Nurse Factors In Enhancing De-escalation To Prevent Restraint Sample

Introductoion : Nurse Factors In Enhancing De-escalation To Prevent Restraint

Restraining is one of the most common interventions to deal with mental health patients. There are three types of restraints which are used to manage a patient's movement. Physical restraints are used to limit the movement of the patients (Perez et al. 2019). Chemical restraints are psychoactive medications which are not used for illness but to inhibit movement or any behaviour among patients. Environmental restraints are used for controlling the mobility of the patient. The rate of restraints in mental health care is 3.8% to 51.3% globally. Different countries follow different mental health Act for using restraint. For example, in India, Mental Healthcare Act 2017 is followed for use of restraint and it is used when the patient becomes harmful to others and self. This is supposed to be implemented after checking every possible alternative to manage the situation (El Khatib et al. 2022). However, in the mental care setup, nurses sometimes use restraints to control the patient for no such severe condition. De-escalation is a process which is used instead of restraints to manage the dangerous and aggressive behaviour of the patients. 

Nurse factors play a significant role in enhancing innovative techniques to protect restraint in the healthcare sectors. A proficiency of a nurse in realizing the behaviour of patients, effective communication and empathy is necessary for implementing interventions and identifying trips. Continuous training process in unique strategies equips nurses to foster an effective environment and challenging environments that prioritizes dignity and safety of the patient with the skills (Alikari et al. 2023). Moreover, a collaborative culture cultivates among professionals of healthcare sectors. It enhances trauma-informed principles of care that empowers to employ protective measures of the nurses, developing a patient-centred technique and reducing the requirement for physical restraints to maintain agitation. 

Search strategy 

The database that has been used here is MEDLINE, for selection of the paper. One paper has been selected for this research. The selection of the paper has been done using PRISMA flowchart (Lee and Koo, 2022). Initially 10 papers were shortlisted and then following several inclusion and exclusion criteria, 9 papers have been rejected and the search has been narrowed down to one paper. The chosen paper is “Nurses' Perceptions of Engaging with Patients to Reduce Restrictive Practices in an Inpatient Psychiatric Unit” by Martello et al. (2018). Inclusion and exclusion criteria followed here are as follows

Introductoion : Nurse Factors In Enhancing De-escalation To Prevent Restraint

Restraining is one of the most common interventions to deal with mental health patients. There are three types of restraints which are used to manage a patient's movement. Physical restraints are used to limit the movement of the patients (Perez et al. 2019). Chemical restraints are psychoactive medications which are not used for illness but to inhibit movement or any behaviour among patients. Environmental restraints are used for controlling the mobility of the patient. The rate of restraints in mental health care is 3.8% to 51.3% globally. Different countries follow different mental health Act for using restraint. For example, in India, Mental Healthcare Act 2017 is followed for use of restraint and it is used when the patient becomes harmful to others and self. This is supposed to be implemented after checking every possible alternative to manage the situation (El Khatib et al. 2022). However, in the mental care setup, nurses sometimes use restraints to control the patient for no such severe condition. De-escalation is a process which is used instead of restraints to manage the dangerous and aggressive behaviour of the patients. 

Nurse factors play a significant role in enhancing innovative techniques to protect restraint in the healthcare sectors. A proficiency of a nurse in realizing the behaviour of patients, effective communication and empathy is necessary for implementing interventions and identifying trips. Continuous training process in unique strategies equips nurses to foster an effective environment and challenging environments that prioritizes dignity and safety of the patient with the skills (Alikari et al. 2023). Moreover, a collaborative culture cultivates among professionals of healthcare sectors. It enhances trauma-informed principles of care that empowers to employ protective measures of the nurses, developing a patient-centred technique and reducing the requirement for physical restraints to maintain agitation. 

Search strategy 

The database that has been used here is MEDLINE, for selection of the paper. One paper has been selected for this research. The selection of the paper has been done using PRISMA flowchart (Lee and Koo, 2022). Initially 10 papers were shortlisted and then following several inclusion and exclusion criteria, 9 papers have been rejected and the search has been narrowed down to one paper. The chosen paper is “Nurses' Perceptions of Engaging with Patients to Reduce Restrictive Practices in an Inpatient Psychiatric Unit” by Martello et al. (2018). Inclusion and exclusion criteria followed here are as follows

Apart from these factors, the searching process has considered Boolean operators for effective search results using keywords. PICO format has been followed here to conduct the search process. 

The first step is to identify some search terms and keywords in developing a potential searching strategy. It is significant to allow synonyms and another term to capture a good range of literature. Boolean operators involve “NOT”, “AND” and “OR” that play an effective role in refining searches. 

Evaluation of Boolean operators: Uses of Boolean operators boost refine searches. A search query such as “nurse AND decrease OR restraint protection” helps that articles containing both “nurse” and “decrease” are included. The utilization of “NOT” can be employed to irrelevant terms like” physical self-control is NOT chemical control”.

The criteria of Exclusion and Inclusion: Establishing the criteria of inclusion and exclusion is necessary to filter out some studies and main focus on the pertinent ones. Inclusion criteria may include proper studies that highlight the involvement of nurses in innovative techniques (Doody et al. 2022). On the other hand, exclusion criteria might analyze studies that related to nursing on prevention of restraint.

PRISMA Flowchart support: The flowchart of PRISMA starts with the studies’ identification through searching of the database. Each step includes full texts, screening titles and abstracts for eligibility. The flowchart addressed the systematic system to arrive at the primary article on factors of nurses to prevent restraint. The PRISMA flowchart is an effective tool to analyze the search process (Basantes-Andrade et al. 2022). This flowchart contributes a step-by-step analysis of how studies are screened and assessed for eligibility in the final analysis. 

Different evidence of search strategy: Supporting proof for the search strategy involves utilized database details (PubMed) and use of search strings. Citations of related documentation and articles of the searching dates help replicability of the search system (Hair et al. 2023). 

The effective strategy of the search process includes the attentive selection of search terms, systematic use of the flowchart of PRISMA, Boolean operator’s applications and establishment of clear criteria of inclusion and exclusion. 

Critical appraisal 

In terms of developing an annotated bibliography on this topic, a critical appraisal process has been followed for the selection of the paper. The paper by Martello et al. (2018) has been analyzed using the Caldwell appraisal tool. This tool by Caldwell, Henshaw and Taylor (2011), is used for analyzing a research paper based on some criteria. It was ensured that a number of criteria from the framework is satisfied by the chosen paper (Yong et al. 2022). Mostly all of the criteria of the framework was matched in the chosen paper. The chosen study has followed a primary qualitative research method. In which an interview has been conducted by the researchers involving the nurses. Apart from that, the major concepts of the paper which are de-escalation and restraints and its prevention have been discussed in a good manner. 

The discussing points of critical Appraisal using Caldwell Framework:

1. Research objective: Evaluate the clarity of the question of the research. Does the study highlight an issue that is connected to nurse factors in prevention of restraint and de-escalation?
2. Methodology and design of the study: Assess the specificness of the design of the study. Is it qualitative, experimental and observational? Allow whether the design aligns with the question for the research.

• Size and selection of sample: Allow the sample size and whether it contributes sufficient power of statistics. 

1. Collection and Analysis of Data: Evaluate the systems used for analysis and collection of data. Observe for transparency in assessing if the statistical procedures used are proper for the design of the study (Wang et al. 2022). 

Discussion of factors of nurse in Restraint Prevention and De-escalation:

De-escalation is an important skill for nurses in high-stress situations where restraint may be an effective intervention. Nurse factors play an important role in protecting the irrelevant restraint use and de-escalation efforts. 

• Communication skills: The paper highlighted how the factors of communication were allowed in the study. Effective communication is the underlying basis to de-escalation (Christensen et al. 2022). Nurses with effective skills of communication can conduct empathy and concerns of patients. 

1. The collaboration of the team: De-escalation includes a multidisciplinary technique. Assess if the paper appreciates the teamwork importance and communication among professions in healthcare in preventing the restraint use. 

• Education: Continuous education is important to acquire and manage the skills of de-escalation. Evaluate if the paper enables the training programs impact on the performance of nurses in de-escalation situations (Young et al. 2022). 

1. Individualized care: Nurses recognize each patient's uniqueness and tailor their techniques. The paper discusses how each patient's care factors into the process of de-escalation.
2. Guidelines: Evaluate if the paper allows the control of guidelines and policies of the organization on the practices of nurses in prevention of restraint and de-escalation. Compliance with protocols is complex for safety of staff and confirming patients (Chien et al. 2022).

A complex appraisal of the paper will contribute insights by using the Caldwell framework into the validity of the study. The factors of nurses discussed in the paper align with the de-escalation understanding in healthcare, support to policies, emphasizing the communication importance, collaboration and training in preventing uses of restraint.

Findings 

The main problem area which has been considered in this chosen paper is the restrictive practices that are used in the inpatient psychiatric setting despite having evidence of the negative effects of this practice. Considering this as a key problem area, this research has aimed to analyze the perception of nurses to engage with the patients in terms of reducing restraints. In this case, de-escalation has been considered as a key strategy for nurses’ engagement. A primary qualitative research has been followed here for this purpose. The research has taken place in the psychiatric unit of a University in Canada. In this regard, semi-structured interviews have been conducted by the researchers in this case. Sample size for this research was 6 where 6 nurses from psychiatric care were chosen in 2016 for the research. Their responses regarding the restraints in this ward and the prevention measures followed by them have been documented. Nurses have mentioned the escalation process for prevention of restraint among the patients. Based on the responses gained from the nurses have been used for developing themes and analyzing them. The semi-structured interview was audio recorded for further use. Most participants of this research were female (Read et al. 2022). The selections of the participants were done carefully as they had a work experience of 2 years to more than 15 years in that ward. It was considered that the nurses who have worked for a long time in the ward are able to provide in-depth knowledge about the practices and procedures followed for restraints. Data was gathered in different areas like collaborative practices, for the patients, developing therapeutic alliances for better treatment (Myers et al. 2022). Apart from that, information was taken on the regaining process of sense of control and also nurses shared their point of view on analyzing the escalation process in order to help the patients to express their thoughts and concerns. Also the participants commented on the intervention process as asked. De-escalation has been mentioned as a key process in this case.

Discussion

The goal of this study is to describe how nurses in a hospital psychiatric unit feel about interacting with patients in order to lessen the use of restrictive procedures. In order to define engagement with patients; nurses gave instances of their unit's engagement procedures that matched the engagement principles found in the literature. Many contextual elements that could help or hinder engaging with patients to stop the use of restrictive practices during escalation were mentioned in relation to the escalation management process.

In response to a question about what patient engagement entails, nurses described unit engagement practices like assisting patients in regaining control, forming therapeutic alliances, and working together with patients after admission. Interacting with patients on a personal, interpersonal, and organisational level is reflected (Martello et al., 2018).Nurses make sure that patients are aware that they should contact them when they are not feeling well or have any questions. Nurses try to convey that they are open to receiving courteous, personable, and creative when interacting with patients. In an attempt to build the therapeutic alliance based on trust that will serve as a foundation, a relational level of engagement is apparent.

Ultimately, the practice of working together with patients in multidisciplinary team meetings upon admission and incorporating their objectives into the hospitalisation plan is a reflection of organisational support for engaging (Barr et al., 2019). A trusting nurse-patient relationship that fosters engagement and provides a supportive environment for managing escalation is developed through the unit's commitment to patient engagement. These unit activities establish the groundwork for participating in escalation 

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The common perception of common people: They have to deal very well, because patients are more mentally weak than physical. Treat them as they like. Because of this mental attachment with the psychiatric patient the nurse does not like the patient. While doing this work, the nurses often become mental and then the duo is just an attachment.

According to our research, when a patient's behaviour changes and they need support to voice their concerns, nurses should identify and notify them of this when managing escalation through patient engagement (Gerace and Muir, 2019). Following that, the patient and the nurse identify and initiate an intervention. If the first one proves ineffective, additional attempts at different interventions are chosen. The best practice guidelines "Promoting Safety: Alternative Approaches to the Use of Restraints" included de-escalation tips that were comparable to the patient engagement strategies that the nurses in our study had to offer.

Various terms are used, such as "help patient to cope," "external," and "internal" factors that are contributing to the agitated behaviour, and "empowering patients." Still, it communicates some of the same patient engagement concepts as this study. As per the best practice guidelines for non-restrictive practice approaches, interacting with patients was deemed crucial for enabling the management of an escalation in our study. Patients' perception that their concerns are taken seriously was found to be the reason behind the effectiveness of engaging during escalation to reduce restrictive practices in our study. It is clear from this that a nurse's ability to communicate that they are understanding, accepting, and supportive is crucial because it influences how willing a patient is to cooperate.

Strengths

Expertise of the clinic: Nurses have a potential background of clinic and patient care knowledge. This enables them to analyze the signs of stress before a situation is analyzed to the point. Their clinical experience considers collaborating with other healthcare expertise to develop de-escalation plans of an individual.

Communication skills: The paper highlighted how the factors of communication were allowed in the study. Effective communication is the underlying basis to de-escalation. Nurses with effective skills of communication can conduct empathy and concerns of patients. 

Training techniques in De-escalation: Many institutions of the healthcare system provide proper training in techniques of de-escalation for nursing staff. Techniques may engage active listening, using the good body language and verbal intervention process. 

Weakness

1. Staffing Workload: High workload can decrease the time amount where nurses can dedicate to every patient. Nurses may find themselves involved in leading to a quicker reliance and de-escalation efforts.

• The policies of the organization: The policies of the organization can impact the nurse’s capabilities to employ the techniques of de-escalation. Facilities that prioritizes the environments of restraint-free and supports staff in strategies of implementation of de-escalation which are likely to meet success in the use of preventing restraint. 

Implication of practice 

This study can have a huge impact on the future research field. This study has thoroughly discussed the areas of concern on the topic. Apart from that, the gaps and limitations have been discussed here as well. This can help in identification of the key issues in future research. Apart from that, the suggestions given by the nurses can be implemented and tested within the psychiatric setup to avoid restraints. This is an important area to focus. In this regard, it should be mentioned that the future focus should be on identification of the main reason behind such issues. Apart from that, understanding the patients’ perspective about this process can be effective for the researchers to avoid such issues. Also, the future research can focus on policy development and implementation as a successful way to reduce restraints within the mental health care setup. Apart from that, considering other interventions and developing the de-escalation process is another key area for the future. 

Nurse factors play an important role to prevent the restraints used in developing techniques of de-escalation in healthcare systems. De-escalation is an intervention strategy that aims to minimize the requirement for physical restraint. There are discussed both strengths and limitations that are associated with the engagement in the process.

Recommendations

The competence of culture: The sensitivity of culture is significant to recognize diverse perspectives for nurses on healthcare. The cultural nuances boosts in de-escalation tailoring strategies linked with the cultural backgrounds of the patient and reducing the misunderstandings (Agboola et al.  2023). 

Communicational skills: Nurses play a significant role through effective communication. The strong verbal and non-verbal skill of communication enables the establishment of nurses with patients, conveying the data and realizing the concerns in a cooling manner. 

Emotional intelligence: Nurses can link with patients with high empathy levels on an emotional level and develop the capability to de-escalate tense. It enables nurses to maintain their emotions, develops nurses and advertising a therapeutic environment that conducts de-escalation.

The care of Trauma-Informed: Acknowledging the trauma impact on patients is necessary for nurses. The care of Trauma-informed includes the signs of trauma and developing the strategies that develop to successful de-escalation and avoid retraumatization without restraint restoration (Hennessy et al. 2023). 

Conclusion 

In conclusion, Nurse Factors play a significant role in enhancing innovative techniques to protect restraint in the healthcare sectors. A proficiency of a nurse in realizing the behaviour of patients, effective communication and empathy is necessary for implementing interventions and identifying trips. Continuous training in unique strategies equips nurses to foster an effective environment. Effective communication is the underlying basis to de-escalation. Nurses with effective skills of communication can conduct empathy and concerns of patients. A primary qualitative research has been followed here for this purpose. The research has taken place in the psychiatric unit of a University in Canada. In this regard, semi-structured interviews have been conducted by the researchers in this case. A proficiency of a nurse in realizing the behaviour of patients, effective communication and empathy is necessary for implementing interventions and identifying trips. Continuous training process in unique strategies equips nurses to foster an effective environment and challenging environments that prioritises dignity and safety of the patient with the skills. Moreover, a collaborative culture cultivates among professionals of healthcare sectors. It enhances trauma-informed principles of care that empowers to employ protective measures of the nurses, developing a patient-centred technique and reducing the requirement for physical restraints to maintain agitation. 

Apart from that, understanding the patients’ perspective about this process can be effective for the researchers to avoid such issues. Also, the future research can focus on policy development and implementation as a successful way to reduce restraints within the mental health care setup. Apart from that, considering other interventions and developing the de-escalation process is another key area for the future. 

References

• Agboola, I.K., Rosenberg, A., Robinson, L., Brashear, T.K., Eixenberger, C., Shah, D., Pavlo, A.J., Im, D.D., Ray, J.M., Coupet Jr, E. and Wong, A.H., 2023. A qualitative study of racial, ethnic, and cultural experiences of minority clinicians during agitation care in the emergency department. Annals of emergency medicine.
• Alikari, V., Gerogianni, G., Fradelos, E.C., Kelesi, M., Kaba, E. and Zyga, S., 2023. Perceptions of caring behaviors among patients and nurses. International journal of environmental research and public health, 20(1), p.396.
• Basantes-Andrade, A., Casillas-Martín, S., Cabezas-González, M., Naranjo-Toro, M. and Guerra-Reyes, F., 2022. Standards of teacher digital competence in higher education: A systematic literature review. Sustainability, 14(21), p.13983.
• Chien, L.J., Slade, D., Dahm, M.R., Brady, B., Roberts, E., Goncharov, L., Taylor, J., Eggins, S. and Thornton, A., 2022. Improving patient?centred care through a tailored intervention addressing nursing clinical handover communication in its organizational and cultural context. Journal of Advanced Nursing, 78(5), pp.1413-1430.
• Christensen, S.S., Lassche, M., Banks, D., Smith, G. and Inzunza, T.M., 2022. Reducing Patient Aggression Through a Nonviolent Patient De?escalation Program: A Descriptive Quality Improvement Process. Worldviews on Evidence?Based Nursing, 19(4), pp.297-305.
• Doody, O., Hennessy, T. and Bright, A.M., 2022. The role and key activities of Clinical Nurse Specialists and Advanced Nurse Practitioners in supporting healthcare provision for people with intellectual disability: An integrative review. International journal of nursing studies, 129, p.104207.
• El Khatib, M., Alhosani, A., Alhosani, I., Al Matrooshi, O. and Salami, M., 2022. Simulation in Project and Program Management: Utilization, Challenges and Opportunities. American Journal of Industrial and Business Management, 12(4), pp.731-749.
• Gerace, A. and Muir?Cochrane, E., 2019. Perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments: An Australian survey. International Journal of Mental Health Nursing, 28(1), pp.209-225.
• Hair, K., Bahor, Z., Macleod, M., Liao, J. and Sena, E.S., 2023. The Automated Systematic Search Deduplicator (ASySD): a rapid, open-source, interoperable tool to remove duplicate citations in biomedical systematic reviews. BMC biology, 21(1), p.189.
• Hennessy, B., Hunter, A. and Grealish, A., 2023. A qualitative synthesis of patients' experiences of re?traumatization in acute mental health inpatient settings. Journal of Psychiatric and Mental Health Nursing, 30(3), pp.398-434.
  Martello, M., Doronina, O., Perillo, A., La Riccia, P. and Lavoie-Tremblay, M., 2018. Nurses’ perceptions of engaging with patients to reduce restrictive practices in an inpatient psychiatric unit. The Health Care Manager, 37(4), pp.342-353.
  Barr, L., Wynaden, D. and Heslop, K., 2019. Promoting positive and safe care in forensic mental health inpatient settings: Evaluating critical factors that assist nurses to reduce the use of restrictive practices. International Journal of Mental Health Nursing, 28(4), pp.888-898.
• Lee, S.W. and Koo, M.J., 2022. PRISMA 2020 statement and guidelines for systematic review and meta-analysis articles, and their underlying mathematics: Life Cycle Committee Recommendations. Life Cycle, 2.
• Myers, C., Thompson, G., Hughey, L., Young, J.L., Rhon, D.I. and Rentmeester, C., 2022. An exploration of clinical variables that enhance therapeutic alliance in patients seeking care for musculoskeletal pain: A mixed methods approach. Musculoskeletal Care, 20(3), pp.577-592.
• Perez, D., Peters, K., Wilkes, L. and Murphy, G., 2019. Physical restraints in intensive care–An integrative review. Australian critical care, 32(2), pp.165-174.
• Read, P., Mehta, R., Rosenbloom, C., Jobson, E. and Okholm Kryger, K., 2022. Elite female football players’ perception of the impact of their menstrual cycle stages on their football performance. A semi-structured interview-based study. Science and Medicine in Football, 6(5), pp.616-625.
• Wang, S.V., Pottegård, A., Crown, W., Arlett, P., Ashcroft, D.M., Benchimol, E.I., Berger, M.L., Crane, G., Goettsch, W., Hua, W. and Kabadi, S., 2022. HARmonized Protocol Template to Enhance Reproducibility of hypothesis evaluating real-world evidence studies on treatment effects: A good practices report of a joint ISPE/ISPOR task force. Value in Health, 25(10), pp.1663-1672.
• Yong, X., Chen, W., Wu, Y., Tao, Y., Zhou, J. and He, J., 2022. A two-stage framework for site selection of underground pumped storage power stations using abandoned coal mines based on multi-criteria decision-making method: An empirical study in China. Energy Conversion and Management, 260, p.115608.
• Young, J., Fawcett, K. and Gillman, L., 2022. Evaluation of an immersive simulation programme for mental health clinicians to address aggression, violence, and clinical deterioration. International journal of mental health nursing, 31(6), pp.1417-1426.

Apart from these factors, the searching process has considered Boolean operators for effective search results using keywords. PICO format has been followed here to conduct the search process. 

The first step is to identify some search terms and keywords in developing a potential searching strategy. It is significant to allow synonyms and another term to capture a good range of literature. Boolean operators involve “NOT”, “AND” and “OR” that play an effective role in refining searches. 

Evaluation of Boolean operators: Uses of Boolean operators boost refine searches. A search query such as “nurse AND decrease OR restraint protection” helps that articles containing both “nurse” and “decrease” are included. The utilization of “NOT” can be employed to irrelevant terms like” physical self-control is NOT chemical control”.

The criteria of Exclusion and Inclusion: Establishing the criteria of inclusion and exclusion is necessary to filter out some studies and main focus on the pertinent ones. Inclusion criteria may include proper studies that highlight the involvement of nurses in innovative techniques (Doody et al. 2022). On the other hand, exclusion criteria might analyze studies that related to nursing on prevention of restraint.

PRISMA Flowchart support: The flowchart of PRISMA starts with the studies’ identification through searching of the database. Each step includes full texts, screening titles and abstracts for eligibility. The flowchart addressed the systematic system to arrive at the primary article on factors of nurses to prevent restraint. The PRISMA flowchart is an effective tool to analyze the search process (Basantes-Andrade et al. 2022). This flowchart contributes a step-by-step analysis of how studies are screened and assessed for eligibility in the final analysis. 

Different evidence of search strategy: Supporting proof for the search strategy involves utilized database details (PubMed) and use of search strings. Citations of related documentation and articles of the searching dates help replicability of the search system (Hair et al. 2023). 

The effective strategy of the search process includes the attentive selection of search terms, systematic use of the flowchart of PRISMA, Boolean operator’s applications and establishment of clear criteria of inclusion and exclusion. 

Critical appraisal 

In terms of developing an annotated bibliography on this topic, a critical appraisal process has been followed for the selection of the paper. The paper by Martello et al. (2018) has been analyzed using the Caldwell appraisal tool. This tool by Caldwell, Henshaw and Taylor (2011), is used for analyzing a research paper based on some criteria. It was ensured that a number of criteria from the framework is satisfied by the chosen paper (Yong et al. 2022). Mostly all of the criteria of the framework was matched in the chosen paper. The chosen study has followed a primary qualitative research method. In which an interview has been conducted by the researchers involving the nurses. Apart from that, the major concepts of the paper which are de-escalation and restraints and its prevention have been discussed in a good manner. 

The discussing points of critical Appraisal using Caldwell Framework:

1. Research objective: Evaluate the clarity of the question of the research. Does the study highlight an issue that is connected to nurse factors in prevention of restraint and de-escalation?
2. Methodology and design of the study: Assess the specificness of the design of the study. Is it qualitative, experimental and observational? Allow whether the design aligns with the question for the research.

• Size and selection of sample: Allow the sample size and whether it contributes sufficient power of statistics. 

1. Collection and Analysis of Data: Evaluate the systems used for analysis and collection of data. Observe for transparency in assessing if the statistical procedures used are proper for the design of the study (Wang et al. 2022). 

Discussion of factors of nurse in Restraint Prevention and De-escalation:

De-escalation is an important skill for nurses in high-stress situations where restraint may be an effective intervention. Nurse factors play an important role in protecting the irrelevant restraint use and de-escalation efforts. 

• Communication skills: The paper highlighted how the factors of communication were allowed in the study. Effective communication is the underlying basis to de-escalation (Christensen et al. 2022). Nurses with effective skills of communication can conduct empathy and concerns of patients. 

1. The collaboration of the team: De-escalation includes a multidisciplinary technique. Assess if the paper appreciates the teamwork importance and communication among professions in healthcare in preventing the restraint use. 

• Education: Continuous education is important to acquire and manage the skills of de-escalation. Evaluate if the paper enables the training programs impact on the performance of nurses in de-escalation situations (Young et al. 2022). 

1. Individualized care: Nurses recognize each patient's uniqueness and tailor their techniques. The paper discusses how each patient's care factors into the process of de-escalation.
2. Guidelines: Evaluate if the paper allows the control of guidelines and policies of the organization on the practices of nurses in prevention of restraint and de-escalation. Compliance with protocols is complex for safety of staff and confirming patients (Chien et al. 2022).

A complex appraisal of the paper will contribute insights by using the Caldwell framework into the validity of the study. The factors of nurses discussed in the paper align with the de-escalation understanding in healthcare, support to policies, emphasizing the communication importance, collaboration and training in preventing uses of restraint.

Findings 

The main problem area which has been considered in this chosen paper is the restrictive practices that are used in the inpatient psychiatric setting despite having evidence of the negative effects of this practice. Considering this as a key problem area, this research has aimed to analyze the perception of nurses to engage with the patients in terms of reducing restraints. In this case, de-escalation has been considered as a key strategy for nurses’ engagement. A primary qualitative research has been followed here for this purpose. The research has taken place in the psychiatric unit of a University in Canada. In this regard, semi-structured interviews have been conducted by the researchers in this case. Sample size for this research was 6 where 6 nurses from psychiatric care were chosen in 2016 for the research. Their responses regarding the restraints in this ward and the prevention measures followed by them have been documented. Nurses have mentioned the escalation process for prevention of restraint among the patients. Based on the responses gained from the nurses have been used for developing themes and analyzing them. The semi-structured interview was audio recorded for further use. Most participants of this research were female (Read et al. 2022). The selections of the participants were done carefully as they had a work experience of 2 years to more than 15 years in that ward. It was considered that the nurses who have worked for a long time in the ward are able to provide in-depth knowledge about the practices and procedures followed for restraints. Data was gathered in different areas like collaborative practices, for the patients, developing therapeutic alliances for better treatment (Myers et al. 2022). Apart from that, information was taken on the regaining process of sense of control and also nurses shared their point of view on analyzing the escalation process in order to help the patients to express their thoughts and concerns. Also the participants commented on the intervention process as asked. De-escalation has been mentioned as a key process in this case.

Discussion

The goal of this study is to describe how nurses in a hospital psychiatric unit feel about interacting with patients in order to lessen the use of restrictive procedures. In order to define engagement with patients; nurses gave instances of their unit's engagement procedures that matched the engagement principles found in the literature. Many contextual elements that could help or hinder engaging with patients to stop the use of restrictive practices during escalation were mentioned in relation to the escalation management process.

In response to a question about what patient engagement entails, nurses described unit engagement practices like assisting patients in regaining control, forming therapeutic alliances, and working together with patients after admission. Interacting with patients on a personal, interpersonal, and organisational level is reflected (Martello et al., 2018).Nurses make sure that patients are aware that they should contact them when they are not feeling well or have any questions. Nurses try to convey that they are open to receiving courteous, personable, and creative when interacting with patients. In an attempt to build the therapeutic alliance based on trust that will serve as a foundation, a relational level of engagement is apparent.

Ultimately, the practice of working together with patients in multidisciplinary team meetings upon admission and incorporating their objectives into the hospitalisation plan is a reflection of organisational support for engaging (Barr et al., 2019). A trusting nurse-patient relationship that fosters engagement and provides a supportive environment for managing escalation is developed through the unit's commitment to patient engagement. These unit activities establish the groundwork for participating in escalation 

The common perception of common people: They have to deal very well, because patients are more mentally weak than physical. Treat them as they like. Because of this mental attachment with the psychiatric patient the nurse does not like the patient. While doing this work, the nurses often become mental and then the duo is just an attachment.

According to our research, when a patient's behaviour changes and they need support to voice their concerns, nurses should identify and notify them of this when managing escalation through patient engagement (Gerace and Muir, 2019). Following that, the patient and the nurse identify and initiate an intervention. If the first one proves ineffective, additional attempts at different interventions are chosen. The best practice guidelines "Promoting Safety: Alternative Approaches to the Use of Restraints" included de-escalation tips that were comparable to the patient engagement strategies that the nurses in our study had to offer.

Various terms are used, such as "help patient to cope," "external," and "internal" factors that are contributing to the agitated behaviour, and "empowering patients." Still, it communicates some of the same patient engagement concepts as this study. As per the best practice guidelines for non-restrictive practice approaches, interacting with patients was deemed crucial for enabling the management of an escalation in our study. Patients' perception that their concerns are taken seriously was found to be the reason behind the effectiveness of engaging during escalation to reduce restrictive practices in our study. It is clear from this that a nurse's ability to communicate that they are understanding, accepting, and supportive is crucial because it influences how willing a patient is to cooperate.

Strengths

Expertise of the clinic: Nurses have a potential background of clinic and patient care knowledge. This enables them to analyze the signs of stress before a situation is analyzed to the point. Their clinical experience considers collaborating with other healthcare expertise to develop de-escalation plans of an individual.

Communication skills: The paper highlighted how the factors of communication were allowed in the study. Effective communication is the underlying basis to de-escalation. Nurses with effective skills of communication can conduct empathy and concerns of patients. 

Training techniques in De-escalation: Many institutions of the healthcare system provide proper training in techniques of de-escalation for nursing staff. Techniques may engage active listening, using the good body language and verbal intervention process. 

Weakness

1. Staffing Workload: High workload can decrease the time amount where nurses can dedicate to every patient. Nurses may find themselves involved in leading to a quicker reliance and de-escalation efforts.

• The policies of the organization: The policies of the organization can impact the nurse’s capabilities to employ the techniques of de-escalation. Facilities that prioritizes the environments of restraint-free and supports staff in strategies of implementation of de-escalation which are likely to meet success in the use of preventing restraint. 

Implication of practice 

This study can have a huge impact on the future research field. This study has thoroughly discussed the areas of concern on the topic. Apart from that, the gaps and limitations have been discussed here as well. This can help in identification of the key issues in future research. Apart from that, the suggestions given by the nurses can be implemented and tested within the psychiatric setup to avoid restraints. This is an important area to focus. In this regard, it should be mentioned that the future focus should be on identification of the main reason behind such issues. Apart from that, understanding the patients’ perspective about this process can be effective for the researchers to avoid such issues. Also, the future research can focus on policy development and implementation as a successful way to reduce restraints within the mental health care setup. Apart from that, considering other interventions and developing the de-escalation process is another key area for the future. 

Nurse factors play an important role to prevent the restraints used in developing techniques of de-escalation in healthcare systems. De-escalation is an intervention strategy that aims to minimize the requirement for physical restraint. There are discussed both strengths and limitations that are associated with the engagement in the process.

Recommendations

The competence of culture: The sensitivity of culture is significant to recognize diverse perspectives for nurses on healthcare. The cultural nuances boosts in de-escalation tailoring strategies linked with the cultural backgrounds of the patient and reducing the misunderstandings (Agboola et al.  2023). 

Communicational skills: Nurses play a significant role through effective communication. The strong verbal and non-verbal skill of communication enables the establishment of nurses with patients, conveying the data and realizing the concerns in a cooling manner. 

Emotional intelligence: Nurses can link with patients with high empathy levels on an emotional level and develop the capability to de-escalate tense. It enables nurses to maintain their emotions, develops nurses and advertising a therapeutic environment that conducts de-escalation.

The care of Trauma-Informed: Acknowledging the trauma impact on patients is necessary for nurses. The care of Trauma-informed includes the signs of trauma and developing the strategies that develop to successful de-escalation and avoid retraumatization without restraint restoration (Hennessy et al. 2023). 

Conclusion 

In conclusion, Nurse Factors play a significant role in enhancing innovative techniques to protect restraint in the healthcare sectors. A proficiency of a nurse in realizing the behaviour of patients, effective communication and empathy is necessary for implementing interventions and identifying trips. Continuous training in unique strategies equips nurses to foster an effective environment. Effective communication is the underlying basis to de-escalation. Nurses with effective skills of communication can conduct empathy and concerns of patients. A primary qualitative research has been followed here for this purpose. The research has taken place in the psychiatric unit of a University in Canada. In this regard, semi-structured interviews have been conducted by the researchers in this case. A proficiency of a nurse in realizing the behaviour of patients, effective communication and empathy is necessary for implementing interventions and identifying trips. Continuous training process in unique strategies equips nurses to foster an effective environment and challenging environments that prioritises dignity and safety of the patient with the skills. Moreover, a collaborative culture cultivates among professionals of healthcare sectors. It enhances trauma-informed principles of care that empowers to employ protective measures of the nurses, developing a patient-centred technique and reducing the requirement for physical restraints to maintain agitation. 

Apart from that, understanding the patients’ perspective about this process can be effective for the researchers to avoid such issues. Also, the future research can focus on policy development and implementation as a successful way to reduce restraints within the mental health care setup. Apart from that, considering other interventions and developing the de-escalation process is another key area for the future. 

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