Physical Restraint Practices, Attitudes, and Ethical Perceptions Among Intensive Care Unit (ICU) Doctors and Nurses in Morocco: A Cross-Sectional Survey Highlighting the Training-Use Paradox.

backgroundPhysical restraint is routinely used in adult intensive care units (ICUs) to prevent patient self-injury and protect medical devices, but is associated with skin injury, prolonged immobilisation, post-traumatic stress, and unresolved ethical tensions. Data from Moroccan ICUs are scarce.

objectivesThis study aimed to describe and compare the practices, attitudes, and ethical perceptions regarding physical restraint among doctors and nurses in adult ICUs of a Moroccan tertiary teaching hospital and to identify factors independently associated with high acceptance of restraint.

methodsA cross-sectional self-administered questionnaire survey was conducted between June and September 2024 in four adult ICUs of the Ibn Rochd University Hospital complex in Casablanca, Morocco. All doctors and nurses with at least one month of ICU experience were eligible and approached by convenience sampling. The 28-item instrument, developed from a structured literature review and validated by three content experts (pilot n=8), covered demographics, training, practices, attitudes, ethics, legal, and family dimensions. A composite attitude score (range: 4-20) was computed by summing four Likert items (necessity, acceptance, effectiveness, personal experience; Cronbach's α=0.78) and dichotomised at the sample median to define high versus lower acceptance. Analyses used Fisher's exact test, the Mann-Whitney U test, and a multivariable logistic regression limited to three predictors (profession, experience, training) to respect the events-per-variable rule. Reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

resultsOf 100 eligible staff, 60 returned complete questionnaires (response rate: 60%): 40 doctors (66.7%) and 20 nurses (33.3%). Only 5% of doctors (95% CI: 1.4-16.5) and 15% of nurses (95% CI: 5.2-36.0) had received formal training on restraint. Complications were observed by 72.5% of doctors and 85% of nurses; skin injury was the most prevalent (93.1% and 100%, respectively). Despite this, 77.5% of doctors and 85% of nurses supported maintaining restraint; 72.5% of doctors and 80% of nurses reported restraint use on sedated patients; only 57.5% of doctors and 65% of nurses systematically informed families. In a complete-case analysis (n=51), 56.9% of respondents were classified as high acceptance. In an exploratory multivariable analysis, after adjustment for experience and training, nurses had significantly higher odds of high acceptance than doctors (adjusted OR: 4.89; 95% CI: 1.28-18.7; p=0.021); neither experience nor prior training was independently associated with acceptance.

conclusionIn this single-centre survey, physical restraint was frequently reported and commonly practised in Moroccan ICUs, with scarce formal training, frequent observed complications, and incomplete family communication: a training-use paradox. Acceptance is shaped more by professional role than by individual exposure or preparation. Mandatory training, standardised protocols, routine sedation and delirium screening, and systematic family engagement are warranted; a multicentre study with patient-level outcomes is the logical next step.