Clinical Excellence A Reflection on Physical Restraint Practice in Intensive Care Settings Physical restraints are widely used in intensive care settings to prevent patients from inadvertent removal of medical devices and self-harm. However, studies have suggested that restraints, regardless of their nature, can lead to adverse physical and psychological sequelae. In extremis, physical restraint can result in death if used inappropriately. 1 Therefore we should always advocate minimal and rational use of restrictive interventions. ‘Prophylactic’ application of physical restraints are not uncommonly practiced in patients with multiple infusions or artificial airways. Ironically, it was observed in multiple studies that unplanned extubationhadoccurred even thoughpatients were physically restrained. 2,3,4 This indicated that physical restraints were not effective in preventing self-extubation: a decision support tool on physical restraint that links patient assessment with risk-based recommendations is advocated as it can inform nurses in selecting the most appropriate level of restraints, thus potentially reducing unnecessary restraints. The use of decision wheel to assist nurses who are undecided or need support on their decision on restraint use is an example of the successful implementation of a decision support instrument. 5 Physical restraints should never be used for convenience or as a substitute for nursing supervision when staffing is inadequate. Restraint application should be considered only as a last resort after attempting or exploring other measures, 6 such as assignment of staff or allowing family members to accompany the patient, use of distraction strategies, offering reassurance, use of bed or chair alarms, and administration of medications targeting at symptomatic control or underlying pathology. 7 Regular reassessment of the patient’s condition is equally important and nurses should always aim restrain patients for the least amount of time possible. Through regular reassessment, nurses can closely evaluate their patient’s condition and adjust their initial restraint decision as indicated. Working environments supportive of restraint minimization can facilitate change in staff attitudes towards the use of physical restraints. 8 When making restraint decisions, nurses may face ethical, legal and practical dilemmas due to the potentially conflicting roles between defending patient’s rights and maintaining patient safety. 9 Provision of in-service training regarding ethical principles regarding physical restraint application can ensure that nurses are making the right decision in the case of ethical dilemmas. Management can also play a role in cultivating restraint minimization practice by providing suitable resources, education and clear corporate policy to frontline staff. 10 In conclusion, nurses have a pivotal role in ensuring appropriate use of physical restraint in the vulnerable patient population. The ultimate objective is to enhance patient safety while preserving patients’ rights and dignity. References 1. Berzlanovich AM, Schöpfer J, Keil W. Deaths due to physical restraint. Dtsch Arztebl Int . 2012;109(3):27-32. 2. Birkett KM, Southerland KA, Leslie GD. Reporting unplanned extubation. Intensive Crit Care Nurs . 2005;21(2):65-75. 3. Mion LC, Minnick AF, Leipzig R, Catrambone CD, Johnson ME. Patient- initiated device removal in intensive care units: a national prevalence study. Crit Care Med . 2007;35(12):2714-2720. 4. Chang LY, Wang KW, Chao YF. Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study. Am J Crit Care . 2008;17(5):408-415. 5. Hevener S, Rickabaugh B, Marsh T. Using a Decision Wheel to Reduce Use of Restraints in a Medical-Surgical Intensive Care Unit. Am J Crit Care . 2016;25(6):479-486. 6. Luk E, Burry L, Rezaie S, Mehta S, Rose L. Critical care nurses’ decisions regarding physical restraints in two Canadian ICUs: A prospective observational study. Can J Crit Care Nurs . 2015;26(4):16-22. 7. Michaud CJ. Thomas WL, McAllen KJ. Early pharmacological treatment of delirium may reduce physical restraint use: a retrospective study. Ann Pharmacother . 2014;48(3):328-334. 8. Huang HT, Chuang YH, Chiang KF. Nurses’ physical restraint knowledge, attitudes, and practices: the effectiveness of an in-service education program. J Nurs Res . 2009;17(4):241-248. 9. Yönt GH, Korhan EA, Dizer B, Gümüş F, Koyuncu R. Examination of ethical dilemmas experienced by adult intensive care unit nurses in physical restraint practices. Holist Nurs Pract . 2014;28(2):85-90. 10. Suliman M, Aloush S, Al-Awamreh K. Knowledge, attitude and practice of intensive care unit nurses about physical restraint. Nurs Crit Care . 2017;22(5):264-269. Mr. Peter Lai Nurse Consultant (Intensive Care) Hong Kong West Cluster, Hospital Authority 4 Vision to L ead Mission to Serve