ethical dilemma of restraints

Psychiatric patients exhibiting violent, agitated or aggressive behavior are restrained in order to prevent harm to self and others. A Case Scenario Reflecting upon the situation, I came up with a positive opinion about the action of not restraining the patient. Physical restraint in a therapeutic setting; a necessary evil?. The importance of team work that was adapted to the situation cannot be denied. Refer to Disclaimer and Policies section for more details. As psychological patients are usually going through emotional trauma they need support from their family, friends and also from the staff members. Dealing With Aggression Through Restraining — When is it a Necessity? Lai & Wong (2008) found that the use of restraints has a negative impact on the patients and their families. Or is …, The present decade has witnessed an exponential group in the number of social media users. The ethics of restraint The following example illustrates the application of ethical principles in practice. During my clinical rotations I encountered an 18 year old female psychiatric patient exhibiting highly aggressive behavior along with severe agitation. The ethical issues most prevalent in the arguments for and against the use of mechanical restraints to prevent falls center around the principles of autonomy and beneficence. Significance The application of such restraint poses difficult ethical questions as to when, how, and under what conditions the choice not to be restrained can be honored by nurses and the families of patients whose physical safety is at risk. Patients’ families often believe that the hospital staff is restraining a client as punishment, retaliation or for their own conveniences. Restraining patients in opposition to their wishes is not lawful, particularly if there is no concern for harm to the patient (Oberle & Bouchal, 2009). The best ethical justification for restraining patients is that it prevents them from harming themselves. Restraints are provided on the basis of patient’s current behavior and situation, never to be used with the thought of punishment, oppression, convenience of staff or revenge. •       Mohr, W. K. (2010). Canadian Journal of Psychiatry, 48(5), 330-337. Contemporary Nurse, 27(2), 177–184. These include the right to autonomy, dignity, respect, justice and equality. Paternalism simply means to take a decision on behalf of someone for her/his benefit. A recent opinion piece about the role of restraint in UK nursing practice (Morgan, 2010), published on the Nursing Timeswebsite, generated a great deal of discussion and dissent among readers, particularly in relation to patient safety. However, I thought about the consequences of leaving him unrestrained. Patient restrictions: Are there ethical alternatives to seclusion and restraint? Such a circumstance left me stunned and in silence; to me it felt like the client was a prisoner who needed to be restrained. These considerations include why physical restraints are used, what is the importance of using physical restraints, and who is affected the most, the patient, family, or nursing staff. The PEG tube was already halfway out of the stomach; meaning that harm had already been done. Retrieved from 9927120, Moran, A., Cocoman, A., Scott, P., Mathews, A., Staniuliene, V., & Valimaki, M. (2009). According to the Canadian Nurses Association (2008), the nursing interventions are always there for patients’ well-being and more-being. Attention should be given to an ongoing nursing education, which would help nurses to understand patients’ needs and the factors that cause distress or agitation among patients. Often applied in intensive care units with patients experiencing agitation and insufficient sedation, physical restraint techniques are advised for prevention of self-harm and unplanned extubations. An environmental restraint refers to the controlling a patient’s behavior by modifying his/her surroundings in order to confine movement to a particular space; seclusion and time-out are prime examples of this. Restraint and seclusion: A distressing treatment option? She hit and abused the ward staff. Leaving him without restraints would also help nurses to handle the patient and reduce the staff’s emotional distress (Moran et al., 2009). Chemical restraints may affect the client’s cognitive abilities and memory causing confusion, poor concentration, loss of short term memory etc. At this juncture also the principle of beneficence and non maleficence is applied. Relying on Restraints in Psychiatric Settings: Distasteful yet Necessary? Latest from Journal of Pakistan Medical Students, Expression Analysis of the Peripheral Blood Mononuclear Cells miR-21 and miR-155 in Systemic Lupus Erythematosus Patients and Healthy Controls, Anti-N-methyl-D-Aspartate (NMDA) Receptor Encephalitis– A Case Report, Nasopharyngeal Tuberculosis Mimicking Recurrence Nasopharyngeal Carcinoma: A Case Report, Supraclavicular Atypical Lipomatous Tumour: Lesson Learnt, Higher TSH Level is associated with Increased Risk of Malignancy in Thyroid Nodules. Thus, this situation impacts everyone in the family equally, and most likely the patient in terms of a prolonged hospital stays. Nursing practice revolves around patients’ care, wellbeing, safety, non-pharmacological interventions, and nursing outcomes. These nurses felt that it was a dehumanizing treatment to use physical restraints on patients (Moran et al., 2009). •       Gatens, C., & CRRN-A, M. N. R. N. (2007). The client, Mr. A.C. had physical restraints placed on both of his arms because of his distressed behavior, as well as to provide safety and continuity of care for him. They state that physical abuse of patients is against the law. Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. The position paper described ethical dilemmas inherent in the use of seclusion and restraint, and reviewed research that suggested ways to reduce the use of restrictive interventions and prevent violence. Oberle, K., Bouchal, S. (2009). The client became aggressive as soon as the visitor left and he pulled his PEG tube half way out; he refused the nurse’s use of physical restraints on him. No paper submission or publication charges. Chemical restraints refer to controlling the patient’s behavior by using a psychoactive drug. This drug is not always meant to be of therapeutic purpose, but is used to cause sedation, for instance haloperidol, midazolam and olanzapine (Practice standard restraints, 2009). The use of Physical restraints should be minimized by using the alternative ways to defeat the emotional distress among agitated patients. The primary purpose of physical restraint in intellectual disability care is to prevent injury or harm to the service user or others, yet research evidence shows it can cause trauma and injury. Restraints are applied against a patient’s aggressive behavior only when there is actual potential harm to the patient himself, to other patients or to staff members. It is human nature to feel discomfort against restrictions, especially when it comes to physical or emotional harm (Lai & Wong, 2008). js.src = ''; For nurses to make ethical decisions about the use of restraints, involves high quality of nurse-client relationship, nurses’ morality, truthfulness with their profession, accountability, and team approach (Oberle & Bouchal, 2009). Due to the severity of the circumstances, he had a Percutaneous Endoscopic Gastrostomy (PEG) tube for his continuous feeding and medication. (HONS) Nursing, a graduate from York University Toronto, Ontario, Canada. In the above mentioned scenario, the nurse did not apply the debriefing after restraining which was immoral. International journal of law and psychiatry, 35(1), 43-49. The challenges and conflicting feelings faced by nurses in restraining elderly patients with dementia [9] can cause nurses to question their abilities to deliver high-quality care. Nursing in Critical Care, 12(1), 6-    11. The client was previously upset, the forceful application of the restraints would make him even more infuriated and agitated. involuntary admission, seclusion, restraint) is a complex ethical dilemma in psychiatric care. However, it is also a moral and professional dilemma for health care members, when to use restraints and when to respect their patients’ autonomy. However, the social side of this intervention seems more important to be considered (Lai & Wong, 2008). This practice can be considered as silver. Submit your articles online (click here) or send them as an Email to:, Tags: autonomy, emotionalhealth, humanitarian, legalissues, medicalethics, Patients, psychiatric, restraints, safety, self-harm, violence, Sitting in the huge auditorium of a renowned medical school in Lahore, I looked around and found women all around. •       Bonner, G., Lowe, T., Rawcliffe, D., & Wellman, N. (2002). Given that the ethical issue is an essential dimension of nursing practices, the use of physical restraints has caused an ethical dilemma because balancing the human rights, ethical value, and clinical effect is challenging. The quality of nursing care can be assessed by positive outcomes which are the prime objective of nursing care. Reflecting upon the situation as well as reviewing available literature reinforced the need for competent nurses, alternative ways to reduce the harm and overcome patients’ aggressive behavior, and the importance of the continuous development of nurses. It was nurses’ knowledge and experience which worked as a protective shield and prevented further harm to the patient and nurses. Journal of Psychiatric and   Mental Health Nursing, 16, 599–605. Effect of Restraints on Physical and Mental Health However, psychiatrists and nurses face patients in a quite different way since nurses are with the patients on the 24-h basis, and thus, their ethical dilemmas in using physical restraint may be more challenging. (Demir, 2007). The use of alternatives was also helpful in conquering the aggressive behavior of Mr. A. C. The staff nurses and I used therapeutic touch and addressed the patient with his name to settle the war which was going on in his mind. According to Perkins, E., Prosser, H., Riley, D., & Whittington, R. (2012), “best practice means practitioners will strive to de-escalate buy maxalt behavior and so avoid restraint” (pg. Beneficence means for the good of patient and non-maleficence simply means to do no harm, prevent harm, remove harm, and facilitate good (Mohr, 2010). Disclaimer: JPMS Medical Blogs are published by the publisher of Journal of Pioneering Medical Sciences (JPMS). Adverse effects associated with physical restraint. In general terms, to restrain is to limit someone’s liberty. Bio: Peggy Schaefer Whitby is an associate professor at the University of Arkansas and serves as the program coordinator for special education. Nurses still fail to do proper risk assessments because they lack education and are unaware of Nursing Ethics, 17, 65–76. The possibility of restraint-related injury and the legislated non-use of physical restraint in Japanese patients under long-term care have created an ethical dilemma for nurses [7,8]. fjs.parentNode.insertBefore(js, fjs); Dealing with the situation, whether to restrain the patient or let him be free from restraints was definitely a difficult decision to make. The decision for not restraining the patient is also supported by many authors. In order to make sure that I was making an ethically right decision and staying within the boundaries of my limits, I asked the staff nurses for their suggestions to handle this situation. 2.1.2. Nurses’ competency for handling agitated and aggressive patients depends upon their continuous education. In addition to this ethical issues will be discussed and how they relate/ link to different laws. At that particular moment of care we were in need of his comfort, not making a decision based on his long term outcomes (Obrele & Bouchal, 2009). Join JPMS Medical Blogs Team as Editor or Contributor, email your cover letter and resume to, We welcome Guest posts. As an ethical dilemma, if we accept the notion that restraints and seclusion are necessary, then we must reject or suspend, at least on some level, the key principles of … The Mental Health Act (1983) dictates that restraint can be defined as placing a person under control when necessary so as to prevent serious bodily harm to the patient or to another person only by the minimal use of such force. The use of physical restraint in critical care. The goal of all nursing interventions, nursing theories, institutional values, country laws, and bioethics is to enhance the beneficence of such nursing interventions for patients (Oberle & Bouchal, 2009). In some situations where nurses are the only witnesses for their actions, this moral agency of nurses guides them throughout the decision making for patients’ good. Nurses should be careful while taking care of their clients with regards to patients’ dignity, honor, respect, and expected outcomes (cited in Oberle & Bouchal, 2009). However, they seem helpless and for that reason allow healthcare professionals to restrain their loved ones. There are certain things that need to be considered in regards to the use of physical restraints and the ethics of the circumstances. Seclusion is in Norway defined as an intervention used to contain the patient, accompanied by staff, in a single room, a separate unit, or an area inside the ward. (2007). A father took his eight-month old son to a local healthcare provider (HCP) in his hometown (Sindh, Pakistan), where the healthcare provider (HCP) gave his son numerous intravenous (I/V) drips and injections. abusive use of restraint can occur, but even for the vast majority of caring and conscientious nurses, decisions about restraint are not easy or straightforward. With respect to the dilemma where nurses working in general wards at community hospitals who also live with elderly adults at home are faced with the physical restraint of elderly persons, four factors in the clarification of the dilemma were extracted: accomplishment of medical-treatment and accident prevention, characteristic features in nursing for elderly patients with dementia, healthcare … Families’ perspectives on the use of physical restraints. This would definitely make the situation even worse. In nursing and medical ethics, restraining a client always presents a difficult question. (Springe, 2015). Use of restraints should be minimized because it increases unnecessary demands on the healthcare system by increasing nursing workload, which results in poor quality of care and also provides the bases for an increase in budget for healthcare. Certain factors play a major role in making an ethical decision in nursing practice such as lack of knowledge, lack of therapeutic communication skills, considering other staff as a team in decision making, evaluating harm against the good for the patient, and analyzing the current situation (Oberle & Bouchal, 2009). Journal of Nursing Scholarship, 39(1), 38-45. Common ethical dilemmas. Nursing practice is for the beneficence of the people who are suffering and fighting for their lives against diseases. Facebook alone has an estimated over 500 million users. Unintentionally, if a wrong decision is made, it would impact the patients’ outcomes dramatically; these decisions would also cause distress for families and the nursing staff (Moran, Cocoman, Scott, Mathews, Staniuliene, & Valimaki, 2009; Lai, & Wong, 2008). The main ethical principles of nursing are intended to guide decision-making to ensure the best outcomes for patients, while respecting patient rights. Retrieved September 23, 2015, from A nurse should search for alternatives before applying restraining measures. The nurse must consider a few possibilities about the harm and good for the patient factor; would I be harming the patient if I put his restraints back on, what would be the consequences if I cared about the patient’s desires and did not restrain him, was I lacking in knowledge and therapeutic communication skills, would I be honoring the patient’s autonomy and giving him the freedom of choice and the due respect, and what were the risks involved in both options. Ann Gallagher is a reader in nursing ethics, director of the International Centre for Nursing Ethics, University of Surrey, and editor of Nursing Ethics. (2008). This morality and truthfulness of nurses is the central pillar to the nursing practice and patients’ beneficence. Her research interests are in the area of implementing evidence-based practices and sexuality education. When they observed that patient was not calmed, they used chemical restraining with haloperidol and medaziolam injection along with 4.0 physical restraints to limit her mobility and to get her aggression under control. The Sound of Loneliness: Human Nature and the Need to Connect and Belong, HIV in Pakistan: Healthcare providers, Intended Harm and Ethics. According to Felicia “Liz” Stokes, JD, RN, senior policy advisor at the ANA’s … This paper examines the ethical actions of nurses based on theories of nursing ethics, the codes of ethics, nursing standards, and views of nursing scholars for the use of restraints and some alternatives to cope with particular nursing scenarios. The Role of CNA Codes of Ethics in Decisions Making and Outcomes. Nurses are accountable for their actions, as stated in the CNA codes of ethics (cited in Oberle & Bouchal, 2009). Patients’ families often believe that the hospital staff is restraining a client as punishment, retaliation or for their own conveniences. “When and How to Use Restraints.” American Nurse Today 10, no. (function(d, s, id) { A chief recommendation is to increase the use of debriefing after restraining. In another study conducted by Moran et al. Demented patients are agitated, confused, and many times become aggressive. What is science? Is it the right way forward? This philosophy of nursing also helps choose the best options for their patients’ health, giving them respect and honoring their wishes. The ethical dilemma was whether to use physical restraints for the client to prevent further harm or whether to go with the client’s wishes. Author information: (1)International Centre for Nursing Ethics, University of Surrey. He was a demented patient, and had wrist restraints on both of his arms for his safety, not to pull on to the PEG tube. Psychological impact of restraints in psychiatric patients includes feelings of annoyance, helplessness, uncertainty, loss of control, lack of ability to trust, feeling of anger and all negative past experiences as well as past use of restraints strike back to their memory in the form of flashbacks and nightmares (re-traumatizing). Many families are unaware of their rights to refuse the use of restraints and to ask for alternatives (Lai & Wong, 2008). Using force to manage a patient will always be a socio-cultural issue as it is always against the patient’s will and it can be seen as cruel and offensive. Some families consider restraints a good tool for their dear family members; while others believe that restraints are not the only solution to the problems.

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