A workable definition for physical or chemical restraint is required

Participants highlighted confusion about the words used to describe physical restraint such as ‘mittens’, ‘gloves’, ‘holding’, mirroring the findings of Freeman et al’s study.1 During the Twitter chat, mental health practitioners suggested that clear definitions are available and were surprised at how little consideration was given to restraint outside of the mental health arena. During the discussions, there was an inference that the choice of terminology or language used could be a way of ‘humanising’ the restraining intervention or masking the implications of using restraints, one participant noting that ‘holding’ had more positive connotations than the term ‘restraining’ (figure 1). Participants of the chat often cited a caveat to the use of physical restraint, for example restraint is often in the patient’s best interest or essential to maintain safety because the patient may be at risk of harm to self or staff, supported by research findings.4 Yet a clear, consistent, single definition of what constitutes a physical restraint appears to be lacking within the literature. Martin and Mathisen define physical restraint as ‘all patient articles, straps, bed linen and vest, used as an intervention to restrict a person’s freedom of movement or access to their own body’.5 Whereas, Mion et al define physical restraint as any ‘device that was attached to the patient for the purpose of limiting voluntary movement’, more explicitly restrains were defined as wrist and chest restraints, mittens, elbow splints, bed sheet used as a restraint but excluded the use of bedside rails as a form of restraint.6 This lack of clarity for critical care staff has led to a sense of confusion regarding what constitutes restraint. These definitions fail to consider chemical restraining interventions, which also aim to ensure compliance with treatment. Not having a clear understanding of restraint interventions, physical and chemical, could result in an underestimation of their use in critical care settings, having implications for nursing practice.

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Figure 1

Language associated with restraining patients lacks clarity. 

Understanding the clinical problem

A complex issue that emerged from the Twitter discussion was that agitation, anxiety and delirium are often used interchangeably. Agitation is not the same as delirium, and agitation without delirium is common in critically ill patients.7 Agitation is a result of increased motor and psychological activity causing loss of control and disorganised thought processing.7 In contrast, delirium has been linked to the development of white matter changes similar to those seen in dementia, manifesting as an acute change in metal health state.8 Patients physically restrained in critical care without additional sedation have been shown to develop delusional memories, which can increase the development of post-traumatic stress disorder.9 Validated tools exist to assist nurses in identifying delirious patients, but subjective interpretation of delirium or agitation can lead to erroneous overdiagnosis of delirium.10

Both the American College of Critical Care Medicine11 and the UK Intensive Care Society12 have published practice guidance that included the detection, prevention and management of delirium and agitation. Although approaches for managing ‘dangerous motor activity’ in the form of pharmacological interventions were outlined, there remains a lack of guidance for managing the acute event of a mobile, agitated patient who is a risk to themselves, visitors and staff. Although short-term sedative use may reduce the agitation or anxiety, in the longer term, their use may have significant cognitive consequences.13 Participants described observing a range of forms of restraint, both physical and chemical, and perceived that clinical staff considered chemical restraint, such a boluses of sedative drugs as ‘kinder’, allowing the patient to ‘sleep’ (figure 2). However, research suggests that the use of chemical restraint to deeply sedate an agitated patient can cause long-term mental health problems.14

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Figure 2

Concerns about restraining patients.

Ethical considerations of coercively managing a patient in critical care

The use of restraint is often seen as a balance between risk and patient benefit. Many participants highlighted the importance to consider the intent behind a particular course of action, be that physical restraint or increasing sedation, particularly in the absence of a robust evidence base to guide practice. One participant suggested it was difficult to ascertain intent—questioning whether restraint is the best course of action for the patient or staff. Anecdotally, participants suggested the issue of the use of restraint in relation to in whose best interest was linked to staffing levels and skill-mix. In Freeman et al’s study, the use of physical restraint was linked to staffing levels.1 It was recognised that managing a patient who is delirious or agitated is challenging and yet junior nursing staff are often allocated to care for this patient group. These nurses may lack the resources to cope with such patients without resorting to restraint. Some participants commented that a cultural shift was required in the care delivery in critical care, ‘allowing’ patients to be more ‘aware’ and ‘active’ (figure 3). Interestingly, there has been one observation study exploring the cultural differences between America and Norway on the use of physical restraint in critical care settings.5 The American cohort of patients were more likely to be physically restrained and receive lower level of sedation and/or analgesic than the Norwegian cohort. Although findings were inconclusive as to whether the more agitated patients were physically restrained or patients in physical restraint become more agitated, the Norwegian unit had higher nurse-to-patient ratio.

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Figure 3

Rethinking the management of agitated patients.