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Nursing Ethical Dilemma Around Restraints

Introduction

The nursing profession imposes various moral obligations upon practitioners since it often includes interactions with vulnerable members of society. This statement may sound pretentious, but sometimes nurses have to deal with matters of life and death. As a result, their decisions may make the difference between the former and the latter, which amplifies responsibility. In addition to actual medical skills, nurses are expected to address any arising ethical issues dutifully; however, this commendable expectation is far from straightforward (Ion et al., 2018).

For instance, I faced an ethical dilemma around the use of restraint in the inpatient forensic mental health unit, which was quite difficult to resolve. The New Zealand Nurses Organization (NZNO) Code of Ethics was written to assist nursing personnel with exploring ethical beliefs (NZNO, 2019). However, while guidelines and legal acts are important, they can only support one’s judgment. The final decision remains in nurses’ responsibility and ability to find a fragile compromise between ideal scenarios and reality.

Relevance and Challenges of Ethics in Nursing

Before exploring ethical dilemmas from a personal perspective, I would like to discuss the general relevance of ethics in nursing. First of all, it is necessary to clarify what is “ethical”. Ion et al (2018) defined ethical aspect behind decisions as engaging others or responding to situations with a potential adverse impact. Consequently, ethics in nursing can be understood as a guideline for treating the patients and resolving challenging situations. Jahn (2011) provided four fundamental ethical principles applicable to forensic activities: respect for autonomy, beneficence, non-maleficence, and justice. However, this classification is not limited to the forensic field, as it can be applied to nursing in general. In particular, the NZNO Code of Ethics (2019) listed all four principles described by Jahn (2011) as ethical values in nursing. Therefore, ethics appear to be relevant for a wide selection of nursing activities.

High relevance of ethics means a wide spread of ethical issues in nursing practice. For instance, Ion et al. (2018) claimed that nurses face ethical dilemmas on a daily basis. The sources of those dilemmas might have diverse nature — from providing personal care to people of different ages, gender, culture, and sexuality to restraining in mental health settings (Ion et al., 2018). While both types of intervention undoubtedly require medical and technical skills, the ethical aspect adds an extra challenge to seemingly routine procedures. Moreover, avoiding those challenges to make a nurse’s life easier can potentially undermine the treatment quality.

According to a survey among 295 patients of burn wards at the Sina Hospital in Tabriz, Iran, the patients did not know their nurse in over 80% of cases (Lotfi et al., 2019). As a result, the patients expressed dissatisfaction with treatment as they “felt like a case, not an individual” (Lotfi et al., 2019, p. 1191). Therefore, the main challenge of ethics in nursing lies in their unavoidable nature. Neglection of ethical perspective might remove the psychological pressure from the nurse; however, that would be an obvious violation of the nurse’s professional duty, which is unacceptable in my opinion.

Situation Account and Ethical Issue

Previously it has been concluded that ethics are always relevant to nursing, and a nurse cannot neglect the ethical issues if they have any sense of professional duty. Therefore, a nurse should be mentally ready to face ethical problems and find solutions to them. In my second year of learning in a clinical setting, I encountered an ethical dilemma of environmental and mechanical restraint. We had a patient diagnosed with Tourette syndrome and autism with a history of adverse childhood trauma. He exhibited unpredictable, aggressive behavior and already physically assaulted several members of the nursing staff.

On my first two weeks in the forensic mental health unit, I noticed that this man’s movement was limited to a tiny isolated room. When he took part in music therapy and psychology meetings, he had an enabler belt attached to his wrist and waist. However, the patient was in a good mood, complied with all instructions from us, and behaved well. Despite those positive signs, my colleagues were against removing environmental and mechanical restraints and claimed that they benefit the patient for now. Their position initially confused me, as I was not sure whether it was morally right to keep restraining the patient for such a long time. I have to admit — this situation did not fit my vision of ethical nursing. However, after some deliberation, I started seeing the actions of nursing staff as a bridge for patient’s rehabilitation rather than a punishment.

Regardless, a nurse has to analyze every case of restraint application from the ethical perspective, and this analysis might lead to conclusions different from the ideal scenario. In my situation, the patient was not restrained for a punishment. Moreover, in reflection, I must admit that restrictive measures allowed his safe participation in rehabilitative activities. Overall, now I think one should consult with ethical guidelines and base their decisions on official recommendations and logic instead of emotions and good intentions.

Analyzing Ethical Issue Through the NZNO Ethical Principles

Since I aspire to become a registered nurse in New Zealand, I reckon that the ethical issue from my learning experience should be analyzed from the NZNO Code of Ethics perspective. Initially, I felt quite uncomfortable when my colleagues decided to keep the patient restrained despite the visible improvements in his behavior. In that regard, I can relate to nurses who felt strong compassion towards the restrained patients (Walker and Tulloch, 2020). However, now I believe that the actions of nursing staff during my learning period can be justified by the principles of beneficence and non-maleficence articulated in the Code.

In general, the concept of beneficence implies doing good to the other and patient’s wellbeing. NZNO defines beneficence as performing actions leading to outcomes that would be considered worthwhile (NZNO, 2019). In addition, the Code explicitly expresses that the meaning and value of good can vary depending on the context (NZNO, 2019). In that regard, nursing personnel adhered to the ethical principle of beneficence. My colleagues had to make decisions given the context of violent, unpredictable behavior exhibited by the patient before. Nevertheless, the seclusion applied to the patient was not total, and he was able to participate in all rehabilitative activities to his benefit. Moreover, a moderate form of restraint enabled safe physical contact between the patient and others. In the end, the patient’s condition and behavior improved, which can be considered a beneficial outcome.

The ethical principle of non-maleficence implies preventing harm from occurring to others. According to NZNO (2019), non-maleficence implies avoidance of harm, prevention of future harm, and minimising harm in situations where it is unavoidable. Overall, my colleagues managed to accomplish all goals encompassed by this definition. Most importantly, the application of restraints in a limited scope eliminated the majority of safety risks for the staff.

I would agree with the position stated by the American Nurses Association (ANA), according to which nurses have a duty to assure their own safety (ANA, 2020). In addition, a combination of environmental and mechanical restraints allowed to prevent any possible violence between the patients. Overall, after looking at the situation through the ethical principles of beneficence and non-maleficence, I find the actions of my colleagues fitting the situation. Their decision can be considered ethical since it was made for the patient’s benefit without any intention to diminish his dignity and at the same time increased overall safety in the unit.

Interaction Between the NZNO Principles in the Context of Situation

The influence of context around the situation on the application of ethical principles deserves special attention. Ideally, a nurse should act in a way guided both by considerations of beneficence and non-maleficence, so these ethical principles should support each other. In the case of my clinical experience, both principles were duly applied; however, the history of the patient’s violent behavior and safety considerations created a reason for a seemingly questionable decision to keep moderate restraints.

There is a significant difference between an ideal application of ethical principles and their implementation in actual practice. For example, restraints are incompatible with ethical principle of autonomy, since they limit patient’s freedom (Mohr, 2010). Moreover, Mohr (2010) concluded, that restraints cannot be perceived as a therapeutic solution, and they are detrimental to beneficence and non-maleficence. However, in my case it is possible to argue that the prolonged use of limited restraints fit the principles of beneficence and non-maleficence. When the principle of autonomy was satisfied, the patient used their freedom to assault staff members. On the contrary, with limited restraints in place the patient has safely undergone a therapy that improved his condition.

Therefore, if one looks at my experience from the perspective of definitions provided by the NZNO, the ethical principles of beneficence and non-maleficence clearly supported each other. In the end, my colleagues decided to keep moderate restraining measures because they facilitated rehabilitative activities for the patient. In addition, the patient was prevented from harming himself, the nursing staff, and other patients. As a result, a synthesis of two ethical principles created a reason behind the decision to keep restraints for a longer time.

However, multiple authors and organizations blame environmental and mechanical restraints for causing effect opposite to harm prevention. The Substance Abuse and Mental Health Services Administration (SAMHSA) deemed seclusion and restraints dangerous and traumatic (SAMHSA, 2010). O’Hagan et al. (2008) urged to eliminate seclusion and restraints in an article published by Te Pou, a national workforce center for mental health, addiction, and disability in New Zealand. Such a negative disposition towards seclusion and restraints proves the immense importance of context in situations that require their use.

As a consensus, the use of restraint is advised only as a last resort. For instance, Smethurst (2015) concluded that restraint should be used only if other means were tried. According to Mohr (2010), nurses also find using restraints uncomfortable, which was relatable to my situation. Horsburgh (2004) suggested emphasizing such pre-emptive actions as verbal reasoning and confident non-verbal communication from an adequate distance before using restraints. Moosa and Jeenah (2009) argued that the use of restraints should be an extraordinary event authorized by written order. Lastly, the New Zealand Ministry of Health officially supported the reduction in the use of restraints (Ministry of Health, 2020). In my opinion, these views on restraints are commendable since they stress their extraordinary, non-therapeutic nature.

Professional Nursing Response to Address the Ethical Issue

Previously I argued that the decision to keep restrictive measures for a longer time was ethically justified. However, it does not automatically mean that such a strong intervention as environmental or mechanical restraints should be applied in any given situation. For instance, seclusion can be detrimental to nurse-patient relationships ruining the trust necessary for a good treatment outcome (Zheng et al., 2020). Therefore, one should always weigh the risks versus benefits and apply ethical principles before authorizing seclusion or physical restraints. Ideally, all decisions should be based on official documents such as the NZNO Code of Ethics.

Most importantly, a registered nurse should remember that any restraint type must remain a part of treatment instead of turning into a punitive measure. A registered nurse must strictly follow Right 1 of Consumers’ Code — every consumer has a right to be treated with respect (The Health and Disability Commissioner, 2012). As such, it would be morally right to obtain informed consent from the patient. Taylor (2013) defined consent in clinical practice as patient’s informed and voluntarily agreement for medical interventions.

Bonsall (2015) relates a story of how her supervisor forced the patient of a psychiatric unit to sign the necessary consent form. In the case of New Zealand, such an action would be a direct violation of Consumer’s Right 7 (The Health and Disability Commissioner, 2012). Only the lack of patient’s competence or a person who can provide consent on their behalf allows the caregiver to act independently.

In any case, even if the use of environmental or mechanical restraints is ethically justified and the staff managed to obtain informed consent, a nurse should select the least restrictive measures. It is necessary to realize that restraints may lead to such dangerous consequences as psychical and psychological risks, negative reactions in patients, and misuse as a form of punishment (Moosa & Jeenah, 2009). Therefore, a registered nurse must evaluate the context of the situation, especially the implications for patients and personnel safety.

For instance, in the situation from my learning experience, the patient had access to the bathroom and kitchen. He also was able to participate in such rehabilitative activities as music therapy and psychology meetings. The personnel treated him with respect despite the patient physically assaulted and injured several nurses before. In the end, this careful strategy paid off, and the patient’s mental condition improved. However, if nursing staff decided to punish the patient by using harsh restrictive measures, the outcome would probably be much worse.

Conclusion

The ethical issue of environmental and mechanical restraints use in clinical settings can put a nurse in front of an ethical dilemma. Judging from my experience, I find it necessary to evaluate potential decisions through the ethical principles presented in official sources. Applying ethics would help the nurse alleviate possible doubts and take action in morally challenging situations. Overall, it is crucial to consider the context around particular cases and resort to the least restrictive restraint options possible even if their use is ethically justified.

One must remember, that restraints are not a therapeutic solution, and their application is usually detrimental to the patient-nurse relationships and treatment outcome. In my experience, moderate environmental and physical restraints allowed the patient to participate in therapy without compromising safety in the unit. However, this was a rare case when the principles of beneficence and non-maleficence supported use of moderate restraints, rather than a proof that restraints are universally beneficial and non-maleficent.

References

American Nurses Association. (2020). The ethical use of restraints: Balancing dual nursing duties of patient safety and personal safety. Web.

Bonsall, L. (2015). Informed consent: An ethical way of nursing. NursingCenter. Web.

Horsburgh, D. (2004). How, and when, can I restrain a patient? Postgraduate Medical Journal, 80(939), 7-12. Web.

Ion, R., DeSouza, R., & Kerin, T. (2018). Teaching ethics: Intersectionality, care failure and moral courage. Nurse Education Today, 62, 98-100. Web.

Jahn, W. T. (2011). The 4 basic ethical principles that apply to forensic activities are respect for autonomy, beneficence, nonmaleficence, and justice. Journal of Chiropractic Medicine, 10(3), 225-226. Web.

Lotfi, M., Zamanzadeh, V., Valizadeh, L., & Khajehgoodari, M. (2019). Assessment of nurse–patient communication and patient satisfaction from nursing care. Nursing Open, 6(3), 1189-1196. Web.

Ministry of Health. (2020). Guidelines to the mental health (compulsory assessment and treatment) Act 1992. Web.

Mohr, W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24(1), 3-14. Web.

Moosa, M. Y. H., & Jeenah, F. Y. (2009). The use of restraints in psychiatric patients. South African Journal of Psychiatry, 15(3), 72-75.

New Zealand Nurses Organization. (2019). Guideline – Code of Ethics, 2019. Web.

O’Hagan M., Divis M., & Long J. (2008). Best practice in the reduction and elimination of seclusion and restraint; Seclusion: time for change. Te Pou. Web.

Smethurst, L. J. (2016). Applying ethical principles to restraint practice. Learning Disability Practice, 19(1), 23-26. Web.

Substance Abuse Mental Health Services Administration (2010). Issue brief #1. Promoting alternatives to the use of seclusion and restraint. A national strategy to prevent seclusion and restraint in behavioral health services. Web.

Taylor, H. (2013). What does consent mean in clinical practice? Nursing Times, 109(44), 30-32.

The Health and Disability Commissioner. (2012). Code of health and disability services consumers’ rights. Web.

Walker, H., & Tulloch, L. (2020). A “necessary evil”: Staff perspectives of soft restraint kit use in a high-security hospital. Frontiers in Psychiatry, 11, 1-11. Web.

Zheng, C., Li, S., Chen, Y., Ye, J., Xiao, A., Xia, Z., Liao, Y., Xu, Y., Zhang, Y., Yu, L., Wang, C., & Lin, J. (2020). Ethical consideration on use of seclusion in mental health services. International Journal of Nursing Sciences, 7(1), 116-120. Web.

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