#ICUrestraint study: using audio-visual vignettes

Using audio-visual vignettes to explore how nurses make the decision to restraint delirious patients on the critical care unit

How do nurses make the decision to restrain a delirious patient? What influences their decision? Do they follow protocols or base their decision on an individual assessment of the patient? If they assess the patient, what impacts on this process: the nurse’s experience, the acuity of the unit, or perhaps just how they felt that day? These are some of the questions I am seeking to answer through my PhD research.

My background research showed that nurses were the main decision makers when managing patient agitation and lacked support from medical colleagues. The literature suggests that nurses found caring for agitated and delirious patients physically and emotionally challenging. Nurses used negative subjective terms such as ‘mad’ and ‘poorly behaved’ to describe patient behaviours associated with hyperactive delirium despite the existence of objective, validated tools such as RASS and CAM-ICU. This can lead to the sharing of judgements of dysfunctional or deviant patient behaviour (Carveth, 1995). Wide variations in restraint use appear to be influenced by previous adverse clinical experiences and unit custom rather than evidence based practice.

What is delirium? Delirium is a rapid onset, reversible, fluctuating condition characterised by inattention, changes in cognition, disordered sleep-wake cycle and increased or decreased psychomotor activity (American Psychiatric Association, 2013). It affects approximately 20-50% of mechanically ventilated patients in critical care (Krewulak et al., 2018).  Hyperactive delirium presents as psychomotor agitation, which is often cited as a rationale for initiating chemical and physical restraint in critical care despite a poor evidence base (Ai et al., 2018).

Think aloud

To answer these questions, I wanted to develop a data collection method which would help me to understand how nurses make the decision to restrain a patient, and identify potential modifiable factors. I rejected direct observation because it risked disrupting clinical care and I decided against written scenarios as i doubted these could convey the clinical urgency of caring for an agitated patient. Together with my supervisors, I chose audio-visual vignettes, or short films with ‘Think Aloud’ as the data collection method. ‘Think Aloud’ aims to reveal the thought processes involved in making decisions by encouraging participants to vocalise their thoughts.

Developing the method

I began by writing scenarios based on my reflections on practice and cues identified from my background research. I asked a clinical expert (an Advanced Critical Care Practitioner) to check the scenarios before I developed illustrated storyboards that detailed the patient behaviours I wanted to ask participants about. An enthusiastic group of colleagues agreed to simulate these patient behaviours, and I filmed and edited the audio-visual vignettes early this year. The vignettes depict a range of delirious critical care patients with varying levels of potential risk inference, such as agitated or combative behaviour or the presence of medical devices. Each film is preceded by a verbal handover, which provides an opportunity to explore whether subjective descriptors influence how the participants perceived the patient and if this affected their decision-making.

I piloted the vignettes with three participants. The method works well and simulates decision-making under time-pressure in the critical care environment. Early data suggests variations in practice, and a focus on short-term management over a consideration of the long-term impact of restraint use.

For more information about my PhD research please visit my study page. Data collection is ongoing and the study is actively recruiting new participants.

Would you like to take part?

please see the Participant Information Sheet

Your can contact me at a.m.teece@leeds.ac.uk. You can also follow me on Twitter @AngelaTeece

References

AI, Z.-P., GAO, X.-L. & ZHAO, X.-L. 2018. Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis. Intensive & Critical Care Nursing, 47, 62-68.

AMERICAN PSYCHIATRIC ASSOCIATION, D. S. M. T. F. 2013. Diagnostic and statistical manual of mental disorders: DSM-5, Arlington, Va;London;, American Psychiatric Association.

CARVETH, J. A. 1995. Perceived Patient Deviance And Avoidance by Nurses. Nursing Research, 44, 173-178.

KREWULAK, K. D., STELFOX, H. T., LEIGH, J. P., ELY, E. W. & FIEST, K. M. 2018. Incidence and Prevalence of Delirium Subtypes in an Adult ICU: A Systematic Review and Meta-Analysis. Critical Care Medicine, 46, 2029-2035. 3

CArDiNAL: A New Clinical Academic Research Fellowship

The beginning…

I am delighted to be starting my PhD journey with the University of Leeds in tandem with Leeds and York Partnership Foundation Trust. The new CArDiNAL (ClinicAl Doctoral Nurses and ALlied Health Professionals) Clinical Academic Research Fellowship embeds and promotes my research role within my clinical (Speech and Language Therapist) Specialist post. A strength of this new post is the support of a cohort of clinical academic fellows – including different Allied Health Professionals and Nursing Specialists – together, we form a community of research active clinicians across the Yorkshire and Humber footprint.

“The service users on my clinical caseload, their caregivers and the multidisciplinary team have directly influenced my research topic.”

Without this important initiative by Yorkshire and Humber NIHR CLAHRC I would not have been able to embark on this research journey whilst continuing to practice as a Speech and Language Therapist. As well as adding to the wider evidence-base for dysphagia in mental health, my research and ongoing clinical practice will inform each other. The service users on my clinical caseload, their caregivers and the multidisciplinary team have directly influenced my research topic and I will use my specialist skills to support involvement from other service users with communication difficulties in co-production.

“How can service users, caregivers and clinicians be supported to recognise the early warning signs of eating, drinking and swallowing problems?”

My PhD research will consider everyday quality of life around mealtimes and I will continue to identify and unpack good practice. My pilot work progressed from an initial case study (highlighting the different perspectives of an inpatient and members of his staff team; see Guthrie et al. 2012) to projects considering the risks associated with swallowing difficulties, communication and choking incidents in adults with mental health conditions (Guthrie and Stansfield 2017; Guthrie and Roddam 2011), leading me to ask: how can service users, caregivers and clinicians be supported to recognise the early warning signs of eating, drinking and swallowing problems? I developed a free booklet to support service user, carer and staff discussions about mealtimes (Guthrie 2013). The pictures, text and checklist suggest conversation topics, including aspects of swallowing difficulty that may have gone unrecognised or been overlooked. Any concerns about swallowing should always be referred to Speech and Language Therapy for assessment and advice.

I am keen to hear any patient or caregiver “stories” of the experience of living with mental health conditions and dysphagia.

Susan Guthrie is a Highly Specialist Speech and Language Therapist and CArDINAL Clinical Academic Research Fellow. For more information about her PhD research you can contact her here or directly via hcsg@leeds.ac.uk. You can also follow Susan on Twitter @SusanGuthrieSLT and on Researchgate.

References

Guthrie, S. and Roddam, H. (2011) Reporting and learning from choking incidents in adults with learning disabilities. Speech and Language Therapy in Practice.

Guthrie, S., Roddam, H., Panna, S. and Fairburn, G. (2012) Capacity to choose and refuse? A case study. Advances in Mental Health and Intellectual Disabilities, 6(6), pp.293-300.

Guthrie, S. (2013) Me at Mealtimes [Free online booklet]

Guthrie, S. and Stansfield, J. (2017) Teatime Threats. Choking Incidents at the Evening Meal. Journal of Applied Research in Intellectual Disabilities, 30(1), pp.47-60.

Tickets Available – Reducing Restrictive Practices: Understanding Key Intervention Components

As we move into the final stages of COMPARE: Establishing components of programmes to reduce restrictive practices: an evidence synthesis, we are pleased to announce that we will share our findings at a dedicated event:

Reducing Restrictive Practices: Understanding Key Intervention Components

12.30-15.30 5 June 2019
Horizon Conference Centre, Leeds

We have identified and mapped over 100 interventions that have been implemented in various adult mental health settings across the world. A free, interactive directory will be made available following this event. Using a specially designed taxonomy, we were able to discern between the active components of a substantial proportion of these interventions. Consequently, for the first time, we will be able to indicate which intervention components have the most (or least) potential to reduce restrictive practices.

We will also introduce a new study that builds on and extends this work: CONTRAST: Establishing components of interventions to reduce restrictive practices with children and young people: an evidence synthesis. Here, we will seek to identify interventions to reduce restrictive practices with children in a range of residential settings.

“We particularly encourage service users and carers to come along and join in the discussion.”

A draft programme for the event can be found below. Please join us for a complimentary lunch from 12.30 onwards. We hope that we will be joined by a wide range of stakeholders with an interest in the reduction of restrictive practices for plenty of networking and discussion. We particularly encourage service users and carers to come along and join in the discussion and we can cover travel expenses for those who wish to do so. Please contact us to make arrangements.

If you have any questions about the event, please do not hesitate to contact us. For travel and parking information visit Horizon, Leeds

Tickets are available via Eventbrite.