Table 2. Summary of Reviewed Articles and Key Findings.

Author, Year & Place of research conducted	Title & Objective	Research design & Sample	Findings
Ahmadi et al., 2019, Iran 1	• Effect of Interventional Educational Programs on Intensive Care Nurses’ Perception, Knowledge, Attitude, and Practice about PRs. ○ Modify negative attitudes of intensive care nurses regarding the use of PRs.	▪ A quasi-experimental study with a pre-/post design with the census method ○ All nurses (n = 30) working in the ICUs had at least a bachelor’s degree and 1 year of working experience in ICUs.	▪ Interventional educational programs about the use of PR improved the level of knowledge and perception and led to a positive attitude and improved practice in nurses in the ICUs. ▪ All participants (100%) had used PRs before, and 20 of them (66.7%) had experienced complications caused by PRs.
Gu et al., 2019, China 4	▪ Investigating influencing factors of PR use in China ICU: A prospective, cross-sectional, observational study. ○ 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 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. ▪ The median length of PR use was 20 shifts (8hrs shift). 42.9% of patients were continuously restrained for more than 24 hours. In 75.9% of the cases, PR was used only once, and for the remaining, it was reapplied during the ICU stay. ▪ For 51.3% of patients, observational data was recorded in nurses' notes. There is no data for removal time, patient responses, or complications. Less than 1/ 3 of patients gave informed consent for PR. ▪ 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.
Jiang et al., 2015, China 16	• Nurses’ perceptions and practice of PR in China. ○ 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,	▪ 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. ▪ Qualitative findings: staff shortages and heavy workload were the most common reasons for PR. In-service/education is needed to minimize PR use in China.
Hamilton et al., 2017, Canada 17	• The prevalence and incidence of restraint use in a Canadian adult ICU: A prospective cohort study. ○ Determine the extent of PR use in an urban teaching ICU. ○ 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.
Kooi et al., 2015, Netherland 18	• Use of PRs in Dutch ICU: A Prospective Multicenter Study. ○ 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.	▪ 23% were physically restrained during the researcher's visit. In 11 units (44%), the use of PR was more frequent, although this finding was not significant. 31% of nurses reported the use of a protocol for PR. ▪ The risk of PR is increased in patients with delirium or coma who cannot communicate verbally and are receiving psychoactive or sedative medications. There is no independent relationship between PR use and gender, illness severity, or nurse-to-patient ratio.
Luk et al., 2014, Canada 19	• Predictors of PR use in Canadian ICUs. ○ Describe patterns of PR use in mechanically ventilated patients (prevalence, number of days of use, number of episodes of use). ○ Identify patient, treatment, and ICU/hospital characteristics associated with PR use and number of days of use.	▪ A secondary analysis of a prospective observational study ○ A sample of mechanically ventilated patients was admitted to 51 Canadian ICUs.	▪ PR was used with 374/711 patients. The average use of PR is 4.1 (SD 4.0) days (1 to 26 days). 83% applied only once, while the remaining reapplied multiple times during their ICU stay. ▪ Restrained patients experienced more adverse events and received higher daily doses of sedatives, analgesics, and antipsychotics. Use of sedative, analgesic, and antipsychotic drugs, agitation, heavy sedation, and the occurrence of an adverse event predicted PR use or the number of days used.
Kandeel & Attia, 2013, Egypt 20	• PRs practice in adult ICU in Egypt. ○ Investigate the practices of PRs among CCNs in El-Mansoura City, Egypt.	▪ A descriptive cross-sectional design with repeated observations ○ A convenience sample of two groups Group 1 consists of 275 physically restrained ICU patients. Group 2: 153 ICU nurses with at least one year of experience in one of the ICUs	▪ Restrained sites assessment is not documented in patients' records. Nurses’ self-report: PR is commonly (68%) used in ICUs. ▪ Individuals responsible for the decision to apply PR are nurses (58.2%), followed by physicians and nurses (41.1%). ▪ The most common PR behavior is an attempt to remove medical equipment (79.1%). 64.7% for resisting treatment or care and 46.4% for the attempt to get out of bed. Ensuring patient safety (96.1%) is the most important rationale for applying PR. ▪ Upper and lower limb restraints (37.9%) are the most common PR. Nurse-patient ratios and nurse workloads strongly contribute to the use of PR. ▪ Documentation of PR and assessment of restrained body parts is maintained by experienced nurses rather than novice nurses.
Yönt et al., 2014, Turkey 21	• Examination of Ethical Dilemmas Experienced by Adult ICU Nurses in PR Practices. ○ Determine perceptions of ethical dilemmas by nurses in the application of PR.	▪ A descriptive and cross-sectional study ○ There are 55 intensive care nurses working in two hospitals' adult ICUs.	▪ 92.7% of nurses experienced the application of PR. 85.5% received training on ethics; 78.2% did not participate in training regarding ethical dilemmas. 94.5% of nurses reported that PR must be applied in ICUs. ▪ According to 70.9% of nurses, the decision of PR was jointly by the nurse and the physician and 25.5% by the physician alone. According to 65.5% of nurses, no family consent was taken for PR. 63.6% did not hesitate over PR. ▪ The reasons for PR are to prevent falls (25.4%), harming themselves (25.4%), removing the tubes (18.5%), maintaining the posture of the patient (3.8%), applying medical treatment (13.0%), and calm down the patient (13.9%). ▪ 36.4% of nurses felt difficulty in deciding PR use and experienced ethical dilemmas.
Langley et al., 2011, South Africa 22	• Restraints in ICU-A mixed method study. ○ Provide a detailed description of the use of restraints in three ICU.	▪ Mixed methods—quantitative observational data and qualitative in-depth individual interviews ○ 5 medical practitioners and 15 registered nurses from 3 ICUs. There were 219 patients observed.	▪ Quantitative results: 1:1 was the nurse-patient ratio. 48.4% of the patients were restrained. 21.46% of patients were on analgesics and/or sedatives. 21.46% were restrained but not sedated. Patients were restrained for an average of 9 days (between 1 and 53). Ineffectively tied to nine patients ▪ Qualitative findings: restraint, a balancing act: all agreed that there is a place for the use of restraints in the ICU. Patients’ agitation needs to be assessed before PR. ▪ Proper PR use is described as a “balancing act” between its benefits and disadvantages. More than half of them stated that PR is primarily used to allow clinical staff to leave the patient unattended. ▪ Mostly, nurses are the decision-makers for PR. Not required Doctor’s prescription & they reluctant for that. Communication between the doctor, the patient, and their families is critical.
Luk et al., 2015, Canada 23	• CCNs’ decisions regarding physical restraints in two Canadian ICUs: A prospective observational study. ○ Describe reasons for physical restraint application, alternative measures attempted, if any, prior to PR application, and reasons for restraint discontinuation.	▪ A prospective, observational study ○ Medical records of 141 patients from two medical-surgical ICUs	▪ Patients were mostly restrained using wrist restraints (91%). Four-point (all four limbs) restraints (.4%) and unilateral wrist-ankle and wrist-mitten restraint combinations are used infrequently (.2%). 83% of restraints were applied on the preceding night shift. ▪ Agitation 43%, restlessness 17%, and restraining as a precautionary measure to prevent accidents. In 33%, alternative measures were considered before PR. Device removal and maintaining patient safety 17% are the common reasons for PR. In 21% of patients, chemical restraint was used as an alternative. ▪ Restraint discontinuation was recorded for 57% patients, with the most common being a calm and cooperative patient for more than two hours.
Turgay et al., 2009, Turkey 24	• PR Use in Turkish ICU. ○ Determine intensive care nurses’ reasons for the application and removal of PR. ○ Determine PR patterns used in Turkey ICUs.	▪ Descriptive and cross-sectional research designs. ○ 190 nurses work in the ICUs of 7 hospitals.	▪ There is no set policy or guidelines for restraint application practice. 84.7% PR without a physician’s order. 59.5% are not documented in nursing notes. Wrist and ankle ties are often (59.5%) used for PR. There was no difference in the frequency of restraint use between day and night shifts. ▪ 36.8% of complications were reported, and the most common one was skin breakdown. Maintenance of the placement of medical devices is the main (86.8%) reason for PR. ▪ Improved mental status is an important reason for the removal of restraints (68.9%).
Benbenbishty et al., 2010, Europe 25	• PR use in ICU across Europe: The PRICE study. ○ Examine PR practices across European ICUs.	▪ Point prevalence survey conducted prospectively ○ In 9 countries, 34 general (adult) ICUs were observed and examined for charts or medical records by registered nurses and doctors. Out of 669 patients, physical and chemical restraints were used on 566 patients.	▪ 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. ▪ Restlessness and delirium are the most common reasons for PR. Commercial wrist restraints are the most common. Patient safety is the dominant rationale for PR.
Unoki et al., 2019, Japan 26	• PRs in ICU: a national questionnaire survey of PR use for critically ill patients undergoing invasive mechanical ventilation in Japan. ○ Describe the frequency of PR use among Japanese patients undergoing mechanical ventilation. ○ To verify the hypothesis that insufficient human resources have increased the frequency of PRs.	▪ Cross-sectional online open-anonymous survey ○ Nurses in the ICU with a patient-to-nurse ratio of no more than 2.	▪ PR is commonly used among mechanically ventilated patients in Japan. PR use varies among ICUs, irrespective of human resources and the proportion of beds in private rooms. ▪ A systematic approach is needed to reduce PR use in mechanically ventilated patients.
Ertuğrul & Özden, 2019, Turkey 27	• The effect of PR on neurovascular complications in ICU. ○ Investigate the effect of PR on the occurrence of neurovascular complications and their rate.	▪ A prospective observational cohort study ○ 90 patients from anaesthesia and the internal ICU.	▪ PR was used in the first 24 hours of hospitalization for 85.6% of patients.71.1% of patients had restraints on both wrists, with 17.8% having restraints on the right wrist and 11.1% having restraints on the left wrist. 71.6% was a roll of gauze, 17.6% was tough cuff material, and 10.8% was a green foam tie. ▪ After the first 24 hours, complications increased. A roll of gauze was used most commonly on the wrist. The roll of gauze and tough cuff material types led to an increase in redness. ▪ The duration of PR increases the risk of neurovascular complications. Nurses did not regularly check the restrained wrist and did not focus on the peripheral circulation.
Guenette et al., 2017, Canada 28	• Psychotropic drug use in physically restrained, critically ill adults receiving mechanical ventilation. ○ Characterize psychotropic drug interventions before and after the use of PRs in critically ill adults receiving mechanical ventilation.	▪ A single-centre, prospective, observational study. ○ 93 patients who were admitted to the ICU	▪ All patients have 2-point Posey soft wrist restraints. Two patients started with the use of 4-point restraints and subsequently transitioned to 2-point restraints. ▪ The indication for PR was documented for 91 patients, and 2 patients were not documented. The most common documented indication was the prevention of treatment interference. ▪ The median duration of restraint was 21 hours (interquartile range, 9–70 hours); 43 patients (48%) were restrained for more than 24 hours. More patients received psychotropic drugs after PRs than before. ▪ Administration of opioids was more common after the use of PRs and accounted for more drug interventions. ▪ More patients received a psychotropic drug intervention after physical restraints were applied than before (86% vs. 56%). Administration of opioids was more common after the use of physical restraints (54% vs 20%) and accounted for more drug interventions (45% vs 29%). ▪ 16% remained over sedated and remained agitated before and after physical restraint. However, after the application of physical restraint, 20% of patients became over sedated and 6% less sedated. ▪ 10% of the patients become more agitated, compared to 8% less agitated.
Dolan & Looby, 2017, Massachusetts, US 29	• Determinants of nurses’ use of PRs in surgical ICU patients. ○ Describe nurses’ determinants of initiation and discontinuation of restraints in surgical ICU patients.	▪ Qualitative descriptive design. ○ 13 nurses working in the Surgical ICU.	▪ The initiation or discontinuation of PR is determined by the threat to patient safety (interruption or removal of monitoring and therapeutic devices). Surgical ICU experiences variable degrees of altered mental status. Restraints are used as an intervention to reduce self-extubation. Restraints are occasionally used to prevent injury to the staff because of patient behavior. ▪ Nurses identify patient-specific behaviors, including orientation and functional capacity, that determine restraint use. Nurses describe patient behaviors that predict the successful discontinuation of restraints without perceived negative effects. Thoughtful consideration is given to delirium patients due to the inconsistent responses to restraint use experienced by this patient population. ▪ The nurse’s ability to be vigilant in-patient care provides an atmosphere of security. Targeted nurse-driven interventions help in reducing restraint use, especially in delirious patients.
Hevener et al., 2016, California, US 30	• Using a decision wheel to reduce use of restraints in a medical-surgical ICU. ○ Decrease use of restraints in a medical-surgical ICU. ○ To determine if a decision support tool is useful in helping bedside nurses determine whether or not to restrain a patient	▪ A pilot study with a quasi-experimental design was conducted. ○ Bedside nurses from the medical-surgical ICU	▪ In month one, 64 device dislodges occurred and 38% of the patients were restrained. During months 2 to 4, 51 devices were dislodged, and 12% of the patients were restrained. ▪ 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.
Salehi et al., 2019, Iran 31	• Factors behind ethical dilemmas regarding PR for CCNs. ○ Explore factors behind ethical dilemmas for CCNs overusing PR for patients.	▪ Qualitative study using conventional content analysis approach. ○ The 17 CCNs were purposefully recruited from the 4 ICUs.	▪ The outcome of using PR is the factor behind ethical dilemmas for CCNs. ▪ PR is used to ensure patient safety and prevent damage to patients and others. They were compelled to ignore patient rights and autonomy and use PR because of heavy workload and ward crowdedness. ▪ Other than PR, there is no choice but to use it to ensure patient safety. ▪ PR mentally damages patients and causes them problems such as fear of the ICU, depression, anger, aggression, restlessness, agitation, and anxiety. ▪ The risks of not using PR are delays in treatments, long hospital stays, falls, tissue trauma, pulling or removal of connections, heavy treatment costs, and even death. ▪ Nurses are not authorized to use PR without a medical order, but restraints are used without a physician’s order. Nurses perceive low support from physicians if a patient experiences a fall. ▪ Nurses felt conflicted due to the violation of patient rights and experience. Some of them felt uncertainty even after leaving the hospital.
Balcı & Arslan, 2018, Turkey 32	• Nurses' Information, Attitude and Practices towards use of PR in ICU. ○ Determine the knowledge, attitude and application levels of nurses working in critical care units about PR applied on patients.	▪ Descriptive and correlation studies ○ 158 nurses who work in medical-surgical intensive ICUs in hospitals and graduated from the faculty of health sciences	▪ Nurses deciding on the use of PR have higher scores than physicians. Nurses' attitude scores were found to be higher than those of physicians. Physicians' practice scores were found to be higher than those of nurses. ▪ Nurses have a sufficient level of information but negative attitudes and are insufficient in practice.
Mitchell et al., 2018, Delaware, US 33	• Reducing Use of Restraints in ICU: A Quality Improvement Project. ○ Reduce and sustain the restraint rates to less than the national database means rates for all 5 ICU	▪ A quality improvement process Quantitative observational data from five ICUs with nine non-validated survey tools ○ 119 ICU nurses and ICU data from five ICUs	▪ The Restraint collaborative lowered the restraint rate. Bedside nurses engaged in evidence-based practice using the latest evidence-share willingly with colleagues. The restraint culture shifted from most patients to minimal use of restraints. ▪ The use of restraints was added to the daily-goals 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.
Hall et al., 2017, Virginia, US 34	• Impact of a Restraint Management Bundle on Restraint Use in an ICU. ○ Explored the impact of a restraint management bundle on restraint use, quality, and safety outcomes.	▪ Secondary data analysis of the pre and post cohort groups ○ Data was extracted for 2701 patients from a 24-bed general ICU. There are 65 clinical RNs and 12 nursing care partners. Data from the EMR is used. In the pre-cohort group of 1339 patients and the post-cohort group of 1362 patients,	▪ There were 24.3% of patients restrained in the pre-cohort group compared to the post-cohort group (20.9%). The number of restrained patients per patient-day averaged 0.075 for the pre-cohort group compared with 0.059 for the post-cohort group. The number of restraint episodes per patient day averaged 0.191 for the pre-cohort group, compared with 0.133 for the post-cohort group. ▪ The average ICU length of stay was 3.64 days in the pre-cohort group compared with 3.60 days in the post-cohort group. ▪ The result shows a significant reduction in restraint use and duration, although ICU length of stay remained stable over time.

PR - Physical Restraint; ICU - Intensive care nurse; CCN - Critical care nurse; SD - Standard deviation; RDW - Restraint decision wheel.