An integrative review on physical restraint in adult critical care unit

Background Physical restraints (PRs) are frequently used in adult critical care units to protect staff and prevent self-harm, despite the fact that they represent significant safety risks. Restraint complications may have an impact on the patient’s long- and short-term outcomes. This integrative review aimed to meticulously evaluate existing evidence pertaining to physical restraint practices in adult critical care settings. The review was specifically geared towards examining the prevalence of PR, identifying influential factors, elucidating the role of nurses in PR implementation, exploring nurses’ experiences in caring for patients under restraint, and scrutinizing the complications associated with PR application Method This integrative review included the studies published between January 2009 and December 2019 and the literature search was conducted in July 2020. The databases searched included EBSCOhost, Ovid, ProQuest, PubMed, Wiley Online Library, SCOPUS, and ScienceDirect. The keywords included in the search were restraint, critical care, intensive care, ICU, mechanical ventilation, intubation, nursing, and experience. A checklist based on the CASP checklist and the JBI Critical Appraisal Tool was used to assess the methodological quality. Results The findings were evaluated and summarized into seven key topics after twenty-one publications were found to be evaluated. i) High prevalence of PR application in adult critical care unit; ii) determinants of PR applications; iii) types of PR in adult critical care units; iv) decision maker of PR; v) moral and ethical dilemma in PR application; vi) awareness and guidelines for PR applications; vii) common complications and use of sedation, analgesics, antipsychotic drugs in PR application. Conclusion The number of days PR is used is related to the risk of an adverse event. In order to standardize nursing practice, ICU nurses require greater training on the ideas of PR use. Evidence-based recommendations will assist critical care nurses in making the best judgments possible concerning the use of PR.


Introduction
Delirium and increased anxiety are common issues in ICU patients, especially those who are on mechanical ventilation.Disturbing actions that lead to the endotracheal tube dislodging or interfering with other medical devices place these people at a higher risk of self-harm and even death. 1,2Critically ill patients who are receiving intensive care are under a great deal of stress.A number of factors can contribute to the severity of the underlying disease, including the use of medical equipment, pain, and anxiety.Maintaining the highest degree of patient comfort and safety is crucial to the patient's care in these situations. 3Chemical and physical restraints (PRs) are frequently used in the intensive care unit (ICU) when caring for critically ill patients to reduce patient discomfort and anxiety.However, PRs result in considerable safety risks. 3,4e use of any mechanical device or physical materials, or equipment that is attached to or around a patient's body and that person cannot easily remove, restricting the patient's range of motion or regular access to his or her body, is referred to as a PR. 5 It's uncertain whether the usage of restraints is based on scientific facts or on custom and culture. 6e patient who is physically restrained faces various risks, including lactic acidosis, incontinence, bone fracture, a sense of powerlessness and vulnerability, limited ROM, hospital-acquired pressure injury, venous thromboembolism, stress cardiomyopathy, respiratory depression, aspiration, choking, asphyxia, and even death. 7,8The best ethical justification for PRs is that they prevent people from harming themselves. 9PRs are often used despite the lack of evidence supporting their effectiveness. 10PR practices have been studied in a number of countries.As a result, having a thorough understanding of current facts and practice is critical.

Aim
The aim this integrative review was to conduct a thorough assessment of the available evidence on PR in the adult critical care unit focusing on: 1) the prevalence of PR; 2) factors that influenced PR; 3) the role the nurses in the implementation of PR; 4) the nurse's experiences in caring for patients with PR; and 5) the complications associated with applying PR.

Search methods and strategy
This integrative review included quantitative, qualitative, mixed methodologies, and quality improvement projects from accessible literature, referring to studies published between January 2009 and December 2019 and a literature search was conducted in July 2020.
EBSCOhost, Ovid, ProQuest, PubMed, Wiley Online Library, SCOPUS, and ScienceDirect were among the databases searched.Restraint, critical care, intensive care, ICU, mechanical ventilation, intubation, nurses, and experience were utilized as search terms.The "AND" and "OR" Boolean operators were employed.
To map the search process, a flow diagram was used (Figure 1).Initially, the database identified 3840 articles, and 852 duplicates were removed.From the remaining articles, 1205 were excluded electronically using exclusion criteria.Out of 1783, articles were found relatively relevant to the topic and 1498 articles were eliminated after limiting the search using the Boolean operator "AND".A further seven were sourced from bibliographies and three of them were considered relevant to the screening.A total of 288 articles were considered for the title and abstract screening.238 nonrelevant articles were excluded and 50 full-text articles were retrieved.The screening process was conducted by two people independently.Twenty-nine of them were excluded after screening the full text and finally, 21 articles were considered for synthesis.EndNote X9.3.3 for Windows was used to manage the articles.

Inclusion criteria
Only peer-reviewed research involving patients or nurses in all types of adult ICUs was evaluated for this review, which was solely focused on the use of PR in adult critical care units.All full-text English papers with various techniques (quantitative research, qualitative studies, and quality improvement programs) are included.

REVISED Amendments from Version 1
In the current version, the aim of the study has been clearly presented under the heading "Aim" and consistently integrated throughout the abstract and content.The exclusion criteria are clearly mentioned in the new version.Furthermore, grammatical corrections have been applied to enhance clarity and coherence.This revision ensures that the aim of the study is effectively communicated and remains consistent throughout the manuscript.

Exclusion criteria
Exclusion criteria for this review included review papers, editorials, conference abstracts, and commentaries.Additionally, studies focusing on chemical restraints, studies conducted in settings outside of ICUs only, and previous literature reviews were excluded.EndNote X9.3.3 electronically removed words in the title that contained animals (e.g.rat), psychiatric, neonatal, and pediatric.Restraint and intensive care unit/critical care unit/ventilated/intubated/nurses/ experience were used with the Boolean operator "AND" to narrow the search.Non-relevant papers were eliminated by manually scanning the title and abstract for exclusion criteria such as animal research, psychiatric/pediatric/neonatal units, and so on.The decision to include an article in the final stage was based on the study's eligibility 36 and the content's relevance.

Eligibility of data
The systematic review of literature for a particular intervention, condition, or issue is at the heart of evidence synthesis.The systematic review entails a number of sophisticated procedures that include an analysis of the existing literature (that is, evidence) and a judgment of the effectiveness or otherwise of practice. 11The initial assessment of articles was done using the Critical Appraisal Sklls Programme (CASP) 12 checklist tool.This paradigm was chosen because it allowed for a systematic and rigorous approach to analyzing and evaluating article quality that could be used in both quantitative and qualitative methodologies. 13The initial papers were screened using the inclusion/exclusion criteria.The literature was evaluated using the CASP tool's three major questions: i) Is the research valid?(ii) What were the outcomes?(iii) Will the findings be usefully locally?. 12 The articles answered sufficiently for these three questions were further considered.According to Whittemore & Knafl, 14 two quality criterion instruments should be utilized during the review process to assure the authenticity, methodological quality, and informative value of the included research.Because of the wide sample frame, evaluating the quality of the research paper in integrative reviews might be difficult.The articles were re-evaluated using the more specific questions from the CASP 12 checklist tool and JBI (Joanna Briggs Institute) Critical Appraisal Tool. 11,36e CASP tool and JBI Critical Appraisal Tool includes a set of detailed questions to enhance visualization of the data and to simplify this complex comparison of CASP tool and JBI Critical Appraisal Tool, a common checklist was adapted.Each article was assessed using the adapted checklist and used effectively to analyze the articles clearly and succinctly.While these checklists were designed to assess qualitative research papers, they were adjusted to include the essential criteria stated in both the CASP tool and the JBI Critical Appraisal Tool for a qualitative and quantitative approach.The modified checklist includes a clear aim, methodology, design, recruitment, data collection, researcher and participant relations, participants and their voices, ethical considerations, data analysis and rigor, findings, and research value.

Data analysis
By permitting the use of a combination of studies with diverse methodologies, the integrative review method is the only strategy that has the potential to play a larger role in nursing evidence-based practice. 14Data analysis in research reviews necessitates the ordering, coding, categorization, and summarization of primary source data into a cohesive and integrated conclusion regarding the research problem. 15The data collected from multiple resources were compiled into a table to provide a more complete picture of the subject at hand.Combining many data sources, on the other hand, is difficult and time-consuming. 14These challenges were approached by organizing data in a manageable framework.According to Whittemore & Knafl, 14 data reduction, data presentation, and data comparison are all part of the data analysis phase of integrative reviews.The phases of data reduction and presentation involved extracting and coding data to be organized into a manageable framework, which then increased the visualization of their linkages and patterns.This approach suited the review framework due to the varied data collected by the researchers through various approaches.Whittemore & Knafl, 14 proposed a consistent comparative approach for comparing integrative reviews, which was used in this review and presented in Table 2.

Results
Twenty-one articles were found to be suitable for this review (Table 2).The studies were conducted in China, Japan, Turkey, Egypt, Iran, Canada, South Africa, the United States of America, the Netherland, and Europe.The quantitative data were gathered from various sources via observation and survey, while the qualitative data were gathered through face-to-face interviews.Each study had a different sample size.
The following were the themes that developed from the literature: i) high prevalence of PR application in adult critical care units; ii) determinants of PR applications; iii) types of PR in adult critical care units; iv) decision maker of PR; v) moral and ethical dilemma in PR application; vi) awareness and guidelines for PR applications; vii) common complications and use of sedation, analgesics, antipsychotic drugs in PR application.

High prevalence of PR application in the adult critical care unit
The fact that PRs are were commonly employed in the adult critical care unit was obvious.Descriptive research in China found that ICUs used PRs more frequently than medical-surgical wards. 168][19] Critical care nurses (CCNs) (68%) reported that PRs were most commonly used in ICUs. 20According to 94.5% of CCNs physical restraint must be applied in ICU. 21ost nurses working in critical care units experienced (68% to 100%) the use of PRs. 1,21According to Langley et al., 22 all of the participants in their study agreed that PRs have a place in the ICU.And they stated that, before using PR the patient's agitation must be assessed.
According to a study conducted in Canada by Luk et al., 23 83% of restraints were employed on the night shift and Jiang et al. 16 support that PR is more commonly used on the night shift.Turgay et al. 24 on the other hand, found no variations in the frequency of PR use between night and day shifts.PRs were utilized by 57% of nurses prior to the patient's interference with medical equipment. 17ve studies looked into nurse-to-patient ratios.According to Kandeel & Attia, 20 nurse workloads play a significant effect on the use of PR.Benbenbishty et al. 25 found that PRs were frequently utilized for sedated and mechanically ventilated patients in units with a lower daytime nurse-to-patient ratio.And according to Hamilton et al. 17 restraint use was more likely with low nurse-to-patient ratios.The nurse-to-patient ratio was mentioned in the other two studies, but there was no discussion of the relationship between the ratio and PR applications. 18,22Regardless of personnel resources or the number of beds in private rooms, PR usage varied among ICUs in a cross-sectional online survey conducted in Japan. 26cording to Ertu grul & Özden, 27 out of total restrained patients, 85.6% were initiated in the first 24 hours of their hospitalization.The duration of PRs varied from hours to days.An article from Canada explored the median duration of restraint as 21 hours 28 while a study from China found that patients stayed restrained for up to 20 shifts (8 hrs shift). 4ccording to Langley et al. 22 and Luk et al. 19 the patients were restrained for an average of 9 and 4.1 days respectively.In a study, Hamilton et al. 17 found a prevalence rate of 358 restraint days per 1,000 ICU days.From two observational studies, out of total restrained patients, 42.9% to 48% were restrained for more than 24 hours. 4,28Repeated application of

○
To identify patient-specific factors that may contribute to the application of PRs.

○
Explore nurses' rationale for use.▪ Mixed-methods study.A prospective cohort design was used to collect patient data, and semi-structured interviews were used to collect nurse data.

○
In total, 30 permanent ICU staff nurses and 72 patients were admitted during the study period in the mixed medical-surgical ICU.
▪ Quantitative Data: Gender is not a contributing factor to the use of PRs.75% of patients are restrained during their hospitalization.The prevalence rate was 358 restraint days per 1,000 ICU days.
▪ Four self-extubations were documented during the study (3 patients without restraint and one documented as a fear of being restrained).The presence of an endotracheal tube increased the odds of PR application eight-fold.Low nurse-to-patient ratios increased the odds of restraint use.All opioids (95%) or midazolam administration (95%) increased the odds of restraint use.
▪ Qualitative data: nurses' interviews ▪ According to 57% of nurses, patients are restrained prior to interference with medical equipment.They did not consult with the physician before they restrained the patient.
They had no alternative but to use PR to prevent extubation.
▪ Many of them expressed negative feelings about using PRs.Most nurses had empathy for tied patients and employed creative strategies to reduce their use or minimize the impact on the patient's freedom.
▪ Deciding to remove restraints is dependent on patient behavior.
▪ The decision to remove the restraint was made when the patient demonstrated "cooperation with the nurse, was awake and aware of the surroundings," and did not try to touch the tube, or when the patient was ready to have the endotracheal tube removed.▪ During the study, the use of restraints was reduced by 32%.There is a significant difference in restraint incidence before and after the use of the RDW, and there are no appreciable differences between the day shift and the night shift.For months 2 to 4, the RDW was used for 28.6%.
▪ 81% strongly agreed that the RDW was easily accessible.62% slightly agreed that the RDW was useful in making decisions about the use of restraints.
▪ According to 85% of participants, the primary rationale for restraints is to prevent people from pulling out ET tubes.77% felt comfortable removing restraints without a physician's order.
▪ 84% responded to using RDW on a regular basis.Many explained that an additional resource would also be beneficial and wanted to rely on their own clinical judgment on restraints.▪ The use of restraints was added to the dailygoals checklist and the need for restraints was assessed during daily inter-professional rounds.
▪ There is a lack of alternatives as a barrier to the removal of PRs.PRs may increase moral distress for nurses who care for these patients.PRs highlighted in some studies however, in most of the cases (75.9% -83%) the PR was applied only once during ICU stay. 4,19cumentation is vital when a nurse takes care of a patient.It protects them from legal consequences arising from the outcome or lack of restraint.In a study, patients' observational data were recorded in 51.3% of nursing notes and no data for removal time, patient responses, or complications were accurately recorded. 4The indication for PR was reported for 91 patients and two individuals were not documented, according to Guenette et al. 28 More than 59% had no documentation of PR as per Turgay et al. 24 According to Kandeel & Attia, 20 patient records did not contain information about the assessment of restraint sites.According to them, experienced nurses maintained better documentation regarding PR application and assessment than novice nurses.
Many studies support the lack of documentation of PR applications among patients. 4,20,24,28Hence, the prevalence rate of PR applications can be more than the available data suggests.The high prevalence rate of PRs shows its importance in the adult critical care unit, making it inevitable in the care of patients.

Determinants of PR applications
The primary justification for restraints is patient safety.0][31] The presence of an endotracheal tube raised the probabilities of PR application eight-fold, according to Hamilton et al. 17 who also emphasized the incidence of self-extubation in patients who were not restrained.Restraints were utilized as a preventative measure to prevent self-extubation. 29The most prevalent documented indication in a observational study was the prevention of treatment interference. 28Other indications for PR included prevention of falls or attempts to get out of bed, maintenance of posture & calming down the patient, and managing treatment resistance or care. 20,21 this review, two studies showed heavy workload and ward overflow with staff shortages as common reasons for PR. 16,31According to the response of more than half of the samples in qualitative data collected by Langley et al., 22 PRs were used primarily for the benefit of the clinical staff and to leave the patient unattended.Nurses face difficulties to identify an alternative as a barrier to the removal of PRs to ensure patient safety. 17,30,31However, in a study, for 33% of patients, alternative measures were considered prior to PR, and in 21% of cases chemical restraints were used instead. 23straints were sometimes employed to prevent injury to personnel or to oneself as a result of patient behavior such as agitation, delirium, restlessness, and varying degrees of impaired mental status. 17,23,25,29Patients with delirium or coma, who were taking psychoactive or sedative drugs, and who were unable to speak vocally, were at a higher risk of receiving PR. 18 Establishing an alternative measure for reducing the use of PRs while ensuring patient safety remains a predominant challenge for nurses.
Patient's requirements and desires must be addressed when applying for PR.Due to the variable responses to restraint treatment in this patient population, special consideration to be given to delirium patients.The nurse's capacity to maintain vigilance in patient care creates a safe environment. 29e decision to release restraints is based on the patient's behavior.Improved mental status (68.9%) is a vital indicator of the removal of restraint. 24Restraints were removed from 57% patients who were generally calm and cooperative for more than two hours. 23The nurses described that successful withdrawal of restraints without perceived negative effects is predicted according to patient behaviors. 29According to the CCNs, the decision to remove the restraint was made when the patient cooperated with the nurse, was awake and aware of their surroundings, and did not attempt to touch the tube, or when the patient was ready to have the endotracheal tube removed. 17Before stopping PR, however, it should be determined if there is a risk to the patient's safety.Falls, tissue injuries, pulling or removing connections, delays in therapies, extended hospital stays, high treatment costs, and even death are all risks of not utilizing PR. 31 Types of PR in adult critical care units In critical care units, bilateral upper limb restraints were most commonly used. 27,28ICU patients were also restrained using four-point restraints. 4,20,24Among 141 patients in Canada, most were restrained using wrist restraints (91%).Allfour-limb restraints were used on a few patients (4%) and combinations of unilateral wrist-ankle and wrist-mitten restraints were rarely employed (2%). 23nbenbishty et al. 25 explored the common use of commercial wrist restraints.In a study in Turkey, PR was used with tough cuff material, green foam tie, and a roll of gauze at a rate of 17.6%, 10.8%, and 71%, respectively.The roll of gauze was used most commonly on the wrist. 27Hence, it can be articulated that the type of PR depends on the need of the patient and the material available in the unit.

Decision maker of PR
The majority of the research in this review supports the nurse's role as the principal decision-maker in the application and removal of PRs.In Egypt, nurses were responsible for 58.2% of the choice to use PR, while 41.1% was decided by both physicians and nurses. 20According to Turgay et al., 24 84.7% of PR were applied without a physician's order in Turkey and according to Balcı & Arslan, 32 nurses deciding on the use of PR have higher scores than physicians.However, Yönt et al. 21stated that 70.9% were decided jointly by the nurse and the physician and 25.5% by the physician alone.Before restricting a patient in Canada, nurses did not confer with the physician. 17Nurses were the primary decision-makers in PR, according to Langley et al. 22 from South Africa.Nurses in Iran were not allowed to use PR without a medical order; however, restraints are used without a physician's order since nurses believe physicians are unsupportive if further complications arise from not using PR (e.g. if a patient falls). 31In California, 77% of nurses felt confident releasing restraints without a doctor's order.Nurses wanted to rely on their own clinical judgment when determining whether or not to restrain a patient. 30e literature shows that nurses play a significant involvement in the decision to use restraints on patients.In this review, no studies mention the role of patients or their families.Inconsistencies in the role should be addressed with a standard guideline that specifies each individual's role (physician, nurse, patient, or family), and it should be very clear about a physician's written order for PRs.

Moral and ethical dilemma in PR application
Moral distress may increase among the nurses who care for patients under PR. 33Many nurses voiced dissatisfaction with the use of PRs.Most of them empathized with restrained patients and established innovative ways to diminish PR use or lessen the impact on the patient's freedom. 17The ethical issues for CCNs are caused by the outcomes of utilizing PR.Because of the overwhelming workload and nursing unit overflow, they felt obligated to disregard patient rights and autonomy in favor of PR.Due to the breach of patient rights and experience, nurses were conflicted.Even after leaving their shift, some of them felt uncertain. 31Nurses encounter ethical issues due to harm and benefit principles, according to Yönt et al. 21In their study, according to 65.5 % of nurses, no family consent was obtained for PR, and 63.6 % of nurses have no reservations about PR.
In a Chinese study, only about a third of restrained patients gave informed consent for PR. 4 Communication between physicians, patients, and families is paramount.The proper application of PR should be a balancing act between its benefits and drawbacks. 22These studies show the moral and ethical dilemmas facing nurses in the application of PR.Appropriate organizational policies will help nurses to overcome moral and ethical dilemmas.In addition, adequate training and education may be needed to prevent the psychological impact on the nurses.

Awareness and guidelines for PR applications
A quality improvement project conducted in the US 33 showed a reduction in restraint rate after restraint collaboration and the restraint culture shifted from heavy to minimal use.The use of restraints was included in the daily-goals checklist, and the need for restraint was assessed daily during the multidisciplinary rounds.Furthermore the researcher added that, nurses who engage in evidence-based practice use the most up-to-date evidence and gladly share it with their colleagues.The impact of a restraint management bundle in an ICU on restraint utilization was studied by Hall et al. 34 When compared to the pre-cohort group, there was a reduction in the total number of restraint patients in the ICU in the postcohort group (24.3% vs 20.9%).The average number of restrained patients per patient day decreased among the group (0.075 vs 0.059), and the average of restraint events per patient day also decreased (0.191 vs 0.133).According to the data, restraint use, and duration were reduced dramatically.The length of stay in the ICU, on the other hand, remained consistent over time (3.64 vs 3.6 days).
Targeted nurse-led interventions can help reduce the usage of restraints, especially in delirious patients. 29Hevener et al. 30 conducted a quasi-experimental study in an ICU with the implementation of a restraint decision wheel (RDW) to reduce the usage of restraints, and the results demonstrate that restraints are gradually reduced in critical care units.In the first month, 64 devices were dislodged, and 38% of the patients were restrained; in the second to fourth months, only 51 devices were dislodged and 13% were restrained.During the research, the restraint used decreased to 32%.This study suggested 81% of nurses strongly agreed that the RDW was easy to use, and 62% thought that it was helpful in deciding whether or not to employ restraints, and 84% of nurses supported using the RDW on a regular basis.Many of them, however, stated that having another resource would be good.
In a descriptive and correlational study regarding PR, physician's practice scores were found to be higher than those of nurses.Nurses have a sufficient level of information regarding restraint but have negative attitudes towards it.However, nurses' attitude scores were found to be higher than those of physicians.And in practice, nurses' skillset is lacking/ insufficient. 32This opened a floor for the training need of nurses about PRs.Ahmadi et al.In a prospective multicenter study at Dutch ICUs, only 31% of nurses reported the use of a protocol for PR. 18In this review, two studies highlighted the need for a set policy or guideline for the restraint practice 4,16 and Unoki et al. 26 suggested in-service education and the establishment of a systematic approach to reducing PR use in mechanically ventilated patients.However, the effectiveness and possibility of de-escalation in critically ill patients were not tested in any of the studies in this review.
The overall analysis of the data in this theme shows the high need for training for nurses regarding PR application.
The establishment of a protocol or guidance will be more beneficial in the management of a patient with restraint.Implementation of Restraint Management Bundle, restraint decision wheel, and Targeted nurse-driven interventions can improve restraint application in ICU.
Common complications and use of sedation, analgesics, antipsychotic drugs in PR application Studies in this review show the negative outcomes of PRs like neuromuscular complications, increasing the need for sedation, analgesics, and antipsychotics.Turgay et al. 24 reported 36.8% complications and the most common one was skin breakdown.In Iran, 66.7% of the nurse had experienced complications caused by PRs. 1 According to prospective observational cohort research, most issues increased after the first 24 hours.An increase in redness was generated by the roll of gauze and tough cuff material.The length of PR raises the risk of neurovascular problems.Nurses failed to pay attention to peripheral circulation and failed to check the restrained wrist on a frequent basis. 27Observational data from South Africa shows that 21.46% of patients with analgesics and/or sedatives.There were patients managed with restraint (21.46%) and no sedation. 22re patients obtained psychiatric medicines after PRs were applied, according to a single-center, prospective, observational study done in Canada.According to that study, following the adoption of PRs, opioid administration became more widespread, accounting for more pharmacological interventions.Prior to PR, fewer people were treated with psychiatric drugs than subsequently (56% vs 86%).The administration of opioids was more common after the use of PRs (20 % vs 54%) and accounted for more pharmacological interventions (29% vs 45%).Before and after PR, 16% of 50 patients remained oversedated and disturbed.However, 20% of individuals got overly sedated after receiving PR, whereas 6% became less sedated.Furthermore, 10% of patients become more agitated, compared to eight percent who become less agitated. 28According to Hamilton et al., 17 all opioid or midazolam administration (95 %) increased the likelihood of restraint use.Analgesic, sedative, and antipsychotic medication use, excessive sedation, agitation, and the incidence of an adverse event all predicted PR use or days utilized. 19However, according to Gu et al., 4 analgesic use can be an independent protective factor for PR use.
PRs have a psychological effect on patients, causing issues including fear of the ICU, depression, anger, aggression, restlessness, agitation, and anxiety. 19The impact of PR on the outcome of the physical and psychological elements was disclosed in this overview of studies on this topic.Restraint complications may have an impact on the patient's long-term and short-term outcomes.Those issues can be avoided by assessing the restraints on a frequent basis.

Discussion and implications
The magnitude of restraint utilization in adult critical care units is shown through a study of the current literature.PR is a common procedure in ICUs, according to this review.The review's goal was driven by five questions, which were addressed and discussed under seven themes.Restraint is a technique for preventing the unintentional removal of medical or therapeutic equipment in order to reduce the risk of death. 31It is frequently used to prevent treatment interference. 28R was extensively used to maintain medical devices among intensive care patients, and the type of PR was easily constructed by nurses.24 The most prevalent reason for restraint removal noted by nurses in a study was the recovery of mental status. 1 CCNs will continue to utilize restraints until other ways have been scientifically proven to be effective in ICUs.24 Restraints may be used as a result of a heavy workload and a shortage of staff nurses.16,31 A systematic approach is needed to reduce PR use among mechanically ventilated patients 26 and implementation of the ABCDEF bundle can help avoid the use of restraints, prevent delirium and improve the management of delirium.33 Nurses encounter practical, legal, and ethical challenges when administering PR to patients. Inservice training on the use of PRs and ethical principles should be given to nurses to ensure that they make the best option possible on ethical issues.Furthermore, it is suggested that an evidence-based institutional policy governing the use of PR in ICUs be established.Create awareness among ICU nurses about the detrimental effects of PR on patients.21 The importance of nurses as decision-makers in PR is highlighted in this literature. To ensure a patient's safety, the least restrictive technique with the least risk and the most benefit to the patient should be used.It is necessary to analyze and resolve any unmet care needs or concerns.Restraints should not be used for the prevention of falls or the management of patient behavior as a routine.Consider a medical condition or symptom that suggests the necessity for immediate protective intervention to avoid violent behavior or getting out of bed. Brg the patient closer to the nurse's station so that he or she can closely observe.Adequate staffing is required to monitor the patients closely.Non-self-destructive behavior should be described to the patient in simple terms, and the patient should be able to articulate his or her understanding.People who are agitated as a result of pain or an adverse reaction to a current drug or medication require intervention instead of applying restraints.35 Evidence-based guidelines and educational interventions should be developed to support restraining practices. 17 Ths review underlines the lack of research on patients' experiences with restraint throughout their ICU admission.There are variations in the way restraint is prescribed and documented. Futhermore, a restraint protocol and guidelines have the ability to improve the critical care unit's restraint culture and practice.

Conclusion
The use of PRs in the adult critical care unit is important for the treatment of life-threatening behavior.The number of days of PR usage is linked to the occurrence of an adverse event.As a result, long-term physical restrictions on patients should be avoided, and patients who are physically restrained should have a neuromuscular, circulatory, and skin assessment.
The necessity for clear norms and policies for PR use is reflected in this review.Evidence-based guidelines will assist and support CCNs in making the best judgments possible about the use of restraints.To standardize nursing practice linked to the use of restraints for the protection of patient rights, and handling of ethical, legal, and emotional difficulties associated with PR, intensive care nurses require further education on the principles of restraint application.Furthermore, more study is needed to determine appropriate restraint alternatives.
Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).
following questions."More details are needed to allow the replication of this review.For example, it would be helpful to provide the full search strategy for one of the databases (e.g., Medline).
In the section discussing exclusion criteria, it appears that researchers primarily outlined how they limited the search rather than explicit criteria for excluding studies from the review.To enhance the reproducibility of this review, I recommend explicitly stating the predetermined criteria for exclusion.For example, exclusion of chemical restraints studies, studies conducted in any other setting outside ICUs, previous literature reviews, editorials, and conference abstracts, etc.Finally, I would recommend a review of the grammar used in the article as there was a mix-up of tenses (present, past, future).For example, under the aim it says "this review will look into...".Past tense should be used here, and there are many instances throughout.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

References
The review listed a few aspects of physical restraints, which is a common procedure, in adult critical care units.The authors performed an integrative review which included comprehensively all research designs -i.e., quantitative, qualitative, mixed methodologies, and quality improvement projects.Twenty-one published articles were scrutinized according to the PRISMA protocols and the findings were evaluated and summarized into seven key topics which are insightful for future researchers to consider when it comes to adult critical care.These themes, especially the high prevalence of PR application in the adult critical care unit and the determinants of PR applications will be useful for consideration when it comes to the use of PRs in the adult critical care units.Additionally, the other important but often times silent aspects such as the moral and ethical dilemma, awareness and guidelines for PR applications were also identified and discussed.Most importantly, this integrative review underlined the lack of research on patients' experiences with restraint throughout their ICU admission.
Are the rationale for, and objectives of, the Systematic Review clearly stated?Yes

Are sufficient details of the methods and analysis provided to allow replication by others? Yes
Is the statistical analysis and its interpretation appropriate?Yes

Are the conclusions drawn adequately supported by the results presented in the review? Yes
If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified?('Living Systematic Review' or a variation of this term should be included in the title.)Yes Competing Interests: No competing interests were disclosed.
Reviewer Expertise: As I work as a counsellor, my area of expertise may not be directly involved with critical care which may serve as a limitation if this is a clinical study.However, I have published a few systematic review papers.

Table 1 .
Quality Assessment Checklist: Adapted from JBI and CASP.36

Table 2 .
Summary of Reviewed Articles and Key Findings.three ICUs at a general hospital ▪ 61.2% of the patients were restrained.56.5% of the patient's bilateral upper limb restraints were used, and 22.3% of four-point restraints.Mostly restraint aimed to prevent the accidental removal of the medical devices to decrease any threat to the airway.▪ Use of analgesics as an independent protective factor for PR use.The nurse's record reflects a need for standard guidelines and policies for PR use in hospital ICUs in China.Age, delirium, mechanical ventilation, and analgesic use are risk factors related to PR use.Quantitative findings: PR is commonly used for patient safety.It is more often used in ICUs than in medical-surgical wards.more often used on the night shift.
○ Characterized the use of PRs in three ICU (ICUs) in a general hospital in Nantong, China.○ Explored risk factors potentially related to PR use.• Prospective, cross-sectional, observational study ○ 312 patients from ○ Identify the perceptions and practice of PR in China.▪ Mixed methods Descriptive study Qualitative interviews A quantitative cross-sectional survey ○ 18 nurses were interviewed.Of 330 nurses surveyed, ▪

Table 2 .
Continued ○Determine the extent of PR use in an urban teaching ICU.

Table 2 .
Continued ○Characterize the use of PR in ICU.○ Prevalence, adherence to protocols, and correlates of the use of PR was determined.○ For comparisons between ICUs, adjustments were made for differences in patients' characteristics.▪ A prospective, cross-sectional, observational multicenter study with two visits to each ICU ○ The sample included 379 patients and 346 nurses from 25 different Dutch ICUs.○ ○

Table 2 .
ContinuedDetermine intensive care nurses' reasons for the application and removal of PR.The extent of PR varied across units.use of PR not related to the time of the week.PR is more likely in ventilated and sedated patients in the unit with a lower daytime nurse-patient ratio. ○

Table 2 .
Continued ▪ Qualitative descriptive design.○ 13 nurses working in the Surgical ICU.

Table 2 .
Continued ○Decrease use of restraints in a medicalsurgical ICU.○

•
Impact of a Restraint Management Bundle on Restraint Use in an ICU.
21onducted Interventional Educational Program for ICU nurses to modify negative attitudes regarding the use of PRs.It leads to a positive attitude and improved the level of knowledge, perception, and practice among them.In the descriptive and cross-sectional study, Yönt et al.21concluded that 36.4% of nurses felt difficulty in deciding on PR use and ethical dilemmas.The majority of them (78.2%) did not participate in training regarding ethical dilemmas.They recommended providing training for the nurses regarding ethical principles related to PR and PR application.In addition, they suggested having established policies for the use of PR in the ICU.

Are the rationale for, and objectives of, the Systematic Review clearly stated? Partly Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified? ('Living Systematic Review' or a variation of this term should be included in the title.) Yes Competing Interests:
1. Perez D, Peters K, Wilkes L, Murphy G: Physical restraints in intensive care-An integrative review.Aust Crit Care.2019; 32 (2): 165-174 PubMed Abstract | Publisher Full Text 2. Alostaz Z, Rose L, Mehta S, Johnston L, et al.: Implementation of nonpharmacologic physical restraint minimization interventions in the adult intensive care unit: A scoping review.Intensive Crit Care Nurs.2022; 69: 103153 PubMed Abstract | Publisher Full Text No competing interests were disclosed.
Reviewer Expertise: Physical restraint use in ICUs.

expertise to confirm that it is of an acceptable scientific standard.
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.comPage 27 of 27 F1000Research 2024, 12:114 Last updated: 05 AUG 2024