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Physical Restraint (PR) is defined as, "any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body " (Code of Federal Regulations, 2006, p. 71387).

(Nursline Healthcare, 2018).

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PR should only be used to manage nonviolent , non-self-destructive patient behavior after appropriate alternatives have been considered or implemented and proved unsuccessful. When used, the goal should always be to employ the least restrictive means possible in the particular situation (Springer, 2015).

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Which methods are used in Intensive Care Units (ICUs)?

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Which methods are used in Intensive Care Units (ICUs)?

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PRs typically used on critically ill ICU patients include hand mitts, soft splints, soft wrist restraints, and chest vests (Rose, 2015).

(Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, 2003).

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The use of PR should be an exceptional and irregular event in all healthcare settings, but it is frequently regarded and implemented as an aspect of standard, routine patient care in Intensive Care settings. Although these settings constitute less than a quarter of all patient days, they are responsible for more than half of all restraint days (Hevener, Rickabaugh, & Marsh, 2016).

(EnvisionHealthEd, 2008).

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Healthcare & Nursing Training: Avoiding Use of Restraints

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The overuse and sustained use of PR in ICUs has the potential to directly affect all of the patients admitted to these units, however, certain factors increase patients' likelihood of being affected. Factors related to patient behavior include patients' level of: orientation, functional capacity, restlessness, confusion, agitation, and delirium (Dolan & Dolan Looby, 2017). In addition to these, hyperactivity is a factor related to patient behavior that greatly increases patients' likelihood of being affected (Azizpour, Moosazadeh, & Esmaeili, 2017). Aspects of treatment or care that increase the likelihood of patients' being affected include: invasive treatment mechanisms, such as a mechanical ventilator, central lines, and/or other tubes or drains; the use of certain medications, such as opioid analgesics or sedatives; as well as patient awakening from sedation (Hamilton, Griesdale, & Mion, 2017). Patients' likelihood of being affected is also increased by certain staff-related factors, such as inadequate staffing (Lynn & Brooks, 2017). Patients being cared for by staff members with inadequate knowledge of appropriate alternatives to PR as well as those receiving care in ICU environments in which implementing PR is generally regarded as acceptable also have an increased likelihood of being affected (Hamilton et al., 2017).

(Elbing, 2002).

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Why are these patients directly affected?

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Why are these patients directly affected?

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Many of the patient behavior-related factors that increase patients' likelihood of being affected by the overuse and sustained use of PR in Intensive Care settings do so because of their correlation with patient safety and the widespread belief that the use of PR enhances patient safety through eliminating some of these risks. For example, PR is often implemented in patients whose mental status is altered because it's believed to reduce the associated risk of sustaining a fall (Dolan & Dolan Looby, 2017). Because the use of certain medications, such as opiates and sedatives, often result in the manifestation of many of these patient behavior-related factors, their use also increases patients' likelihood of being affected (Hamilton et al., 2017).
Patients who are receiving treatment through invasive mechanisms as well as those who are being awakened from sedation are at an increased risk of being affected due to the widespread belief that the use of PR reduces the risk of treatment interference, which may potentially be life-threatening (Hamilton et al., 2017).
Low nurse-to-patient ratios that result from inadequate staffing reduces the vigilance with which nurses are able to observe and care for their patients and thus increases patients' likelihood of being affected by the overuse and sustained use of PR (Lynn & Brooks, 2017). Patients being cared for by nurses who have deficient knowledge of appropriate alternatives to PR are at an increased risk of being affected due to these alternatives not being attempted prior to the application of PR, which is often implemented as an initial intervention. Evidence shows that unit-specific attitudes regarding PR influences its use, implying that patients being treated in ICUs with an attitude of acceptance have an increased likelihood of being affected by the overuse and sustained use of PR (Hamilton et al., 2017).

(Lann, 2017).

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The application of PR causes multiple concerns related to patient safety and the quality of their care due to its direct correlation with lengthened hospital stays and the increased mortality of hospitalized patients, both of which result from the many complications associated with the use of PR (Hall, Zimbro, Maduro, Petrovitch, Ver Schneider, & Morgan, 2018).
Some of these complications are related to the restraint itself, such as injuries to patients' local vasculature as well as the areas distal to it, underlying skin, underlying nerves, and/or the affected musculoskeletal structures (De Jonghe, Constantin, Chanques, Capdevila, Lefrant, Outin, & Mantz, 2013). The most severe complication resulting from the restraint itself is patient death resulting from manual asphyxiation or strangulation (American Nurses' Association Board of Directors, 2012).
Other complications resulting from the use of PR are related to the implicit immobility associated with it, such as deconditioning, pressure ulcer development, and/or thromboembolism development (Azizpour et al., 2017). Additionally, immobility may result in complications associated with the development of nosocomial infections, such as pneumonia, and their potential progression to sepsis (Hamilton et al., 2017).
Although there is a widespread belief that the use of PR decreases patients' risk of sustaining a fall and interfering with invasive  treatment methods, evidence indicates that it actually increases the risk of both. Furthermore, evidence shows that the extent of injury sustained from both falls and treatment interference is increased in patients who are physically restrained (Hall et al., 2018). Likewise, evidence disputes the use of PR as a protective mechanism in patients who are experiencing agitation, confusion, disorientation, and/or delirium, indicating that it can contribute to the development or worsening of these behavior-related factors (Azizpour et al., 2017).
Many of the physical complications resulting from the use of PR increase patients' oxygen consumption and thus oxygen demand, which may negatively affect their overall outcome by aggravating their underlying disease process (Nirmalan, Dark, Nightingale, & Harris, 2004). In addition to physical complications, the use of PR also results in several psychological complications for the patients, significant others, and staff involved with or exposed to its implementation, the most severe of which being the development of post traumatic stress disorder in patients who were physically restrained (Hall et al., 2018).

(Registered Nurses' Association of Ontario, 2018).

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Physical restraints in intensive care: An integrative review

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Physical restraints in intensive care: An integrative review

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In addition to preserving their dignity and protecting their basic human rights, ICU nurses are morally obligated to uphold the principles of non-maleficence, beneficence, and autonomy when caring for patients. Despite these obligations, PR use persists as a common intervention implemented by nurses in intensive care settings. The use of PR in these settings is often justified as means needed to ensure patient safety and continuity of essential treatment, which is evidenced by its incidence and prevalence among certain patient groups within ICUs.
Many ICUs have policies intended to minimize and even eliminate the use of PR, however, it is still frequently viewed as a necessary intervention by the nursing staff on these units. Because its use, "ultimately encroaches on patient's autonomy and interferes with the...ability to preserve patient dignity" (p. 2), the minimization of PR must continue to be actively sought to improve critical care nursing practice until Intensive Care settings are restraint-free (Perez, Peters, Wilkes, & Murphy, 2018).

(Restraint Reduction Network, 2018).

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American Nurses' Association Position Statement

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American Nurses' Association Position Statement

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In their position statement on this topic, the American Nurses' Association (ANA) fully backs the involvement of nurses in the reduction of patient restraint in healthcare settings, which they identify as problematic and describe as, "contrary to the fundamental goals and ethical traditions of the nursing profession, which upholds the autonomy and inherent dignity of each patient..." (American Nurses' Association Board of Directors, 2012, p. 1).
The ANA recognizes that nurses need adequate education to develop the skills necessary to effectively reduce the use of restraint in healthcare settings and offers several recommendations to maintain high quality patient care while doing so. In addition to education, the ANA views an open, ongoing dialogue regarding the importance of restraint reduction and means of doing so as an important factor in facilitating nursing practice changes (American Nurses' Association Board of Directors, 2012).

(American Nurses' Association, 2018).

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The Joint Commission has identified ten standards regarding the use of restraint and seclusion/nonviolent crisis intervention that healthcare organizations (HCOs) must adhere to in order to achieve or maintain their accreditation.
First, HCOs must ensure that patient restraint is only used when clinically warranted or as a mechanism to ensure immediate safety and as a last resort; when used, the least restrictive mechanism should be implemented and it should be discontinued as soon as possible.
HCOs must support the safe use of patient restraint through identifying techniques in their policies and procedures that are congruent with legal requirements and changes in patients' plans of care.
The use of patient restraint in HCOs must be initiated based on individual orders from the patient's physician or other licensed independent practitioner (LIP). The renewal of these orders must be in accordance with hospital policy.
HCOs must ensure that the physical and psychological needs of restrained patients are monitored by staff who are appropriately trained to do so.
HCOs must have written policies and procedures in place to guide the use of patient restraint. These policies and procedures should include the following: the definition of both patient restraint and seclusion; training requirements for physicians, other LIP, and staff; determination of who can order, initiate, and discontinue patient restraints; determination of who can assess and monitor restrained patients and time frames for doing so; circumstances that warrant discontinuation; and the requirement that patient restraints are discontinued as soon as safely possible.
HCOs must ensure that restrained patients are evaluated by their physician, other LIP, or a nurse or physician's assistant (PA) who has been trained to do so within an hour of being restrained and are reevaluated per protocol and as indicated. These evaluations should include the following: the patient's immediate situation and reaction to the restrictive intervention used, the patient's medical and behavioral condition, and whether the use of restraint needs to be continued or discontinued based on these findings.
HCOs must ensure that patients who are simultaneously restrained and secluded are monitored continuously.
HCOs must ensure that all patient restraint use is appropriately documented in patient medical records. The documentation of patient restraint should include the following: any in-person evaluation of the patient's medical and behavioral condition; a description of the patient's behavior and the intervention implemented; any alternative, less restrictive interventions that were attempted; the patient's condition or symptom(s) that warranted the use of restraint; the ordering physician or other LIP; the orders themselves; notification of the attending regarding use, if indicated; individual patient assessments and reassessments; time intervals for patient monitoring; revisions to the patient's plan of care; the patient's behavior and staff's safety concerns that necessitated restraint use; injuries to the patient; death associated with restraint or seclusion use; and any related consultations.
HCOs must ensure that their staff are trained by an adequately educated, trained, and experienced individual to safely and appropriately implement patient restraint use at staff members' orientation, before their participation in restraint use, and periodically thereafter. Staff education, training, and demonstrated knowledge should focus on the following: strategies to identify factors that may produce circumstances requiring patient restraint; nonphysical intervention skills; methods for choosing the least restrictive intervention appropriate based on patient assessment; safe application and use of all types of restraint used; identifying clinical changes indicating restraints can be safely discontinued; and monitoring of the patient's physical and psychological well being (respiratory status, circulatory status, skin integrity, vital signs, special requirements associated with the in-person patient evaluation per policy, first aid technique use, CPR certification, etc.). The completion of this training and competence needs to be documented in the HCO's staff records.
Lastly, HCOs must ensure that deaths associated with patient restraint or seclusion are reported to the appropriate external agency and/or are documented in the patients' medical records.
(Crisis Prevention Institute, 2009).

(The Joint Commission, 2018).

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(Sentara Healthcare, 2014).

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Restraint and Seclusion Management of Non Violent Self Destructive Patients in  Non- Behavioral Health Areas June 2016  (2) (2).pdf

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Many nurses in Intensive Care settings view PR as a preventive safety strategy and thus often apply it before any risk for or actual treatment interference is demonstrated by patients. This prophylactic application of PR that is frequently seen in ICUs may also be related to nurses' lack of trust in patients who aren't being continuously monitored, their belief that other options do not exist, their presumption of patients' response upon awakening from sedation, and/or fear of the potential complications of treatment interference (Hamilton et al., 2017).
The use of PR in ICU patients is frequently both initiated and discontinued by nurses based on their professional gumption and practical judgement rather than written medical orders. This can contribute to both the overuse and the sustained use of PRs on this patient population (De Jonghe et al., 2013). Nurses' fear of being held liable for potential patient injury or damages is another commonly identified reason for the application and maintenance of PR in ICU patients (Azizpour et al., 2017).
Generally, ICU nurses are inconsistent in both documenting and reporting on their use of PRs (Hamilton et al., 2017).

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ICU nurses are often quick to physically restrain their patients prior to attempting or even considering the use of appropriate alternatives (Improper use of restraints leads to patient safety concerns, 2015).
ICU nurses frequently fail to adhere to policy and procedure related to the requirement of a written medical order for PR application and continuation as well as the requirement that their use be meticulously documented in patient medical records (Perez et al., 2018). Many ICU nurses also fail to adhere to hospital policy regarding the use of PR because they are under the belief that this policy does not apply to ICU patients due to the nature of Intensive Care and Intensive Care environments (Hamilton et al., 2017).
ICU nurses often apply PRs to patients without any discussion of criteria regarding their use or monitoring or withdrawal (Azizpour et al., 2017). ICU nurses also frequently fail to continuously communicate about the indications for and use of PR in their patients with other members of the interdisciplinary team, which hinders the comprehensiveness of patients' clinical picture and team exploration of appropriate alternatives based on pertinent assessment data (Hamilton et al., 2017).

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Is this improving or worsening the issue?

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Is this improving or worsening the issue?

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Generally, what ICU nurses are and are not doing regarding the overuse and sustained use of PR in their patients is worsening the issue, as PR use remains a common, accepted practice in Intensive Care settings (Hamilton et al., 2017).

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Why is the involvement of ICU nurses important?

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Why is the involvement of ICU nurses important?

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The involvement of ICU nurses in reducing the use of PR in critically ill ICU patients is important because they are typically the healthcare professionals who interact with these patients the most consistently and observe them the most frequently, which facilitates their ability to assess patients on an ongoing basis. ICU nurses' consistent interaction with and frequent observation and ongoing assessment of their patients places them in an optimal position for gaining and sharing insights on the use of PRs on this patient population. Because of this position, the viewpoint of ICU nurses should be considered when establishing policies and programs related to PR use and its reduction (Dolan & Dolan Looby, 2017).

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How would the involvement of ICU nurses help?

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How would the involvement of ICU nurses help?

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The involvement of ICU nurses would help to improve the issue in numerous ways, including but not limited to the following:
They could facilitate a more comprehensive clinical picture of patients through engaging in continuous communication with other members of the interdisciplinary team, potentially reducing PR use through increasing the team's understanding of patient situations (Hamilton et al., 2017).
They could consider, advocate for, and implement appropriate alternatives based on assessment data prior to the application of PR to reduce its use (Springer, 2015). Additionally, they could advocate for the discontinuation of PRs as soon as safely possible to decrease their sustained use (Perez et al., 2018).
They could act as participants in the team collaboration that is necessary to reduce PR use through promoting peer-to-peer accountability among themselves in documentation, bedside shift reports, and daily interdisciplinary rounds (Lynn & Brooks, 2017).
Additionally, they could become involved in their hospital's interdisciplinary restraint reduction committee (Azizpour et al., 2017).

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Will the involvement of ICU nurses help resolve or improve the issue?

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Will the involvement of ICU nurses help resolve or improve the issue?

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Absolutely! The involvement of ICU nurses is integral to Intensive Care settings becoming restraint-free care environments (Lynn & Brooks, 2017).

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Challenges and barriers to ICU nurses involvement

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Challenges and barriers to ICU nurses involvement

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Limited staffing, fear of liability, and a lack of education among ICU nurses all serve as challenges and barriers to their involvement (Perez et al., 2018).
Throughout the clinical decision making process, the best interest of the patient should always take precedence over any and all third party concerns regarding the application of of PRs (Nirmalan et al., 2004).

(WeClipArt, 2018a).

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The education of nurses caring for critically ill patients in Intensive Care settings is essential in order to reduce the use of PR in this patient population (American Nurses' Association Board of Directors, 2012). This education should be intended to eradicate false beliefs held by ICU nurses related to PR use through providing them with information about evidence-based best practices (Lynn & Brooks, 2017). The information provided must be comprehensive and should include material regarding patients' inherent rights, indications for the use of PR, appropriate alternatives to PR, how to properly document PR use, and tools that nurses can use to assist them in deciding to apply PRs to their patients (Hevener et al., 2016).
Educating ICU nurses to enhance their knowledge of appropriate PR use has the potential to positively change the way in which they regard PR and subsequently improve the quality of care that they provide to the ICU patient population (Lynn & Brooks, 2017). Depending on the identified educational needs as well as unit-specific factors throughout Intensive Care settings, this education can be effectively provided on either a group or a one-on-one basis (Hall et al., 2018).

(UC Davis Health, 2012).

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Restraint management bundles can be used to effectively educate staff members and reduce restraint use, subsequently promoting the quality and safety of care provided to critically ill patients in Intensive Care settings. Bundle components shown to effectively reduce the use of restraints on ICU patients include: daily reporting of restraint use to hospital leadership personnel, daily auditing of restraint orders and documentation of restraint use, reporting of audit findings during unit safety huddles held during shift change, daily rounding on restrained patients by unit coordinators to determine the need for continued use or discontinuation of restraints, and providing staff education on appropriate restraint use (Hall et al., 2018).

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ICU nurses can use decision wheels to assist them in determining whether the use of PR is appropriate based on specific patient and clinical factors. Patient and clinical factors shown to effectively reduce the use of PR and thus that should be included in restraint decision wheels include patients' behaviors, the devices used in patients' care, and the degree of patients' functional dependence and independence. The consideration of this criteria standardizes and supports ICU nurses' decision to use PR, appropriate alternatives, or no intervention, and results in the reduction of PR use through ensuring that it's strictly used in appropriate situations (Hevener et al., 2016).

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The concepts of ethical principles and dilemmas have been integrated into the curriculum throughout my nursing school career at Sentara College of Health Sciences. These concepts relate to the presented issues surrounding PR, as PR use itself is often viewed as an ethical dilemma and involves conflict between the ethical principles of beneficence and non-maleficence.
The integration of both of these concepts into curriculum has equipped me with the knowledge necessary to maintain ethical standards in my personal nursing practice. Additionally, it has given me the ability to identify areas of nursing practice in which ethics are not being upheld and to implement corrective measures upon recognizing such areas. This knowledge and ability both prepare me to take a leadership role upon my transition to professional practice through promoting ethical practice and contributing to the cultivation of an ethical environment in my workplace.

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The concept of patient safety has been integrated into the curriculum of each course that I have taken throughout my nursing school career at Sentara College of Health Sciences. This concept relates to the presented issues surrounding PR, as the use of PR jeopardizes patient safety and poses several associated concerns.
The inclusion of this curricular concept has provided me with the insight needed to ensure that my personal nursing practice promotes and enhances patient safety. It has also prepared me to take a leadership role upon my transition to professional practice through advocating for the safety of my patients and contributing to the cultivation of a culture of safety in my workplace.