Currently, Spain is one of the countries in the Organization for Economic Co-operation and Development (OECD) with the highest use of Physical Restraint (PR) in all settings. While this traditional usage of restraints continues, multiple organizations, such as the Joint Commission on Accreditation of Healthcare Organizations or the Avedis Donabedian Foundation, are advocating for a minimum and thoughtful use of PR. There are different justifications for this positioning, from the acknowledgement of their adverse effects to the consideration of practices not based on evidence, lack of adjustment to the lex artis in force, or the fact that its unlimited use infringes the fundamental rights of the person, and goes against excellent, humanized, and patient-focused care.

While there has been an advance in the road towards a thoughtful and minimum usage of restraints in the past 10-15 years in settings such as Geriatrics or Mental Health, some authors consider that Intensive Care Units (ICUs) are the last frontier for PR usage. However, we are currently aware of the existence of adverse effects in critical patients, which might for example trigger delirium, increasing the morbimortality of these patients.

In the last months-years of the pre-pandemic age, this thoughtful attitude was starting to be discreetly implemented in the ICUs, including members of other professional categories such as physicians. Besides, there was an initial insight that strategies like refinement in monitoring and interpretation of patients’ behaviour, interdisciplinary work, or family support at the ICU, were measures associated not only with success in the minimization of PR usage, but also coherent with excellence, social changes, and new demands by patients and families.

However, COVID has forced us to a level of care similar to what was available last century, and many of the measures previously listed have been relegated. Sadly, in this context of pandemic care restraints have been applied again. Therefore, for many of ICU professionals who were previously committed to the excellence and care of the 21st century, the fact of going back to last century care has probably increased their feeling of impotence and moral suffering in the face of their experience.

What seems clear is that the pandemic has highlighted many deficiencies in the healthcare setting, including the ICUs. Therefore, it must be considered that post-pandemic reconstruction will require a deep analysis, where some of the traditionally established components should be reviewed from a more contemporary perspective. Almost with complete certainty, this updated perspective must include concepts such as adaptation to social demands, current lex artis, patient/family empowerment, or excellent evidence-based care. In this line of updating, the use of PR must be taken into account.

This change of perspective included healthcare professionals from all settings, but managers are expected to make strategic decisions which will strengthen some lines of work or others. In this sense, it can be very enlightening to learn about the experience of successful management models in other settings. Thus, there are management models that using the “prevalence of restraint usage” indicator, generate changes in the dynamics of the institution, encouraging ethical reflection and initiating a road of excellence boosting which will result in a very significant reduction in the use of PR, thus improving the satisfaction by users and professionals (1). Undoubtedly, the implementation of these management strategies must adapt to the setting of care and patient characteristics. Specifically at ICUs, the nuclear role of nurses cannot be dismissed, as well as their deep knowledge of the patient and their needs, in order to orientate treatment decision-making (2). Therefore, another of the key points that the pandemic has made clear is probably the need to give formally recognition to Critical Care Nursing through the specialty and/or implementation of advanced practice profiles in critical care.
Summing up, the post-COVID age opens a time for reflection and innovation, in order to build a contemporary model of care, where the minimization of restraints at ICU can become strengthened as an improvement strategy for patients, models and institutions. Let’s give this model of care the opportunity it deserves.