js.src = 'https://connect.facebook.net/en_US/sdk.js#xfbml=1&version=v3.0&appId=160541900690768&autoLogAppEvents=1'; It gives the client an opportunity to ventilate their feelings regarding being restrained and also the chance to validate the reason of such violent behavior towards self or others (Bonner., Lowe., Rawcliffe., & Wellman., 2002). This article examines some of the ethical issues associated with the use of physical restraint in psychiatry and neurology. 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. It was difficult for the staff and psychiatrist to manage her. It is also important to involve patients in the decision-making process as much as possible. In practice, however, there is significant variability in use and many patients across the US … International journal of law and psychiatry, 35(1), 43-49. Patients’ families often believe that the hospital staff is restraining a client as punishment, retaliation or for their own conveniences. Chemical restraints refer to controlling the patient’s behavior by using a psychoactive drug. Facebook alone has an estimated over 500 million users. Join JPMS Medical Blogs Team as Editor or Contributor, email your cover letter and resume to blogs@jpmsonline.com, We welcome Guest posts. Reflecting upon the situation, I came up with a positive opinion about the action of not restraining the patient. For details email us at blogs@jpmsonline.com or follow the link for details: http://blogs.jpmsonline.com/sponsor/. 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. Undoubtedly, mental health-care workers primarily involve psychiatrists and nursing staff. •       Bonner, G., Lowe, T., Rawcliffe, D., & Wellman, N. (2002). They further explain this connection as nurses’ moral obligation to their jobs. Please contact author for any queries at 416-648-2717 or email: 23.ahmad@gmail.com. The physical restraints were removed during the visit of a family member, as requested by the family. The conclusion the staff and I came upon was fundamentally an influence of the nurses’ moral values. Definition of Ethical Dilemma . The Role of CNA Codes of Ethics in Decisions Making and Outcomes. 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). In the psychiatric setting, paternalism counts more over autonomy of the client as the patient is mentally unstable, it is up to the health care member to take charge and act in the interests of the patient. Nurses were obligated to honor his wishes morally and ethically because those restraints were positioned to protect him from self-extubation. The Ethical Dilemma of Using Restraints in Treatment Facilities A patient receiving mental care behaves unpredictably. There will be better outcomes if the interventions are set accordingly and in consideration with the standards of nursing practice (as cited in Oberle & Bouchal, 2009). At this juncture also the principle of beneficence and non maleficence is applied. Restraining patients in opposition to their wishes is not lawful, particularly if there is no concern for harm to the patient (Oberle & Bouchal, 2009). Oberle, K., Bouchal, S. (2009). Many times the nursing care of clients places the nurse on a path which is further divided into two diverse pathways, quite in opposite directions. He was already in discomfort because half of the PEG tube was out of his stomach. Hine (2007) found that use of physical restraints is more common across North America and some other parts of the world, but is not practiced as much in the United Kingdom. Therapeutic communication skills, such as calling the patient by his name, were also helpful in developing a relationship of trust and enhancing the patient’s compliance to deal with his distress. There is further need to create awareness among the general public about their rights to refuse the use of restraints for their loved ones and asking healthcare professionals for alternatives (Kontio et al., 2010). These patients tend to fidget on their intravenous lines, extubating their PEG tubes, or an endotracheal tube, which ultimately interferes with the course of treatment. It asks whether the continued use of physical restraints is consistent with ethical practice through the lens of those principles. Retrieved from http://cinahl.com/cgi-bin/refsvc?jid=597&accno=200 9927120, Moran, A., Cocoman, A., Scott, P., Mathews, A., Staniuliene, V., & Valimaki, M. (2009). There are certain things that need to be considered in regards to the use of physical restraints and the ethics of the circumstances. 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. Contemporary Nurse, 27(2), 177–184. Nurses’ competency for handling agitated and aggressive patients depends upon their continuous education. To ensure safety of the staff and patient herself, the psychiatrist decided to restraint the patient. 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. Following the restraining procedure they may experience the feelings of shame, humiliation, and loss of self-respect in front of others due to which patient may go into isolation. Duration: 102 minutes. Retrieved September 23, 2015, from https://www.cno.org/Global/docs/prac/41043_Restraints.pdf This ultimately increases the need for more nurses which would impact the finances of the facility, with a need to increase the budget for healthcare (Moran et al., 2009). Restraints demolish the sense of dignity for patients and cause emotional distress among family members (Lai & Wong, 2008). Nursing Ethics, 16, 192-202. doi: 10.1177/0969733008100079, These articles have been written by Nasir Ahmad BSc. Physical restraint in a therapeutic setting; a necessary evil?. This philosophy of nursing also helps choose the best options for their patients’ health, giving them respect and honoring their wishes. According to the Canadian Nurses Association (2008), the nursing interventions are always there for patients’ well-being and more-being. Understanding and providing support also speed up recovery of a patient after restraining. Patient restrictions: Are there ethical alternatives to seclusion and restraint? Due to the severity of the circumstances, he had a Percutaneous Endoscopic Gastrostomy (PEG) tube for his continuous feeding and medication. Submit online via: http://blogs.jpmsonline.com/submit/, We also publish Sponsored Articles. Mr. A.C. is a 68 year-old client, who had been reported to the facility with an ischemic stroke, and underwent diagnosis of dementia in 2004. However, the social side of this intervention seems more important to be considered (Lai & Wong, 2008). Ethics in Canadian Nursing Practice. What is science? Journal of Nursing Scholarship, 39(1), 38-45. js = d.createElement(s); js.id = id; (function(d, s, id) { They state that physical abuse of patients is against the law. The patients have the autonomy and freedom of choice. 2.1.2. Lai & Wong (2008) found that the use of restraints has a negative impact on the patients and their families. Patients may develop extreme agitation and frustration during periods of physical restraint. Paternalism simply means to take a decision on behalf of someone for her/his benefit. restraints that are intended to protect the older adult. The father noticed …, Copyrights: Journal of Pioneering Medical Sciences, http://www.rehabnurse.org/uploads/files/pdf/GeriatricsRestraints.pdf, https://www.cno.org/Global/docs/prac/41043_Restraints.pdf, http://www.americannursetoday.com/wp-content/uploads/2014/12/ant1-Restraints-1218_RESTRAINT.pdf, In Perspective: Implications of Using Physical Restraints in Clinical Settings. Restrained patients increase the workload for nurses by increasing the documentation work and hourly checks for skin integrity. http://www.americannursetoday.com/wp-content/uploads/2014/12/ant1-Restraints-1218_RESTRAINT.pdf. The reason behind their approval is the lack of awareness about the alternatives of restraints. 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). With these staggering figures, it becomes clear right at the onset …. Disclaimer: JPMS Medical Blogs are published by the publisher of Journal of Pioneering Medical Sciences (JPMS). Both options seemed equally important to me for a split second. Restraints are often recognized as penalizing and cruel by the patient which contributes in developing antipathy toward clinical staff members. 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 … These nurses felt that it was a dehumanizing treatment to use physical restraints on patients (Moran et al., 2009). Physically Restraining Psychiatric Patients: More Harm that Good? Nursing Ethics, 17, 65–76. It also examines where the necessity to use restraints in the absence of empirically supported alternatives leaves professionals in terms of conflicts between ethical principles and makes recommendations for changes in education … The alternative methods include the use of communication skills, therapeutic use of touch, involving family members in the care plan, massage, and acupuncture therapy (Kontio et al., 2010). Nonetheless, the restraints perhaps hold different significance for the patient himself, the family members, and the staff. During my clinical rotations I encountered an 18 year old female psychiatric patient exhibiting highly aggressive behavior along with severe agitation. Recommendations 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. At that moment of care, two options entered my thoughts: restrain the patient for safety purposes, or respect the patient’s desires and let him be in his own world of contentment. Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. 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. In nursing and medical ethics, restraining a client always presents a difficult question. In such situations, it may be ethically justifiable for physicians to order the use of chemical or physical restraint to protect the patient. 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. Retrieved from http://cinahl.com/cgi-bin/refsvc?jid=1681&accno=2009 546326, Kontio, R., Valimaki, M., Putkonen, H., Kuosmanen, L., Scott, A., & Joffe, G. (2010). The main ethical principles of nursing are intended to guide decision-making to ensure the best outcomes for patients, while respecting patient rights. HLSC220 Assignment - Ethical Dilema Debate- Presentation-submit ACU skills list 2016 HLSC 122 ELJ Seminar Materials - Aut 18 Exam 2018, questions Preview text 1 Use of Physical Restraint: An Ethical Perspective This essay focuses on Sam, a man, who gets admitted to … Restraints and Alternatives. However in the case described, human rights and patient’s bill of rights were violated since the patient’s right of self determination was sacrificed. Is it the right way forward? The family was involved in this decision making. 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]. Anne Martin (not her real name) is 87 years old and has senile dementia. Restraining the patient could result in more disturbed behavior, which could ultimately harm the patient, or in the worst case scenario, could cause the patient to harm me (Lai & Wong, 2008). This article examines the use of physical restraints through the four broad principles of ethics common to all helping professions. Lastly, since the use of restraints is very high in psychiatric setting, a good surveillance system is also required in order to prevent the unnecessary use of it. Chemical restraints may affect the client’s cognitive abilities and memory causing confusion, poor concentration, loss of short term memory etc. In the above mentioned scenario, the nurse did not apply the debriefing after restraining which was immoral. The theory of aggression relates several stages but the most essential stage with regard to restraining a client is the stage of escalation. In general terms, to restrain is to limit someone’s liberty. We also publish Conference Proceedings and Conference Abstracts as Supplement. While dealing with the situation in respect to Mr. A.C., who was left unrestrained, the actions resulted in positive outcomes. (HONS) Nursing, a graduate from York University Toronto, Ontario, Canada. 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. 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. She hit and abused the ward staff. Therefore, ethical principles should be seriously considered before drawing an ethical conclusion. 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. •       Mohr, W. K., Petti, T. A., & Mohr, B. D. (2003). Nursing in Critical Care, 12(1), 6-    11. All this adversely affects their mental health and patient may end up having severe depression. var js, fjs = d.getElementsByTagName(s)[0]; doi: 10.1177/0969733009350140, Lai, C., & Wong, I. This article examines the ethical issues that arise in relation to restraint in mental health, dementia care and stroke care. (Mohr, W., Petti., & Mohr, B., 2003). The use of team work not only helped the staff to resolve the problem and achieve the expected outcomes, but it also encouraged the nurses to use a team work based approach (Oberle & Bouchal, 2009). Healthcare Institution, Legislation, and Policies. The use of physical restraints poses dilemmas for die nursing staff. The importance of team work that was adapted to the situation cannot be denied. Broader ethical issues. Use of restraints not only steals patients’ freedom of choice or autonomy, this also causes emotional distress for families and the staff (Lai & Wong, 2008). 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). I felt that the patient’s thoughts and desires were to have autonomy and not be attached to restraints. I did an assessment of the choices and compared the benefits versus the tribulations involved in the situation. The best ethical justification for restraining patients is that it prevents them from harming themselves. The use of physical restraint in critical care. 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. However, it is also a moral and professional dilemma for health care members, when to use restraints and when to respect their patients’ autonomy. This article does not reflect the policies of JPMS or its Staff or Editorial nor does it intend to provide legal, financial or medical advice. No paper submission or publication charges. 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. 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. Toronto: Pearson Canada Inc. Yamamoto, M., & Aso, Y. Significance 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. Many families are unaware of their rights to refuse the use of restraints and to ask for alternatives (Lai & Wong, 2008). The decision for not restraining the patient is also supported by many authors. 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). Physical restraint is a controversial topic and it is important for nurses to remain up to date with clinical governance strategies, regulation and policy developments. Obrele and Bouchal (2009) explain the laws in accordance with the situation. (2009), it was shown that physical restraints also caused emotional distress for nurses. Her research interests are in the area of implementing evidence-based practices and sexuality education. Bio: Peggy Schaefer Whitby is an associate professor at the University of Arkansas and serves as the program coordinator for special education. It was nurses’ knowledge and experience which worked as a protective shield and prevented further harm to the patient and nurses. Would we restrain him for our own convenience or what was best for the client at that moment? Leaving him without restraints would also help nurses to handle the patient and reduce the staff’s emotional distress (Moran et al., 2009). 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. Refer to Disclaimer and Policies section for more details. Restraint and seclusion: A distressing treatment option? 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. The patient’s beneficence was the prime objective in this situation. An informed consent was also obtained from the family to restrain the client for his beneficence and to provide the family with satisfaction regarding the expected outcome. Physical restraints encompass all material appliances used to limit the client’s mobility or conduct, such as belts, limb ties, and bed rails. Thus, this situation impacts everyone in the family equally, and most likely the patient in terms of a prolonged hospital stays. How would someone react to the situation when they see their loved ones restrained? These comments prompted the question: “In wh… The ethics of restraint The following example illustrates the application of ethical principles in practice. A nurse should search for alternatives before applying restraining measures. Nursing practice revolves around patients’ care, wellbeing, safety, non-pharmacological interventions, and nursing outcomes. Leaving the patient unrestrained did not further harm the patient. Restraints are a common practice for this purpose; however, they may inflict harm and contradict patient rights of freedom, autonomy, and respect. However, I had to single out one decision based on what was better for the patient. While I was trying to restrain the patient for the patient’s good, I was also thinking about the effects of restraints against the patient’s desires. In addition to this ethical issues will be discussed and how they relate/ link to different laws. 43). Physical Restraint in Health Care: Is Paternalism Justified? She has been a resident in a care setting for older people for three years, after becoming unable to cope at home because of short-term memory loss and confusion. As many research articles into the issue show, however, the harms of restraints outweigh their benefits. There is need to use alternatives, such as use of therapeutic communication skills, addressing patients with names, therapeutic touch, and massage (Kontio et al., 2010). The Sound of Loneliness: Human Nature and the Need to Connect and Belong, HIV in Pakistan: Healthcare providers, Intended Harm and Ethics. Nurses need to understand the psychology of patients and the factors that trigger those antagonistic behaviors (Kontio et al., 2010). 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. Journal of Psychiatric and   Mental Health Nursing, 16, 599–605. •       Gatens, C., & CRRN-A, M. N. R. N. (2007). no. 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. “When and How to Use Restraints.” American Nurse Today 10, no. Nurses’ use of physical restraints in four Turkish hospitals. The aforementioned scenario demonstrates the principle of autonomy vs. paternalism, and also autonomy vs. beneficence by preventing her from self-harm by restraining her chemically and physically. •       Mohr, W. K. (2010). Relying on Restraints in Psychiatric Settings: Distasteful yet Necessary? 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. (Frengley 1986) stated that use of restraint can prolong the length of hospitalization and long term restraint will lead to more harm, such as higher mortality, physical trauma and psychological trauma to patient than benefit. According to Gaten (2007), restraint in medical practice can be anything or any method which is use to restrict a client’s movement or to control his/her behavior. Retrieved from: http://www.rehabnurse.org/uploads/files/pdf/GeriatricsRestraints.pdf However, it is also a moral and professional dilemma for health care members, when to use restraints and when to respect their patients’ autonomy. These include, for example, decision-making in end-of-life care, use of restraints and a lack of resources. restraints without consent in order, as they it, to prevent physicalperceive harm such as falls. A discussion of the ethical, legal, practical, and professional issues follows, to help nurses understand the difference between unacceptable or … At first they tried the method of de-escalation by having words with the client. Seclusion is an invasive clinical intervention used in inpatient psychiatric wards as a continuation of milieu therapy with vast behavioural implications that raise many ethical challenges. Nursing profession is self regulatory, where every nurse is obligated to follow the standards of practice set by College of Nurses Ontario (CNO), Canadian Nurses Association (CNA) Codes of ethics, laws, and institutional policies (Obrele & Bouchal, 2009). Canadian Journal of Psychiatry, 48(5), 330-337. However, I thought about the consequences of leaving him unrestrained. The authors Obrele and Bouchal (2009) describe a strong bond between nursing morality, the healthcare, and patients’ beneficence. We care for our .... http://cinahl.com/cgi-bin/refsvc?jid=1681&accno, http://cinahl.com/cgi-bin/refsvc?jid=597&accno=200 9927120, Mediacation management for people with disabilities, The Most Common In-Home Injuries for Seniors and How to Prevent Them, How to Reduce Hoarding and Clutter to Prevent Falls, How to Make & Pay for Home Modifications to Enable Aging in Place, Top 7 Garage Safety Hazards that You Shouldn’t Be Ignoring, Making Aging in Place Easier with Digital Health Technology, Caregiver/ PSW Needed In Toronto Midtown (Part time Job). The themes can, … 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). Use of restraints in broader healthcare context covers social, economical, and physical aspects. Nursing practice is for the beneficence of the people who are suffering and fighting for their lives against diseases. However, any unauthorized copying or distribution of these articles will be dealt strictly by the laws of the state. 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.
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