Understanding the decision-making of critical care nurses when restraining a patient with psychomotor agitation secondary to hyperactive delirium: A ‘Think Aloud’ study.

Abstract

Aims & Objectives: This study aimed to explore the decision-making processes undertaken by critical care nurses when considering restraint to manage a patient with psychomotor agitation secondary to hyperactive delirium. Background: Psychomotor agitation is frequently cited as clinical rationale for initiating chemical or physical restraint. Despite the presence of clinical guidance for restraint in critical care, wide variations in nursing and prescribing practice are evident. Nurses are the primary decision makers when initiating restraint, but little is known about this process and influencing factors. Design: A pragmatic qualitative approach was used to explore critical care nurses’ decision-making processes. Methods: A ‘think aloud’ approach was undertaken. Audio-visual vignettes featuring simulated patients were used as stimulus to elicit decision-making processes from thirty critical care nurses and practitioners. The COREQ checklist was followed. Results: Five themes relating to restraint were identified: Intrinsic beliefs and aptitudes; Handover and labelling; Failure to maintain a consistent approach; Restraint might be used to replace vigilance; The tyranny of the now. Conclusions: Restraint was more frequent when staffing ratios were reduced below 1:1 and opportunities for vigilance reduced. Participants described physical and psychological exhaustion when caring for a patient with delirium and how this might lead to restraint to create ‘space’ for respite. Variations in practice were evident and restraint use appears rooted in custom and culture rather than objective assessment. Relevance to clinical practice: The lack of pre-emptive management for hyperactive delirium and reduced staffing ratios lead to the decision to restrain to preserve safety in acute agitation. The struggle to manage agitated behaviour is associated with nurse burnout and reduced engagement with therapeutic management methods, suggesting the need for psychological and educational support for clinical staff. Delirium is an important and debilitating form of organ dysfunction which should be collaboratively managed by the multi-disciplinary team.