Restraint during medical procedures in hospitalized preschool children. An exploratory study.

Background: This study examined the use of physical restraint during medical procedures on newly admitted preschool children in a pediatric hospital unit. The use of physical restraint during medical procedures can be a distressing experience for children, parents and health care providers. Peripheral vein cannulation (PVC) is a commonly performed medical procedure in hospitals and was used as an example to study restraint. While some guidelines exist regarding how to care for children during medical procedures, physical restraint is seldom discussed in clinical practice and research and is not specifically regulated in legislation. Perspectives from symbolic interactionism (SI) were used in this study to develop a more thorough understanding of the multiple meanings of the interactions that occurred in the observed situations involving the use of physical restraint. Symbolic interactionism considers how we construct meaning and how people interact based on those meanings in addition to establish “a definition of the situation” one operates in as well as how this structures human interaction. Results: Children’s expressions when they faced a PVC were explored. Based on analysis of the video recorded observations and field notes, we suggest a typology of the participating children’s expressions during the PVC procedure; protest, escape and endurance. When expressing protest, the children showed an insistent attitude, disagreed with adults and maintained their own views. When expressing escape the children “panicked” and avoided the hands of adults when being approached. When expressing endurance, the children were stiff, motionless and introverted. The observations showed that the children appeared to resist participation, and minimal or no physical restraint was required when they expressed endurance. Interactions between parents and health care providers during the PVC were explored. The analysis of video recorded observations and field notes revealed three patterns of interactions between parents and health care providers during the PVC. In the first pattern, parents and health care providers pacified the children’s strong protests by keeping an ongoing, distractive conversation about everyday matters and parents acted as co-helpers to perform firm restraint. The second pattern showed that the parents either stopped or distanced themselves in interaction with the health care providers. The parents’ restraint grip became looser which allowed the children to uphold resistance. This was observed after failed attempts to insert the PVC. The third pattern followed as a consequence of parental distancing in the second pattern. When the parents did not support the health care providers anymore, they either helped each other to continue distracting the children, or they ceased distraction attempts and just concentrated on finishing the procedure. Nurses’ and physicians’ perspectives on their performance of the PVC, and the use of restraint were explored. Health care providers had different perspectives on restraint during the observed PVC procedures which resulted in three main themes. “Disparate views on the concept of restraint and restraint use”, exhibited as tension in their naming of and deliberations about restraint. “Ways to limit the use of physical restraint and its negative consequences”, concerned meanings about why the medical procedure was necessary and the importance in helping parents and children to remain rational and calm to prevent the need for restraint. “Experiences with the role of parents and their influence on restraint”, concerned how reluctant and unconfident parents were associated with an escalation of emotions and an increase in forceful restraint. Parents/close relative were interviewed about their participation in the observed PVCs and the use of restraint. The analysis revealed two major themes. The first theme that emerged, “Negotiating what quality of PVC performance to expect”, was based on how: parents expected child-friendly encounters, the performance of PVC caused unexpected and unnecessary suffering for the child, and parents explained and excused the negative experience with the performance of PVC. The second theme: “Negotiating own role and participation in child suffering during the PVC”, was based on parents’ ceaseless strive to be acknowledged for suggestions regarding ways to ease the procedure, uncertain consequences of the procedure and the use of restraint for the children, and the parental protective role and self-criticism. Discussion: The results demonstrate different interactions, expressions, and challenges for children, parents and health care providers during the PVC procedure. Reduction of restraint is difficult to accomplish unless the existence of restraint is acknowledged and made a part of the professional debate among health care providers. Some children’s expressions were ignored, and despite strong resistance to the PVC, restraint was applied. By acknowledging the relevance of “experienced restraint” in research and clinical practice, it may help secure the children’s and parent’s experience, and allow health care providers to better customize their practices. Health care providers need to prepare themselves and the parents better in the planning and management of medical procedures where restraint may occur. Reported differences in perspectives among health care providers such as whether the use of restraint in a practice is sound, necessary, justifiable and legal, highlights the need for discussion around professionalization and formalization of the use of restraint in medical procedures on children. Conclusion: The results may contribute to better acknowledge children’s opinions and emotions, and to increase awareness of the unclear roles parents are given or expected to assume during medical procedures. The multiple perspectives, insecurity, disagreement, negative views and lack of discussions about restraint, call for reflection and critical assessment of appropriateness and alternative strategies. This may lead to more careful and judicious consideration of restraint in pediatric units, and opportunities to critically discuss ongoing practices of restraint management. Research and open discussions are more difficult if restraint is illegal or if it is unclear what is legal. More research on restraint in the pediatric setting and learning from other fields of health care where coercion is common, may contribute to harm-reduction, reduced use of physical restraint, and better quality of care