The nursing practice revolves around patients’ care, well-being, safety, non-pharmacological interventions, and nursing outcomes. Many times the nursing care of clients places the nurse on a path that is further divided into two diverse pathways, quite in opposite directions. This bifurcation of nursing intervention makes it difficult for nurses to make decisions, based on the ethics of nursing practice and in accordance with the laws of the country. 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). Mr. A.C. is a 68 year-old client, who had been reported to the facility with an ischemic stroke and underwent a diagnosis of dementia in 2004. Due to the severity of the circumstances, he had a Percutaneous Endoscopic Gastrostomy (PEG) tube for his continuous feeding and medication. He was a demented patient, and had wrist restraints on both of his arms for his safety, not to pull onto the PEG tube. The physical restraints were removed during the visit of a family member, as requested by the family.
The client became aggressive as soon as the visitor left and he pulled his PEG tube halfway out; he refused the nurse’s use of physical restraints on him. 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. 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.
Ethics of the Situation
There are certain things that need to be considered in regards to the use of physical restraints and the ethics of the circumstances. 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.
Demented patients are agitated, confused, and many times become aggressive. 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. This interference not only prolongs the course of treatment; it also causes an increased stay at the facility (Hine, 2007; Yamamoto & Aso, 2009). Lai & Wong (2008) found that the use of restraints has a negative impact on the patients and their families. Sometimes, the excessive use of physical restraints might cause additional agitated behaviors and anguish among these clients, ultimately causing emotional distress for the family as well (Lai & Wong, 2008). In another study conducted by Moran et al. (2009), it was shown that physical restraints also caused emotional distress for nurses. These nurses felt that it was a dehumanizing treatment to use physical restraints on patients (Moran et al., 2009).
The client, Mr. A.C. had physical restraints placed on both of his arms because of his distressing behavior, as well as to provide safety and continuity of care for him. The physical restraints were protecting and preventing him from the self-extubation of the PEG tube. The family was involved in this decision-making. 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. Nonetheless, the restraints perhaps hold different significance for the patient himself, the family members, and the staff. This might be one of the reasons that the family members requested to remove the restraints when relatives were present with the patient. Mr. A.C. pulled his PEG tube half way out because he was not immediately restrained after the visit of his family member. Thus, this situation impacts everyone in the family equally, and most likely the patient in terms of a prolonged hospital stays. Such a circumstance left me stunned and in silence; to me it felt like the client was a prisoner who needed to be restrained.
Two Possible Actions
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. As a student nurse, I was looking at the situation and trying to figure out what actions to take for handling such circumstances. 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. I used therapeutic communication skills to calm the patient down and make him realize the importance of having restraints. 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. 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 would definitely make the situation even worse. The second option was to honor the patient’s wishes, which would make the patient happy and calm him down. However, I thought about the consequences of leaving him unrestrained. No restraints could also put the already nervous client in jeopardy of harming himself by pulling the IV lines out and further self-extubating the PEG tube (Hine, 2007).
Response to the Situation for Patient’s Beneficence
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). 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.
Both options seemed equally important to me for a split second. However, I had to single out one decision based on what was better for the patient. The patient’s beneficence was the prime objective in this situation. I did an assessment of the choices and compared the benefits versus the tribulations involved in the situation. The PEG tube was already halfway out of the stomach; meaning that harm had already been done. The client was previously upset, the forceful application of the restraints would make him even more infuriated and agitated. Taking care of the patient’s wishes and leaving him unrestrained would likely make his aggressive behavior tranquil (Lai & Wong, 2008). This would also make communication with the client much easier, and ultimately the patient’s wellbeing would be enhanced. Leaving him without restraints would also help nurses to handle the patient and reduce the staff’s emotional distress (Moran et al., 2009). 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. Based on the team work, keeping in view the patient’s benefit, and providing patient autonomy and freedom of choice, it was decided not to restrain the patient. Leaving the patient unrestrained did not further harm the patient. This also helped him cool down and follow the directions provided by the staff for his beneficence.
The Role of CNA Codes of Ethics in Decisions Making and Outcomes
According to the Canadian Nurses Association (2008), the nursing interventions are always there for patients’ well-being and more-being. 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). As described by the CNA codes of ethics (2008), every patient has the right to be treated as a human being. The patients have autonomy and freedom of choice. 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).
While dealing with the situation in respect to Mr. A.C., who was left unrestrained, the actions resulted in positive outcomes. Giving the patient freedom of choice and honoring his wishes helped him to settle down. Talking to the patient with due respect helped the nurses to overcome the circumstances. 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. The importance of team work that was adapted to the situation cannot be denied. 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). Nurses are accountable for their actions, as stated in the CNA codes of ethics (cited in Oberle & Bouchal, 2009). This philosophy of nursing also helps choose the best options for their patients’ health, giving them respect and honoring their wishes. This would ultimately meet the predictable outcomes of the client’s care and the competence of the nurse.
Reflection on the Situation and Literature Support
Nursing practice is for the beneficence of the people who are suffering and fighting for their lives against diseases. This practice can be considered as silver. However, reflecting upon the practice increases its value and makes it gold (Kontio, Valimaki, Putkonen, Kuosmanen, Scott, & Joffe, 2010). Reflecting upon the situation, I came up with a positive opinion about the action of not restraining the patient. The decision for not to restrain the patient is also supported by many authors. As mentioned earlier, some researchers believe that use of restraints have a negative impact on agitated patients; they should not be restrained if there is no harm involved in the situation. Physical restraints provoke patients to become anxious and worried, lose their autonomy, freedom of choice, and dignity. It is human nature to feel discomfort against restrictions, especially when it comes to physical or emotional harm (Lai & Wong, 2008). 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. The reasons for not restraining the patients involved the images of cruelty and imprisonment (Hine, 2007).
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. Nurses’ competency for handling agitated and aggressive patients depends upon their continuous education. Nurses need to understand the psychology of patients and the factors that trigger those antagonistic behaviors (Kontio et al., 2010). The use of physical restraints should be minimized by using alternative ways to defeat the emotional distress among agitated patients. 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).
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. It was nurses’ knowledge and experience which worked as a protective shield and prevented further harm to the patient and nurses.
Broader Healthcare Context
The use of restraints in a broader healthcare contexts covers social, economical, and physical aspects. However, the social side of this intervention seems more important to be considered (Lai & Wong, 2008). In our society, people have different opinions about the use of restraints. 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. Restraints demolish the sense of dignity for patients and cause emotional distress among family members (Lai & Wong, 2008). How would someone react to the situation when they see their loved ones restrained? However, they seem helpless and for that reason allow healthcare professionals to restrain their loved ones. The reason behind their approval is the lack of awareness about the alternatives of restraints. Many families are unaware of their rights to refuse the use of restraints and to ask for alternatives (Lai & Wong, 2008). Restrained patients increase the workload for nurses by increasing the documentation work and hourly checks for skin integrity. 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).
Role of Moral Values in Decision Making
Nurses’ personal moral values play a significant role in dealing with ethical dilemmas in their practice. This morality and truthfulness of nurses is the central pillar to the nursing practice and patients’ beneficence. 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. The authors Obrele and Bouchal (2009) describe a strong bond between nursing morality, healthcare, and patients’ beneficence. They further explain this connection as nurses’ moral obligation to their jobs. Nurses can only be truly beneficent to their patients if they are honest, accountable for their actions, and morally at a great height (Obrele & Bouchal, 2009).
Dealing with the situation, whether to restrain the patient or let him be free from restraints was definitely a difficult decision to make. The conclusion the staff and I came upon was fundamentally an influence of the nurses’ moral values. Would we restrain him for our own convenience or what was best for the client at that moment? He was already in discomfort because half of the PEG tube was out of his stomach. 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).
Healthcare Institution, Legislation, and Policies
The nursing profession is self-regulatory, where every nurse is obligated to follow the standards of practice set by the College of Nurses Ontario (CNO), Canadian Nurses Association (CNA) Codes of ethics, laws, and institutional policies (Obrele & Bouchal, 2009). The decision made for not restraining the patient against his wishes is supported by the institutional policies and CNA codes of ethics. For example, codes of ethics give preference to patients’ choices if there is no harm involved in the situation. Looking at the circumstances, the patient had dementia and there was no family member there at the moment to decide. Nurses were obligated to honor his wishes morally and ethically because those restraints were positioned to protect him from self-extubation. There was no further harm involved after he had pulled his PEG tube (Oberle & Bouchal, 2009).
Obrele and Bouchal (2009) explain the laws in accordance with the situation. They state that physical abuse of patients is against the law. Restraining patients in opposition to their wishes is not lawful, particularly if there is no concern for harm to the patient (Oberle & Bouchal, 2009).
Conclusion
The quality of nursing care can be assessed by positive outcomes which are the prime objective of nursing care. 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). For nurses to make ethical decisions about the use of restraints, involves the high quality of the nurse-client relationship, nurses’ morality, truthfulness with their profession, accountability, and team approach (Oberle & Bouchal, 2009). Attention should be given to ongoing nursing education, which would help nurses to understand patients’ needs and the factors that cause distress or agitation among patients. This should be kept in mind that restraints are not a preferred choice to control the agitated behavior of patients, even for patients’ beneficence. There is a need to use alternatives, such as the use of therapeutic communication skills, addressing patients with names, therapeutic touch, and massage (Kontio et al., 2010).
The 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 basis for an increase in budget for healthcare. There is a further need to create awareness among the general public about their rights to refuse the use of restraints for their loved ones and ask healthcare professionals for alternatives (Kontio et al., 2010). The areas for further research might include how physicians can help reduce the use of restraints and the use of restraints from patients’ perspectives.
References
Hine, K. (2007). The use of physical restraint in critical care. Nursing in Critical Care, 12(1), 6- 11. 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). Patient restrictions: Are there ethical alternatives to seclusion and restraint? Nursing Ethics, 17, 65–76. doi: 10.1177/0969733009350140
Lai, C., & Wong, I. (2008). Families’ perspectives on the use of physical restraints. Contemporary Nurse, 27(2), 177–184. 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). Restraint and seclusion: A distressing treatment option? Journal of Psychiatric and Mental Health Nursing, 16, 599–605. doi: 10.1111/j.1365-2850.2009.01419.x
Oberle, K., Bouchal, S. (2009). Ethics in Canadian Nursing Practice. Toronto: Pearson Canada Inc.
Yamamoto, M., & Aso, Y. (2009). Placing physical restraints on older people with dementia. Nursing Ethics, 16, 192-202. doi: 10.1177/0969733008100079
These articles have been written by Nasir Ahmad BSc. (HONS) Nursing, a graduate from York University Toronto, Ontario, Canada. The writer of these articles authorizes Peace In-Home Health Care Services Inc to use these articles on their website as an additional resource for their clients & home health care professionals. However, any unauthorized copying or distribution of these articles will be dealt with strictly by the laws of the state. Please contact the author for any queries at 416-648-2717 or email: [email protected]
