Ethics Paper

Running head: USE OF RESTRAINTS

The Use of Restraints versus Patient Autonomy
Kerry B. Bledsoe
MidAmerica Nazarene University

The Use of Restraints versus Patient Autonomy
Introduction
The use of physical restraints has been a controversial yet frequently used nursing intervention for confused and hospitalized patients with severe mental disorders over the past two decades. In many Western countries there were between 3.4% and 30% of acute elderly care and rehabilitation patients subjected to some form of physical restraint during their hospitalization (Evans & FitzGerald 2002).
Patient safety has always been a priority in healthcare. Regulatory organizations like that offered by the Joint Commission on Accreditation on Healthcare Organizations Committee for the Prevention of Torture and Inhuman or Degrading Treatment of Punishment. The practice of physical restraint on patients remains widespread and appears an ethical issue.
History of Physical Restraints
Archival records of physical restraint usage at the St. Louis Insane Asylum (now the St. Louis State Hospital) were examined from January through June 1885. The demographics of restrained patients were determined from archival admission records. In the 6-month (181-day) sample period, 53 patients accounted for the total of 2,537 incidents of night restraint. Sixty percent of the restrained patients were women and 53% were immigrants.
By far most (98.5%) of the incidents of restraint were brought on by violent behavior (fighting, destroying property, injury to self) while most incidents in modern hospitals result from verbal threats or shouting. When these records were combined with day restraint records from the same 6-month period in 1889, an overall incidence rate of 9.7% per month was estimated. This is similar to rates reported from modern psychiatric hospitals. Possible reasons for the discrepancies and similarities in the types of patients restrained and the activities which brought on restraint in the nineteenth and twentieth centuries.
(Retrieved from www.ncbi.nlm.nih.gov/pubmed/11619210)
Literature Review and General Consensus
As suggested by Jenelli et al (2006), these changes in nurses’ attitudes and practices might be influenced by the recent development of regulatory standards and nursing education related to restraint use in acute settings, and they varied a great deal in diverse clinical settings such as general and psychiatric units, and across countries. In addition, an understanding of nurses’ attitudes towards restraint use should be considered when a department or hospital intends to improve nursing practice.
There are a few studies found which explore the factors influencing nurses’ decision-making in restraint use, particularly in other countries where restraint use can often be seen in psychiatric and non-psychiatric settings. Understanding these factors is essential for an adequate interpretation of nurses’ perceptions and attitudes, as well as their practices, regarding restraint use.
Concept of Physical Restraints
A review of the literature suggests that physical restraints can be viewed differently by nurses. A physical restraint refers to the use of belts, handcuffs and the like, which either partially or totally restrict the patient’s movements (Currier & Farley-Toombs 2002; Sailas & Wahlbeck 2005). It can be described by reference to the mechanical devices used, including various cloth or leather devices, and the methods of application such as to the patient’s body or wheelchair, or even by using bedside rails. These variations depend largely on the users’ justification of the need for restraint. Use of physical restraints in hospital is often considered to be an accepted and perhaps unquestioned practice related to patient safety. In the elderly care settings, prevention of injury to patients themselves or others, and prevention of patient falls, are the most frequently cited rationales given by nursing professionals.
Physical restraint may be also considered by nurses to make care-giving more efficient and less worrisome, and prevent lawsuits (Fradkin, Kidron & Hendel 1999). Whether restraint use is in the best interests, and for the greatest benefit, of patients or of the nurses is an open question.
Current Literature Opposing Perspectives
Barnett, R., Stirling, C., & Pandyan, A. (2012). A review of the scientific literature related to the adverse impact of physical restraint: gaining a clearer understanding of the physiological factors involved in cases of restraint-related death. Medicine, Science And The Law, 52(3), 137-142.
Deaths occurring during and/or in close proximity to physical restraint have been attributed to positional asphyxia, a conclusion primarily based on opinion and reviews of case studies. This review sought to identify the current scientific evidence available in regard to the etiology of adverse events or death occurring during or in close proximity to physical restraint. A systematic search of electronic databases for papers published, between 1980 and 2011, using keywords that related to restraint, restraint position and cardiovascular function resulted in 11 experimental papers being found for review. The term positional asphyxia as a mechanism for sudden death is poorly understood. The literature shows that restraint position has the ability to impede life-maintaining physiological functions, but that the imposed impediment is not uniform across all restraint positions/techniques. Further research is required to ascertain the risks posed by struggling during restraint for more prolonged periods of time and in different positions using varied techniques of restraint. This research should seek to and rank known or future risk factors of adverse events occurring during restraint, seeking to understand the interactions and if present the cumulative effect of these risk factors. Finally, future research should focus on populations other than apparently healthy male adults.
Effective Use of Restraint Alternatives
In spite of a range of practice myths among nurses that the use of physical restraints can protect patients from any harm or injury, a range of serious adverse effects and consequences, such as physical problems (Minnick, Mion, Leipzig, Lamb & Palmar 1998) and even accidental death by strangulation (Sailas & Wahlbeck 2005), have been reported in previous studies. There are also psychosocial effects on patients who had one or more restraint experiences, such as low social functioning, increasing confusion and adverse emotional reactions (Thomas, Redfern & John 1995).
It is commonly agreed by health professionals in the literature that physical restraint should not be the first choice among methods intended to ensure patient safety or treatment compliance (Macpherson, Lofgren, Granieri & Myllenbeck 1990; Sailas & Wahlbeck 2005). However, research evidence and clinical reports indicate that physical restraints have been considered and used by the nurses for various reasons, particularly during emergency situations, to manage the patients’ disturbed emotions and behaviors in a variety of clinical settings (Evans & FitzGerald 2002). Some conclusive evidence on minimization of restraint use has been identified in general care settings. For example, Johnson & Beneda (1998) suggested that increasing nurses’ knowledge of restraint use is one of the effective alternative measures to the use of physical restraints. Janelli, Scherer & Kuhn (1994) also reported that promotion of a secure and comfortable environment for agitated or confused older patients may also help in reducing restraint use. Nevertheless, there is limited research and few suggestions on reduction of restraint use for patients in psychiatric care settings.
Ethical Considerations in Use of Restraints
Whenever nurses have to make decisions regarding the use of restraints, they may find themselves in the midst of conflicts between their professional obligation to care for a patient’s well-being and concerns about a patient’s right to make an informed choice (Mayhew, Christy, Berkebile, Miller & Farrish 1999). There is no consensus among nurses as to whether the benefits of its use outweigh the physical and psychosocial risks in elderly care (Johnson & Beneda 1998).
Although some nurses have attempted to use physical restraint as an intervention to safeguard older patients in wards from any harm, accidents, physical disability and emotional distress among patients do occur (Kanak 1992; Sailas & Fenton 2003). Therefore, criticisms and arguments are raised among nurses, as well as other health professionals, about whether this is an effective and first-line intervention for older patients who appear to face higher risks of falls or of violence. It is also questioned whether nurses have been well prepared in developing the knowledge, techniques, attitudes, and moral values to deal appropriately and effectively with complex patient situations (Johnstone 1994). Consistent with the suggestion by Sailas and Wahlbeck (2005), the findings of this study demonstrated that psychiatric patients, in particular demented, frail older patients, may have limited opportunity to make their views, needs and dislikes known before being restrained. This again highlights the need for psychiatric nurses to assess and understand the perceptions and feelings of patients about being restrained, before restraints are administered. As recommended by previous literature (Johnstone 1994; Dawkins 1998; Sailas & Fenton 2000), the majority of the psychiatric nurses in this study expressed little conflict between the patients’ right to self-determination and their role responsibility to do the best for their patients. Johnstone (1994) suggested that registered nurses sometimes may be ‘morally blind’ to patients’ needs as they have seldom seen the effects of their inaccurate and subjective nursing assessments on their patients’ physical and emotional needs, and therefore do not see subsequent decision making as a moral problem.
The use of physical restraints on patients was perceived by the psychiatric nurses in this study as a ‘beneficial’ and an ‘effective’ nursing intervention, with little consideration being given to patients’ feelings, to a loss of dignity and a denial of informed consent. They experienced only limited feelings of guilt on placing a patient in restraint. Chien et al (2005) and Johnstone (1994) questioned whether or not the nurses are well prepared in managing ethical and legal situations in elderly care.
In this study, the nurses showed a lack of sufficient knowledge in bio-ethics and mental health legislation such as the patients’ (and families’) right to informed consent and choices for their own health care and treatment. In the past few years, the recurring message in all of the new legislations, recommendations (eg the Final Rules of Patients’ rights and Centers for Medicare and Medicaid Services 2006), professional guidelines (eg Ten Basic Principles of Mental Health Care; World Health Organization 1996), and some court cases in psychiatry, has been the need to practice caution when applying restraints or when using other coercive measures. There is some evidence that these documents and measures can reduce the use of restraints. However, a lack of comprehensive and accurate knowledge of mental health legislation and ethical issues concerning restraint use among nurses in different clinical settings, such as the psychiatric nurses in this study, has been shown to exist. Nurses should continue to be educated and updated in order to appreciate the ethical and legal dimensions of restraint use
Scanlan, J. (2010). Interventions To Reduce the Use of Seclusion and Restraint in Inpatient Psychiatric Settings: What We Know So Far a Review of the Literature. International Journal Of Social Psychiatry, 56(4), 412-423.
Introduction: In recent times, much attention has been focused on the reduction of seclusion and restraint in psychiatric settings. This paper analyzes evidence available from evaluations of single seclusion and/or restraint reduction programs. A total of 29 papers were included in the review. Results: Seven key strategy types emerged from the analysis: (i) policy change/ leadership; (ii) external review/debriefi ng; (iii) data use; (iv) training; (v) consumer/ family involvement; (vi) increase in staff ratio/crisis response teams; and (vii) programme elements/changes. Outcomes indicate that a range of reduction programmes are successful in reducing the frequency and duration of seclusion and restraint use, while at the same time maintaining a safe environment.Conclusion: The development of new seclusion and restraint reduction programmes should include strong leadership from local management; external seclusion and restraint review committees or post-incident debriefing and analysis; broad-based staff training and programme changes at a local level. Behavioural and cognitive-behavioural programmes appear to be very useful in child and adolescent services. Further systematic research should be conducted to more fully understand which elements of successful programmes are the most powerful in reducing incidents of seclusion and restraint.
Joint Commission article:
Kobs, A. (1997). Patient restraints. Nursing Management, 28(1), 14-15.
IntroductionThe use of restraints to manage patients in the emergency department (ED) is controversial. The Joint Commission on Accreditation of Healthcare Organization (JCAHO) and numerous advocacy groups have pushed for the use of alternatives to restraints. The need to protect the patients' rights while also reducing the risks they may pose to themselves, other patients, and medical staff is difficult to balance. The purpose of this study was to assess which agitation reduction techniques, if any, are used prior to restraints in the ED as recommended by the JCAHO. The second purpose was to determine the reasons for differing levels of usage and/or compliance with the JCAHO recommendations.MethodsA survey tool was developed to include the new restraint and seclusion standards from Joint JCAHO. It was sent to a random sample of the EDs from a randomized list of hospitals in the United States and to all psychiatric EDs from the American Association for Emergency Psychiatrists (AAEP). A mailed survey allowed for institutions to review their yearly census for the information to questions. The survey included questions on the use of agitation reduction techniques, what are those methods, what methods are most effective for ED doctors, has staff received training in how and when to use those methods, and reasons why they do or do not use them in the ED. The study was IRB approved as exempt.ResultsA 40% response rate was obtained overall (391 out of 960). The majority, 70%, of general ED have no psychiatric unit vs. 87% of specialized EDs having a unit attached. The overwhelming majority of both, at 90% to 98%, do use alternatives to restraints prior to restraints. When restraints are used, 30% used physical and 30% used physical and chemical restraints combined. A management protocol is in place at 90% of the institutions to use alternative first and 76% of the staff is educated on the use of alternative methods. The methods in order of popularity are verbal interventions at 84%, one-to-one at 79%, decrease in stimulation at 74%, and food or drink at 69%. The rating of the effectiveness of those methods is low, with the following percentages feeling that the respective techniques were effective: one-to-one, less than 48%; verbal intervention, 36%; decreasing stimulation, 15%; and food or drink, 18%. However, 61% feel that chemical restraints were effective.DiscussionThe majority of respondents have training on alternatives to restraints. They do use alternatives to restraints, with one-to-one, food or drink, and verbal interventions being the most frequently used. These are seen as not very effective. The use of physical and/or a combination of physical and chemical restraints is used by 60% of respondents due to the perceived high level of effectiveness.
Downey, L. A., Zun, L. S., & Gonzales, S. (2007). Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department. General Hospital Psychiatry, 29(6), 470-474.
Questions & answers from the JCAHO. Restraints revisited..
Journal article
Kobs, A. (1998). Questions & answers from the JCAHO. Restraints revisited.. Nursing Management, 29(1), 17-18.
Responds to comments by J. S. Hutter (see record 2010-06110-002) on the author's original article concerning psychiatric nurses' decisions to use physical restraint. It has been established that nurses do view the decision to restrain as a moral practice dilemma in which they must balance the patient's right to self-determination with the desire to protect the patient and others from harm. It has been suggested that the focus of research regarding aggression management should now move toward prevention and safe alternatives to restraint. To accomplish this, it is essential that leadership establish a culture that values restraint reduction and a clear restraint reduction plan. The key seems to be establishing an organizational commitment and a strategic plan to reduce or eliminate restraint use. Some argue whether the elimination of restraint use altogether is a realistic goal, but certainly it is a worthy aspiration.