Identifying determinants for the application of physical or chemical restraint in the management of psychomotor agitation on the critical care unit

Aims and objectives:

To identify key determinants, which lead to the decision to apply physical or chemical restraint on the critical care unit.

Background:

Psychomotor agitation and hyperactive delirium are frequently cited as clinical rationale for initiating chemical and physical restraint in critical care. Current restraint guidance is over a decade old, and wide variations in nursing and prescribing practice are evident. It is unclear whether restraint use is grounded in evidence‐based practice or custom and culture.

Study design:

Integrative review.

Method:

Seven health sciences databases were searched to identify published and grey literature (1995–2019), with additional hand‐searching. The systematic deselection process followed PRISMA guidance. Studies were included if they identified physical or chemical restraint as a method of agitation management in adult critical care units. Quality appraisal was undertaken using Mixed Methods Appraisal Tool. Data were extracted, and thematic analysis undertaken.

Results:

A total of 23 studies were included. Four main themes were identified: the lack of standardised practice, patient characteristics associated with restraint use, the struggle in practice and the decision to apply restraint.

Conclusions:

There are wide variations in restraint use despite the presence of international guidance. Nurses are the primary decision‐makers in applying restraint and report that caring for delirious patients is physically and psychologically challenging. The decision to restrain can be influenced by the working environment, patient behaviours and clinical acuity. Enhanced clinical support and guidance for nurses caring for delirious patients is indicated.

Relevance to clinical practice:

Delirium and agitation pose a potential threat to patient safety and the maintenance of life‐preserving therapies. Restraint is viewed as one method of preserving patient safety. However, use appears to be influenced by previous adverse experiences and subjective patient descriptors, rather than robust evidence‐based knowledge. The need for a precise language to describe restraint and quantify when it becomes necessary is indicated.