increased level of plasma corticosterone. Moreover, our PICS model displayed reproducible anxiety- and depression like behavior and cognitive impairments. Neurobiological investigations revealed a significant up-regulation of the microglial marker CD68 and pro-inflammatory cytokine IL-6 in the hippocampus of stressed mice. Notably, chronic treatment with fluoxetine for three weeks reversed most of the affected parameters. In summary, we believe that we have developed a new model of PICS that is clinically relevant, which could advance the mechanism research and the development of therapeutic strategies.

The Conditions for Ethical Application of Restraints

Despite the lack of evidence for the effectiveness of physical restraints, their use in patients is widespread. The best ethical justification for restraining patients is that it prevents them from harming themselves. We argue that even if the empirical evidence supported their effectiveness in achieving this aim, the use of restraints would nevertheless be unethical, so long as well-known exceptions to informed consent fail to apply. Specifically, we argue that ethically justifiable restraint use demands certain necessary and sufficient conditions. These conditions are that the physician obtained informed consent for their application, that their application be medically appropriate, and that restraints be the least liberty-restricting way of achieving the intended benefit. It is a further question whether their application is ever medically appropriate, given the dearth of evidence for their effectiveness.

Nurses' knowledge, attitudes and practices related to physical restraint: a cross-sectional study

AIM

To investigate nurses' knowledge, attitudes and practices related to physical restraint in tertiary hospitals and identify the factors that influence physical restraint use.

BACKGROUND

Physical restraint is used to maintain patient safety. Nurses play an important role in the restraint process. It is important to identify their understanding, feelings and approach regarding the use of physical restraint.

INTRODUCTION

Physical restraint is widely practiced in hospitals in China. However, it results in a range of serious negative consequences. This article provides a clear description of nurses' knowledge, attitudes and practices related to physical restraint.

METHODS

A cross-sectional survey was conducted. The participants were asked to complete a questionnaire examining their knowledge, attitudes and practices related to physical restraint use. A total of 200 questionnaires were distributed in four tertiary hospitals in Hubei Province, China between August and October 2014.

RESULTS

The nurses' responses indicated a good level of knowledge regarding physical restraint use. However, they held some misconceptions. The nurses' attitudes towards physical restraint tended to be neutral. The nurses were well experienced in the use of physical restraint. Nurses who had received on-the-job training performed better than those who had received no training related to knowledge and practices regarding physical restraint use.

CONCLUSIONS AND IMPLICATION FOR NURSING/HEALTH POLICY

In-service training is highly recommended for nursing managers to improve nurses' physical restraint related knowledge and practices. Regulations regarding the use of restraints should be established as soon as possible by healthcare administration system.

IMPLICATIONS FOR NURSING

Nurses should be open to evaluate and improve their views and attitudes regarding effective physical restraint use via multidimensional interventions.

Critical care nursing: caring for patients who are agitated

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