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

Angela Teece, PhD student


  • To explore critical care nurses’ decision-making when employing restraint to manage patients with hyperactive delirium
  • To identify potential modifiable factors which lead to the use of physical or chemical restraint on the critical care unit


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 (Krewulak et al., 2018). Of the three delirium subtypes (hyper and hypo-active, mixed), hyperactive delirium is the most obvious and clinically disruptive (Krewulak et al., 2018).

Delirious and agitated patients are at risk of disrupting life-sustaining therapies, for example, dislodging an endotracheal tube or vascular access devices. Chemical or physical restraint are often cited by staff as the main method of preserving patient safety (Benbenbishty et al., 2010). However, the efficacy of restraint in improving patient safety is unproven and its use is associated with impaired long-term recovery (Jones, 2010, Zaal et al., 2015, Khan et al., 2014). In addition, critical care nurses have expressed confusion regarding the lack of precise language to describe restraint, and the challenge of objectively quantifying the point at which restraint could become clinically appropriate (Freeman and Teece, 2017).

An integrative review identified four themes which influence restraint use on the critical care unit: The lack of standardised practice; patient characteristics; the struggle in practice; the decision to apply restraint. The review identified nurses as the primary decision makers in restraint management. They reported agitation management to be physically and psychologically challenging and experienced a lack of support from medical colleagues. Restraint use appeared to be influenced by unit custom and previous adverse experiences, rather than evidence-based practice.


This PhD project uses an innovative data collection method to explore how critical care nurses make the decision to restrain agitated or delirious patients. Six short audio-visual vignettes featuring patients of varying clinical acuity have been created. The vignettes will be used in conjunction with ‘Think Aloud’ to explore factors which might influence a critical care nurse’s decision making and management of a patient with hyperactive delirium.


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

BENBENBISHTY, J., ADAM, S. & ENDACOTT, R. 2010. Physical restraint use in intensive care units across Europe: The PRICE study. Intensive and Critical Care Nursing, 26, 241-245.

FREEMAN, S. & TEECE, A. 2017. Critical care nursing: caring for patients who are agitated. Evidence Based Nursing.

JONES, C. 2010. Post-traumatic stress disorder in ICU survivors. Journal of the Intensive Care Society, 11, 12-14.

KHAN, B. A., FADEL, W. F., TRICKER, J. L., CARLOS, W. G., FARBER, M. O., HUI, S. L., CAMPBELL, N. L., ELY, E. W. & BOUSTANI, M. A. 2014. Effectiveness of implementing a wake up and Breathe program on sedation and delirium in the ICU. Critical Care Medicine, 42, e791-e795.

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.

ZAAL, I. J., DEVLIN, J. W., PEELEN, L. M. & SLOOTER, A. J. 2015. A systematic review of risk factors for delirium in the ICU. Critical Care Medicine, 43, 40-7. ffffffffffffff