Prevalence of chemical restraint use in hospital care: a consensus and cross-sectional study

Abstract

Background

Restrictive practices are interventions that limit the rights or freedom of movement of a care recipient. Using medicines to manage behaviours that pose a threat to the patient or others is referred to as chemical restraint. Guidance in Australia for monitoring chemical restraint has largely focused on the aged care and disability sectors. In contrast, far less is known about chemical restraint use in the hospital inpatient setting. This study aims to reach a health service-wide consensus on a chemical restraint definition and a list of medicines used for inpatient care. It also aims to determine the prevalence of chemical restraint use across a large health network.

Methods

A modified-Delphi consensus and cross-sectional period prevalence study was undertaken across a large health service in Australia. A multidisciplinary clinical reference group participated in three survey rounds to determine a definition and list of medicines. Period prevalence (%) was determined using inpatient medical notes, and differences between clinical speciality prescriptions and administration were determined by odds ratio (P < .05).

Results

The Australian Commission on Safety and Quality in Healthcare definition was adopted, and any prescription of an antipsychotic, sedative/hypnotic, ketamine, or propofol was assessed. There were 16.73% (95% CI 14.4% to 19.1%) of patients prescribed and 10.03% (95% CI 7.97% to 12.09%) administered a medicine for chemical restraint. Chemical restraint was prevalent across a range of clinical specialties, with mental health patients 17 times more likely to be exposed ([OR] 17.18, 95% CI 8.74–33.77, P < .001). Olanzapine was the most commonly prescribed medicine (69, 29.11%) with 79.75% (189) of all medicines prescribed pro re nata. Consent was documented for four (5.63%) patients.

Conclusion

Chemical restraint is prescribed across a range of hospital clinical specialties with low rates of documented consent. Adopting a standardized approach could improve existing hospital safety and quality policy and practices.

Introduction

Restrictive practices are interventions that limit the rights or freedom of movement of a care recipient [1]. In this context, using medicines to manage behaviours that pose a threat to the patient or others is referred to as chemical restraint [2]. Whilst chemical restraint can be clinically appropriate, it is associated with significant harms and should be used judiciously and monitored for both intended benefits and known adverse effects [3, 4].

Guidance in Australia for monitoring chemical restraint has largely focused on the aged care and disability sectors. Two recent Royal Commissions in Australia (Aged Care Quality and Safety; Violence, Neglect and Exploitation of People with Disability) reported widespread inappropriate use of chemical restraint [3, 5]. These reports estimated that up to 42% of aged care residents were exposed to chemical restraint, whilst 50% of restrictive practices in the disability sector involved chemical restraint [3, 5]. These findings have driven mandated reporting and other reforms [3, 5]. In contrast, far less is known about chemical restraint use in the hospital inpatient setting [6–8].

To be accredited, Australian health service organizations must meet national safety and quality standards [9]. Reporting requirements for physical restraint are currently embedded in these standards; however, no equivalent mandate exists for chemical restraint [9]. Consequently, there is a dearth of standardized data on the prevalence of chemical restraint in Australian hospitals. The majority of international studies focus on mental health settings; however, one Canadian study found 27% of older adults in hospital care were subjected to chemical restraint [10].

A major obstacle to standardized monitoring is the lack of a universally accepted definition. Definitions of chemical restraint vary widely across different clinical settings and patient populations, complicating efforts to monitor and compare data [11]. This heterogeneity hinders the development of effective hospital policies and practices to minimize the use of chemical restraints and ensure patient safety [8, 12]. The Australian Commission on Safety and Quality in Health Care (ACSQHC) published the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard in 2024, providing a national definition for chemical restraint; however, this Standard was released after this study had commenced, and its scope is specifically limited to patients with cognitive disability or impairment, rather than the broader acute inpatient population examined in this study.

The aims of this study were two-fold. Firstly, we aimed to reach a health service-wide consensus on a definition of chemical restraint and a list of relevant inpatient medicines. Secondly, we aimed to determine the prevalence of chemical restraint based upon these definitions across a large health network. Outcomes are intended to inform the standardization of monitoring and reporting to optimize patient outcomes.

Materials and methods

Study design

This study was multi-modal, using a modified-Delphi consensus method and a cross-sectional period prevalence approach. The study was conducted in two phases between December 2023 and November 2024.

Setting

This study was undertaken across Metro North Health (MNH), the largest health network in Queensland, Australia. MNH delivers care across a geographically and clinically diverse network that includes six major hospitals. The network provides comprehensive acute and subacute care across a range of specialties (medical, surgical, mental health, geriatrics, and women’s and children’s services) to approximately one million people [13].

Phase 1: modified-Delphi consensus

Panel recruitment and composition: Expressions of interest were sought from Health Service Medication Safety and Comprehensive Care Governance committees, comprised of medical doctors, nurses, pharmacists, and allied health, to form a multidisciplinary clinical reference group (CRG) (Supplementary Material C—Supplementary Fig. S1). All participants who expressed an interest were included. The modified-Delphi method was selected as it has been widely used in clinical and health services research as a valid approach to solving contentious issues, leveraging both existing evidence (literature review and environmental scan) and anonymized expert opinion (recommended panel size: 9 to 18 experts) [14–17].

Delphi procedures: An anonymous web-based survey (Microsoft Forms) was administered in three rounds. Round 1 presented 15 definitions of chemical restraint identified through review of the academic and grey literature, as well as health service procedures (see Supplementary Material A). In addition, seven medicine groups and 37 individual medicines were presented as identified within the literature and reconciled against the hospital formulary (see Supplementary Material A). Participants rated agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). Each round remained open for 2 weeks, including a reminder email. Aggregate results were presented to the CRG between rounds and discussed at one virtual CRG meeting to clarify reasons for disagreement. A final real‑time Round 3 survey was distributed. The ACSQHC Psychotropic Clinical Care Standard definition was published during the study period and, upon identification through ongoing literature monitoring, was incorporated into the final round of the Delphi process alongside the candidate definitions already under consideration.

Consensus thresholds and handling non-consensus: For all rounds, consensus for inclusion was defined a priori as ≥75% agreement; exclusion as <25% agreement. Items between these thresholds were carried forward for reconsideration and discussion in subsequent rounds. These consensus levels were chosen to align with previously published methods using the Delphi technique in pharmacy practice research [18].

Data analysis and reporting: Demographics of CRG panelists are presented descriptively. Survey participation and outcomes were analysed using Excel 365 MSO (V2405/1.0) and presented in proportion of responders, proportion of responders by agreement scale, or preferred choice.

To achieve the project objectives of consensus, in the event of sustained disagreement (lack of consensus to include or exclude) as experienced in previous research of this nature, we planned an iterative approach leveraging survey responses, virtual group CRG discussion outcomes, and research team discussion.

The reporting of this study phase aligns with the Recommenda­tions for the Conducting and REporting of Delphi Studies (CREDES) [15].

Phase 2: Cross-sectional period prevalence

Population and data collection: A period prevalence study was undertaken in March 2024. On the designated days, trained data collectors, supported by senior researchers and pharmacists, screened all inpatient medication charts to identify prescriptions of at least one consensus chemical restraint medicine. Virtual care and emergency care services were excluded.

From the screened cohort, we drew a stratified random sample (stratified by clinical specialty and proportionate to each hospital’s inpatient census) to enable in‑depth verification of indication, administration, and contextual variables (see Fig. 1 in the results for sampling framework).

Figure 1.

Cross-sectional study sampling frame for estimating period prevalence of chemical restraint in hospital.

Variables and measures: We extracted demographics and clinical variables from medication charts and medical records (see Supplementary Material C—Supplementary Table S1). Chemical restraint exposure was defined as prescribing or administration of a consensus medicine specifically for the purpose of chemical restraint (as verified during detailed review).

Statistical analysis: We summarized data as percentages and means (SD) where appropriate and included 95% confidence intervals for extrapolated results. Differences in prescribing and administration for each clinical specialty (compared to the remaining cohort) were assessed using odds ratios (OR) with 95% confidence intervals and significance set at P < 0.05. Analyses were performed using Excel 365 MSO (V2405/1.0) and MedCalc 23.1.7 [19].

The reporting of this study phase aligns with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for reporting cross-sectional studies [20].

This project received exemption from Metro North Health (MNH) Human Research Ethics Committee (HREC) A (EX/2023/MNHA/104331). The project was registered with the University of Queensland HREC (2024/HE000532).

Results

Phase 1: modified-Delphi consensus

The CRG included 20 members representing six of the seven MNH directorates. The response rates for each survey round were 15 (75%), 13 (65%), and 10 (50%). Most responders had at least 10 years of experience in their roles, with pharmacists being the most common profession represented (Supplementary Material A). After completing the third survey, there was 70% agreement to use the newly published Australian Commission on Safety and Quality in Health Care (ACSQHC) definition (Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard, 2024) with some CRG member reservations relating to the broadness of the definition and lack of clarity around scenarios where chemical restraint is clinically appropriate (Box 1) [21]. The CRG reached consensus on including the following medicines: all antipsychotics, all sedatives/hypnotics, ketamine, and propofol (see Supplementary Materials C—Supplementary Fig. S2).

Box 1.

Consensus on definition of chemical restraint [21].

Australian Commission on Safety and Quality definition of chemical restraint in cognitive disability, released in May 2024, before survey round 3 (70% agreement in round 3):

Chemical restraint is a form of restrictive practice that involves the use of medicine or a chemical substance for the primary purpose of influencing a person’s behaviour but does not include the use of medicine primarily prescribed for the treatment of, or to enable treatment of, a diagnosed mental health disorder, a physical conditions, of for end-of-life care.

Phase 2: use of chemical restraint across MNH hospitals

The cross-sectional study included 1792 patients, of which 1660 medication charts were available for review, and 695 patients were identified as prescribed a chemical restraint consensus medicine. A representative random sample of 311 charts (45%) was selected for detailed review, with 288 charts screened (23 were unavailable) (Fig. 1).

The average age of the sample population was 57.4 years (SD 20.40), and males represented just over half of the sample (158, 54.86%).

Of the 288 reviewed charts, 115 patients (39.93%) were prescribed at least one consensus medicine for the purpose of chemical restraint, with 69 patients (60.00%) having the medicine administered. When this is extrapolated out to the whole inpatient population, the estimated chemical restraint prescribing rate was 16.72% (95% CI 14.4% to 19.1%) and administration rate 10.03% (95% CI 7.97% to 12.09%) (Table 1) (see Supplementary Material B for all samples and extrapolated results).

Table 1.

Period prevalence of CR prescription and administration in total population estimated from a representative sample.

Population/sample description	Population (n)	Patients (n)	Proportion (%)
Patients were prescribed a consensus medicine in the total population	1660	695	41.87
Patients prescribed a consensus medicine in a representative sample	288	115	39.93
Patients are prescribed a consensus medicine for the purpose of chemical restraint in the total population	1660	278a	16.73a
Patients were prescribed and administered a consensus medicine for the purpose of chemical restraint in the representative sample	115	69	60.00
Patients were prescribed and administered a consensus medicine for the purpose of chemical restraint	1660	167a	10.03a

^aExtrapolated (see Fig. 1 for sampling frame).

The highest prevalence of a consensus medicine for chemical restraint was observed in mental health patients, followed by sub-acute medical (Table 2). Acute medical, acute surgical and ICU/CCU patients were less likely to be prescribed a medicine for chemical restraint ([OR] 0.24, 0.15–0.47, P < .001; [OR] 0.12, 0.04–0.30, P < .001; [OR] 0.52, 0.29–0.92, P = .02, respectively) while mental health patients were more likely to be prescribed a medicine for chemical restraint ([OR] 17.18, 8.74-33.77, P < .0001) (Table 3). The probability of being administered a medicine for chemical restraint did not significantly differ between clinical specialities (Table 4).

Table 2.

Chemical restraint prescribing by clinical specialty.

	Acute medical	Acute surgical	ICU/CCU	Maternity/obstetrics and gynaecology	Mental health	Sub-acute medical	All
Total patients audited (n)	660	365	78	47	195	315	1660
Proportion of total patients prescribed a medicine with potential to be used as chemical restraint (numerator/denominator, %)	231/660 (35.00%)	124/365 (33.97%)	25/78 (32.05%)	9/47 (19.15%)	193/195 (98.97%)	113/315 (35.87%)	695/1660 (41.87%)
Sample of medication charts audited of patients prescribed a medicine with the potential to be used as chemical restraint (numerator/denominator, %)	96/231 (41.56%)	54/124 (43.55%)	6/25 (24.00%)	6/9 (66.67%)	80/193 (41.45%)	46/113 (40.71%)	288/695 (41.44%)
Total of sampled patients determined to have been prescribed a medicine for chemical restraint (numerator/denominator, %)	20/96 (20.83%)	5/54 (9.26%)	2/6 (33.33%)	0/6 (0.00%)	67/80 (83.75%)	21/46 (45.65%)	115/288 (39.93%)
Extrapolated proportion of total patients prescribed a medicine for chemical restraint (%)	7.29%	3.15%	10.68%	0.00%	82.89%	16.38%	16.72%

Table 3.

Comparison of chemical restraint prescribing within a representative random sample by clinical specialty.

Clinical specialty	Prescribed a medicine for chemical restraint (n)	Not prescribed a medicine for chemical restraint (n)	Proportion (%)	Odds ratio [OR]	95% confidence interval	P-value
Acute medical	20	76	20.83	0.27	0.15–0.47	<.001
Acute surgical	5	49	9.26	0.12	0.04–0.30	<.001
ICU/CCU	2	4	33.33	0.52	0.29–0.92	.020
Maternity/obstetrics and gynaecology	0	6	0.00	0.11	0.00–2.00	.14
Mental health	67	13	83.75	17.18	8.74–33.77	<.001
Sub-acute medical	21	25	45.65	1.32	0.70–2.50	.39
All	115	173	39.93	1.00	NA	NA

Table 4.

Proportion of the representative random sample prescribed and administered a consensus medicine for the purpose of chemical restraint by clinical speciality.

Clinical specialty (ward)	Administered a medicine of interest (n)	Not administered a medicine of interest (n)	Proportion (%)	Odds ratio [OR]	95% confidence interval	P-value
Acute medical	11	9	55.00	0.78	0.29–2.06	.62
Acute surgical	3	2	60.00	0.91	0.15–5.68	.92
ICU/CCU	1	1	50.00	0.66	0.04–10.85	.77
Maternity/obstetrics and gynaecology	0	0	NA	NA	NA	NA
Mental health	43	24	64.18	1.58	0.74–3.39	.24
Sub-acute medical	11	10	52.38	0.68	0.26–1.77	.43
All	69	46	60.00	1.00	NA	NA

Of the 237 prescriptions for chemical restraint, the most frequently prescribed medicines were olanzapine (n = 69, 29.11%), lorazepam (n = 61, 25.74%), and diazepam (n = 41, 17.30%) (Supplementary Material B). Most prescriptions were pro re nata (when required) (n = 189, 79.75%). Of the 237 chemical restraint prescriptions, 61 (25.74%) were continued on discharge, of which 34 (55.74%) prescriptions were newly prescribed during admission. In total, there were 140 (59.07%) prescriptions for chemical restraint that were commenced while an inpatient, but were not continued upon discharge (Supplementary Material B).

Forty-four patients (38.26%) were under a treatment authority (i.e. receiving involuntary treatment under a legal order), with consent documented in four (5.63%) of the remaining cases. Behavioural screening tools were utilized in 92 patients (80.00%) prescribed chemical restraint, and 105 patients (91.30%) had their behaviour monitored for response (Supplementary Material B).

Discussion

Statement of principal findings

This study is the first to evaluate chemical restraint across a large, clinically diverse hospital cohort using a definition and comprehensive list of medicines established through a health service-wide consensus process. Near-consensus (70%) was reached on the ACSQHC Psychotropic Clinical Care Standard definition; however, the 30% non-consensus rate highlights the inherent challenge of applying a single standardized definition across the breadth of clinical specialties present in the acute hospital setting. Our prevalence results are the most representative of chemical restraint in hospital settings to date, with 17% of patients prescribed and 10% administered a medicine for chemical restraint. Before this study, existing chemical restraint research in hospital settings was either limited to specific patient populations, such as psychiatric care, or the use of a particular medicine [7, 9, 22, 23].

Strengths and limitations

The findings of our study align with previously published research that demonstrates the challenges with achieving consensus for a definition of chemical restraint [7, 8]. Our findings suggest that clinicians’ agreeability of definitions for chemical restraint is variable, which begs the question whether a single definition of chemical restraint should be used across a health service or whether it would be appropriate to have different definitions in different clinical settings. Our study adopted the recently published definition defined in the Psychotropic Clinical Care Standard (CCS) published by the Australian Commission on Safety and Quality in Health Care [21]. Importantly, the ACSQHC Psychotropic Clinical Care Standard was published after this study had commenced; nonetheless, the definition was incorporated into the final Delphi round. The clinical reference group’s near-consensus support for the ACSQHC definition (70%) independently corroborates its appropriateness for the hospital setting and demonstrates alignment with the national standard, despite the Standard having been developed primarily for the cognitive disability and impairment context. However, this definition did not reach the pre-defined consensus level of 75% proposed in our method. Despite this, and after considering a pragmatic approach to implementation of the CCS, as well as near consensus (70%), we opted to progress to the second phase of the study with this definition. Based upon the results of the Delphi survey, feedback during the chemical restraint clinical reference group meetings, and free text survey responses, this definition may require amendment as it may not adequately capture the use of chemical restraint in different clinical practice settings. A known risk of standardizing clinical practice is the over-simplification of complex clinical scenarios [24]. This study strongly supports the adoption of a standardized, nationally aligned approach to defining and monitoring chemical restraint in the acute hospital setting. The ACSQHC Psychotropic Clinical Care Standard provides an important foundation for this standardization, and our findings demonstrate near-consensus clinician support for its application in the hospital context. It is emphasized that standardized evidence-based approaches and patient-centred care are not mutually exclusive but complementary: adherence to a national standard ensures consistency and safety, whilst clinical judgement ensures that individual patient circumstances are appropriately considered within that framework [24].

In the past, national and international literature have provided a wide range of medicines considered to be used for chemical restraint with inconsistent application across health settings [12]. The consensus list of medicines developed in this study reflects a balance between real-world experience in hospital care and the potential to under- or overestimate chemical restraint, leading to unreliable data for quality improvement activities. For example, in the Australian aged care setting, chemical restraint medicines include any medicine with psychotropic properties that contains over seven groups of medicines, including antidepressants and anticonvulsants [25]. The final list of medicines in this study represents those medicines which are most likely to be used for chemical restraint in the hospital setting, and is an important step towards standardized reporting and quality improvement in this sector. Whilst there are a variety of included medicines in the chemical restraint literature, the most common medicines used for chemical restraint in our study (olanzapine and lorazepam) are similar to those reported in other studies, suggesting that the decision to omit commonly included medicine groups, such as antidepressants and anticonvulsants, is a more targeted approach to identifying true chemical restraint [1, 21, 22, 26].

Whilst the consensus methods in this study adhered to international guidelines for consensus Delphi methods, we cannot guarantee that the outcomes are generalizable to all inpatient settings and clinicians’ views. The final round sample of 10 respondents, whilst consistent with the recommended panel size of 10 to 18 experts for modified-Delphi studies [14–17], represents the lower bound of this range and should be acknowledged as a constraint on the generalizability of the consensus outcomes. The 50% response rate for Survey 3 may have limited the generalizability of the results and biased them away from consensus. The definition and list of medicines may not reflect the opinions of all clinicians, as the majority of panellists were pharmacists.

The cross-sectional study estimates are reflective of the total inpatient population within the period prevalence timeframe; however, they may not be a true reflection of inpatient chemical restraint prescribing and administration where there is clinically relevant seasonality to patient hospital admissions. This study did not include emergency department presentations, and therefore, findings should not be extrapolated to this patient cohort.

In addition, our study did not explore the clinical decision-making processes by prescribers of chemical restraint. Gaining insights into these processes could be beneficial for understanding how the perceived benefits and potential adverse effects of medications influence clinical decisions for managing patients exhibiting challenging behaviours.

Interpretation within the context of the wider literature

Our results differ from previous research. In a Canadian study, the prevalence of chemical restraint in hospitalized patients aged 65 years or older (defined as an electronic prescription for antipsychotics, benzodiazepines, and or trazodone) was found to be 27.1% [10]. This result is 10% higher than our study result of 16.72%; however, it is likely that the prevalence reported in the Canadian study is an overestimation, as dispensing data were used to estimate prescribing rather than a medical chart review, where indication and administration were verified.

Two previous meta-analyses (2020 and 2024) reported a wide range of exposure to chemical restraint among mental health inpatients, with estimates varying 7.4% (range 2.17%–17.6%) and a pooled proportion estimate of 25.6% (CI 0.18-0.31), respectively [6, 8]. These rates are notably lower than those identified in our study, where 82.89% of mental health inpatients were prescribed chemical restraint. However, our findings are consistent with an Australian study, which reported a 12-month incidence rate of 91.67% for involuntary chemical restraint use in acute adult psychiatric units [26].

In a 2024 meta-analysis, the authors reported high heterogeneity in the included studies, which may be due to variation in included medicines and lack of a standardized explicit definition of chemical restraint [8]. These findings support the outcomes of our study with respect to improving the validity and reliability of monitoring chemical restraint across inpatient populations using a standardized definition and list of consensus medicines.

Another unique feature of this study is the reporting of newly prescribed consensus medicines on admission to and discharge from the hospital, which has not been previously reported in the literature. One quarter of patients prescribed a medicine for chemical restraint were discharged with at least one prescription for a consensus medicine, of which over 50% were newly prescribed on admission. Given that most inpatient prescriptions were for pro re nata and not administered, this finding highlights the opportunity to review the necessity for continuing these consensus medicines once a patient is discharged into the community.

Implications for policy, practice, and research

This study represents a significant step towards standardizing the measurement and reporting of chemical restraint in the inpatient hospital setting. By adopting a definition of chemical restraint and identifying consensus medications, we have provided a foundation for a more consistent approach to evaluating chemical restraint practices across Australian health services.

While this study did not set out to assess whether chemical restraint use was appropriate or inappropriate, it measured some elements of quality of care which could be used as proxies for appropriateness, such as behavioural screening and monitoring. Anticipatory prescribing within our study was high, with over 80% of patients prescribed consensus medicines pro re nata. This, along with the high rates of behavioural screening (80%) and monitoring (91.3%), suggests the judicious use of medicines for chemical restraint.

In our study, documented consent rates for chemical restraint were low. This is a significant finding, as most international definitions of chemical restraint include the criterion of administration ‘without consent’, a factor not incorporated into our study’s definition. This omission contrasts with the standards of care expected within Australian hospitals, where informed consent is a fundamental component of patient care.

This study has provided a snapshot of chemical restraint prescribing and administration across an inpatient hospital setting; however, the medical record review methodology employed in this study was resource-intensive. It took approximately 600 hours to facilitate data collection across the breadth of this study. Future work should focus on leveraging electronic health records to increase the feasibility of continuous and real-time reporting.

The release of the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard in 2024 will support health service organizations in assessing the quality of care for this specific cohort [21]. Our study demonstrated that chemical restraint was prescribed across almost all hospital clinical specialties. Therefore, it is imperative that consideration is given to broadening the standard to ensure comprehensive inpatient monitoring and quality improvement in the use of chemical restraint.

Conclusions

Application of a standard definition and list of medicines to a large inpatient hospital population revealed that chemical restraint is prescribed across a range of clinical specialties, with low rates of documented consent and high rates of discharge prescribing. This standardized approach should be adopted into hospital safety and quality policy and practices.

Author contributions

Jodie Hillen (Supervision, Project Administration, Methodology, Data Curation, Formal Analysis, Validation, Visualization and Writing—Original Draft, Writing—Review & Editing), Martin Canning (Conceptualization, Supervision, Project Administration, Methodology, Data Curation, Investigation, Formal Analysis, Validation, Visualization, Writing—Original Draft, Writing—Review & Editing), Nagham Ailabouni (Conceptualization, Supervision, Project Administration, Methodology, Visualization, Writing—Review & Editing), Hunter Alker (Investigation, Data Curation, Investigation, Formal Analysis, Validation, Writing—Review & Editing), Grace Hart (Investigation, Data Curation, Investigation, Formal Analysis, Validation, Writing—Review & Editing), Dicky Soen (Investigation, Data Curation, Investigation, Formal Analysis, Validation, Writing—Review & Editing), and Christopher Freeman (Conceptualization, Supervision, Project Administration, Methodology, Visualization, Writing—Original Draft, Writing—Review & Editing)

Supplementary material

Supplementary material is available at IJQHC online.

Conflicts of interest

No known conflicts of interest.

Funding

This project received nil specific funding. Nagham Ailabouni was supported by a National Health and Medical Research Council (NHMRC) Investigator Grant (GNT2025939).

Data Availability

The data underlying this article cannot be shared publicly due to compliance with ethical approvals. The data may be shared on a reasonable request to the corresponding author.

Ethics and other permissions

This project received exemption from Metro North Health HREC A (EX/2023/MNHA/104331). The project was registered with the University of Queensland HREC (2024/HE000532).