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Running head: TO RESTRAIN OR NOT TO RESTRAIN

To Restrain or Not to Restrain


Todd Shumway, Reina Fujiwara, Anthony Paguyo, Virginia Small, Chris Hillman, and Christine
Rombawa
Kapiolani Community College

TO RESTRAIN OR NOT TO RESTRAIN

Physical restraints are any manual method, physical, mechanical device, material, or
equipment that immobilizes or reduces the ability of a patient to move freely (Potter, Perry,
Stockert, & Hall, 2013). These can include vests, straps, wheelchair bars, and bed sheets.
Restraints are usually used for patients who have a high risk for falls, who are disoriented and
confused, for patients who try to remove medical devices, and to ensure the safety of the patient
when less restrictive methods are not successful (Pellfolk, Gustafson, Bucht, & Karlsson, 2010).
Although the intention to use restraints is in the best interests of care for the patient, there are
potentially many negative outcomes associated with using them, including physical and
psychological problems, and even death (Huang, Chuang, & Chiang, 2009). Nurses are the key
decision makers in the application of the restraint process, however there are many ethical issues
that may occur with the use of restraints.
The setting for our scenario took place in a mental health institute, where a 27 year old,
schizoaffective patient became manic, as she refused her medications, for the past three days.
This patient became verbally and physically abusive towards the staff and other patients, and
changed the milieu to an unsafe environment. This patient also has a history of suicide attempt,
and she started stating that she wanted to kill herself. The nurses and MHS staff members tried
techniques such as redirection, breathing/relaxing techniques, group therapies, and de-escalating
to calm the patient down, but none of these methods worked. She put herself and others at risk,
so the nurse felt that it was appropriate to call the physician and order restraints so that the
patient can calm down and proceed with other treatments. However, when the nurse informed the
family member of the physicians decision regarding restraints, the family member became upset
and refused restraints, as he believed it would make her more crazy and do more harm. This
family member is the POA for this patient, as she is unable to make decisions at this point. So the

TO RESTRAIN OR NOT TO RESTRAIN

question is, what would you do? In this paper, we will argue the different sides, along with
ethical principles that regard the use of restraints in the hospital setting.
By applying restraints, nurses practice the conduct of beneficence the act that is done
for the benefit of others. Beneficent actions can be taken to help prevent or remove harm or to
simply improve the situation of others (Pantilat, 2008). In this case, the nurse felt that it was right
to call the doctor and inform him about the current situation, and the physician weighed and
balanced the benefits against the possible risks for restraints. He decided that because the manic
patient and other patients were at risk for harm, and the nurses already tried other methods to
calm the patient, that restraints were the best possible action to implement at this time. This goes
hand in hand with the act of non-maleficence, the act of doing no harm. Non-maleficence
refrains from providing ineffective treatments or acting with malice toward patients (Pantilat,
2008). In this case, trying to calm the patient down using nonpharmacologic methods such as
redirection, breathing techniques, and de-escalating were shown to be ineffective in calming the
patient. It is hard for the staff to work and be calm with a patient who is in a manic state and is
being harmful, so by practicing beneficence and non-maleficence, and providing restraints, this
will control the situation in a safe and well-practiced way.
Even though some may argue that restraints are harmful for the patient, the Joint
Commission has standards regarding restraints and seclusions for nonviolent crisis intervention
that provides safety regulations to prevent harm or any other negative effect. Some standards
include using restraints to calm the individual and used to protect, not to punish, no element of
pain is involved, the hospital does not use standing orders or PRN, physician needs to reassess
before writing in a new order, individual is not restrained on the floor (reducing the risks of
restraint-related positional asphyxia and other injuries), offer food and water every hour, assess

TO RESTRAIN OR NOT TO RESTRAIN

skin integrity, having the hospital train staff to safely implement the use of restraints and
seclusions with knowledge of who can order it and discontinue it, and there is also a time frame
for restraints (1 hour for children under 9 years of age, 2 hours for children and adolescents 9-17
years of age, and 4 hours for adults 18 years of age or older). With these standards and
regulations in place, it sets a boundary for the use of restraints in a therapeutic and safe way. The
Joint Commission is based off of the best practices, so if the hospitals follow these protocols,
restraints can be used effectively and efficiently, causing no patient harm or adverse effects (CPI,
2009).
As being the other patient in the milieu with Virginia, Chris has rights as a patient that
was violated. According to the Patient Bill of Rights, as a patient, you have the right to receive
considerate, respectful and compassionate care in a safe setting regardless of your age, gender,
race, national origin, religion, sexual orientation, gender identity or disabilities, and to receive
care in a safe environment free from all forms of abuse, neglect, or mistreatment (N.A., 2012). In
this case, the patient's bill of rights were violated and tested, which influences the nurses decision
in whether to apply restraints or not.
In arguing against the need for restraints, restraints of any kind is a form of imprisonment
and the reasonable and prudent nurse will closely adhere to all laws, rules, and policies
pertaining to the use of restraints. The goal when restraints are clinically indicated is to use the
least restrictive restraint and only when all other strategies to ensure patient safety have been
exhausted (Cherry, 2014). There are potentially many negative outcomes associated with using
them, including physical and psychological problems, and even death (Huang, Chuang, &
Chiang, 2010). In the case Estate of Hendrickson v. Genesis Health Ventures the jury awarded 1

TO RESTRAIN OR NOT TO RESTRAIN

million dollars when a restrained patient was found dead who was found wedged between the
side of the mattress and the bedside rail (Cherry, 2014). Applying these restraints cannot only
endanger this patient, but also can cause her to become more confused agitated, and violent.
Patient restraints can harm the treatment process and exacerbate the patients condition (Gelkopf
et al., 2010). It has been considered a disciplinary intervention and a breach of patients rights
(Gelkopf et al.).
As for Anthony, the POA, a durable power of attorney is a legal document that authorizes
the patient to name the person (agent) who will make the day-to-day decisions if the patient
becomes decisionally incompetent (Cherry, 2014). When patients are no longer able to make
decisions, they may assign an agent to carry out the patients desires. Respecting patients rights
is always a priority in any healthcare setting. In addressing the ethical principle of autonomy
from the patient's standpoint, applying restraints would be a violation of the patients as well as
the patients POA in personal freedom and the right to make choices. If an autonomous persons
actions do not infringe on the autonomous actions of others, that person should be free to decide
whatever he or she wishes (Cherry, 2014). Unfortunately, in this case, the patient is infringing on
others autonomy and disrupting others freedom and choices, which directs the nurses to wanting
to apply restraints.
The need to establish safe and alternative treatments when it comes to handling at risk
patients is needed so that patient health is always maintained at a high standard. Although in this
case, it was stated and shown that there were alternatives used, in assessing the level of
education, experience, and knowledge about restraints was unclear. Understaffing, inexperienced
staff, or lack of patients by the ward all display problems to the environment that nurses face
(Gelkopf et al., 2010). More experienced nurses view restraints as a therapeutic instrument for

TO RESTRAIN OR NOT TO RESTRAIN

dealing with violence, while less experienced nurses view restraints as a negative implication of
humiliation, punishment, and staffs inability to cope with violence (Gelkopf et al.). Hospital
education and teachings about restraints could also benefit health care workers. Huang et al.
(2010) conducted a 90-minute pretest-posttest physical restraint education program for nurses in
an intervention and control group. Part of the program assessed the effects of physical restraint
use and alternatives to physical restraints (Huang et al.). The results showed that the in-service
education program did affect nurses knowledge regarding physical restraints. It revealed that
the frequency of proper use, knowledge, and attitudes toward restraints improved (Huang et al.).
Overall, nurses attitudes and beliefs, potential side effects to the patient, and alternative
treatments continue to be an issue in health care settings. Nurses feelings about the use of
restraints vary from nurse to nurse showing an inconsistency as to why restraints should be
applied. Restraints can cause major side effects physically and mentally that are detrimental to
the patients health. The need for alternative therapies such as increased verbal intervention and
relaxation techniques can produce positive outcomes for patients and nurses alike. Although the
use of restraints is still being used in health care settings, the adaption of new techniques and inservice education programs can benefit nurses knowledge and attitudes of restraints. This can
increase patient safety and provide better quality of care for both the patient and nurse.

TO RESTRAIN OR NOT TO RESTRAIN

References
Cherry, B., & Jacob, S. R. (2014). Nursing leadership and management. In B. Cherry & S. R.
Jacob (Eds.), Contemporary nursing: Issues, trends, & management (6th ed., pp. 285308). St. Louis, Mo: Elsevier Mosby.
CPI. (2009). Joint Commission Standards on Restraint and Seclusion. Retrieved from
https://www.crisisprevention.com/CPI/media/Media/Resources/alignments/Joint-CommissionRestraint-Seclusion-Alignment-2011.pdf.
Gelkopf, M., Roffe, Z., Behrbalk, P., Melamed, Y., Werbloff, N., & Bleich, A. (2010). Attitudes,
opinions, behaviors, and emotions of the nursing staff toward patient restraint. Issues in
Mental Health Nursing, 30(12), 758-763.
Huang, H. T., Chuang, Y. H., & Chiang, K. F. (2010). Nurses' physical restraint knowledge,
attitudes, and practices: The effectiveness of an in-service education program. Journal of
Nursing Research (Taiwan Nurses Association), 17(4), 241-248.
N.A. (2011). Code of ethics overview. American Nurse Association. Retrieved from

http://www.nursingworld.org/Mobile/Code-of-Ethics/code-of-ethics.html.
N.A. (2012). Patient bill of rights and responsibilities. Retrieved from
http://www.hopkinsmedicine.org/the_johns_hopkins_hospital/_docs/bill_of_rights.pdf.
Pantilat, S. (2008). Beneficence vs. Nonmaleficence. Retrieved from
http://missinglink.ucsf.edu/lm/ethics/Content Pages/fast_fact_bene_nonmal.htm
Pellfolk, T. E., Gustafson, Y., Bucht, G., & Karlsson, S. (2010). Effects of a restraint
minimization program on staff knowledge, attitudes, and practice: A cluster randomized

TO RESTRAIN OR NOT TO RESTRAIN


trial. Journal of the American Geriatrics Society, 58(1), 62-69. doi:10.1111/j.1532
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Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing (8th
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