Critically ill patients admitted to an intensive care unit (ICU) commonly require an array of invasive procedures and medical apparatus (Martin & Mathisen, 2005). Despite the necessity of these interventions, they can cause patients a great degree of pain and discomfort leading to restlessness and agitation (Langley, Schmollgruber & Egan, 2011). Restraints are often applied to prevent patients from accidently or purposefully removing medical devices, often termed as ‘treatment interference’ (Hofsø & Coyer, 2007), which can be detrimental for their health, safety and medical progress and may even result in death (Kielb, Hurlock-Chorostecki & Sipprell, 2005). While nurses strive to deliver care to patients that align with their ethical code of conduct of beneficence, non-maleficence, dignity and autonomy, it is still common practice in many countries for this to occur.
Restraints are therefore often considered to be an unavoidable intervention in ICUs to protect patients and ensure they receive essential treatment (van der Kooi et al., 2015). However, PR ultimately encroaches on patient’s autonomy and interferes with the clinician’s ability to preserve patient dignity (Jiang, Li, Gu & He, 2015). Restraints can also cause physical injuries, exacerbate delirium and agitation, and have been associated with a higher risk for the development of post-traumatic stress disorders (PTSD). (Warlan & Howland, 2015) Patients receiving mechanical ventilation are particularly vulnerable as they are already susceptible to a great degree of pain and discomfort and are also unable to verbally communicate (Wang, Zhang, Li & Wang, 2009). Patients’ families can also be affected by this experience as they are often present during their ICU admissions and witness PR during mechanical ventilation possibly generating greater familial distress (Fink et al., 2015).
Purpose
The purpose of this presentation was to explore contemporary literature regarding the use of physical restraints in intensive care.
Methods
Quantitative and qualitative research that explored the experiences of physical restraints in ICU that were published between January 2007 and July 2016 were considered for this review. Studies that focused on the use of physical restraints in ICU, roles of nurses in the application and removal of physical restraints, and patient/family experiences were included. Search terms used included: physical restraints, intensive care, mechanical ventilation, experience, patients, families and nurses. Databases searched were Cinahl, Proquest, Medline, Pubmed and Cochrane. A total of 17 papers (13 quantitative, 2 qualitative and 2 mixed method) were included in this review.
Results
Five major themes emerged from the review of the current literature regarding physical restraint ICU and will be further discussed.
Prevention of treatment interference
The prevention of treatment interference was identified as the most common rationale for the use of physical restraints in intensive care, particularly for the prevention of self-extubation (Benbenbishty, Adam & Endacott, 2010). Self-extubation is the accidental or purposeful removal of an endotracheal or tracheostomy tube performed by the patient on themselves (Chang, Wang & Chao, 2008). This was closely followed by the prevention of the removal of lines, tubes and other medical devices (Benbenbishty et al., 2010). It was identified through the literature that despite the evidence showing the causes for self-extubation is complex and multifactorial, health care professionals often use physical restraints as the simplest remedy (Chang, Liu, Huang, Yang & Chang, 2011). However, three out of the four studies included in the review found that >80% of patients who self-extubated were in fact restrained during the time of extubation (Chang et al., 2011; Chang et al., 2008; Curry, Cobb, Kutash & Diggs, 2008). This suggests that physical restraints can often be an ineffective method to combat against treatment interference despite being the most commonly used one.
Nurses as the primary decision makers in the application and removal of physical restraints
The current literature suggests that the nurses have inherited the role as the primary decision makers in the application and physicians, with physicians suggesting that this may result from doctors’ attitudes that physical restraints do not play an integral part of a patient’s medical management (De Jonghe et al., 2013).
Flaws in the practice and documentation of physical restraints were also highlighted by the recent literature. A large proportion of nurses surveyed admitted to applying physical restraints without documenting in patient notes and often without a written medical order (Turgay, Sari & Genc, 2009). It was also found that more experienced nurses were more likely to document in patient notes regarding restraints, as well as regularly assess restrained body parts than novice nurses. It was suggested that this may result from the significantly less education and training novice nurses receive in comparison to the accumulated knowledge gained by experienced nurses in restraint practices (Kandeel & Attia, 2013). This highlights the need for improved education and training in this area.
Adherence to protocols
Restraint minimization policies and protocols are in place to prevent patients from being unnecessarily restrained and to provide safe, standardised care to patients (Luk, Burry, Rezaie, Mehta & Rose, 2015). The studies found exploring restraint protocols in ICU revealed that many ICUs did not have protocols in place and those that did had minimal adherence to them (Luk et al., 2015; van der Kooi et al., 2015). This led to widely varying methods of application from those that were firmly applied, to restraints that were ineffective where patients were in easy reach of their endotracheal tubes (Langley et al., 2011). However, despite the negative aspects of physical restraints it was found that clinicians still believed that there was a valid place for them in ICUs and ultimately it comes down to a balancing act between its necessity and negative outcomes (Langley et al., 2011).
Moral and ethical dilemmas faced by nurses
The findings of two studies revealed that the application of physical restraints can cause nurses moral distress, ethical dilemmas, guilt and ambivalent feelings (Choe, Kang & Park, 2015). Despite this, the majority of nurses reported they had not received any education or training in dealing with ethical dilemmas resulting in them being inadequately prepared to cope with these issues in the workplace (Yönt, Korhan, Dizer, Gümüş & Koyuncu, 2014). This not only highlights the need for support, education and training for nurses but the scarcity in the knowledge available in this area.
Experiences of patients and families
The last major theme was the experiences of ICU patients and families. Only one qualitative study was found. While this paper highlighted the importance of communication between nurses to patients and family on reasons behind physical restraint use it did not provide much insight onto other aspects of the experience which only emphasizes the gap in the literature regarding this phenomenon (Weyant & Roberts, 2012). It can be difficult for nurses to improve the care they provide to patients if there is no knowledge available on patient experiences or perspectives.
Conclusion
The review of the current literature confirms the high prevalence in the use of physical restraints in intensive care. While the fundamental objective of its use is patient protection, there are a myriad of areas within its practice that could be improved. These areas include the development and implementation of policies and protocols, the need for improved education and training surrounding physical restraint practices in an ICU context, and the provision of support for nurses in dealing with the associated moral and ethical dilemmas. The literature also highlights the paucity of current knowledge surrounding the lived experiences of physical restraints in ICU from the perspectives of patients, family members and nurses.
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