Understanding nurses’ perspectives of physical restraints during mechanical ventilation in intensive care: A qualitative study

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Intensive care nurses are responsible for providing specialised care for critically ill patients requiring mechanical ventilation and other invasive devices (Gueret et al., 2020). These patients often become restless and agitated from the discomfort of these devices, which may be further exacerbated due to pain, sleep deprivation, delirium and their underlying illness (Langley et al., 2011). As a result of their restlessness and agitation, ICU patients will often accidentally or purposefully attempt to remove these potentially life-saving interventions which can be highly detrimental to their health and safety. This phenomenon is commonly termed as ‘treatment interference’ (da Silva et al., 2013, p.1237).

In order to prevent treatment interference and maintain patient safety, PR are often applied in the ICU setting (Kisacik et al., 2020). Nurses are often the primary decision-makers in PR application and removal (De Jonghe et al., 2013). Current literature also suggests that patients who are mechanically ventilated are more likely to be restrained to prevent self-extubation (Kisacik et al., 2020). While there are many perceived benefits of PR for the prevention of treatment interference, they can also cause patients physical injuries, interfere with their dignity and autonomy and prevent patients from effectively communicating, particularly for those who are intubated and mechanically ventilated (Pan et al., 2018). In addition, previous studies have found that PRs are often inconsistently or incorrectly applied and are ineffective in preventing self-extubation (Chang et al., 2011).

The conflict between the widely accepted practice of PR within ICU and its negative consequences places ICU nurses in a difficult predicament. Nurses are responsible for maintaining patient safety and ensuring their patients receive their prescribed medical treatment. However, they are given little guidance in the form of policies and protocols for best practice or alternatives to PR for the prevention of treatment interference (Luk et al., 2015).

While ample quantitative research has been conducted internationally on specific components of PR practice, there has been limited qualitative data on this experience, particularly from patient and family perspectives (Perez et al., 2019). Therefore, a larger study was conducted with the aim of gaining holistic insight into the experience of PR in ICU from the three groups of people most impacted by the experience being patients, families and nurses (Choe et al., 2015; De Jonghe et al., 2013). Therefore, the research question posed was ‘What are the experiences of physical restraints during mechanical ventilation in intensive care from the perspectives of patient, families and nurses?’ This paper, however, focuses on the nurses’ experiences and the findings from the patient and family groups will be disseminated in future publications. This was necessary as there were discreet aspects of the nurses’ experience that were vastly different from the patient and family groups. While the patient and family groups explicitly focused on intimate experiences they had of PR in intensive care, the nurse group gave new insights into the practice of PR and the workplace culture within ICU. This is supported by Jackson et al. (2013) who stated that in many circumstances, particularly with qualitative and mixed-method studies, reams of valuable data may not be effectively reported within a single article. The new knowledge generated from these findings not only gave insight into the experience of PR from the nurses’ perspective but also have the potential inform future PR practices through policy and education, which may address the issues that currently exist within the practice.

The study was implemented using qualitative methodology within a naturalistic inquiry framework. This research aimed to gain a holistic understanding of the experience of physical restraints during mechanical ventilation in intensive care from the perspectives of patients, families and nurses through one-on-one conversations. Therefore, as the naturalistic inquiry framework views reality as multiple, relative and context bound (Lincoln & Guba, 1985), it was fitting for this study as it gives value to not only the experiences of each of the groups of participants, but also to each individual within the groups. Understanding the commonalities and differences between their experiences provided greater insight into the complexities that exist within the practice of PR use in ICUs. These insights have the potential to better inform the nursing profession on ways to improve PR practice and reduce the potential for negative patient outcomes.

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