Physical Restraint in Critically Ill Older Patients: ICU Nurses' Attitudes and Ethical Decision-Making

Physical restraint use in intensive care units (ICUs) raises important ethical, clinical and decisional challenges, particularly among critically ill older patients who are especially vulnerable to its adverse physical and psychological effects. Although nurses play a central role in restraint-related decisions, little qualitative evidence has examined their experiences of using physical restraint with older adults in critical care settings, particularly in Saudi Arabia.

To explore ICU nurses' attitudes toward physical restraint use in critically ill older patients, examine their decision-making processes and understand the ethical dilemmas they encounter in practice.

An exploratory qualitative study was conducted across multiple healthcare settings in the Al-Ahsa region, Saudi Arabia. Semi-structured, in-depth interviews were conducted with ICU nurses who had direct experience with physical restraint use in critically ill older patients. Data were analysed using reflexive thematic analysis following Braun and Clarke's six-phase approach. Reporting was guided by the Consolidated Criteria for Reporting Qualitative Research.

Interviews with 15 ICU nurses identified three interrelated themes: navigating the safety-autonomy tension, the weight of restraint decisions and working within systemic and cultural boundaries. Nurses described restraint as a measure used to protect patients from device removal, falls and self-harm, yet also as a practice that compromised dignity and autonomy. Decision-making was shaped by moral distress, clinical uncertainty, family expectations, staffing constraints, policy gaps and cultural values related to elder respect and family involvement.

Physical restraint decision-making in critically ill older patients is shaped by a complex interplay of clinical urgency, ethical tension, organisational constraints and cultural influences. ICU nurses occupy a central yet under-supported role in these decisions and often experience considerable moral distress.

ICU policy and practice should support restraint minimisation through clear evidence-based guidance, structured ethical decision-making, culturally sensitive family communication and education on alternatives to restraint to protect the safety and dignity of critically ill older patients.