Use of Restraints in Psychiatric Patients: An Ethical Dilemma
In general terms, to restrain is to limit someone’s liberty. 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. Restraints are categorized into three types: environmental, chemical and physical.
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. Physical restraints encompass all material appliances used to limit the client’s mobility or conduct, such as belts, limb ties, and bed rails. 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).
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. 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. They should be the physician’s last resort, only for when all alternative interventions have failed. (Springe, 2015).
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. Patients’ families often believe that the hospital staff is restraining a client as punishment, retaliation or for their own conveniences. However, it is also a moral and professional dilemma for health care members, when to use restraints and when to respect their patients’ autonomy.
A Case Scenario
During my clinical rotations I encountered an 18 year old female psychiatric patient exhibiting highly aggressive behavior along with severe agitation. She hit and abused the ward staff. It was difficult for the staff and psychiatrist to manage her. To ensure safety of the staff and patient herself, the psychiatrist decided to restraint the patient.
At first they tried the method of de-escalation by having words with the client. 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.
Ethical and Legal Issues
In nursing and medical ethics, restraining a client always presents a difficult question. Psychiatric patients exhibiting violent, agitated or aggressive behavior are restrained in order to prevent harm to self and others. In restraining, a client’s autonomy and liberty have been taken away for their own and other people’s benefit; and this creates a delicate ethical and legal issue.
Autonomy is the right to liberty and self determination; in restraining patients both these components are violated. Paternalism simply means to take a decision on behalf of someone for her/his benefit. 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.
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. At this juncture also the principle of beneficence and non maleficence is applied. 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).
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.
The theory of aggression relates several stages but the most essential stage with regard to restraining a client is the stage of escalation. This stage has its significance in lowering the application of restraints in aggressive patients. If a nurse becomes successful in lowering the patient aggression in escalation phase then the need of restraints gets lowered down in such patient. According to Perkins, E., Prosser, H., Riley, D., & Whittington, R. (2012), “best practice means practitioners will strive to de-escalate behavior and so avoid restraint” (pg. no. 43).
Effect of Restraints on Physical and Mental Health
Physical impact of restraints include edema, cyanosis, contractures, muscular aches and rigidity, bedsores, loss of movement etc. (Demir, 2007). 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). Patients may develop extreme agitation and frustration during periods of physical restraint.
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. All this adversely affects their mental health and patient may end up having severe depression. Chemical restraints may affect the client’s cognitive abilities and memory causing confusion, poor concentration, loss of short term memory etc. Restraints are often recognized as penalizing and cruel by the patient which contributes in developing antipathy toward clinical staff members. (Mohr, W., Petti., & Mohr, B., 2003).
A chief recommendation is to increase the use of debriefing after restraining. The clients feel feeble and anguish, they need someone to talk to. 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).
In the above mentioned scenario, the nurse did not apply the debriefing after restraining which was immoral. A nurse should search for alternatives before applying restraining measures. De-escalation techniques should be explored, furthermore, reducing environmental stimuli would also minimise violent behaviour.
As psychological patients are usually going through emotional trauma they need support from their family, friends and also from the staff members. Understanding and providing support also speed up recovery of a patient after restraining. 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.
• Gatens, C., & CRRN-A, M. N. R. N. (2007). Restraints and Alternatives. Retrieved from: http://www.rehabnurse.org/uploads/files/pdf/GeriatricsRestraints.pdf
• Practice Standard: Restraints. (2009). College of Nurses of Ontario. Retrieved September 23, 2015, from https://www.cno.org/Global/docs/prac/41043_Restraints.pdf
• Springe, Gale. “When and How to Use Restraints.” American Nurse Today 10, no. 1 (2015). http://www.americannursetoday.com/wp-content/uploads/2014/12/ant1-Restraints-1218_RESTRAINT.pdf.
• Mohr, W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of psychiatric nursing, 24(1), 3-14.
• Perkins, E., Prosser, H., Riley, D., & Whittington, R. (2012). Physical restraint in a therapeutic setting; a necessary evil?. International journal of law and psychiatry, 35(1), 43-49.
• Demir, A. (2007). Nurses’ use of physical restraints in four Turkish hospitals. Journal of Nursing Scholarship, 39(1), 38-45.
• Mohr, W. K., Petti, T. A., & Mohr, B. D. (2003). Adverse effects associated with physical restraint. Canadian Journal of Psychiatry, 48(5), 330-337.
• Bonner, G., Lowe, T., Rawcliffe, D., & Wellman, N. (2002). Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9(4), 465-473.
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