#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


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

Does policy and procedure keep service users secluded longer than necessary?

International concerns (United Nations, 2013; World Health Organisation, 2017; Duxbury, 2019) have been expressed about seclusion use in mental health settings. Although initiatives such as Safewards and No Force First recommended strategies staff can use to prevent aggression or de-escalate potential incidents, healthcare staff continue to support its use (Muir-Cochrane, 2018). Our study ‘Factors influencing decisions of mental health professionals to release service users from seclusion’ – published recently in the Journal of Advanced Nursing – echoed these findings. We found previous research focussed upon which services are likely to be secluded and why they may be secluded (Bowers et al, 2017), plus how professionals’ decision-making to seclude service users is heavily influenced by local ward cultures and team personalities (Larue, 2009; Mann-Poll, 2011). However our work was the first to explore the factors that professionals consider when deciding to release a person from seclusion.

The Mental Health Code of Practice and NICE Guidance requires involvement from a range of professionals from the multi-disciplinary team (MDT) and outline a strict schedule for reviews:

  • medical review within 1 hour of seclusion starting,
  • 2 hourly nursing reviews,
  • 4 hourly medical reviews, and
  • 8 hourly multi-disciplinary team reviews.

Our findings raise questions about policy and procedure for reviewing the use of seclusion. We also found that, despite policy, decisions to release service users from seclusion were highly subjective and may be eroding professional skills, autonomy and confidence:

‘…the policy provides safeguards but years ago it was different. We once used a low stimulus room, after around 20 minutes went in. We de‐escalated through the door. Got him to move back, put his weapon down. Now it would be more formal, get a doctor, start the paperwork. It would probably would have turned out different and lasted longer and affected our relationship with him.’

Following instructions

The professionals in our study admitted – with some discomfort – that they told secluded service users to ‘calm down’ and ‘behave’ as it was important to be satisfied they would cooperate and comply with instructions when released. Professionals said they thought they had no choice but to use seclusion as they were unsure how else they could manage some incidents of violence and aggression. Professionals explained that they drew on their previous knowledge of the service user when considering what someone could or could not realistically manage and deciding how trustworthy they were:

‘We have all seen patients who say the right the right things to get out, hold it together for so long and then it all spills out’

Others warned against ‘being played’ by service users showing remorse that might be insincere or temporary. Service users in seclusion were not seen as passive, however. Professionals suggested release was as much in service users’ hands as theirs, because they knew what was expected and had the choice to take control and engage appropriately if they wanted to be released.

Fear of getting it wrong

These decisions also took into account the physical and ‘emotional tone’ of the ward: professionals acknowledged they could not release someone into ‘chaos’. They thought about the resources such as the size, permanency and skill-set of the team they had at their disposal asking themselves would the team cope post-release and deliberated about the consequences if they did not:

‘If you’re wrong, there goes your credibility’.

The nurses interviewed suggested that they could sometimes lose focus on the service user in seclusion as they struggled to manage the review timetable, assemble MDT colleagues and ensure documentation was correct. Nurses talked about needing to protect themselves and feared ‘getting it wrong’, ‘being judged incompetent’, or being ‘taken down a formal capability route’. In contrast, medical professionals did not feel this pressure, stating that as long the service user was safe they were not concerned about reviews being overdue or that their practice would be subject to scrutiny.

Daring to make bolder decisions

Staff numbers, permanency and skills were described as important, particularly the experience and confidence of the decision maker which had a strong influence on the likelihood of release and length of seclusion. Junior doctors depicted their role as managing physical health and supporting the nurses, and junior nurses worried about maintaining safety and supporting their team. Some Allied Health Professionals interviewed appeared confused as to why they were included, felt their skills were not used and doubted they had any influence on decisions. In contrast senior staff, who had greater experience and authority to move service users to other wards, said they made bolder choices and did not feel constrained by policy:

‘I’ll be honest and say if I want to bring somebody out then I’ll do that and I’ll let a medic know that’s what I have done’.

Our recommendations

Based on our findings, we made some recommendations:

  • We need to have conversations about how current policy is applied to ensure impracticable and counterproductive standards do not hamper efforts to release people from seclusion at the earliest opportunity:
    • Senior staff should be available to facilitate release, and,
    • Organisational procedures and support for staff nurses should enhance (not undermine) their confidence or autonomy to manage situations.
  • There could be better use of the skills of Allied Health Professionals to support planning for release.

Professionals would benefit from greater awareness of the factors that hinder or facilitate decisions to release people from seclusion. This study did not examine how the person secluded was involved in the planning or decision-making about their release. Increased understanding of how service users could be empowered to be involved in such decisions certainly warrants further investigation and is the focus of future research.

Haley Jackson is a PhD student in the mental health research group. You can follow her @haleyj102 or contact her at hchj@leeds.ac.uk.


Bowers, L., Cullen, A.E., Achilla, E., Baker, J., Khondoker, M., Koeser, L., Moylan, L., Pettit, S., Quirk, A., Sethi, F., Stewart, D., McCrone, P. and Tulloch, A. 2017. Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services. Health Services and Delivery Research. pp. 1-142. ISSN 2050-4357.

Department of Health (DOH). 2015. Mental Health Act 1983: Code of Practice. London: DH.

Duxbury, J., Baker, J., Downe, S., Jones, F., Greenwood, P., Thygesen, H., McKeown, M., Price, O., Scholes, A., Thomson, G. and Whittington, R. 2019. Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’). International journal of nursing studies. 95, pp.40-48.

Jackson H, Baker J, Berzins K. (2019) Factors influencing decisions of mental health professionals to release service users from seclusion: A qualitative study. Journal of Advanced Nursing https://doi.org/10.1111/jan.14086.

Laiho, T., Lindberg, N., Joffe, G., Putkonen, H., Hottinen, A., Kontio, R. and Sailas, E. 2014. Psychiatric staff on the wards does not share attitudes on aggression International Journal of Mental Health Systems 8(1), pp.14-14.

Larue, C., Dumais, A. and Ahern, E. 2009. Factors influencing decisions on seclusion and restraint. Journal of Psychiatric and Mental Health Nursing. 16(5), pp.440-446.

Mann-Poll, P.S., Smit, A., de Vries, W.J., Boumans, C.E., Hutschemaekers, G.J., Mann-Poll, P.S., Smit, A., de Vries, W.J., Boumans, C.E. and Hutschemaekers, G.J.M. 2011. Factors contributing to mental health professionals’ decision to use seclusion. Psychiatric Services. 62(5), pp.498-503.

Muir-Cochrane, E., O’Kane, D. and Oster, C. 2018. Fear and blame in mental health nurses’ accounts of restrictive practices: Implications for the elimination of seclusion and restraint. International Journal of Mental Health Nursing. 27(5), pp.1511-1521.

National Institute for Clinical Excellence (NICE). 2015. Violence and aggression: short-term management in mental health, health and community settings (NG10). London: NICE.

United Nations. 2013. Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez, 1 February 2013 (A/HRC/22/53). Para 78. Geneva: United Nations Human Rights Council (UNHRC).

World Health Organisation (WHO). 2017. Strategies to end the use of seclusion, restraint and other coercive practices. WHO QualityRights training to act, unite and empower for mental health (pilot version). Geneva: WHO.

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.


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.