Rethinking Physical Restraints in the ICU: How Nurses Are Leading the Way

November 13, 2018
Table with stethoscope and medical mask

ICUs account for more than half of all US hospital physical restraint use—and nurses are leading the way in understanding and mitigating its associated risks.

Approximately 27,000 people are placed in physical restraints each day in US hospitals. ICUs are responsible for 56% of all restraint days, despite accounting for only 16% of all patient days. Several adverse outcomes are associated with the use of physical restraints in the ICU setting, including:

  • Agitation and delirium
  • Post-traumatic stress
  • Physical injury
  • Death

These risks are compounded by medical devices that regulate bodily functions, along with greater levels of sedation and pain management. While physical restraints are ostensibly used in the ICU to prevent a patient from disrupting a medical device, research has found that up to 74% of patients are physically restrained at the time of device disruption (PDD).
In an article that sought to challenge the status quo of ICU restraint, the authors—all nurses—observed, “Given that more than half of all physical restraint use occurs in ICUs, reducing PDD by means other than physical restraint would reduce the majority of physical restraint in the United States.”
Their recommendation? Focus on the behaviors that drive PDD, and identify supportive responses to those behaviors. Restraint reduction should organically follow. This strategy can also be found at the root of CPI training:

  • Restraint reduction starts by learning to accurately interpret behavior as communication.
  • Staff are then empowered to choose an appropriate, supportive, and safe intervention.
  • A consistent, coordinated approach leads to long-term reduction and prevention of critical incidents.

Nurses must make choices rapidly in the ICU, so training at orientation and in-service can help ensure an evidence-based approach to restraint use.

If there are known adverse outcomes and inconsistent rationales for its use, why are the rates of physical restraint in the ICU so high? Research has found that without education on new evidence of adverse outcomes and awareness of effective alternatives, nurses largely rely on their intuition and heuristics to make quick decisions about restraint use with confidence in the ICU.
The timing of this training is critical to implementing a consistent and successful approach to restraint reduction. After assessing the way that their peers synthesize data to make care decisions, nurses studying the issue recommend training at orientation and in-service to improve knowledge that supports the best practices of physical restraint in the ICU setting.  
Shifting long-held paradigms through training is a great idea, but does this approach really work when it comes to targeting restraint reduction in the ICU? Is it worth the time and effort to implement?
ICU nursing teams who have embraced this approach report that it does work, and it’s worth it.

“As staff embraced the successes, the culture shift from restraining most patients to minimal use of restraints spread from nurses to the entire interdisciplinary team.”

One hospital system tested the theory that focused training could help reduce restraint usage in the ICU. Measuring themselves against the National Database of Nursing Quality Indicators (NDNQI), they established a goal to have their rate of physical restraint use fall below the NDNQI’s benchmark mean rate of restraint. But the ICUs across their hospital system couldn’t achieve it.
Initial conversation around the issue of restraint use in the ICU illuminated the power of perception—restraint use was high because nurses believed it was necessary to prevent adverse patient advents, and a lack of available alternatives was reinforcing this belief. Evidence that might prove or disprove the soundness of this belief was not necessarily being considered in the decision-making process.  
Another factor in high restraint rates was a lack of coordination across staff. Departments weren’t working together to share information and alternatives when it came to physical restraint practices, which meant that even if one team made improvements, another team in the same system couldn’t replicate them.
A collaborative team was formed to coordinate an evidence-based approach to ICU restraint reduction, making sure to identify and include teammates who could help shift staff dynamics, like bedside nurses, who they considered to be “the key stakeholders and play a major role in providing education on reduction in the use of physical restraints, acting as mentors, and gathering feedback on their individual units.”
Here’s a general summary of their process, according to the study:

  • The clinical nurse specialist team facilitated training across ICU staff to empower nurses to move from a heuristic to an evidence-based approach.
  • Training was reinforced with ongoing, strategic communication to keep staff mindful of best practices.
  • This communication was paired with more inclusive staff dynamics—for example, nurses were able to participate in the selection of a mitt product that worked better for patients than the traditional physical restraints that had previously been available.
  • Consistency was established by including an assessment of restraint use in daily rounds. This created regular opportunities to re-educate, reinforce training, and revisit the NDNQI standards.

The result was a focused approach to patient safety that generated measurable change over time: all ICUs within the hospital system successfully lowered their mean restraint rates—and sustained this improvement over a period of years.
“As staff embraced the successes, the culture shift from restraining most patients to minimal use of restraints spread from nurses to the entire interdisciplinary team,” the study authors observed.

Physical restraint use can pose a tough moral dilemma for ICU nurses—but this stress can be mitigated with training that boosts their skills and confidence.

Surveys indicate that while nurses may often opt for restraints in the ICU, the choice itself is fraught for them. Yet another study of successful ICU restraint reduction found that empowering nurses with training relieved this ethical stress: “This eagerness to learn might be explained by the fact that many nurses believe that the restraining procedure is not ethically accepted; however, [they] feel it is required in some situations for the benefit of the patient. They consider it a ‘necessary evil.’”
The moral conflict around restraint use indicated to researchers that there was a definite need for “in-service education programs in acute care settings” that focused on evidence-based restraint approaches and effective alternatives.
Relieving staff anxiety by boosting their skills and confidence is also the basis of CPI’s Nonviolent Crisis Intervention® training. In CPI training, healthcare professionals have an opportunity to develop their professional abilities with skills and confidence to make challenging decisions from an evidence-based perspective with skills like:

  • Decision-making practices that consider the severity and likelihood of various risks
  • Debriefing methods that foster transparency and reinforce preventive measures for the future
  • De-escalation and disengagement skills that emphasize safety and minimize risk for patients and staff in a person-centered way
  • A standardized approach to safety that fulfills regulatory expectations, and supports collaboration and coordination across every level of staff

 The success of a multiple-ICU hospital system in reducing their use of physical restraint speaks to a larger change taking place across healthcare—the drive for greater professional collaboration. In a recent article on leadership in health care, critical care specialist Sumita B. Khatri, MD, MS wrote:
“In the past, traditional concepts of professional success required a healthy element of rugged individualism. A successful research career or thriving clinical practice (or a combination of both) required an entrepreneurial spirit to achieve the rewards of autonomy, professional satisfaction, and fulfilling relationships with patients and communities.
While such qualities remain necessary for success, the need for coordination and collaboration has become ever more important in the current health care environment.”
Coordination matters when it comes to building holistic and sustainable cultures of safety in health care. With evidence building that when staff work together significant change is possible, what choices can you make to support an inclusive and supportive approach to restraint reduction in the critical care setting?

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