Intensive & Critical Care Nursing 69 (2022) 103153

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Intensive & Critical Care Nursing

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Review Article

Implementation of nonpharmacologic physical restraint minimization

interventions in the adult intensive care unit: A scoping review
Ziad Alostaz a, *, Louise Rose b, Sangeeta Mehta c, d, Linda Johnston a, Craig Dale a, e
a
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St., Suite 130, Toronto, ON, Canada
b
Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
c
Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada
d
Mount Sinai Hospital, 600 University Ave, Rm 18-216, Toronto, ON, Canada
e
Sunnybrook Health Sciences Centre, Toronto, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To identify the elements informing the successful implementation of nonpharmacologic physical re­
Implementation straint minimization interventions in adult intensive care unit patients. To map those elements to innovation,
Intensive care unit context, recipients and facilitation domains of the integrated–Promoting Action on Research Implementation in
Physical restraint
Health Services (i-PARIHS) framework and to describe the outcomes of those interventions.
Practice change
Scoping review
Methodology: A scoping review of studies published in English reporting on restraint minimization interventions
in adult intensive care units. We searched seven databases (MEDLINE, CIHAHL, Embase, Web of Science,
Cochrane Library, PROSPERO and Joanna Briggs) from inception to 2021. Two authors independently screened
articles for inclusion, extracted study characteristics and mapped intervention data to the i-PARIHS domains.
Results: Seven studies met inclusion criteria. Innovations comprised multicomponent interventions including
education, decision aids/protocols and restraint alternatives. No studies utilised an implementation science
framework to diagnose the baseline practice context. A commonly reported barrier to restraint minimization was
a risk averse culture. Change was mostly driven by the external context (i.e. national regulations). Overall, nurses
were the primary facilitators and recipients of practice change. Outcomes were changes in restraint incidence
and prevalence abstracted from the medical record. However, no study validated the accuracy of restraint
documentation. All studies documented an initial decrease in physical restraint use, but no long-term results
were reported.
Conclusion: Restraint minimization intervention studies report nurse-facilitated multicomponent interventions
and short-term practice change. Future restraint minimization research incorporating implementation science
frameworks, interprofessional teams and patient/family perspectives is warranted.

Implications for clinical practice

• Implementation strategies for physical restraint minimization in the intensive care unit might include education, decision aids/protocols and
restraint alternatives. However, the most effective interventions or combination of interventions for reducing physical restraint are unclear.
• Our findings draw attention to the influential interplay of the intervention components, the context and the recipients when designing and
implementing a physical restraint minimization intervention.
• Further research is needed to develop consensus on outcomes, their definitions and physical restraint measurement and reporting in the
intensive care unit (i.e. a core outcome set).
• Greater involvement of the interprofessional team, patient-family members in the design, implementation and delivery of physical restraint
minimization interventions is warranted.

* Corresponding author at: Lawrence S. Bloomberg Faculty of Nursing, 155 College St., Toronto, ON, Canada.
E-mail address: ziad.alostaz@mail.utoronto.ca (Z. Alostaz).

https://doi.org/10.1016/j.iccn.2021.103153
Received 13 July 2021; Received in revised form 16 August 2021; Accepted 13 September 2021
Available online 14 December 2021
0964-3397/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Z. Alostaz et al.
Background
Physical restraints (PR) are used to prevent intensive care unit (ICU)
patients from removing medical devices (e.g., advanced airways, cath­
eters and vascular access lines) or causing injury to themselves or others
when agitated (Perez et al., 2019). Evidence suggest that PRs do not
prevent patients from removing medical devices (Chang et al., 2008;
Mion et al., 2007). Moreover, the application of PR may have adverse
short- and long-term emotional and psychological consequences,
including worsening of agitation during ICU treatment (Burk et al.,
2014) and post-traumatic stress disorder following ICU discharge
(Franks et al., 2021). Internationally, several legislative measures,
accreditation standards and professional society guidelines mandate PR
minimization in hospital units, including ICUs (Government of Ontario,
2001; Bray et al., 2004; Maccioli et al., 2003). Nevertheless, PRs
continue to be used extensively in ICUs in many countries (Benbenbishty
et al., 2010; De Jonghe et al., 2013; Rose et al., 2016).
The need for, and effectiveness of, implementation methods to suc­
cessfully integrate evidence-based PR minimization interventions in the
ICU has gained increasing attention in the literature. This interest is
derived, in part, from reviews reporting positive effects of PR reduction
interventions in ICU (Franks et al., 2021) and non-ICU settings (Möhler
et al., 2016). Abraham et al. (2020) published a review of multicom­
ponent PR minimization interventions (e.g., education, audits, and
physical restraint alternatives), demonstrating successful PR reductions
with no increase in adverse events (e.g., self extubation). While multi­
component interventions may result in PR reduction, approaches to
implement such interventions are lacking. The implementation of
practice change in the ICU is known to be difficult, costly and time-
consuming. The complexity of the interprofessional ICU environment,
heightened by an unstable patient population and multiple technolog­
ical interventions, makes the ICU a challenging area for the imple­
mentation of practice innovation (Kajdacsy-Balla Amaral et al., 2012).
With respect to the implementation of innovative interventions in
ICU settings, cumulative evidence suggests that successful imple­
mentation is positively influenced by the use of an implementation
strategy underpinned, or informed by, implementation science frame­
works (McNett et al., 2020). Such frameworks may help to identify
barriers to and facilitators of, implementation, guide the selection of
implementation strategies to overcome those barriers and inform what
outcomes should be measured to determine implementation success.
Frameworks ultimately help those responsible for introducing innova­
tive practices to attend to the influential interplay of the intervention
components, the context and the recipients. Several theories, frame­
works and models have been used to identify the supporting and hin­
dering factors in healthcare innovation implementation (Birken et al.,
2017). However, the use of such frameworks in the implementation of
physical restraint minimization interventions in adult ICU patients re­
mains unclear.
The integrated–Promoting Action on Research Implementation in
Health Services (i-PARIHS) (Harvey and Kitson, 2016) is a determinant
framework that can be used to identify potential barriers and facilitators
to address when undertaking an implementation project. Underpinned
by relevant theories of innovation, behavioral and organizational
change, the i-PARIHS framework reflects the assumption that imple­
menting research into healthcare practice is complex and non-linear. It
positions facilitation as the active element of implementation, which
includes efforts to align the innovation to be implemented with the
intended recipients in their local, organizational and wider system
context (Harvey and Kitson, 2016). The i-PARIHS framework was
developed with complex multi-disciplinary team-based interventions in
mind, rendering it appropriate for ICU settings which comprise a
diverse, interprofessional workforce.
The primary aim of this scoping review was to answer the following
2
Intensive & Critical Care Nursing 69 (2022) 103153
question: What are the implementation elements (i.e., innovations,
contexts, recipients, and facilitators) informing the successful execution
of PR minimization interventions in adult ICU patients? The objective
was to identify and map the elements to the i-PARIHS framework
(Harvey and Kitson, 2016), namely:
1) To identify PR minimization interventions (i.e., innovations)
2) To explore implementation contexts (i.e., contexts)
3) To identify key stakeholders (i.e., recipients)
4) To describe the roles of individuals within the studies (i.e.,
facilitators)
An additional objective was to describe the manner in which PR
outcomes were evaluated and used as part of the implementation efforts.
Methods
A scoping review was selected as it is recommended when the nature
and extent of the literature on a specific topic is unknown (Munn et al.,
2018). This review was informed by Arksey and O’Malley’s Framework
(2005). The framework comprises five steps: (1) identifying the research
question; (2) identifying the relevant studies; (3) selecting the studies;
(4) charting the data and (5) collating, summarizing and reporting the
results (Arksey and O’Malley, 2005). This scoping review also followed
the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines
(Tricco et al., 2018) (Additional file 1).
Inclusion criteria for the reviewed studies
Types of studies
Studies were included if the primary objective was minimization in
PR use in the adult ICU setting. A wide range of quantitative study de­
signs were eligible for inclusion: cluster and parallel-group randomized
controlled trials, crossover trials; quasi-randomized and non-
randomized trials, including non-randomized controlled trials; inter­
rupted time series analyses, controlled before-and-after studies, and
quality improvement projects. Qualitative studies were also eligible
where the aim was to identify the barriers to, and facilitators of, PR
minimization.
Participants
Studies that recruited adults aged 18 years or older and who required
admission to high-intensity care settings, such as ICUs, specialized
weaning centers and high-dependency or step-down units, were eligible.
Studies conducted in psychiatric facilities, nursing homes and long-term
care settings were excluded. In addition, studies conducted in non-ICU
hospital settings, including emergency departments, postoperative re­
covery units and hospital wards, were excluded.
Interventions
Studies reporting interventions designed primarily to minimize PR
were included. The interventions were restricted to nonpharmacological
interventions because they are deemed low-risk, non-invasive, and with
potentially fewer adverse effects when compared to pharmacological
interventions (Johnson et al., 2016). We anticipated that non­
pharmacological interventions might comprise staff education pro­
grams, provision of PR alternatives (e.g., one-on-one patient sitters), and
institution-wide interventions (e.g., quality improvement projects and/
or implementation of new policy).
Search techniques
The search strategy was developed by one author (LR) in consulta­
tion with an information specialist (Additional file 2). The following
databases were searched from the inception to August 2020: Ovid
Z. Alostaz et al.
MEDLINE, CINAHL, Embase, ISI Web of Science, Cochrane Library,
PROSPERO and Joanna Briggs Institute. In addition, the International
Clinical Trials Registry Platform was searched to identify completed
clinical trials. Search was repeated in May 2021. The reference lists of
the included articles and relevant reviews were also checked for addi­
tional eligible studies. A combination of controlled vocabulary (e.g.,
“Restraint, Physical,” “Intensive Care Unit” and “Critical Care”) and
keywords (e.g., restrain*, intensive or critical or acute) was used.
Animal-only studies, case reports and opinion pieces, such as editorials
and letters, were excluded. Language restrictions were not imposed on
the database search; however, for pragmatic reasons, only English-
language articles were included.
Study selection and data extraction
One reviewer (ZA) combined and deduplicated all database searches
in Endnote™ X9 reference management software (The EndNote Team,
2013). The obvious irrelevant references were excluded. The remaining
references were imported to COVIDENCETM, software for managing
systematic reviews, and two reviewers (LJ and ZA) independently
screened the title and abstract against the eligibility criteria. The full
texts of the potentially relevant articles selected by each reviewer were
retrieved and examined for eligibility. The authors used a pre-designed
data form to independently extract data on the study designs, methods,
participant characteristics, interventions, recipients, context, facilitators
and outcomes. Disagreements during study selection and data extraction
were resolved through discussion and consensus. A third author (CD)
was consulted when agreement could not be reached.
Consistent with Arksey and O’Malley’s framework and the study goal
of identifying the implementation science elements underpinning
physical restraint minimization studies, the methodological quality of
the included studies was not evaluated. The results of this scoping
Fig. 1. PRISMA flow diagram.
3
Intensive & Critical Care Nursing 69 (2022) 103153
review are presented as a narrative description.
Results
Search results
The search yielded a total of 5441 records. This included 543 du­
plicates that were removed. Following title and abstract screening, 4844
articles were excluded. An additional 47 that did not meet the inclusion
criteria were excluded during the full-text review. The reasons for
exclusion are presented in the PRISMA flow diagram (Fig. 1). Thus, the
review comprises seven studies that met the inclusion criteria. Three
relevant reviews summarizing restraint minimization interventions
were identified (Perez et al., 2019; Abraham et al., 2020; Teece et al.,
2020). The references in these reviews, in addition to the reference lists
of the discussed articles, were screened for potentially relevant studies.
No further studies were identified.
Study characteristics
The seven included studies were published between 1997 and 2018.
All studies used quantitative designs. No qualitative or mixed methods
studies were retrieved. Of the included studies, six were before-and-after
designs (Hall et al., 2018; Hevener et al., 2016; Johnson et al., 2016; Kirk
et al., 2015; Lin et al., 2018; Mitchell et al., 2018), and one was a quasi-
experimental design (Fitzpatrick, 1997). Six studies were conducted in
single hospital settings (Fitzpatrick, 1997; Hall et al., 2018; Hevener
et al., 2016; Johnson et al., 2016; Kirk et al., 2015; Lin et al., 2018), and
one was conducted in two hospitals (Mitchell et al., 2018). Three studies
were conducted in one ICU, and four were done in multiple ICUs (Kirk
et al., 2015; Lin et al., 2018; Mitchell et al., 2018; Fitzpatrick, 1997).
Most studies (n = 5) did not report the patient inclusion criteria
 Z. Alostaz et al.
Table 1
Characteristics of the included studies (N = 7).
Author(s)/country Design Setting Study timeline Intervention Control Prospective vs retrospective Summary of findings
Source of data
Type of PR
PR metrics

Fitzpatrick (1997) Quasi Single hospital Baseline: 6 months Education Education without Prospective data collection Physical restraint reduceda
USA experimental 8 ICUs and 8 intermediate units intervention: 1 month Decision aid tool decision aid tool Medical records No change in falls, chemical restraints,
Multiple specialties Post intervention: 5 PR include: wrist, ankle, vest self extubation
months and mitt restraint No information on ICU LOS
Rate per 1000 patients-days

Hall et al. (2018) Before/After Single medical surgical ICU Before: 8 months Restraint bundle Data before Retrospective data collection Physical restraint reduced a
USA After: 8 months Education implementation Medical records Increase in falls c
Audit more restrictive (soft wrist Self extubation increased c
Use of sitter when restraint No change in ICU LOS
available least restrictive (freedom
splints and mittens)
proportion of PR

Hevener et al. Before/After Single medical surgical ICU Before: 1 month Education Data before Retrospective data collection Physical restraint reduced b
(2016) USA After: 4 months Alternative to PR implementation Medical records Self extubation rate reduced
Decision aid tool Mitts used as an alternative No information on chemical restraint,
proportion of patients falls, ICU LOS
restrained

Johnson et al. Before/After Single trauma ICU Before: 6 months Education Data before Retrospective data Medical Physical restraint reduced b
(2016) USA After: 12 months Alternatives to PR implementation records No information on chemical restraint,
4

Instruction Protocol No information reported on PR self extubation, falls, ICU LOS

types
Rate per 1000 patients-days

Kirk et al. (2015) Before/After 1 surgical ICU and 1 step down Before: 2 years Education Data before Prospective vs retrospective not Physical restraint reduced c
USA unit in a single hospital After: 3 years Daily PR rounds implementation clearly reported No change in self extubation
Medical records No information on chemical restraint,
More restrictive (soft wrist falls, ICU LOS
restraint)
Less-restrictive (mitts, padded
belts, elbow splint)
Proportion of PR

Lin et al. (2018) Before/After 3 neuro ICUs in a single hospital Baseline: 1 year Education Data before Retrospective data collection Physical restraint reduced c
Taiwan Intervention PR protocol implementation Medical records No information on chemical restraint,

Intensive & Critical Care Nursing 69 (2022) 103153

development: 2 months No information reported on PR self extubation, falls, ICU LOS
After: 10 months types
Rate per 1000 patients-days

Mitchell et al. Before/After 5 ICUs in two hospitals Before: 2 years Education Data before Retrospective data collection Physical restraint reduced
(2018) USA Multiple specialties After: 3 years Alternative to PR implementation Medical records No information on chemical restraint,
committee Mitts used as an alternative self extubation, falls, ICU LOS
Mean restraint rate

PR: Physical restraint, ICU: Intensive care unit, LOS: length of stay.
a
Not statistically significant.
b
Statistically significant.
c
No information about the significance.
Z. Alostaz et al. Intensive & Critical Care Nursing 69 (2022) 103153

(Mitchell et al., 2018; Hall et al., 2018; Hevener et al., 2016; Johnson
et al., 2016; Kirk et al., 2015). Two included only patients at increased
risk for restraint use (Lin et al., 2018; Fitzpatrick, 1997); such as older
patients (>60 years) (Fitzpatrick, 1997) and those with neurological
diseases, such as brain tumors and intracranial hemorrhage (Lin et al.,
2018). The baseline period (control phase) was between one month and
two years, and the post-intervention implementation period was be­
tween four months and three years. Six studies were conducted in the
United States (Mitchell et al., 2018; Fitzpatrick, 1997; Hall et al., 2018;
Hevener et al., 2016; Johnson et al., 2016; Kirk et al., 2015), and one
was performed in Taiwan (Lin et al., 2018). Table 1 summarizes the
characteristics of the seven included studies.
Innovations
Types of innovations
All seven included studies examined multicomponent, non-
pharmacological interventions for minimizing PR use in ICUs. In each
of these seven studies, the core PR minimization component was edu­
cation (descriptions of the content of education programs and delivery
mode are presented in Table 2). In addition, point-of-care strategies to
facilitate PR minimization were used. Four of the studies introduced
decision aid tools or protocols with criteria to assist nurses in making
decisions on PR application (Johnson et al., 2016; Hevener et al., 2016;
Lin et al., 2018; Fitzpatrick, 1997) and four offered alternatives,
including less restrictive forms of restraint (Johnson et al., 2016; Hall
et al., 2018; Hevener et al., 2016; Mitchell et al., 2018). One study re­
ported daily nursing PR rounds to facilitate decision-making (Kirk et al.,
2015) and another reported use of audit/feedback of PR and self-
extubation rates (Hall et al., 2018).
Sources of innovation
Two studies developed the intervention on the basis of published
guidelines (Johnson et al., 2016; Hall et al., 2018). Five studies used
interventions that had been informed by previous research findings
(Hevener et al., 2016; Kirk et al., 2015; Lin et al., 2018; Mitchell et al.,
2018; Fitzpatrick, 1997). In addition to using previous research findings,
four of these studies incorporated clinician expertise in the design of the
intervention (Kirk et al., 2015; Lin et al., 2018; Mitchell et al., 2018;
Fitzpatrick, 1997). Only two studies involved the interprofessional team
in the development and/or implementation of the intervention (Kirk
et al., 2015; Lin et al., 2018). No studies involved patient or family
members at any stage of the research.
No study reported the use of implementation science approaches (i.
e., theories, models or frameworks) to plan, guide, deliver or evaluate
the physical restraint minimization interventions. Two studies cited a
theory (organizational theory or adult learning theory) in the “Discus­
sion” or “Implications” section to explain either the findings (Fitzpa­
trick, 1997) or education process (Kirk et al., 2015).

Table 2
Innovation sources, educational content and intervention recipients.
Study Source of Profession involved in Profession involved in Recipient of Content of education Mode of education
Innovation intervention development intervention rollout intervention delivery

Fitzpatrick Previous Nurses Nurses Nurses Agitation management Mandatory self-learning

(1997) research online module
findings
Local data
Clinician
experience

Hall et al. National Nurses Nurses Nurses Case scenarios 1-to-1 education
(2018) guidelinea Least restrictive devices Group education
Use and application of PR Demonstration on the
application of PR

Hevener et al. Previous Nurses Nurses Nurses Proper use of restraint Online module
(2016) research Alternatives to PR 1-to-1 education
findings Use of decision aid tool

Johnson et al. PAD guidelineb Nurses Nurses Nurses Restraint alternatives Group education
(2016) Protocol included pictures, Demonstration on the
features and benefits of the application of
alternative device alternatives
Laminated packets and
posters

Kirk et al. Previous Interprofessional team Interprofessional team Nurses and Education on agitation 1-to-1 education
(2015) research physicians management & PR alternatives Group education
findings Physicians were educated about Posters, emails, and
Clinician the initiative, devices and order newsletter updates
experience entry

Lin et al. Previous Interprofessional team Interprofessional team Nurses Education about the protocol Group education
(2018) research Posters on information
findings board
Clinician
experience

Mitchell et al. Previous Nurses Nurses Nurses PR and self extubation Group education
(2018) research Determine patient eligibility for Posters, emails, and
findings restraint newsletter updates
Clinician
experience
a
Det Norske Veritas and Germanischer Lloyd (national guideline).
b
Pain, Agitation, Delirium.

5
Z. Alostaz et al.
Table 3
Influencing internal and external factors.
Study Outer context
(i.e., driver for change)
Fitzpatrick (1997) JCAHOa (1996)
Hall et al. (2018) DNV GL standardsb
Hevener et al. (2016) JCAHOa (1996)
Johnson et al. (2016) JCAHOa (2009)
Kirk et al. (2015) The NDNQIc
Lin et al. (2018) Taiwan Joint Commission on Hospital Accreditation (2013)
Mitchell et al. (2018) The NDNQIc
a
JCAHO: The Joint Commission on Accreditation of Healthcare Organizations.
b
DNV GL: Det Norske Veritas and Germanischer Lloyd (national standards).
c
NDNQI: National Database of Nursing Quality Indicators.
Context
None of the studies described using an implementation framework to
examine or to diagnose the baseline PR practice context, i.e., pre-
existing conditions and relationships in the organization prior to inter­
vention development. Two of the studies assessed context prior to
intervention development (Lin et al., 2018; Mitchell et al., 2018); one
asked nurses to determine patient behaviors that warrant PR use (Lin
et al., 2018); and the other one established a collaborative team to assess
the context, including the existing organizational barriers to PR mini­
mization (Mitchell et al., 2018). However, the methods (e.g., surveys,
interviews) for assessing the contexts were unclear.
The most commonly reported barrier to PR minimization at the unit
level was a risk-averse culture (Hall et al., 2018; Hevener et al., 2016;
Kirk et al., 2015; Mitchell et al., 2018; Fitzpatrick, 1997); defined as
shared values and/or behaviors among team members that prioritize the
prevention of potential harmful events (Hofsø and Coyer, 2007), pri­
marily the removal of medical devices (e.g. endotracheal tubes) by a
patient, or falling out of bed. Other barriers included the lack of avail­
able alternatives, the need for staff education on appropriate PR use
(Johnson et al., 2016) and lack of standardized protocols (Lin et al.,
2018). No study provided information on the drivers for change (i.e.,
clinician motivations at point of care) at the unit level. However, all
studies reported on drivers for change at the organizational level (e.g.,
hospital-wide initiatives) and/or within the broader context (national
regulations, quality guidelines, or hospital accreditation standards).
Table 3 summarizes the influencing internal and external factors.
Recipients
All studies addressed ICU nurses as principal recipients of the
implementation interventions. One study also educated physicians, pa­
tients and their family members (Kirk et al., 2015). Only three studies
described the characteristics of nurse recipients; most were between the
ages of 31–40 years (Johnson et al., 2016; Hevener et al., 2016; Fitz­
patrick, 1997); held a baccalaureate degree and had up to 10 years or
more of critical care experience (Johnson et al., 2016; Hevener et al.,
2016; Fitzpatrick, 1997).
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Intensive & Critical Care Nursing 69 (2022) 103153
Inner context
(i.e., existing barriers)
Risk averse culture
Risk averse culture
Risk averse culture
Lack of non-pharmacologic interventions
Lack of education
Nurses attitudes
Risk averse culture
Lack of standardized protocol for the use of physical restraint
Risk averse culture
Lack of availability of effective alternatives
Lack of baseline data on current practices
Lack of knowledge about the NDNQI
Reluctance to share information with others (i.e., silo mentality)
Facilitator types and roles
Six studies used both internal facilitators (i.e., individuals from the
unit or organization) and external facilitators (i.e., individuals from
outside the organization) (Hall et al., 2018; Hevener et al., 2016; Kirk
et al., 2015; Lin et al., 2018; Mitchell et al., 2018; Fitzpatrick, 1997). The
facilitators in one study were from the unit only (Johnson et al., 2016).
The facilitators were either individuals, such as a nurse (e.g., a clinical
nurse specialist) (Johnson et al., 2016; Hall et al., 2018; Fitzpatrick,
1997) or interprofessional teams (Hall et al., 2018; Kirk et al., 2015; Lin
et al., 2018; Mitchell et al., 2018).
The variability in the facilitators’ roles depended on the type of
facilitator (i.e., internal or external) and the stage of study (i.e., before,
during, or after intervention implementation). Table 4 outlines the types
of facilitators and their roles in each study. The main roles of the
external facilitators included team building (Mitchell et al., 2018), evi­
dence base review (Lin et al., 2018; Mitchell et al., 2018; Fitzpatrick,
1997), tool development (Johnson et al., 2016; Hall et al., 2018; Lin
et al., 2018; Fitzpatrick, 1997) and organization-level restraint data
monitoring and comparisons (Mitchell et al., 2018). The facilitators’
roles inside the units included design and/or education delivery
(Mitchell et al., 2018; Hall et al., 2018; Hevener et al., 2016; Johnson
et al., 2016; Kirk et al., 2015), audit (Hall et al., 2018; Kirk et al., 2015),
stakeholder engagement (Hall et al., 2018), daily nursing restraint
rounds (Johnson et al., 2016; Hall et al., 2018; Kirk et al., 2015) and
presentation of audit results demonstrating changes in physical restraint
and self-extubation rates (Kirk et al., 2015).
Outcomes
In all studies PR data were based exclusively on identification via
medical records. No study validated the accuracy of PR documentation.
There were variations in the methods for measuring and reporting
intervention outcomes, which were PR incidence and prevalence. For
example, three studies reported restraint use per 1000 patient days
(Johnson et al., 2016; Lin et al., 2018; Fitzpatrick, 1997), and four re­
ported proportions or mean proportions of patients restrained (Hall
et al., 2018; Hevener et al., 2016; Kirk et al., 2015; Mitchell et al., 2018).
In one study, the PR outcomes were used as part of implementation
 Table 4

Z. Alostaz et al.
Types of facilitators and their roles.
Study Organization/External facilitators Role Local unit facilitators Role

Fitzpatrick Investigator Review charts NCCa CNS+NCC: Distribute & collect education packets
(1997) Develop decision aid tool CNSb CNS- provided content and design assistant for restraint reduction
Coordinate with internal facilitator QACc posters that were developed by the point-of-care nurses.
SDCd QAC: provided access to information required for the study such as
ICU expertse self extubation rates
SDC- announce and coordinate the self-learning module
ICU expert: validate the tool items

Hall et al. Hospital safety team Review safety data in the hospital on daily ICU nurse coordinator Assist in developing the restraint bundle
(2018) basis Monitor restraint practices twice a day
Hospital accreditation coordinator Create restraint audit tool Round on each restraint patient/ focus on patients restrained >72
Nurse leaders Develop restraint bundle management hour
Evaluate the need for continued restraint use
Discuss those patients in day/night shift huddles
Keep hospital safety team appraised

Hevener et al. Center for professional practice of nursing educators Assist in developing the learning module Investigator Check the evidence base and select the decision aid tool
(2016) Performance improvement department Supplied data on restraint use Provide 1 to 1 staff education
Develop the device dislodgment form

Johnson et al. Not reported Not reported Charge nurse Included in their rounds any concern with the intervention
(2016) Not reported Provide education on alternatives
Develop the alternative device instruction protocol
Monitor daily restraint and report monthly rates
Place the protocol as standing agenda item at monthly staff meeting
and share governance meeting

Kirk et al. Value analysis committee Approve the type of mittens selected by staff CNS (project leader) Complete a focused clinical evaluation for each restrained patient
7

(2015) and make it available in the storeroom
Collaborate with industry vendors who
facilitate the project at no cost
Not reported Include restraint skills station in the annual
skills day
Facilitate restraint rounds & real time discussions with the
interprofessional team (charge nurse, physicians, champions)
Coordinate alternative device specific education at the unit level,
shared governance and unit council meetings
Interprofessional team Conduct restraint check rounds
Encourage staff to think critically about restraint use
Unit Educator Communicate with the CNS and learn from the success in the SSU
Team building and obtain buy-in from monthly shared governance
meeting (including mangers and staff members)
Educate staff at 6 am and 11 pm
Perform rounds and individual discussions
Stay in the patient’s room for 30 minutes after applying mitts
Unit committee Approve and standardize the multidisciplinary education on
assessment, care and device selection
Assign specific staff members to educate on mittens

Intensive & Critical Care Nursing 69 (2022) 103153

Senior staff from shared unit Provide interdisciplinary education on restraint reduction and
governance alternatives
Champions Educate all team member on the weekends & off shifts
Charge nurse Rounds and examine restraint practices and ask the primary RN if the
restraints are absolutely needed

Lin et al. Investigator Develop the guideline with interprofessional Clinical experts (two physicians and Establish common language for promoting communication with staff
(2018) team three senior nurses) (i.e., they review and integrate the 13 scenarios into six indicators)
Establish the PR quality improvement team Consultation team (physician, Required to assess patients within 60 minutes of initiating PR
(consultation team) pharmacist, and respiratory therapist) Pharmacist provided pharmacokinetic information for sedation &
Conduct literature review and determine 13 anaesthetics (appeared in the day shift only)
potential indications for PR use Head nurses Measurement: data collection (before and after)
Survey ICU nurses Not reported Educate staff about the standard protocol for PR and the
responsibility of each discipline

(continued on next page)

Z. Alostaz et al. Intensive & Critical Care Nursing 69 (2022) 103153

strategy, whereby audit of incidence and duration of restraint use were

reported back to the target recipients at shift change (Hall et al., 2018).

Select a new mitt after communication with other institutions and

The manner in which PR outcomes were measured and usage feedback

Meeting with staff to elicit feedback and evaluate the outcomes

delivered (e.g., verbal vs. written) were not described.
Survey nurses to understand current restraint practices
All studies documented an initial decrease in PR use post imple­

Give all ICUs the opportunity to evaluate the new mitt

Survey nurse to seek their opinion on the new product
Conduct a review on use of restraint & self extubation mentation of minimization interventions. Long term results regarding
decreases in physical restraint use post implementation of minimization
interventions were not reported. Four studies reported that the use of PR
was reduced without increase in device removals (Hevener et al., 2016;

Gather feedback on their individual units

Provide education on restraint reduction
Integrate restraint reduction locally Kirk et al., 2015; Lin et al., 2018; Fitzpatrick, 1997) or chemical restraint
email discussion between the team

use (Fitzpatrick, 1997). Two studies reported a slight increase in self-

extubation rates after PR reduction but no information about statisti­
cally significant change from baseline was provided (Hall et al., 2018;
Mitchell et al., 2018).

Discussion
Act as mentors

This review sought to identify the elements informing the successful

Role

implementation of PR minimization interventions in adult ICU patients,

to map those elements to the i-PARIHS framework domains and to
describe the outcomes of those interventions. No implementation
ICU specific collaborative (lead by the

frameworks were described in the seven identified studies. All studies

examined multicomponent PR minimization interventions that were
derived from research evidence and/or clinician experience. The pri­
mary recipients and facilitators were nurses. The patients, families,
Local unit facilitators

medical and allied health professionals, and hospital leaders had little to
no involvement. The external context (i.e., national regulations) pro­
Bedside nurses

vided the impetus for change. The measurement methods varied; how­
ever, documentation in medical records was the only basis for restraint
rate calculations.
CNS)

Evidence in hospital settings confirms implementation frameworks

as useful in anticipating barriers when seeking to reduce or minimize the
Monitored and compared restraint use as part

use of low-value or harmful practices (Birken et al., 2017). An unin­

tended consequence of practice change is clinician reactance in the form
Improve communication between units

Educated the team about the database

of fear or anger (Niven et al., 2016). Reactance may relate to feelings

about patient safety or professional accountability being violated as a
Formed a restraint collaborative

result of the practice minimization. Consequently, clinicians may in­

Engage in solving problem
Shared unit best practices

crease their commitment to the ineffective practices (Niven et al., 2016).

Approve the new mitt
Review evidence base

Without the framework-based identification and amelioration of bar­

riers, particularly in risk-averse settings, practice change might not be
Discuss barriers

sustainable.
In all the included studies, the design of the PR minimization in­
of NDNQI

terventions was based on published research findings and/or clinician

Role

experience. In other words, the innovation was primarily one of

knowledge transfer via education. It is recognized that high-quality
Restraint collaborative (bedside nurses, nurse educators,
CNS, nurse managers) from units with high restraint use

evidence alone is not sufficient to change practices (Harvey et al.,

2002). The i-PARIHS framework suggests that implementation is more
administrators, nurse managers, educators, bedside

likely to be successful if the intervention is derived from robust research

NDNQI: National Database of Nursing Quality Indicators.

that is aligned with clinician experience and patient preferences (Harvey

System wide Restraint committee (nursing

QAC: Quality Assessment/Improvement Coordinator.

and Kitson, 2016). The evidence informing a PR minimization inter­

vention would ideally be based upon empirical data demonstrating
Organization/External facilitators

positive short or long-term patient health outcomes and cost effective­

ness. It is not clear that the included studies uniformly addressed clini­
cian and patient concerns about the nature of the evidence as part of
SDC: Staff Development Coordinator.

their implementation process

Purchasing committee

With respect to the forementioned reactance among clinicians, ex­

NCC: nursing care coordinator.
NDNQI expert f

perts suggest minimization of unsafe or ineffective practices can be

CNS clinical nurse specialist.
nurses, CNS)

optimally achieved by offering an alternative, i.e., a less restraining

ICU: intensive care unit.

device (Augustsson et al., 2021). Several studies highlighted innovations

in the provision of decision aids or protocols and least-restraint options,
Table 4 (continued )

such as mittens. Decision aids could help to define patient eligibility or

the timing of PR application and removal. In addition, replacements
Mitchell et al.

such as mittens may act as an evidence-based intervention that targets

(2018)

similar short or long-term patient-oriented health outcomes. This may

Study

follow expert recommendations, whereby the proposed innovation is

simple and requires similar or less cognitive or behavioral effort (Norton
d
b
a

e
c

8
Z. Alostaz et al.
and Chambers, 2020).
None of the reviewed studies involved former ICU patients or their
family members as active agents in minimization design, delivery, or
evaluations despite previous reports of the negative sequela associated
with PRs (Demir, 2009). Patient and/or family involvement is impor­
tant. First, it aligns with the current era of patient- and family-centred
care, which empowers patients by allowing them to make decisions
about their care or treatment (Carman et al., 2013). Second, it provides
opportunities for patients to share their lived experiences. This could
motivate clinicians to consider practice changes.
In none of the included studies were clinician stakeholders from all
ICU professions involved throughout the implementation. The focus on
nurses could reflect the perception of PR as a nursing rather than an
interprofessional team responsibility. The involvement of clinicians
from all professions is important. First, it is important to access multiple
perspectives on the influential factors in current practices to increase the
relevance and ultimate success of intervention design and imple­
mentation (Majid et al., 2018). Second, previous studies have reported
ICU nurses’ fears of medical reprisals (e.g., blame from other pro­
fessions) in the event of perceived preventable harm (e.g., self-
extubation) as the leading reason for PR use (Freeman et al., 2016).
Third, the evidence suggests that clinicians who are involved in the
design of an intervention are more likely to change their practices
(Grimshaw et al., 2012). Last, the dissemination of the innovation to
other professions has been shown to be important in ensuring sustain­
ability (Harvey and Kitson, 2016).
The current review found that national regulations and quality da­
tabases, which comprised data benchmarked with other units and hos­
pitals, were the key change drivers. The regulations were not ICU-
specific (Government of Ontario, 2001); thus, they were unlikely to
influence local PR practices. This could explain the high PR prevalence
in ICUs in jurisdictions such as Canada (Rose et al., 2016). Why non-ICU-
specific regulations are change drivers in the United States (Hall et al.,
2018) but not in other countries is unclear (Luk et al., 2015; Suliman
et al., 2017). Additional explorations of the external factors could pro­
vide further explanations, such as the possibility of the reinforcement of
compliance in pay-for-performance systems.
In most of the reviewed studies, nurses facilitated the PR minimi­
zation implementations. Few references were made to physician or se­
nior health management guidance. This leadership vacuum suggests
weak facilitation in PR minimization efforts. The i-PARIHS Facilitation
Guide includes recommendations for the skills, attributes, and roles
required for “strong” facilitation (Harvey and Kitson, 2016). However,
the lack of explicit reporting of these characteristics or the facilitation
process precluded determinations about the quality of facilitation.
In all the studies, the PR rate was based on medical record docu­
mentation. Previous studies have found documentation inconsistencies.
For example, in a study at a Turkish hospital, 94% of the nurses reported
not documenting PR use (Akansel, 2007). Poor documentation could
lead to the underestimation of PR use and the inability to determine
intervention outcomes. A strength of the i-PARIHS framework is its focus
on implementation outcome measurements (Harvey and Kitson, 2016),
which can be validated by multiple methods and data sources (e.g.,
observation and documentation).
Only one minimization intervention study reported the application
of restraint outcomes (e.g., PR prevalence) to implementation. The lack
of outcome data in risk-averse settings may pose a barrier to practice
change. In the absence of data on quality (e.g., PR rates) and safety (e.g.,
self-extubation rates), clinicians may retain risk-averse beliefs and
9
Intensive & Critical Care Nursing 69 (2022) 103153
continue the routine use of PR. Previous ICU implementation studies
have indicated the effectiveness of timely (Bradley et al., 2004; Sinuff
et al., 2015) individualized (Sinuff et al., 2015) and non-punitive
(Hysong et al., 2006) feedback for promoting and sustaining practice
change.
No reviewed study provided qualitative stakeholder data on imple­
mentation barriers and facilitators. Clinician narratives can provide
important insights into the influence of contextual factors, including the
barriers to and facilitators of practice innovation, as well as the most
appropriate intervention and implementation strategies to effect change
(Majid et al., 2018). Descriptive qualitative data on implementation can
also facilitate replications of successful interventions.
Strengths and limitations
This scoping review is both unique and important. First, unlike
previous reviews, it was guided by a theoretical framework that in­
corporates exploration of factors for successful implementation of in­
terventions. Second, it was focused on ICUs only rather than clinical
settings that may not be comparable. Third, it complements previous
reviews by describing not only PR minimization interventions but also
the context and facilitator roles in restraint minimization. Fourth, the
study used a rigorous search strategy that was developed in consultation
with an information specialist.
This scoping review has limitations. The English-language criterion
may have precluded inclusion of studies from a number of countries for
which information on PR minimization interventions could be collected.
The included studies, which spanned 21 years (1997–2018), were con­
ducted primarily in the United States. Thus, the generalizability of the
findings to other countries with different health care systems and pol­
icies regarding PR might be limited. A quality appraisal of the included
studies was not performed; therefore, no conclusions about methodo­
logical characteristics can be drawn and no strong statements about the
effect of the interventions, can be made.
Research implications
This scoping review gives rise to several issues that suggest the need
for further research on PR minimization in ICUs. Foremost is the need for
implementation science models, theories, or frameworks to plan, guide,
deliver and evaluate the implementation of PR minimization in­
terventions. Further research is also needed to develop consensus on
outcomes, their definitions and physical restraint measurement and
reporting in the ICUs (i.e. a core outcome set) (Blackwood et al., 2015).
Moreover, studies are required to evaluate the impact of particular
implementation strategies on sustained PR minimization. This might
include examination of different implementation formats, content and
duration.
Conclusion
In the reviewed studies, implementation development was based
primarily on external sources of knowledge and was not guided by a
theoretical framework. The core interventions were education, deci­
sional aids/protocols and restraints alternatives. Primary intervention
recipients and facilitators were nurses. Future PR minimization research
incorporating implementation science frameworks, interprofessional
teams, and patient/family perspectives is warranted.
Z. Alostaz et al.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of data and material
Not applicable.
Funding
This scoping review was funded through graduate awards provided
by Lawrence S. Bloomberg Faculty of Nursing, University of Toronto,
Canada.
Author’s contributions
ZA is responsible for conceiving the review, execution of the search
strategy, coordinating the review, refinement of the review question and
methods, determination of included and excluded studies, data extrac­
tions, interpretation of data and writing the first draft of the manuscript.
LR is responsible for conceiving the review, development of search
strategy, refinement of review question and methodologies and editorial
comments on the manuscript drafts.
SM is responsible for conceiving the review, refinement of review
question and methodologies and editorial comments on the manuscript
drafts.
LJ is responsible for the refinement of the review question and
methods, determination of included and excluded studies data extrac­
tions, interpretation of data and editorial comments on the manuscript
drafts.
CD is responsible for conceiving the review question and methods,
interpretation of data and editorial comments on the manuscript drafts.
All authors read and approve the manuscript.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgment
We would like to acknowledge Becky Skidmore, information
specialist, for her assistance in the design of the search strategy.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.iccn.2021.103153.
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