Table 2

Questions guiding the new work description of physical restraints on the ward

Step	Question	Description	Specific WAI–WAD gap
0	Have you taken the e-learning and successfully completed the practical test?	Since every nurse on the ward is obligated to take a theoretical and practical test before being allowed to apply physical restraints, this step was added as a reminder.	Whereas the protocol made no mention of the practical test altogether, on the ward this was seen as a requirement before restraints may be applied.
1	When does the topic of physical restraints start for us?	Bullet point summary stating how restlessness can be identified, how and why to deal with restlessness, the importance of deliberation with other nurses and the physician about the restlessness and the central tenet of physical restraint use on the ward: is the patient a danger for him/herself, other patients or hospital staff?	The protocol did not recognise the usefulness of identifying and dealing with restlessness in the first part of the WAD process, whereas the importance of deliberation in the latter part of the process was also neglected. These methods were however used to reduce the need for (heavy) restraints by the nurses, or to decide which type of restraint was appropriate for the patients’ situation.
2	How do we deal with restlessness?	The sequence of appropriate steps in dealing with restlessness was stressed. Finding and mitigating the causes of restlessness; the use of sedative medicine prescribed by the physician; the different reasons for, (‘diversion tactics’ and ‘low-stimulus environments’) and examples of, alternative measures; being sensitive toward the situation and knowing that appropriate measures can vary daily; continuous deliberation with other nurses; consultation of restlessness during ward rounds.	In the first part of the WAD process, this was shown to be an uncertain process in which experience and knowledge about the patient matter greatly. Knowing and being able to find causes of restlessness, as well as using the appropriate tactics to mitigate these symptoms, varied between nurses. All WAI documents focused heavily on known beforehand types of at-risk behaviour, and paid scarce attention to restlessness as a first step.
3	When do we consider using physical restraints?	Again, the central tenet was stated and other important aspects were described: ask a fellow nurse for help, inform the physician, family and legal representative beforehand if possible; in acute situations inform afterwards; report the effects of the restraint; at the beginning of a shift, deliberate with fellow nurses and the physician if the restraint is still necessary.	In the last part of the process, WAI depended heavily on the judgement of the physician to decide if restraints were necessary. In practice, nurses first consulted an experienced colleague to determine what action was appropriate before looking for an available physician.
4	Summary	Here, a one-page summary of the previous two pages was given in bullet points.

The questions prompted points of interest in the process of restraint application and were supplied with considerations and tips on how to handle the situation.
WAD, work-as-done; WAI, work-as-imagined.