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research-article2014
QHRXXX10.1177/1049732314541332Qualitative Health ResearchBrenner et al.
Article
Nurses’ Perceptions of the Practice of Restricting a Child for a Clinical Procedure
Qualitative Health Research 2014, Vol. 24(8) 1080–1089 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314541332 qhr.sagepub.com
Maria Brenner1, Margaret Pearl Treacy1, Jonathan Drennan2, and Gerard Fealy1
Abstract Restricting a child for a clinical procedure has been linked to negative physical and psychological sequelae. The practice of restriction remains an implicit and unquestioned aspect of care for children during a clinical procedure. In this study we aimed to describe the practice of restricting a child’s movement for a clinical procedure by conducting focus groups with children’s nurses. Data were analyzed using a thematic network analysis framework. The findings show that nurses are likely to restrict children based on particular characteristics of the child; for example, the child’s age. The findings indicate that there is no consistent approach to the practice of restricting a child for a clinical procedure, suggesting tension between nurses and other health care professionals, and nurses and parents, about this practice. The findings suggest the need for wider exploration of the practice of restriction at the organizational level and a need for children’s nurses to feel more empowered to act as advocates for those in their care. Keywords children; decision making; focus groups; health care, culture of; nursing Many terms are used interchangeably to describe restricting a child’s movement for a clinical procedure; for example: restrictive physical intervention, restraint, immobilization, clinical holding, therapeutic holding, and holding (Brenner, 2007; Brenner & Noctor, 2010; Folkes, 2005; Royal College of Nursing [RCN], 2010). The choice of term appears to be guided by the amount of force required to hold the child still. For example, the RCN suggested that the term restrictive physical intervention refers to the force used to disengage a child from harmful behavior, and that therapeutic holding refers to the use of less force to carry out a clinical procedure. This is supported in the work of Jeffrey (2010), who proposed that holding and restraint are opposite ends of a continuum, depending on the degree of force used. The terms offered in the literature are based on the presumption of an understanding of what constitutes “force” in the care of children undergoing clinical procedures, rather than any empirical evidence. The current literature in this area might leave room for misinterpretation. In the absence of measuring and understanding the concept of force, the term restriction is proposed as a nonjudgmental description of a practice that can occur, when the risk–benefit favors it, for the purposes of delivering timely care to a child. There is a consensus in the literature that there is a need to improve a child’s experience of undergoing a clinical
procedure. For example, many researchers and commentators on child health have explored the value of parental presence to support a child during a procedure (Emergency Nurses Association, 2005; Maxton, 2008; McGrath & Huff, 2003; Piira, Sugiura, Champion, Donnelly, & Cole, 2005; Ryan & Treston, 2007). The majority suggested that parental presence during a clinical procedure can reduce procedural anxiety in a child and facilitates the development of trust between the family and health care professionals. Improving the care of a child during a clinical procedure was also the focus of researchers who explored the benefits of play therapy in a children’s hospital. It was suggested that play therapy provides an outlet for a child’s emotions during a clinical procedure, reduces procedural stress, facilitates communication with the child, and assists in diverting a child’s thoughts from his or her care (Blount, Piira, Cohen, & Cheng, 2006; Jun-Tai, 2008; Weiss, Dahlquist, & Wohlheiter, 2011). 1
University College Dublin, Dublin, Ireland University of Southampton, Southampton, United Kingdom
2
Corresponding Author: Maria Brenner, School of Nursing, Midwifery & Health Systems, Health Sciences Building, University College Dublin, Belfield, Dublin 4, Ireland. Email: [email protected]
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Brenner et al. In contrast, a limited number of researchers have explored specific practices that occur during a clinical procedure, such as restriction of the child. Only two studies were found on nurses’ restriction of a child for a clinical procedure (Robinson & Collier, 1997; Selekman & Snyder, 1995). In the United States, Selekman and Snyder examined nurses’ perceptions of the use of restraints in four pediatric settings, including an acute pediatric hospital, a pediatric rehabilitation unit, a pediatric psychiatric unit, and a general hospital with an attached pediatric unit. Selekman and Snyder found that nurses restrained children based on their need to promote safety and prevent hypothetical adverse sequelae that might occur, such as the removal of dressings by the child. The need to use restraints was associated with particular procedures rather than any individual care needs of a child, though the researchers also identified that overall, nurses were not knowledgeable about the use of restraints. Robinson and Collier (1997) supported these findings and also identified some characteristics of the nurse that might influence care delivery; for example, they found that more-experienced nurses reported a greater need to restrict children than less-experienced members of staff. They recommended increased education and further research on the use of restraints in a children’s hospital. The significance of exploring the practice of restricting a child for a clinical procedure has been emphasized by researchers who have examined the effects of this practice. For example, restricting a child’s movement has been linked to speech delay (Siblinga & Friedman, 1971), high rates of recall of the distressing procedures, and raised cortisol levels postprocedure (Chen, Zeltzer, Craske, & Katz, 1999; Merrit, Ornstein, & Spicker, 1994). The work of theorists on child development and emerging knowledge on emotional development and regulation also support the need to examine practice. Younger children are particularly vulnerable to the stress of being restricted because cognitively they operate in a relatively closed environment, what Bronfenbrenner (1979) referred to as a microsystem. In this microsystem younger children focus on the day-to-day operations of their environment, such as home or hospital routine, with limited capacity to place their experience in any wider context. Their underdeveloped sense of logic and inability to see things from another’s perspective (Piaget, 1951), together with their desire to please (Kohlberg, 1968), mean they have limited capacity to understand their experience, to articulate their fears and concerns, or to cope with the stress of being restricted. Researchers who explored children’s physiological responses to stressful situations support theory on emotional development by showing that young children are biologically challenged to cope with complex interactions because of their physiological immaturity (Herba
& Philips, 2004; Spinrad & Stifter, 2006; Stifter & Spinrad, 2002). For example, prolonged stress in early childhood was associated with the release of excessive cortisol by the hypothalamic-pituitary-adrenal axis, which can lead to a reduction in the volume of the hippocampus and to chronic memory dysfunction (Stansbury & Gunnar, 1994). The National Scientific Council on the Developing Child (2010) likened this process to “revving a car engine for prolonged periods of time” (p. 3), to the detriment of the engine. This emphasizes the potential for negative consequences on children’s well-being if their needs are not considered and addressed during a clinical procedure. For children’s nurses, knowledge of the intrinsic influences on the maturation of the emotional circuit, which identifies that emotional control begins in infancy and that infants have capacity for awareness of emotionally charged events, has implications for practice. Children’s nurses could have a positive effect on enabling emotional regulation for the child through examining and understanding practices such as the restriction of a child’s movement and seeking ways to alleviate the anxieties that are associated with this practice.
Method We used a qualitative descriptive approach to describe children’s nurses’ experiences of restricting a child for a clinical procedure. It was not the intention in our study to generate a theory or recontextualize nurses’ experiences of restricting movement. We conducted focus groups with nurses to portray the emic perspective of this experience, the “insider” perspective of restriction by those involved in the practice, thereby facilitating a deconstruction and exploration of their experiences.
Sample and Recruitment We used purposive sampling to identify and recruit nurses into focus groups. This ensured that only individuals who had experience of the practice of restricting a child’s movement for a clinical procedure would be included. The category of nurses required for the focus groups was nurses working in a large children’s hospital. This included nurses with 3 or more years of experience caring for children in hospital, including nurses who held a Registered Children’s Nurse (RCN) qualification and nurses who were not RCNs but held another nursing qualification. Our specific inclusion criteria were verified by two senior clinical nurse managers in a large children’s hospital, and were used to yield rich information about the practice of restricting a child’s movement with the aim of establishing typical case sampling (Silverman, 2005). Registered nurses who, at the time of data
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collection, were undertaking training to register as a children’s nurse were not included in the study. Participants were between 24 and 60 years of age (mean = 46.3). The years of experience in pediatric nursing ranged from 10 to 40 (mean = 23.75). The participants (N = 20) included 3 staff nurses, 4 clinical nurse educators, 5 clinical nurse specialists, and 8 clinical nurse managers. All participants were educated to a minimum level of a bachelor’s degree, and many held a master’s degree. Three of the participants held a qualification in general nursing and the remaining 17 were registered children’s nurses. We conducted the focus groups at a large urban teaching hospital in Ireland. Ethical approval was obtained from the hospital research ethics committee. Following ethical approval, we posted a notice about the study on public notice boards at the entrance to the nurses’ changing rooms and on the nurses’ education board 8 weeks before the scheduled date for the focus groups. The notice included the title of the study and invited interested nurses who met the stated criteria to contact first author Maria Brenner for further details. Thus, the participants included in the study were self-selecting. Six weeks prior to the scheduled focus groups 23 nurses had volunteered to participate. We sent each nurse a letter of invitation about the aim and significance of the study and provided her with sufficient detail to make an informed decision about participating. We advised prospective participants that participation was voluntary. A reminder letter was sent a week in advance of the focus groups, with details of the time and venue. We conducted three focus groups, two with 8 participants each and the third with 4 participants.
Planning and Conducting Focus Groups Prior to the focus groups, we provided each participant with an information sheet and consent form. Each focus group was conducted in a private room and audiotaped using a digital recorder. We conducted the focus groups according to a topic guide, developed from the literature (Krueger, 2006). Through the topic guide, we asked participants to discuss their experiences of restricting a child for a clinical procedure, the factors that influenced their decisions and practices, and the possible alternatives to restriction. We did not use an assistant moderator because there were eight or fewer participants in each of these groups (Freeman, 2006; Kvale & Brinkmann, 2009). The research topic had the potential to cause distress among participants who might recall uncomfortable experiences when discussing their practices; therefore, the discussions were moderated with great care and sensitivity. Our protocol included a provision for suspending or ending the discussion should individuals experience distress, as well as arrangements for follow-up support
and counseling; these were not needed during the discussions. Judicious group moderation ensured that the physical environment was conducive to open discussion and the active contribution of all participants. We introduced topics with broad general statements or questions and the group members were asked to discuss each topic with reference to their own experiences. We used probing, clarifying, and interpreting questions when necessary and appropriate. The moderator was mindful of group dynamics in each focus group, such as dominance of individuals and silent participants, and we took steps to ensure the widest participation from all members (Krueger & Casey, 2009; Wibeck, Dahlgren, & Oberg, 2007). We encouraged participants to discuss not only their own experiences, decisions, and practices, but also those of the other group members. This ensured a supportive environment in which to generate rich information and to enable the phenomenon of interest to come alive for the participants (Halling, Kunz, & Rowe, 1994). The focus groups lasted between 60 and 90 minutes, and ended when it was evident that the topic of discussion had been exhausted and when the participants consented to close the discussion. The moderator made short reflective notes following each interview to record observations of factors such as group dynamics, group mood and tone of the comments, and key points that emerged.
Analysis We analyzed focus group data using a thematic network analysis framework (Attride-Stirling, 2001). This method of analysis is based on the tenets of Augmentation Theory, the study of how humans reach conclusions through logical reasoning (Toulmin, 1958). The central tenet of the theory is that findings, although reasonable, are not absolute. Moreover, we were not concerned with reconciling different opinions or with reaching conclusions, and were informed by the relativist principle that multiple realities exist about life experiences (Attride-Stirling). First, we read and reread the transcripts independently. We then met to discuss the transcripts and initial coding of the material. Brenner is an RCN, and this informed the discussion and debate on differences in emphasis in the data as we arrived at a consensus of the basic themes. In the second stage of analysis we synthesized the data from the basic themes into organizing themes on nurses’ understandings of restricting a child for a clinical procedure. Individually and collectively we identified tenets of nurses’ understandings of what constitutes restriction, and their insights into how children are managed during a clinical procedure. In the final stage of analysis we looked for the organizing themes that explained nurses’ understandings of
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Interchangeable terminology
Acknowledging restriction
Shifting methods of restricting movement
Restriction as protection
TENSIONS IN CARE
A difficult aspect of caring
“The only way to manage them”
Mechanistic care
Attribute-based care
Figure 1. Emergence of global theme “tensions in care.”
restriction, and we arrived at a qualitative description of their understandings and self-reported practices. This led us to identifying the global theme that encapsulated a position about restricting a child’s movement during a clinical procedure.
Rigor We established credibility of the data by the inclusion of respondents who had experienced a child being restricted for a clinical procedure, and through prolonged engagement with the topic (Lincoln & Guba, 1985). The use of purposive sampling for focus groups addressed the need to include both experienced voices and disconfirming evidence. Each nurse was invited to participate based on her unique experiences, allowing for diverse definitions, rationales, and accounts of experiences of restriction. This also addressed the criterion of authenticity, as we sought to understand the constructs of others through evidence of a variety of realities contained in the data collected. We confirmed accuracy of data collection by preparing verbatim transcripts of the digital audio files, and from consideration that participants’ opinions of our interpretation of their thoughts might deflect from our own insights into the data gathered (Kvale & Brinkmann, 2009; Morse, Swanson, & Kuzel, 2001). Confirmability of the data was supported by keeping an audit trail in which we detailed the data collection processes, thereby aiding us in establishing congruity about our conclusions. We address transferability of data by presenting detailed information on sampling, data gathering, analysis, and interpretation, thereby enabling others to assess the utility of the study for their own practice.
Table 1. Codes, to Basic Themes, to Organizing Theme “Acknowledging Restriction.” Codes
Basic Themes
Organizing Theme
Immobilizing Pedantics Force Holding still Regret Commonplace Difficult procedures The worst Communication
Interchangeable terminology
Acknowledging restriction
A difficult aspect of caring
Findings The global theme “tensions in care” emerged from the data as participants described what it means to restrict a child’s movement for a clinical procedure (see Figure 1). This global theme arose from two organizing themes: “acknowledging restriction” and “the only way to manage them.”
Tensions in Care: “Acknowledging Restriction” The organizing theme “acknowledging restriction” encompassed the basic themes “interchangeable terminology” and “a difficult aspect of caring.” These were developed from nine initial codes from the focus group data that reflected the lack of consensus in each group on what terms might be used to define or capture the practice of restriction (see Table 1). Many words and phrases relating to restricting a child’s movements are used interchangeably in the literature— restraint, clinical holding, immobilization—and therefore
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the initial focus of discussion in each group was to explore if participants had a shared understanding of these words and phrases. The data indicated that there were differing understandings of the terminology; many participants categorized restriction according to how firmly the child might need to be held, although no consensus was reached in any of the groups. The following account suggests that participants were mindful of their professional image: Interviewer (I): In relation to the term “clinical holding,” do you think there is a difference between what clinical holding is and what restraint is? In your practice, do you think they are two different things? Participant (P) 1: I think it is a nice name for restraint. P2: So do I. P3: Because restraint is not as politically correct. P1: I suppose when I think of restraint I automatically think of being tied down to something. With clinical holding, I would think maybe it sounds more gentle.
To understand the meaning given to the term restriction, participants were asked to recall when they had participated in restricting a child for a procedure. They spoke of the variety of methods that might be used to restrict a child’s movement. These included “physical restraint” when referring to the use of equipment such as clinical ties or the nurse’s own hands; “chemical restraint,” through the use of sedation; or “environmental restraint”—keeping a child contained in a room or unit by the use of bedrails or high handles on doors. Participants referred to changes in the practices of restricting over time, with sedation presented as the preferred method. The second basic theme, “a difficult aspect of caring,” highlights restriction of a child as a difficult aspect of their practice. This basic theme comprised the codes “regret,” “commonplace,” “difficult procedures,” “the worst,” and “communication.” Most participants suggested that restriction of children continued to be commonplace, although this did not incorporate the use of physical aids to restrain, as previously used. Many argued that restricting children was so commonplace that nurses often did not even realize they were doing it. This suggestion that restriction is commonplace was evident in the data from all three focus groups, and many participants gave examples of their own experiences of restricting a child for procedures such as lumbar punctures, insertion of nasogastric tubes, and insertion of intravenous cannulae: P1: We were trying to emphasize that it’s almost endemic in children’s nursing; it [be]comes so much a part [of practice] that it’s commonplace. And it’s the commonplace [practice of] restriction that we were trying to emphasize, not just extreme behavior.
Table 2. Codes, to Basic Themes, to Organizing Theme “The Only Way to Manage Them.” Codes
Basic Themes
Organizing Theme
No alternative Safety Expedience Emergency care Quicker is better Relief using sedation Provide comfort Chemical as easier Managing infants Disruptive children Mental illness Tasks Rushing the job A time thing
Restriction as protection
“The only way to manage them”
Shifting methods of restricting movement Attribute-based care
Mechanistic care
P2: I agree with what you’re saying but it’s because it’s so commonplace, because we do it all of the time. We don’t think of it as being restriction.
Tensions in Care: “The Only Way to Manage Them” The organizing theme “the only way to manage them” encompasses the basic themes “restriction as protection,” “shifting methods of restricting movement,” “attributebased care,” and “mechanistic care.” These basic themes were developed from 14 initial codes (see Table 2). Across all three focus groups, data indicated that participants sought to rationalize the practice of restricting a child’s movement. Many participants seemed uncomfortable with the idea that restriction was part of the care of a child, and this was expressed in their emphasis on providing explanations for the practice. For example, some attributed the decision to restrict to medical colleagues and others attributed the practice to specific characteristics of the individual child, such as age or having a behavioral or mental health problem. The first basic theme of restriction-as-protection arose from five initial codes, namely “no alternative,” “safety,” “expedience,” “emergency care,” and “quicker is better.” All of the participants agreed that it was acceptable to restrict a child to ensure the child’s safety and the safety of others. There was consensus in all groups that safety and expediency of care were absolutely necessary, with the most frequently cited examples pertaining to emergency situations in which immediate care was deemed essential: P1: I think the hardest place must be A & E [accident and emergency/emergency department] though, because you don’t have that time.
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Brenner et al. P2: No. I mean there are times, where they’re not acutely ill, and you can give them that time. But a lot of the time it’s very, very acute and it [nasogastric tube] needs to go in now . . . because you’ve only got an hour to give them charcoal and they’ve taken an overdose. You don’t have a huge amount of time if the clock is ticking away and it’s taken the parents quite a length of time to come in. And a lot of the time it’s, “Look, this is what we need to do. We need to pop it in.” But there’s not a huge amount of explanation.
The second basic theme, “shifting methods of restricting movement,” describes how participants justified their involvement in restricting a child’s movement by blaming the absence of the use of sedation. This theme arose from the codes “relief using sedation,” “provide comfort,” and “chemical as easier.” The need for restriction of children undergoing a radiographical examination and in the emergency department (ED) was frequently mentioned as clinical contexts for restriction. In relation to radiography, it was suggested that limited sedation could be used to ensure accurate measurement of a child’s biophysical profile to ensure treatment precision. The arguments for the limited use of sedation in the ED were associated with fear of delaying discharge time, because the child would need time to recover from the sedation. Some participants justified their role in the decision not to administer sedation in such situations by emphasizing that such situations were rare events. The following account typifies these interwoven justifications: I suppose the only time we’re actually involved in restraint is in X-ray [for an invasive procedure] . . . but we would always ask the parents. . . . It would be the parents that would be restraining. We would give one try. . . . We can’t sedate our children . . . because we won’t get pressures and stuff [blood pressure and other vital signs], so we do all the talking, explain exactly what we’re going to do. But some children, particularly the younger ones, they will just not let you [carry out the procedure]. I wouldn’t [have it] myself . . . so you can’t blame them. And we would have to resort to asking parents to restrain them at times. Now, when I say restrain it would be holding their hands while you would have to restrain their legs and try [to carry out the procedure] with one hand while the parents would be at the top [of the table] talking and cajoling and restraining their hands so they’re not pulling at things. Now, as I say, it doesn’t happen very often . . . but the guilt and the “I’m never doing this again,” and “I’m never coming into hospital again” from the parents, and then the guilt on your side as well, it’s huge. But we’re in a situation where we can’t actually sedate the kids.
Most participants agreed that nurses were more likely to restrict certain groups of children. This consensus illustrated the third basic theme, “attribute-based care,” which emerged from codes referring to a child’s age and
mental well-being or cognitive ability. As participants rationalized their role in restricting younger children they conveyed a tone of resignation that the practice was an inevitable part of children’s nursing. The following account, which followed discussion in one group regarding what might influence the practice of restriction, illustrates this: And then for younger children—we’ll say for toddlers— they have an inability to understand the rationale for hurting them. So therefore, whilst you explain to the parents and you then explain to the child what you’re going to do, but all the explaining in the world isn’t going to make the child cooperate with you, we’ll say to give them a suppository. Whereas an older child will cooperate with you. You don’t need to restrain them but the younger child, you have to hold them down to carry out the procedure.
This tone of resignation relating to restricting a child was absent from discussions on the rationale for restricting an infant’s movement; instead, participants sought to justify this practice by emphasizing that it was “more humane to wrap them up.” This acceptance that infants were highly likely to be restricted was predicated on the notion that the practice equated to swaddling, which was generally interpreted as a means of providing comfort to the infant. All participants endorsed this and seemed to hold the position that the practice neutralized or at least lessened the possibility that a children’s nurse would intentionally cause distress to an infant. The tension of the reality that this might happen is evident in the following account, which ensued when participants were asked if they thought nurses were more likely to restrict the movement of any particular group of children: P1: Say it’s a nasogastric tube and you’re helping somebody and they’re passing the tube and you’ve the child all wrapped up in a blanket and you’re kind of cuddling the baby. You don’t feel like you’re restraining the child as much there than if you actually held the child like that on the bed. P2: It doesn’t sound [like] it’s being restrained, even though it is. P1: Even though it is, yeah. P2: It’s just not severe.
At times participants invoked or created biomedical categories to depict special cases in which restriction was warranted, such as children with a mental illness, through their use of phrases such as “psychiatric patients” and “psychiatric children”: I would see restraint as what we do a lot of the time to psychiatric patients. And I think a lot of it is lack of teaching on our behalf. We’re not psychiatrically trained nurses and, unfortunately, because nobody else will facilitate these
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patients we all try our best, but a lot times it’s restraint more than anything else. . . . I would see restraint more with pediatric nurses trying to deal with psychiatric patients who can be very difficult, who can cause self-harm and harm to others, and I would see . . . restraint in an effort to protect others. . . . But I think the issues of dealing with restraint for psychiatric adolescents or children has not been addressed. They’re trying to house these children in an acute setting where there’s other children who are on bed rest or whatever, and [they] are a huge risk.
Many participants suggested that children with a mental health problem did not belong in the ED, particularly after 5:00 p.m. and during the weekends. Accounts suggest that children’s ability to communicate and their level of compliance were likely to influence the possibility of their movement being restricted for a clinical procedure, and some participants suggested that it was inevitable that children with an intellectual disability would also fall into this category. At no point did any of them distinguish between varying levels of intellectual disability; instead, many made sweeping statements about “children with disabilities,” as evidenced in the following excerpt: I suppose I’m thinking of maybe children with disabilities, and I’m just thinking that you’d meet them and they’re fine, you’d talk to them and they’re lovely, I’m just thinking of teenagers I might know. Put into a different situation, what would they be like? They could be very stubborn, couldn’t they, if they don’t understand what’s going on. And they’re very strong too; they seem to have inner strength.
The fourth basic theme, “mechanistic care,” emerged as participants looked beyond nursing and sought to rationalize restricting movement by apportioning blame firmly on their medical colleagues. Mechanistic care refers to the task-orientated care that many participants attributed to their medical colleagues, as they described what they perceived to be an eagerness to “get the job done,” with little regard for a child’s individual needs. Although the notion of limited time emerged earlier when discussing expediency in acute care situations, expediency was often referred to with reference to the physician getting the job done so as to move on to the next task. This perceived medical bias for restricting was portrayed as a particular issue on weekends and out of hours, and some expressed anger about physicians’ practices in this regard: P1: At weekends if we’ve a baby for bloods because there’s no phlebotomy, and it could be a newborn in or it could be . . . someone going to the [operating] theater, and they’re usually newborns, and they have to have their bloods done beforehand and you have to ring the SHO [senior house officer, nonconsultant grade] on call and they literally come in and you see them with just the
[infant’s] arm out and they’d be prodding and all, you’d see beside them is a tray with plenty of needles and they wouldn’t ask for help. P2: It’s a real time issue with them as well. P1: “I have a job to do and I’m going to do it.” They don’t care if they have to stab [cannulate] the child. Not at all. P2: It’s task orientated.
Although many participants expressed negative views of the medical approach to restricting children, very few indicated a willingness to act on their disapproval of medical decision making in relation to restriction. One participant recalled a situation in which she was so distressed that she had to leave the room after a physician attempted to perform a lumbar puncture five times on a child, yet she only left the room to allow some other nurse to take her place. In contrast, another participant indicated that she would consider requesting a physician to stop the restriction in a nonacute situation: If there’s any sort of leeway we’ll say, “Okay, we’ll try once and if she [the doctor] can’t get a cannula in this time we’ll leave it” . . . so they [the parents] don’t feel that you’re just coming in doing whatever you have to do.
Discussion The aim of the study was to describe nurses’ experiences of restricting a child for a clinical procedure, including their understanding of the clinical functions of restriction. The particular issue of caring for a child with a behavioral or mental health problem in a children’s hospital emerged as a significant concern for the nurses who participated in the study. Although this referred to restriction for a behavioral or mental health problem, rather than for any clinical procedure, this issue reflects wider concern about appropriate care facilities for such children. The care of children with a mental health problem in an acute medical facility goes against best practices internationally when staff are not qualified or equipped to address the specific needs of such children and their families. There is a need for examination of care provision for children with mental health problems and a review of the progress made on Irish government policy in this area. The impetus to address the issues raised by the nurses seems to be challenged at the organizational level. Many participants suggested that initiating a discussion on restriction was not the sole responsibility of the nurse; rather, it was an issue for the health care organization. They did not identify a role for nurses in any wider discussion on the practice of restriction. This was very evident in the data in the way the participants sought to rationalize why restriction occurs, but without accepting any responsibility to address their reservations about the practice in their own place of work. This finding of the
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Brenner et al. nurse as a reluctant advocate is contrary to previous findings that nurses caring for children are very focused on being a patient advocate (Hallstrom & Elander, 2004; Howlin, 2008). Furthermore, the finding does not reflect that advocacy was identified as a central component of nurses caring for children and a professional imperative (Davies, 2010; Glasper, 2010). Despite their expressed concern about their medical colleagues’ decision making in relation to restriction, none of the participants stated that they would directly challenge a physician’s practice in restricting a child, even if it seemed unnecessary. Causing distress to a child, even with clinical gain, is something that health care professionals caring for children should strive to avoid. It is arguable that the act of not objecting to restriction—or at a minimum, advocating for the use of distraction or chemical sedation—might be perceived as not demonstrating advocacy, particularly in light of emerging knowledge on children’s emotional development and knowledge of the effect of distress in childhood (National Scientific Council on the Developing Child, 2010). This raises many questions in relation to the power and influence of physicians in the pediatric setting, and also perhaps suggests reluctance on the part of children’s nurses to act as patient advocates. The nurses’ lack of willingness to challenge the practice of restriction might be explained in the actual or perceived powerlessness of hospital nurses to affect change. It was suggested that advocacy is challenged when those seeking to advocate or empower are “less powerful than those working against it” (Christensen & Hewitt-Taylor 2006, p. 696). The findings from this study suggest that nurses involved in restricting a child for a clinical procedure might have a diminished feeling of power to affect change. This reluctance to advocate has been found to play a part in compromising patient care, with evidence found in inquests into reports of poor practices in the care of children. These include the Bristol inquiry in the United Kingdom, which examined practices in the care of children receiving complex cardiac procedures (Department of Health, 2001); the Sinclair inquest in Canada (Sinclair, 2000), which investigated the deaths of children during or immediately after cardiac surgery; and the Lourdes Hospital Inquiry (Government of Ireland, 2006), which investigated the unwarranted hysterectomies by a consultant obstetrician. In each case, concerns by nurses, midwives, or junior physicians were dismissed, despite their repeated expressions of concern about practices. In some of the cases cited, reasons for nonadvocacy on the part of nurses included fear of limited promotional opportunities, the gender of the nurses and midwives, or the fact that concerns were dismissed because nurses were seen as too emotionally engaged.
Many of the participants identified the increased use of sedation as an alternative to physically restricting a child’s movement. Although the use of chemical sedation for children undergoing therapeutic interventions is an established practice in pediatric intensive care units (Dixon & Crawford, 2012) and ED (Shaban, Holzhauser, Gillespie, Huckson, & Bennett, 2012), it is not an established practice in general medical and surgical units. This is an area that requires further exploration, considering the impact that restricting movement can potentially have on a child, including longer recovery time after a procedure, the potential for respiratory complications, and the additional staff education and resources required to facilitate this practice (Dixon & Crawford). It is necessary to have organizational support from a multidisciplinary perspective to address long-established practices such as restriction. This would facilitate discussion of any concerns and support a joint approach to addressing ways of improving care. Nurses need organizational support to enable open discussion on restriction from a multidisciplinary perspective and to encourage discussion of any concerns about restriction. Such a measure would show a commitment to openly discuss sensitive issues that can arise in caring for a child during a clinical procedure. Acknowledgments We thank Kader Parahoo and Laurence Taggart for their contribution to the study.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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3(2), 133–152. Retrieved from www.hhdev.psu.edu/ebp/ stifter%20and%20spinrad%202002.pdf Toulmin, S. (1958). The uses of argument. Cambridge, United Kingdom: Cambridge University Press. Weiss, K. E., Dahlquist, L. M., & Wohlheiter, K. (2011). The effects of interactive and passive distraction on cold pressor pain in preschool-aged children. Journal of Pediatric Psychology, 36(7), 816–826. doi:10.1093/jpepsy/jsq125 Wibeck, V., Dahlgren, M., & Oberg, G. (2007). Learning in focus groups: An analytical dimension for enhancing focus group research. Qualitative Research, 7(2), 249–267. doi:10.1177/1468794107076023
Author Biographies Maria Brenner, PhD, RCN, RGN, is a lecturer at University College Dublin School of Nursing, Midwifery & Health Systems in Dublin, Ireland. Margaret Pearl Treacy, PhD, RGN, is an emeritus professor at University College Dublin School of Nursing, Midwifery & Health Systems in Dublin, Ireland. Jonathan Drennan, PhD, RGN is a professor of health care research, Centre for Innovation and Leadership in Health Sciences, Faculty of Health Sciences, at the University of Southampton in Southampton, United Kingdom. Gerard Fealy PhD, RGN, is an associate professor and associate dean for research and innovation at University College Dublin School of Nursing Midwifery & Health Systems in Dublin, Ireland.
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research-article2014
QHRXXX10.1177/1049732314541332Qualitative Health ResearchBrenner et al.
Article
Nurses’ Perceptions of the Practice of Restricting a Child for a Clinical Procedure
Qualitative Health Research 2014, Vol. 24(8) 1080–1089 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314541332 qhr.sagepub.com
Maria Brenner1, Margaret Pearl Treacy1, Jonathan Drennan2, and Gerard Fealy1
Abstract Restricting a child for a clinical procedure has been linked to negative physical and psychological sequelae. The practice of restriction remains an implicit and unquestioned aspect of care for children during a clinical procedure. In this study we aimed to describe the practice of restricting a child’s movement for a clinical procedure by conducting focus groups with children’s nurses. Data were analyzed using a thematic network analysis framework. The findings show that nurses are likely to restrict children based on particular characteristics of the child; for example, the child’s age. The findings indicate that there is no consistent approach to the practice of restricting a child for a clinical procedure, suggesting tension between nurses and other health care professionals, and nurses and parents, about this practice. The findings suggest the need for wider exploration of the practice of restriction at the organizational level and a need for children’s nurses to feel more empowered to act as advocates for those in their care. Keywords children; decision making; focus groups; health care, culture of; nursing Many terms are used interchangeably to describe restricting a child’s movement for a clinical procedure; for example: restrictive physical intervention, restraint, immobilization, clinical holding, therapeutic holding, and holding (Brenner, 2007; Brenner & Noctor, 2010; Folkes, 2005; Royal College of Nursing [RCN], 2010). The choice of term appears to be guided by the amount of force required to hold the child still. For example, the RCN suggested that the term restrictive physical intervention refers to the force used to disengage a child from harmful behavior, and that therapeutic holding refers to the use of less force to carry out a clinical procedure. This is supported in the work of Jeffrey (2010), who proposed that holding and restraint are opposite ends of a continuum, depending on the degree of force used. The terms offered in the literature are based on the presumption of an understanding of what constitutes “force” in the care of children undergoing clinical procedures, rather than any empirical evidence. The current literature in this area might leave room for misinterpretation. In the absence of measuring and understanding the concept of force, the term restriction is proposed as a nonjudgmental description of a practice that can occur, when the risk–benefit favors it, for the purposes of delivering timely care to a child. There is a consensus in the literature that there is a need to improve a child’s experience of undergoing a clinical
procedure. For example, many researchers and commentators on child health have explored the value of parental presence to support a child during a procedure (Emergency Nurses Association, 2005; Maxton, 2008; McGrath & Huff, 2003; Piira, Sugiura, Champion, Donnelly, & Cole, 2005; Ryan & Treston, 2007). The majority suggested that parental presence during a clinical procedure can reduce procedural anxiety in a child and facilitates the development of trust between the family and health care professionals. Improving the care of a child during a clinical procedure was also the focus of researchers who explored the benefits of play therapy in a children’s hospital. It was suggested that play therapy provides an outlet for a child’s emotions during a clinical procedure, reduces procedural stress, facilitates communication with the child, and assists in diverting a child’s thoughts from his or her care (Blount, Piira, Cohen, & Cheng, 2006; Jun-Tai, 2008; Weiss, Dahlquist, & Wohlheiter, 2011). 1
University College Dublin, Dublin, Ireland University of Southampton, Southampton, United Kingdom
2
Corresponding Author: Maria Brenner, School of Nursing, Midwifery & Health Systems, Health Sciences Building, University College Dublin, Belfield, Dublin 4, Ireland. Email: [email protected]
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Brenner et al. In contrast, a limited number of researchers have explored specific practices that occur during a clinical procedure, such as restriction of the child. Only two studies were found on nurses’ restriction of a child for a clinical procedure (Robinson & Collier, 1997; Selekman & Snyder, 1995). In the United States, Selekman and Snyder examined nurses’ perceptions of the use of restraints in four pediatric settings, including an acute pediatric hospital, a pediatric rehabilitation unit, a pediatric psychiatric unit, and a general hospital with an attached pediatric unit. Selekman and Snyder found that nurses restrained children based on their need to promote safety and prevent hypothetical adverse sequelae that might occur, such as the removal of dressings by the child. The need to use restraints was associated with particular procedures rather than any individual care needs of a child, though the researchers also identified that overall, nurses were not knowledgeable about the use of restraints. Robinson and Collier (1997) supported these findings and also identified some characteristics of the nurse that might influence care delivery; for example, they found that more-experienced nurses reported a greater need to restrict children than less-experienced members of staff. They recommended increased education and further research on the use of restraints in a children’s hospital. The significance of exploring the practice of restricting a child for a clinical procedure has been emphasized by researchers who have examined the effects of this practice. For example, restricting a child’s movement has been linked to speech delay (Siblinga & Friedman, 1971), high rates of recall of the distressing procedures, and raised cortisol levels postprocedure (Chen, Zeltzer, Craske, & Katz, 1999; Merrit, Ornstein, & Spicker, 1994). The work of theorists on child development and emerging knowledge on emotional development and regulation also support the need to examine practice. Younger children are particularly vulnerable to the stress of being restricted because cognitively they operate in a relatively closed environment, what Bronfenbrenner (1979) referred to as a microsystem. In this microsystem younger children focus on the day-to-day operations of their environment, such as home or hospital routine, with limited capacity to place their experience in any wider context. Their underdeveloped sense of logic and inability to see things from another’s perspective (Piaget, 1951), together with their desire to please (Kohlberg, 1968), mean they have limited capacity to understand their experience, to articulate their fears and concerns, or to cope with the stress of being restricted. Researchers who explored children’s physiological responses to stressful situations support theory on emotional development by showing that young children are biologically challenged to cope with complex interactions because of their physiological immaturity (Herba
& Philips, 2004; Spinrad & Stifter, 2006; Stifter & Spinrad, 2002). For example, prolonged stress in early childhood was associated with the release of excessive cortisol by the hypothalamic-pituitary-adrenal axis, which can lead to a reduction in the volume of the hippocampus and to chronic memory dysfunction (Stansbury & Gunnar, 1994). The National Scientific Council on the Developing Child (2010) likened this process to “revving a car engine for prolonged periods of time” (p. 3), to the detriment of the engine. This emphasizes the potential for negative consequences on children’s well-being if their needs are not considered and addressed during a clinical procedure. For children’s nurses, knowledge of the intrinsic influences on the maturation of the emotional circuit, which identifies that emotional control begins in infancy and that infants have capacity for awareness of emotionally charged events, has implications for practice. Children’s nurses could have a positive effect on enabling emotional regulation for the child through examining and understanding practices such as the restriction of a child’s movement and seeking ways to alleviate the anxieties that are associated with this practice.
Method We used a qualitative descriptive approach to describe children’s nurses’ experiences of restricting a child for a clinical procedure. It was not the intention in our study to generate a theory or recontextualize nurses’ experiences of restricting movement. We conducted focus groups with nurses to portray the emic perspective of this experience, the “insider” perspective of restriction by those involved in the practice, thereby facilitating a deconstruction and exploration of their experiences.
Sample and Recruitment We used purposive sampling to identify and recruit nurses into focus groups. This ensured that only individuals who had experience of the practice of restricting a child’s movement for a clinical procedure would be included. The category of nurses required for the focus groups was nurses working in a large children’s hospital. This included nurses with 3 or more years of experience caring for children in hospital, including nurses who held a Registered Children’s Nurse (RCN) qualification and nurses who were not RCNs but held another nursing qualification. Our specific inclusion criteria were verified by two senior clinical nurse managers in a large children’s hospital, and were used to yield rich information about the practice of restricting a child’s movement with the aim of establishing typical case sampling (Silverman, 2005). Registered nurses who, at the time of data
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collection, were undertaking training to register as a children’s nurse were not included in the study. Participants were between 24 and 60 years of age (mean = 46.3). The years of experience in pediatric nursing ranged from 10 to 40 (mean = 23.75). The participants (N = 20) included 3 staff nurses, 4 clinical nurse educators, 5 clinical nurse specialists, and 8 clinical nurse managers. All participants were educated to a minimum level of a bachelor’s degree, and many held a master’s degree. Three of the participants held a qualification in general nursing and the remaining 17 were registered children’s nurses. We conducted the focus groups at a large urban teaching hospital in Ireland. Ethical approval was obtained from the hospital research ethics committee. Following ethical approval, we posted a notice about the study on public notice boards at the entrance to the nurses’ changing rooms and on the nurses’ education board 8 weeks before the scheduled date for the focus groups. The notice included the title of the study and invited interested nurses who met the stated criteria to contact first author Maria Brenner for further details. Thus, the participants included in the study were self-selecting. Six weeks prior to the scheduled focus groups 23 nurses had volunteered to participate. We sent each nurse a letter of invitation about the aim and significance of the study and provided her with sufficient detail to make an informed decision about participating. We advised prospective participants that participation was voluntary. A reminder letter was sent a week in advance of the focus groups, with details of the time and venue. We conducted three focus groups, two with 8 participants each and the third with 4 participants.
Planning and Conducting Focus Groups Prior to the focus groups, we provided each participant with an information sheet and consent form. Each focus group was conducted in a private room and audiotaped using a digital recorder. We conducted the focus groups according to a topic guide, developed from the literature (Krueger, 2006). Through the topic guide, we asked participants to discuss their experiences of restricting a child for a clinical procedure, the factors that influenced their decisions and practices, and the possible alternatives to restriction. We did not use an assistant moderator because there were eight or fewer participants in each of these groups (Freeman, 2006; Kvale & Brinkmann, 2009). The research topic had the potential to cause distress among participants who might recall uncomfortable experiences when discussing their practices; therefore, the discussions were moderated with great care and sensitivity. Our protocol included a provision for suspending or ending the discussion should individuals experience distress, as well as arrangements for follow-up support
and counseling; these were not needed during the discussions. Judicious group moderation ensured that the physical environment was conducive to open discussion and the active contribution of all participants. We introduced topics with broad general statements or questions and the group members were asked to discuss each topic with reference to their own experiences. We used probing, clarifying, and interpreting questions when necessary and appropriate. The moderator was mindful of group dynamics in each focus group, such as dominance of individuals and silent participants, and we took steps to ensure the widest participation from all members (Krueger & Casey, 2009; Wibeck, Dahlgren, & Oberg, 2007). We encouraged participants to discuss not only their own experiences, decisions, and practices, but also those of the other group members. This ensured a supportive environment in which to generate rich information and to enable the phenomenon of interest to come alive for the participants (Halling, Kunz, & Rowe, 1994). The focus groups lasted between 60 and 90 minutes, and ended when it was evident that the topic of discussion had been exhausted and when the participants consented to close the discussion. The moderator made short reflective notes following each interview to record observations of factors such as group dynamics, group mood and tone of the comments, and key points that emerged.
Analysis We analyzed focus group data using a thematic network analysis framework (Attride-Stirling, 2001). This method of analysis is based on the tenets of Augmentation Theory, the study of how humans reach conclusions through logical reasoning (Toulmin, 1958). The central tenet of the theory is that findings, although reasonable, are not absolute. Moreover, we were not concerned with reconciling different opinions or with reaching conclusions, and were informed by the relativist principle that multiple realities exist about life experiences (Attride-Stirling). First, we read and reread the transcripts independently. We then met to discuss the transcripts and initial coding of the material. Brenner is an RCN, and this informed the discussion and debate on differences in emphasis in the data as we arrived at a consensus of the basic themes. In the second stage of analysis we synthesized the data from the basic themes into organizing themes on nurses’ understandings of restricting a child for a clinical procedure. Individually and collectively we identified tenets of nurses’ understandings of what constitutes restriction, and their insights into how children are managed during a clinical procedure. In the final stage of analysis we looked for the organizing themes that explained nurses’ understandings of
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Interchangeable terminology
Acknowledging restriction
Shifting methods of restricting movement
Restriction as protection
TENSIONS IN CARE
A difficult aspect of caring
“The only way to manage them”
Mechanistic care
Attribute-based care
Figure 1. Emergence of global theme “tensions in care.”
restriction, and we arrived at a qualitative description of their understandings and self-reported practices. This led us to identifying the global theme that encapsulated a position about restricting a child’s movement during a clinical procedure.
Rigor We established credibility of the data by the inclusion of respondents who had experienced a child being restricted for a clinical procedure, and through prolonged engagement with the topic (Lincoln & Guba, 1985). The use of purposive sampling for focus groups addressed the need to include both experienced voices and disconfirming evidence. Each nurse was invited to participate based on her unique experiences, allowing for diverse definitions, rationales, and accounts of experiences of restriction. This also addressed the criterion of authenticity, as we sought to understand the constructs of others through evidence of a variety of realities contained in the data collected. We confirmed accuracy of data collection by preparing verbatim transcripts of the digital audio files, and from consideration that participants’ opinions of our interpretation of their thoughts might deflect from our own insights into the data gathered (Kvale & Brinkmann, 2009; Morse, Swanson, & Kuzel, 2001). Confirmability of the data was supported by keeping an audit trail in which we detailed the data collection processes, thereby aiding us in establishing congruity about our conclusions. We address transferability of data by presenting detailed information on sampling, data gathering, analysis, and interpretation, thereby enabling others to assess the utility of the study for their own practice.
Table 1. Codes, to Basic Themes, to Organizing Theme “Acknowledging Restriction.” Codes
Basic Themes
Organizing Theme
Immobilizing Pedantics Force Holding still Regret Commonplace Difficult procedures The worst Communication
Interchangeable terminology
Acknowledging restriction
A difficult aspect of caring
Findings The global theme “tensions in care” emerged from the data as participants described what it means to restrict a child’s movement for a clinical procedure (see Figure 1). This global theme arose from two organizing themes: “acknowledging restriction” and “the only way to manage them.”
Tensions in Care: “Acknowledging Restriction” The organizing theme “acknowledging restriction” encompassed the basic themes “interchangeable terminology” and “a difficult aspect of caring.” These were developed from nine initial codes from the focus group data that reflected the lack of consensus in each group on what terms might be used to define or capture the practice of restriction (see Table 1). Many words and phrases relating to restricting a child’s movements are used interchangeably in the literature— restraint, clinical holding, immobilization—and therefore
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the initial focus of discussion in each group was to explore if participants had a shared understanding of these words and phrases. The data indicated that there were differing understandings of the terminology; many participants categorized restriction according to how firmly the child might need to be held, although no consensus was reached in any of the groups. The following account suggests that participants were mindful of their professional image: Interviewer (I): In relation to the term “clinical holding,” do you think there is a difference between what clinical holding is and what restraint is? In your practice, do you think they are two different things? Participant (P) 1: I think it is a nice name for restraint. P2: So do I. P3: Because restraint is not as politically correct. P1: I suppose when I think of restraint I automatically think of being tied down to something. With clinical holding, I would think maybe it sounds more gentle.
To understand the meaning given to the term restriction, participants were asked to recall when they had participated in restricting a child for a procedure. They spoke of the variety of methods that might be used to restrict a child’s movement. These included “physical restraint” when referring to the use of equipment such as clinical ties or the nurse’s own hands; “chemical restraint,” through the use of sedation; or “environmental restraint”—keeping a child contained in a room or unit by the use of bedrails or high handles on doors. Participants referred to changes in the practices of restricting over time, with sedation presented as the preferred method. The second basic theme, “a difficult aspect of caring,” highlights restriction of a child as a difficult aspect of their practice. This basic theme comprised the codes “regret,” “commonplace,” “difficult procedures,” “the worst,” and “communication.” Most participants suggested that restriction of children continued to be commonplace, although this did not incorporate the use of physical aids to restrain, as previously used. Many argued that restricting children was so commonplace that nurses often did not even realize they were doing it. This suggestion that restriction is commonplace was evident in the data from all three focus groups, and many participants gave examples of their own experiences of restricting a child for procedures such as lumbar punctures, insertion of nasogastric tubes, and insertion of intravenous cannulae: P1: We were trying to emphasize that it’s almost endemic in children’s nursing; it [be]comes so much a part [of practice] that it’s commonplace. And it’s the commonplace [practice of] restriction that we were trying to emphasize, not just extreme behavior.
Table 2. Codes, to Basic Themes, to Organizing Theme “The Only Way to Manage Them.” Codes
Basic Themes
Organizing Theme
No alternative Safety Expedience Emergency care Quicker is better Relief using sedation Provide comfort Chemical as easier Managing infants Disruptive children Mental illness Tasks Rushing the job A time thing
Restriction as protection
“The only way to manage them”
Shifting methods of restricting movement Attribute-based care
Mechanistic care
P2: I agree with what you’re saying but it’s because it’s so commonplace, because we do it all of the time. We don’t think of it as being restriction.
Tensions in Care: “The Only Way to Manage Them” The organizing theme “the only way to manage them” encompasses the basic themes “restriction as protection,” “shifting methods of restricting movement,” “attributebased care,” and “mechanistic care.” These basic themes were developed from 14 initial codes (see Table 2). Across all three focus groups, data indicated that participants sought to rationalize the practice of restricting a child’s movement. Many participants seemed uncomfortable with the idea that restriction was part of the care of a child, and this was expressed in their emphasis on providing explanations for the practice. For example, some attributed the decision to restrict to medical colleagues and others attributed the practice to specific characteristics of the individual child, such as age or having a behavioral or mental health problem. The first basic theme of restriction-as-protection arose from five initial codes, namely “no alternative,” “safety,” “expedience,” “emergency care,” and “quicker is better.” All of the participants agreed that it was acceptable to restrict a child to ensure the child’s safety and the safety of others. There was consensus in all groups that safety and expediency of care were absolutely necessary, with the most frequently cited examples pertaining to emergency situations in which immediate care was deemed essential: P1: I think the hardest place must be A & E [accident and emergency/emergency department] though, because you don’t have that time.
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Brenner et al. P2: No. I mean there are times, where they’re not acutely ill, and you can give them that time. But a lot of the time it’s very, very acute and it [nasogastric tube] needs to go in now . . . because you’ve only got an hour to give them charcoal and they’ve taken an overdose. You don’t have a huge amount of time if the clock is ticking away and it’s taken the parents quite a length of time to come in. And a lot of the time it’s, “Look, this is what we need to do. We need to pop it in.” But there’s not a huge amount of explanation.
The second basic theme, “shifting methods of restricting movement,” describes how participants justified their involvement in restricting a child’s movement by blaming the absence of the use of sedation. This theme arose from the codes “relief using sedation,” “provide comfort,” and “chemical as easier.” The need for restriction of children undergoing a radiographical examination and in the emergency department (ED) was frequently mentioned as clinical contexts for restriction. In relation to radiography, it was suggested that limited sedation could be used to ensure accurate measurement of a child’s biophysical profile to ensure treatment precision. The arguments for the limited use of sedation in the ED were associated with fear of delaying discharge time, because the child would need time to recover from the sedation. Some participants justified their role in the decision not to administer sedation in such situations by emphasizing that such situations were rare events. The following account typifies these interwoven justifications: I suppose the only time we’re actually involved in restraint is in X-ray [for an invasive procedure] . . . but we would always ask the parents. . . . It would be the parents that would be restraining. We would give one try. . . . We can’t sedate our children . . . because we won’t get pressures and stuff [blood pressure and other vital signs], so we do all the talking, explain exactly what we’re going to do. But some children, particularly the younger ones, they will just not let you [carry out the procedure]. I wouldn’t [have it] myself . . . so you can’t blame them. And we would have to resort to asking parents to restrain them at times. Now, when I say restrain it would be holding their hands while you would have to restrain their legs and try [to carry out the procedure] with one hand while the parents would be at the top [of the table] talking and cajoling and restraining their hands so they’re not pulling at things. Now, as I say, it doesn’t happen very often . . . but the guilt and the “I’m never doing this again,” and “I’m never coming into hospital again” from the parents, and then the guilt on your side as well, it’s huge. But we’re in a situation where we can’t actually sedate the kids.
Most participants agreed that nurses were more likely to restrict certain groups of children. This consensus illustrated the third basic theme, “attribute-based care,” which emerged from codes referring to a child’s age and
mental well-being or cognitive ability. As participants rationalized their role in restricting younger children they conveyed a tone of resignation that the practice was an inevitable part of children’s nursing. The following account, which followed discussion in one group regarding what might influence the practice of restriction, illustrates this: And then for younger children—we’ll say for toddlers— they have an inability to understand the rationale for hurting them. So therefore, whilst you explain to the parents and you then explain to the child what you’re going to do, but all the explaining in the world isn’t going to make the child cooperate with you, we’ll say to give them a suppository. Whereas an older child will cooperate with you. You don’t need to restrain them but the younger child, you have to hold them down to carry out the procedure.
This tone of resignation relating to restricting a child was absent from discussions on the rationale for restricting an infant’s movement; instead, participants sought to justify this practice by emphasizing that it was “more humane to wrap them up.” This acceptance that infants were highly likely to be restricted was predicated on the notion that the practice equated to swaddling, which was generally interpreted as a means of providing comfort to the infant. All participants endorsed this and seemed to hold the position that the practice neutralized or at least lessened the possibility that a children’s nurse would intentionally cause distress to an infant. The tension of the reality that this might happen is evident in the following account, which ensued when participants were asked if they thought nurses were more likely to restrict the movement of any particular group of children: P1: Say it’s a nasogastric tube and you’re helping somebody and they’re passing the tube and you’ve the child all wrapped up in a blanket and you’re kind of cuddling the baby. You don’t feel like you’re restraining the child as much there than if you actually held the child like that on the bed. P2: It doesn’t sound [like] it’s being restrained, even though it is. P1: Even though it is, yeah. P2: It’s just not severe.
At times participants invoked or created biomedical categories to depict special cases in which restriction was warranted, such as children with a mental illness, through their use of phrases such as “psychiatric patients” and “psychiatric children”: I would see restraint as what we do a lot of the time to psychiatric patients. And I think a lot of it is lack of teaching on our behalf. We’re not psychiatrically trained nurses and, unfortunately, because nobody else will facilitate these
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patients we all try our best, but a lot times it’s restraint more than anything else. . . . I would see restraint more with pediatric nurses trying to deal with psychiatric patients who can be very difficult, who can cause self-harm and harm to others, and I would see . . . restraint in an effort to protect others. . . . But I think the issues of dealing with restraint for psychiatric adolescents or children has not been addressed. They’re trying to house these children in an acute setting where there’s other children who are on bed rest or whatever, and [they] are a huge risk.
Many participants suggested that children with a mental health problem did not belong in the ED, particularly after 5:00 p.m. and during the weekends. Accounts suggest that children’s ability to communicate and their level of compliance were likely to influence the possibility of their movement being restricted for a clinical procedure, and some participants suggested that it was inevitable that children with an intellectual disability would also fall into this category. At no point did any of them distinguish between varying levels of intellectual disability; instead, many made sweeping statements about “children with disabilities,” as evidenced in the following excerpt: I suppose I’m thinking of maybe children with disabilities, and I’m just thinking that you’d meet them and they’re fine, you’d talk to them and they’re lovely, I’m just thinking of teenagers I might know. Put into a different situation, what would they be like? They could be very stubborn, couldn’t they, if they don’t understand what’s going on. And they’re very strong too; they seem to have inner strength.
The fourth basic theme, “mechanistic care,” emerged as participants looked beyond nursing and sought to rationalize restricting movement by apportioning blame firmly on their medical colleagues. Mechanistic care refers to the task-orientated care that many participants attributed to their medical colleagues, as they described what they perceived to be an eagerness to “get the job done,” with little regard for a child’s individual needs. Although the notion of limited time emerged earlier when discussing expediency in acute care situations, expediency was often referred to with reference to the physician getting the job done so as to move on to the next task. This perceived medical bias for restricting was portrayed as a particular issue on weekends and out of hours, and some expressed anger about physicians’ practices in this regard: P1: At weekends if we’ve a baby for bloods because there’s no phlebotomy, and it could be a newborn in or it could be . . . someone going to the [operating] theater, and they’re usually newborns, and they have to have their bloods done beforehand and you have to ring the SHO [senior house officer, nonconsultant grade] on call and they literally come in and you see them with just the
[infant’s] arm out and they’d be prodding and all, you’d see beside them is a tray with plenty of needles and they wouldn’t ask for help. P2: It’s a real time issue with them as well. P1: “I have a job to do and I’m going to do it.” They don’t care if they have to stab [cannulate] the child. Not at all. P2: It’s task orientated.
Although many participants expressed negative views of the medical approach to restricting children, very few indicated a willingness to act on their disapproval of medical decision making in relation to restriction. One participant recalled a situation in which she was so distressed that she had to leave the room after a physician attempted to perform a lumbar puncture five times on a child, yet she only left the room to allow some other nurse to take her place. In contrast, another participant indicated that she would consider requesting a physician to stop the restriction in a nonacute situation: If there’s any sort of leeway we’ll say, “Okay, we’ll try once and if she [the doctor] can’t get a cannula in this time we’ll leave it” . . . so they [the parents] don’t feel that you’re just coming in doing whatever you have to do.
Discussion The aim of the study was to describe nurses’ experiences of restricting a child for a clinical procedure, including their understanding of the clinical functions of restriction. The particular issue of caring for a child with a behavioral or mental health problem in a children’s hospital emerged as a significant concern for the nurses who participated in the study. Although this referred to restriction for a behavioral or mental health problem, rather than for any clinical procedure, this issue reflects wider concern about appropriate care facilities for such children. The care of children with a mental health problem in an acute medical facility goes against best practices internationally when staff are not qualified or equipped to address the specific needs of such children and their families. There is a need for examination of care provision for children with mental health problems and a review of the progress made on Irish government policy in this area. The impetus to address the issues raised by the nurses seems to be challenged at the organizational level. Many participants suggested that initiating a discussion on restriction was not the sole responsibility of the nurse; rather, it was an issue for the health care organization. They did not identify a role for nurses in any wider discussion on the practice of restriction. This was very evident in the data in the way the participants sought to rationalize why restriction occurs, but without accepting any responsibility to address their reservations about the practice in their own place of work. This finding of the
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Brenner et al. nurse as a reluctant advocate is contrary to previous findings that nurses caring for children are very focused on being a patient advocate (Hallstrom & Elander, 2004; Howlin, 2008). Furthermore, the finding does not reflect that advocacy was identified as a central component of nurses caring for children and a professional imperative (Davies, 2010; Glasper, 2010). Despite their expressed concern about their medical colleagues’ decision making in relation to restriction, none of the participants stated that they would directly challenge a physician’s practice in restricting a child, even if it seemed unnecessary. Causing distress to a child, even with clinical gain, is something that health care professionals caring for children should strive to avoid. It is arguable that the act of not objecting to restriction—or at a minimum, advocating for the use of distraction or chemical sedation—might be perceived as not demonstrating advocacy, particularly in light of emerging knowledge on children’s emotional development and knowledge of the effect of distress in childhood (National Scientific Council on the Developing Child, 2010). This raises many questions in relation to the power and influence of physicians in the pediatric setting, and also perhaps suggests reluctance on the part of children’s nurses to act as patient advocates. The nurses’ lack of willingness to challenge the practice of restriction might be explained in the actual or perceived powerlessness of hospital nurses to affect change. It was suggested that advocacy is challenged when those seeking to advocate or empower are “less powerful than those working against it” (Christensen & Hewitt-Taylor 2006, p. 696). The findings from this study suggest that nurses involved in restricting a child for a clinical procedure might have a diminished feeling of power to affect change. This reluctance to advocate has been found to play a part in compromising patient care, with evidence found in inquests into reports of poor practices in the care of children. These include the Bristol inquiry in the United Kingdom, which examined practices in the care of children receiving complex cardiac procedures (Department of Health, 2001); the Sinclair inquest in Canada (Sinclair, 2000), which investigated the deaths of children during or immediately after cardiac surgery; and the Lourdes Hospital Inquiry (Government of Ireland, 2006), which investigated the unwarranted hysterectomies by a consultant obstetrician. In each case, concerns by nurses, midwives, or junior physicians were dismissed, despite their repeated expressions of concern about practices. In some of the cases cited, reasons for nonadvocacy on the part of nurses included fear of limited promotional opportunities, the gender of the nurses and midwives, or the fact that concerns were dismissed because nurses were seen as too emotionally engaged.
Many of the participants identified the increased use of sedation as an alternative to physically restricting a child’s movement. Although the use of chemical sedation for children undergoing therapeutic interventions is an established practice in pediatric intensive care units (Dixon & Crawford, 2012) and ED (Shaban, Holzhauser, Gillespie, Huckson, & Bennett, 2012), it is not an established practice in general medical and surgical units. This is an area that requires further exploration, considering the impact that restricting movement can potentially have on a child, including longer recovery time after a procedure, the potential for respiratory complications, and the additional staff education and resources required to facilitate this practice (Dixon & Crawford). It is necessary to have organizational support from a multidisciplinary perspective to address long-established practices such as restriction. This would facilitate discussion of any concerns and support a joint approach to addressing ways of improving care. Nurses need organizational support to enable open discussion on restriction from a multidisciplinary perspective and to encourage discussion of any concerns about restriction. Such a measure would show a commitment to openly discuss sensitive issues that can arise in caring for a child during a clinical procedure. Acknowledgments We thank Kader Parahoo and Laurence Taggart for their contribution to the study.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Maria Brenner, PhD, RCN, RGN, is a lecturer at University College Dublin School of Nursing, Midwifery & Health Systems in Dublin, Ireland. Margaret Pearl Treacy, PhD, RGN, is an emeritus professor at University College Dublin School of Nursing, Midwifery & Health Systems in Dublin, Ireland. Jonathan Drennan, PhD, RGN is a professor of health care research, Centre for Innovation and Leadership in Health Sciences, Faculty of Health Sciences, at the University of Southampton in Southampton, United Kingdom. Gerard Fealy PhD, RGN, is an associate professor and associate dean for research and innovation at University College Dublin School of Nursing Midwifery & Health Systems in Dublin, Ireland.
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