Critical care nurses' experiences of physical restraint in intensive care units: A qualitative systematic review and meta‐synthesis

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.

Is physical restraint unethical and illegal?: a qualitative analysis of Korean written judgments

“…One interesting result is that the courts’ decisions on the use of PR due to staff shortages (Ethical dilemma situation 2 and 3) were different. Staff shortages have been identified as a factor that drives the use of PR, regardless of the care recipient’s condition [ 51 , 52 ], and this is generally considered unethical situation, violating the principle of justice [ 16 , 36 ]. However, studies conducted in Iran have shown that in situations of staff shortage, staff suffer ethical distress because there is no alternative for patient safety other than PR [ 52 ].…”

“…However, even if PR is used with good intentions, it has a risk of causing physical and psychological damage [ 13 ] to care recipients, and it can sometimes be abused [ 14 ] for the convenience of health workers. In particular, nurses are the traditional PR decision-makers who are most involved in patient care [ 15 , 16 ], but fear of safety accidents, consequent criticism, and legal responsibility contribute to nurses’ use of PR [ 16 ], as does individual nurses’ poor ethical sensitivity [ 17 ]. All people have the right to equal freedom and dignity [ 18 ]; however, PR has long been controversial because it infringes on individuals’ freedom of movement, forcibly restricts autonomy, and has negative impacts on health workers, who experience guilt and ethical dilemmas [ 10 , 12 , 19 , 20 ].…”

Phase I pilot safety and feasibility of a novel restraint device for critically ill patients requiring mechanical ventilation

“…[7][8][9][10][11][12][13][14][15] For ICU nurses, restraints confer a sense of security, but are also associated with feelings of guilt, sadness, and moral distress. 16,17 The 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) Clinical Practice Guidelines outline the many unintended and harmful consequences of physical restraint use, and recommend that efforts be taken to reduce their usage in the ICU setting. 18 As an alternative to traditional wrist restraints, a novel device, the Exersides ® Refraint ® (Healthy Design, Rutland, VT), was developed with the support of a National Institutes of Health Small Business Technology Transfer (STTR) Program Grant.…”

“…7 –15 For ICU nurses, restraints confer a sense of security, but are also associated with feelings of guilt, sadness, and moral distress. 16,17 The 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) Clinical Practice Guidelines outline the many unintended and harmful consequences of physical restraint use, and recommend that efforts be taken to reduce their usage in the ICU setting. 18…”