Nasogastric tube feeding under restraint: practical guidance for children's nurses

'We are not trained to do clinical work': security staff providing physical restraint for NGT feeding in English paediatric wards-a qualitative multi-informant study

OBJECTIVE

To gain insights into the experience, and impact, of using security staff to facilitate physical restraints for nasogastric tube feeding.

DESIGN

A cross-sectional design using 39 individual interviews, three online focus groups and three written submissions involving young people with lived experience (PWLE), parents/carers, paediatric staff and security staff involved in nasogastric feeding under restraint in paediatric settings in England. Qualitative semistructured interviews were transcribed and thematically analysed.

PARTICIPANTS

53 individuals participated: seven security staff (all men); nine PWLE who experienced the intervention between the ages of 9 and 17 (all female); 20 parents (15 mothers, 5 fathers) and 20 paediatric staff (5 men, 15 women).

RESULTS

Regarding the involvement of security staff, participants spoke in relation to two primary themes (1) short-term impact and (2) long-term impact. Short-term themes included that the intervention felt inappropriate and traumatic while also recognising its lifesaving nature and the fact that involving security guards preserved positive relationships with nursing staff. Longer-term themes included the development of trauma symptoms, while also acknowledging the skill development and improved professional relationships that could result from delivering the intervention.

CONCLUSIONS

This lifesaving clinical intervention can negatively impact security staff as much as the patient, parents/carers and paediatric staff. A prebrief and debrief should be seen as part of the 'process'. Further research is needed to better understand what else can mitigate negative impacts.

Nasogastric tube feeding under physical restraint of children and young people with mental disorders: a comprehensive audit and case series across paediatric wards in England

OBJECTIVE

To estimate the number of patients on paediatric wards in England who received nasogastric tube (NGT) feeding under physical restraint from April 2022 to March 2023, identify the demographics and clinical characteristics of these patients, and which personnel facilitated the restraint.

DESIGN

Audit and anonymous case series SETTING: Paediatric wards in England.

PATIENTS

Children and young people receiving this intervention in a 1-year period.

OUTCOME MEASURES

An online survey was sent to all paediatric wards in England, with the option of submitting anonymous case studies.

RESULTS

136/143 (95.1%) acute paediatric units responded. 144 young people received this intervention across 55 (38.5%) paediatric units. The predominant diagnosis was anorexia nervosa (64.5%), age range 9-18 years (M=14.2, SD=2.1). The duration of NGT feeding under restraint ranged from 1 to 425 days, (M=60.2, SD=80.4). Numerous personnel facilitated the restraints, including mental health nurses, paediatric nurses, security staff, healthcare assistants and parents/carers.

CONCLUSION

NGT feeding under restraint is a relatively common intervention in acute paediatric units in England. Understanding the demographics of those receiving this intervention may highlight where additional support is needed. Further research is needed to understand when this intervention transitions from a lifesaving intervention to ongoing management.

The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study

BACKGROUND

Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice.

AIMS

To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required.

METHOD

PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed.

RESULTS

Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored.

CONCLUSIONS

Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Decision-making and best practice when nasogastric tube feeding under restraint: multi-informant qualitative study

BACKGROUND

Clinicians working in mental health in-patient settings may have to use nasogastric tube feeding under physical restraint to reverse the life-threatening consequences of malnutrition when this is driven by a psychiatric condition such as a restrictive eating disorder.

AIMS

To understand the decision-making process when nasogastric tube feeding under restraint is initiated in mental health in-patient settings.

METHOD

People with lived experience of nasogastric tube feeding under restraint and parents/carers were recruited via the website of the UK's eating disorder charity BEAT. Eating disorder clinicians were recruited via an online post by the British Eating Disorders Society. Semi-structured interviews were administered to all participants.

RESULTS

Themes overlapped between the participant groups and were integrated in the final analysis. Two main themes were generated: first, 'quick decisions', with the subthemes of 'medical risk', 'impact of not eating' and 'limited discussions'; second, 'slow decisions', with subthemes of 'threats', 'discussions with patient', 'not giving up' and 'advanced directives'. Benefits and harms of both quick and slow decisions were identified.

CONCLUSIONS

This research offers a new perspective regarding how clinical teams can make best practice decisions regarding initiating nasogastric feeding under restraint. In-patient mental health teams facilitating this clinical intervention should consider discussing it with the patient at the beginning of their admission in anticipation of the need for emergency intervention and in full collaboration with the multidisciplinary team.