An exploration of how critical care nurses make the decision to initiate restraint when managing hyperactive delirium

Hyperactive delirium and its resulting psychomotor agitation is frequently cited as clinical rationale for initiating chemical or physical restraint. From an integrative review, nurses appeared to be the primary decision makers when initiating restraint, but little was known about this process. This study used a pragmatic qualitative approach to explore critical care nurses’ decision-making processes when considering restraint to manage a patient with psychomotor agitation secondary to hyperactive delirium. Thirty participants were recruited to a ‘Think Aloud’ study. Six audio-visual vignettes featuring simulated critical care patients acted as stimulus for participants to describe their decision-making processes. Two analytical approaches were undertaken. Firstly, the Cognitive Continuum Theory was used to identify modes of decision-making. Secondly, a reflexive thematic analysis was undertaken. This identified five themes: Intrinsic beliefs and aptitudes; Handover and sharing of labels; Failure to maintain a consistent approach; The need to maintain constant vigilance; The tyranny of the now. Decisions relating to restraint drew primarily upon intuitive and reflective cognitive modes. When participants perceived greater time for decision-making, more analytical modes were employed. Restraint was more frequent when staffing ratios were reduced and opportunities for vigilance reduced. This led to intuitive decision-making which was associated with restraint. Caring for a patient with hyperactive delirium was described as relentless and described their physical and psychological exhaustion and how this might lead to restraint to create ‘space’ for respite. Recommendations for practice and future research were made. Pre-emptive planning for delirium and safe staffing was associated with a reduced need to restrain. The struggle to manage agitated behaviour was associated with burnout and reduced engagement with therapeutic management, suggesting the need for additional support. Further research was indicated to identify whether hyperactive delirium is managed differently to non-delirious agitation and explore the role which memories of restraint play in patient recovery from critical care.