Physical Restraint in Health Care: Is Paternalism Justified?
Ethical dimension of care is an integral part of health practice. Therefore, ethical reflection is essential for healthcare practitioners to make balanced decisions.For over centuries, practitioners have argued over how to treat mentally retarded people. Several advancements have been made from chaining them and drilling their heads to unchaining them and treating them like humans. But the issue of dealing with the psychiatric patients still persists.
In psychiatric settings, coercive measures like restraining a mentally ill, are complex ethical dilemmas which place caregivers in question.Restrain, as defined by Merriam-Webster Dictionary (2012), is to “prevent from doing, exhibiting, or expressing something”. In medical terms, the Mental Health Commission (2009)defines physical restraint as the use of physical force to prevent free movement of patient’s body when there is an immediate threat of serious harm to self or others.
In socio-cultural context, it is a controversial practice violating patients’ dignity ethically and legally. Evolving healthcare leads to constant emerging issues which are against the ethico-legal consideration of some groups and cultures, while others are in favor. In eastern society, healthcare professionals have a sacred position to make decisions about patient’s treatment plan; may it be coercion.
However, non-coercive measures, client’s autonomy and patient-centered approach are considered more important in western culture (Firoozabadi & Bahredar, 2009). This topic highlights implications of physical restraint in mental health setting as it is a forceful and traumatic practice which can cause death(Nissen, Rørvik, Haugslett, Wynn, 2013). Thus, it is significant for healthcare practitioners to have sufficient knowledge regarding ethical and legal positions for thorough critical analysis to make sound decisions.
Forty years old female, admitted at psychiatric unit, diagnosed as schizophrenia,presented with irrelevant talk, suspicious behaviour and aggression. One morning, she restlessly started shouting in front of the nursing counter. After several unsuccessful attempts of calming the patient, the nurse restrained her physically for prevention of violence regardless of patient’s refusal of being restrained.
Later that morning while patient was restrained, it was observed that she was still aggressive as evidenced by her shouting and restlessness. The same state of the patient was mentioned in all nursing notes taken forty-eight hours after the initiation of restraint. However due to restraint, she regained some control and was able to listen to the staff.
Analyzing the scenario, it is apparent that patient was restrained with the core purpose of controlling her aggression but it brought negative feelings in patient as her autonomy was violated.Nurses use this measure as a quick solution to aggression but it causes many physical and psychological sufferings (McBrien, 2007). It can cause complications of immobilization like pneumonia, ulcers, deep-vein thrombosis.
Immobilization can cause stress, affecting cognitive skills negatively. Furthermore, its improper application can cause bruises, abrasions, neural lesions, soft tissue compression and even death (Berzlanovich, Schöpfer, & Keil, 2012). Fortunately, these effects were not observed in the case mentioned. Also, the use of restraint should be in due proportion to its benefits and risks.
In the above scenario, when patient was restrained, she regained some of her control (benefit). Yet, emotional effects of anger, frustration, agitation, isolation and loss of dignity observed in patient are unavoidable (risks). In order to evaluate the clash between evident benefits and risks of the action, consideration of ethico-legal frameworks is important.For ethical analysis, an ethical framework of four quadrant approach (Appendix 1)was proposed by Jonsen, Siegler and Winslade (1982, as cited inSchumann& Alfandre 2008).
First quadrant highlights medical indications. Referring to the scenario, physician ordered, five days prior to the event (most recent order), to give Injection Haloperidol, 10mg, stat-dose when patient gets unmanageable and risk of violence is suspected. Moreover, during hospitalization patient had negative history of harming self or others. Yet, physical restraint was used to manage patient’s aggression. Underlying this quadrant are ethical principles of beneficence (doing good) and non-maleficence (no harm).
Physical restraint was opted to control patient’s aggression (beneficence) and prevent violence (non-maleficence). Second quadrant focuses on patient’s preferences. As mentioned in the scenario, patient was continuously refusing to being restrained, the respect for patient’s autonomy was violated and an act of paternalism (autonomy overridden by beneficence) was done.
However, since patient was mentally ill and had unusual behavior, her preferences were not taken into account.Third quadrant is quality of life. Since the term quality of life differs in meaning among individuals, nurses need to consider patient’s preferences and values to decide what best define quality of life for that patient (Schumann & Alfandre, 2008). In this case, restraint deteriorated patient’s state of mind and it could have caused other physical complications.
Thus, consideration of other alternatives and application of timely measures could have brought patient to normal state without the need for restraint, improving her quality of life.Fourth quadrant entails contextual features. There were no economic or socio-cultural factors involved that could influence treatment decision. However, lack of staff’s knowledge regarding de-escalation techniques and other measures influenced the decision; both of which will be discussed later in this paper.
Furthermore, under legal framework of Mental Health Commission: Code of Practice (2009), physical restraint should be used rarely inexceptional circumstances when patient possess immediate threat to self or others and when all other alternatives fail to manage unsafe behaviors. Its use is based on contemporary practice and risk assessment. Additionally, cultural awareness and gender sensitivity should also be considered.
Mentioned scenario indicates that restraint was used when patient was shouting without any verbal threats. Thus, there was no immediate threat towards others. However, alternative like attempts of calming the patient was made before restraint which failed. But the techniques used for de-escalation were inappropriate and other measures for controlling aggression were not taken.
This indicates staff’s lack of contemporary knowledge. Lastly, gender sensitivity was considered as female nurses were involved in restraining process.Since restraint is the last option, measures for aggression control progresses from least to most restrictive. At individual level, Petit (2005) recommends steps to advance from environmental manipulation, de-escalation, physical restraint to pharmacological management.
Environmental manipulation involves modifying environmental variables like stimuli removal, which can be done through time-out strategy i.e. transferring patient from over-stimulating situations to a quiet room. It should be followed by promoting patient’s comfort (offering patient a chair or stretcher to relax and giving something to drink) and de-escalation which are psychosocial techniques for calming the patient.
It involves listening without multitasking, exhibiting calm attitude by avoiding arguments and explaining limits in a firm but respectful tone (Johnson, 2011). Relating it with scenario, although nurse attempted to calm the patient but she did so by convincing and arguing with her to remain calm instead of explaining the limits firmly.Moreover,while listening, multitasking was observed.
Keeping that in mind, it is recommended at institutional level to conduct educational and training programme for aggression control, use of restraint and careful screening of violence-prone individuals. Furthermore, crowded milieu and over structured environment should be avoided for such patients. Lastly, it is governmental responsibility to maintain a check and balance and make the institution or individual liable for unjustified restraint.
At any case, if restraint becomes necessary, Mental Health Commission: Code of practice (2009), asserts Clinical Practice Form for Physical Restraint to be filled timely and important considerations to be taken by healthcare professionals at each step during the physical restraint process .
Furthermore, explaining the necessity of restraint to patient and acting in their best interests protects their right of self-determination, an indirect measure to consider autonomy (Draper, MacDiarmaid-Gordon, Strumidlo, Teuten & Updale, 2006).
Moreover, Mental Health Act (2008) obligates nurses to monitor patient frequently, meet their biological needs, provide comfortable environment and make complete documentation including length of restraining, skin assessment and incident reports.
In a nutshell, physical restraint in psychiatry, possess complex ethical dilemma between client’s dignity and safety, making it difficult to reach a single conclusion.Its effects can be as severe as death, thus, legal frameworks suggest restraint to be used as last resort when all other least restrictive alternatives fail.
Moreover, it is important for nurses to be updated with contemporary knowledge for detailed assessment of the situation keeping ethical frameworks in mind.However, if restraint becomes necessary, nursing considerations should be regarded at each step.Lastly, the focus should not be on changing client’s behaviour for specific period of time but on changing client’s internal attitudes for prevention of such coercive treatments.
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