Journal Reading (SICU)

Journal Reading Report
Source
Dolan, J., & Dolan Looby, S. E. (2017). Determinants of Nurses’ Use of Physical
Restraints in Surgical Intensive Care Unit Patients. American Journal of
Critical Care, 26(5), 373–379. https://doi.org/10.4037/ajcc2017244
Introduction
Restraints should be used with caution and discretion. The decision to use a
restraint must be based on a comprehensive, individualized patient assessment.
Since patients in the surgical intensive care unit (SICU) have complicated diagnoses
that pose specific risks to their health, this qualitative study among the SICU nurses
aimed to explore factors that influence the initiation and discontinuation of the use of
restraints in critical care patients.
Procedures
In the study, the participants consisted of 13 nurses working in the SICU at
Massachusetts General Hospital, Boston, Massachusetts, with a mean age of 43
years, and critical care experience ranging from 2 to 34 years. 12 of the 13
participants were female, with 69% holding a bachelor's degree in nursing. Most of
the participants (70%) said they worked rotational day-night shifts.
For the data collection, the principal investigator and participants scheduled
individual, semiconstructed interviews. The interviews were performed with the help
of an interview guide created by the principal investigator, who has a lot of expertise
in critical care.
During the interview, the participants talked about their experiences utilizing
physical restraints on SICU patients, as well as the factors that impact their decision
to employ restraints or not. Nurses were also asked to describe non-restraint
alternatives.
The researchers then analyzed the collected data to establish categories and
identify themes by determining the keywords and phrases that mirrored the SICU
nurses’ experiences with restraints and the factors that influence its application.
Findings & Conclusions
After a total of 13 interviews over the course of 7 months, the content analysis
revealed 3 general categories and 8 themes, indicating the deliberate assessment
processes employed by nurses in a SICU to decide whether or not to apply
restraints.
Categor Theme 1. SICU nurses consistently identify restraints as an intervention
y 1: that helps to reduce risk factors that may compromise safety in patients with
altered mental status.
Patient
Safety According to all the nurses, patient safety was a primary factor in
deciding whether or not to utilize physical restraints in the SICU. They also
reported that the following were considered as a primary threat to patient
safety—invasive monitoring and therapeutic devices, and the interruption or
removal of these devices. In addition, some nurses described using restraints
in patients with critical devices until the patient’s mental status could be
properly assessed.
Theme 2. Self-extubation is viewed as the highest patient-initiated risk
in the SICU, and restraints are used as an intervention to reduce self-
extubation.
Intubation was a major determinant in the utilization of physical restraints

among all nurses. Restraints were commonly used for patients with
endotracheal tubes and according to some nurses, self-extubation is typically
due to altered mental status caused by the sedating effects of anesthetic
medications and the impact of altered mental status.
Theme 3. Restraints are occasionally used to prevent injury to the
staff as a result of patient behavior.
Of the 13 participants, 4 discussed the use of physical restraints to

prevent injury to SICU staff. According to them after serious discussion with
the medical team and security, restraints may be used temporarily for the
protection of staff members, similar to how restraints are used for perceived
patient safety.
Categor Theme 1. Nurses identify patient-specific behaviors, including

y 2: orientation and functional capacity, that determine restraint use.
Patient The specific behaviors of the patients that were described by the nurses
Behavior that influence the use of restraints were both orientation and functional
capacity, specifically on being restlessness, confusion, agitation, and delirium
which can lead to patients pulling or removal of invasive devices.
Theme 2. Nurses describe patient behaviors that predict successful
discontinuation of restraints without perceived negative effects.
The behavior predictors of discontinuation of restraints were the ability of

the patient to obey instructions and respond to verbal redirection, calmness in
body movement, and lack of impulsivity, as well as their comprehension of the
need for therapeutic devices.
Theme 3. SICU nurses give thoughtful consideration regarding the use
of restraints in patients with delirium due to the inconsistent responses to
restraint use experienced by this patient population.
As claimed by the nurses, patients with delirium were one of the

important aspects to consider before initiating the use of physical restraints
especially if it will increase patients’ agitation.
Category 3: Theme 1. The nurse’s ability to be vigilant in patient care provides
an atmosphere of security.
Nonrestraint
Intervention One of the effective alternatives to the use of restraints identified by
s and the nurses is extra staffing as it allows for 1 to 1 patient supervision. The
Alternatives nurse-to-patient ratio was mentioned by some nurses as influencing their
decision to employ restraints.
Theme 2. Targeted nurse-driven interventions are helpful in
reducing restraint use, especially in delirious patients.
According to the nurse, the following interventions were effective in

reducing the use of restraints— frequent reorientation, treatment of pain,
consistent staff assignments, patient comfort, and repositioning the
patient. However, several nurses stated a desire for greater training on
how to limit the usage of restraints in patients who are delirious or
agitated.
In conclusion, the nurses who participated in the study stated that the top
priorities to determine the use of restraints in SICU patients are patient safety and
patient comfort. Furthermore, the combined factors identified were practice
experience, patient-specific behaviors and risks, and patient need for devices.
Personal Comments
Determining the need for safety measures is considered an independent
nursing function. Though restraints require a physician’s order, as future nurses, we
should exercise our clinical thinking skills in a fast-paced and stressful environment
such as the surgical intensive care unit (SICU) to determine when to initiate or
discontinue the use of restraints in critically ill patients because improper use of
restraints can lead to physical and psychological harm and even death.
The journal article that I have chosen focused on evaluating the determinants
of initiation and discontinuation of the use of restraints in critical care patients among
nurses from a SICU. The results showed that patient safety and patient comfort are
the top priorities of the nurses while practice experience, patient-specific behaviors
and risks, and patient need for devices were considered as factors influencing the
use of restraints.
Just recently, we talked about the use of restraints and their legal implications
in our NCM 119 Jurisprudence class. This is one of the reasons why I chose this
study for we should know whether or not to apply restraints to our patients because if
it is used incorrectly, we may be charged with malpractice and/or false imprisonment.
In the future clinical application, I’ll be able to use the knowledge that I’ve
acquired from reading the journal article about how essential the nurses’
assessments are in determining when to initiate or discontinue the use of restraints
in acutely ill and injured patients especially those in settings like SICU. By doing so, I
can be an efficient and effective nurse while rendering quality care to our SICU
patients.

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Journal Reading Report

Intubation was a major determinant in the utilization of physical restraints

Of the 13 participants, 4 discussed the use of physical restraints to

Categor Theme 1. Nurses identify patient-specific behaviors, including

The behavior predictors of discontinuation of restraints were the ability of

As claimed by the nurses, patients with delirium were one of the

According to the nurse, the following interventions were effective in

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