Moral Dilemmas Regarding Physical Restraints in Intensive Care Units: Understanding Autonomy, Beneficence, Non-Maleficence and Justice in the Use of Physical Restraints

Introduction

The moral issues are naturally more focused in human-centred care.¹ Patients are often vulnerable and require professional help and care, and care involves close interaction with them.² Complex situations arise when caring for patients, and nurses have difficulty making decisions, often facing the greatest legal and ethical responsibilities.²

Many patients in intensive care units (ICUs) experience hallucinations, delirium and agitation.³ Furthermore, they may exhibit abnormal behaviours such as aggression, tube pulling, trying to get out of bed, throwing objects and hurting themselves and others.⁴ Therefore, intensive care nurses may use restraints to ensure patient safety. Physical restraints avoid the physical damage caused by the use of chemical restraints and do not require caregivers to constantly hold patients down to control limb movements. This is therefore a commonly used method in ICUs,⁵ with approximately one-third of patients in ICUs requiring physical restraints.⁶ The definition of physical restraints is the use of any manual technique, such as the use of physical force, materials or equipment, to limit the mobility of the arms, legs, body or head to remove or reduce a patient’s free movement. These techniques harm the patient’s freedom, health and comfort.⁷ As a result, most intensive care nurses face moral dilemmas when deciding whether to use physical restraints.⁸ Not using physical restraints may cause physical and mental damage to patients, but using physical restraints is often against the patient’s wishes.² Nurses, as the implementer, usually experience moral dilemmas over using physical restraints because they need to weigh patient autonomy against patient safety.² The moral dilemmas faced by nursing staff can have a significant impact on the quality of patient care. Some studies have focused on factors that influence the moral issue of nurses, as well as experiences of physical restraints.^9,10 These studies indicate that even if nurses guide physical restraints as necessary, they still face moral issue. Therefore, this paper examines the use of physical restraints in medical settings through the four universal principles of ethics of autonomy, beneficence, non-maleficence and justice to help the nursing profession. Through these principles, the author will critically explore whether the use of physical restraints by nurses is ethical in practice and what moral issues exist. This paper also explores the conflicts and moral dilemmas that nurses face in mechanical restraints. Moreover, the nurse, as a moral agent in ethical decision-making, will be critically discussed. Patient consent and nurse decision-making will be incorporated into an analysis of care ethics. Finally, suggestions are made on changes to education and clinical practice.

This study searched both Chinese (CNKI) and English databases (Pubmed, NCBI), with keywords such as nursing, nurse, physical constraints, and moral dilemmas. The retrieved literature was screened based on inclusion and exclusion criteria. Inclusion criteria: 1) The theme is the moral dilemma of nurses regarding physical constraints; 2) Can obtain the full text. Exclusion criteria: 1) Conference papers; 2) Unable to obtain full text.

Moral Dilemmas Faced by Nursing Staff

Nursing is an interactive process. The attitude of caregivers towards the use of restraints varies.^5,11 Some caregivers regard its use as inhumane, leaving them with a sense of guilt. However, for patient safety, restraints has to be used. To prevent falls and self-harm, older adults may face more physical restraints.¹² The autonomy of the elderly should be respected, and nurses should follow the principle of benefit without harm; however, this leads to a moral dilemma. When the elderly refuse treatment or exhibit self-harming behaviours, nurses must carefully consider the safety of the patients rather than their autonomy. If safety cannot be guaranteed, nurses may bear legal responsibility. Therefore, they may be more inclined to sacrifice the patient’s autonomy.² In addition, moral dilemmas can also cause mental-health issues for nurses. The nurses have negative emotions such as sadness, helplessness, tension and guilt when facing ethical conflicts.¹³ These negative emotions make them doubt their own ability and also lead to clinical misjudgement in their daily nursing activities. These findings are consistent with the previous research.¹⁴ Whether to restrain or not is a double-edged sword in terms of ethical considerations, and the resulting physical and mental damage to nurses affects the quality of nursing. This impacts nursing objectives, creating a vicious circle. In this regard, nurse response measures can be divided into three categories:¹⁴ maintaining a positive attitude and taking action to solve the problem, adopting a negative attitude towards the problem and negative actions, and failing to respond or take action. The researchers suggest that hospital managers encourage nurses to adopt positive attitudes and actions to improve the quality of care of the elderly and mobilise confidence and enthusiasm in their work through the analysis of an ethical-dilemma response scale. In addition, one of the purposes of nursing is to promote patient comfort and guarantee patient well-being. When nursing staff respect the independent decision-making power of elderly patients requiring restraints, they must also consider the well-being of other elderly people.

Ethical Judgement of Physical Restraints Use

As the traditional paternalistic medical model worldwide is being gradually reformed, the autonomy of patients is becoming increasingly valued. In traditional models, patients are cared for but are not decision-makers.¹⁵ The emphasis on autonomy is the result of social transformation; however, it is also derived from the four principles of medical ethics – autonomy, beneficence, non-maleficence and justice.¹⁶

Autonomy

Autonomy is a concept deeply rooted in Western culture, involving humanity and respect.¹⁷ An autonomous person can guide their daily life according to their beliefs and values.¹⁸ Liberty is an integral part of autonomy and refers to the ability of patients to make decisions without being manipulated or coerced.¹⁹

Although there is no absolute autonomy, in clinical practice, patient autonomy is often violated.²⁰ According to its definition, the principle of restraints is incompatible with autonomy because both procedures involve restricting patient freedom in some manner and against their will.¹⁹ In the healthcare profession, experts in their respective fields jointly provide nursing commensurate with their professional knowledge, and patients are expected to accept medical advice while receiving nursing services, which forms the basis of the concept of compliance.¹⁹ Compliance means a tendency to succumb or acquiesce, and the underlying assumption is that the caregiver has sufficient relevant knowledge to decide what the patient’s best interests are to determine the greatest possible outcome for the patient, resulting in appropriate intervention measures. Research found that when the key value-guiding behaviour of medical staff is to generate the most significant benefit for patients, patients lose their voice.²¹ Because of the unequal relationship between patients and caregivers, professional caregivers have a responsibility to create an environment that promotes patient autonomy.¹⁹

Medical professionals seek to protect the autonomy of patients because protecting their autonomy respects their personality.²² In a qualitative study, nurses stated that they tried their best to explain why they used physical restraints and what kind of controls they used. However, because most patients in this situation have limited mental status, informed consent is usually not obtained.²³ Nevertheless, most nurses do participate in a decision-making process with patients’ families.²³ Restraints use, as with any treatment, violates a person’s autonomy unless patients or their agents have provided informed consent or the requirement for informed consent has been excluded.²² Hence, providing this information to patients is considered a necessary condition when considering the use of restraints and shows respect for patients as humans.²³ Thus, in treatment, the value of autonomy can be expressed through adequate informed consent procedures and joint decision-making.

Guidance from the US Department of Health and Human Services clearly outlines patients’ rights in the use of restraints.²⁴ It states that freedom from restraints is a patient’s right and that these coercive measures should only be used in situations that threaten the lives of patients or staff.²⁴ Therefore, in certain unavoidable circumstances, the use of restraints might be the only option for the team responsible for patient safety.¹⁹ For example, when patients are aggressive, hurting themselves or others, staff have the right to expect protection and have tools to ensure their own safety and that of other patients. Thus, in particular circumstances, nursing staff must use physical restraints in violation of the patient’s autonomy.

Beneficence and Non-Maleficence

The use of restraints protects patients and reduces self-harm, but it may causes psychological damage to the patient.^6,9 The Center for Ethics and Human Rights (2012) states that nurses’ primary commitment is to patients, whether individuals, families, groups, communities or populations.²⁵ It also notes that directly or indirectly restricting or isolating patients is considered a violation of the primary goals and ethical traditions of the nursing industry. Therefore, physical restraints use conflicts with the nurse’s moral responsibilities of beneficence and non-maleficence to patients. Moreover, these two moral principles are inevitable results of each other.¹⁹ In healthcare, beneficence refers to the promotion of patient well-being by healthcare staff through research or implementing active therapeutic interventions, and non-maleficence is the responsibility of the clinician not to harm, intentionally or otherwise, the patient.²⁶ To hurt someone means to negatively affect or disadvantage someone in some manner.¹⁶ The harmfulness and lethality of restraints use have been verified in relevant medical fields, such as those related to the elderly, rehabilitation and psychiatry.^27,28 Therefore, when applying physical restraints to patients, attention should be paid to avoiding harm.

Notably, a patient’s exercise of autonomy may conflict with clinical moral obligations.¹⁹ Nursing staff want to provide what they consider to be the most suitable care for patients, but they must also acknowledge their preference during the nursing process. Competent clinicians and nurses follow the principle of beneficence. However, they may not realise that from a professional and patient perspective, the understanding of the nature and content of “good” may differ.²³ Increasing evidence suggests that patients and practitioners may view patient care differently.²⁹ However, except in situations where security is a real concern, the use of restraints is contrary to the principles of non-maleficence and beneficence. Based on the evidence, the use of such under-researched procedures is controversial and dangerous.²⁰

Justice

Justice refers to the fair treatment and rights granted to others and the equitable distribution of resources,³⁰ although some groups may face more restrictive behaviours in relation to justice (eg children, young people and African Americans).³¹ These people are therefore considered vulnerable in the healthcare system. In the United States, parents regard their minor children as personal property, leaving these children with no right to express themselves.¹⁹ In this context, judicial issues have diverged from mainstream medical considerations. When patients are violated or they become a danger to others, the issues of justice and physical restraints come to the forefront.¹⁹ Specifically, blindly applying physical restraints to aggressive patients does not promote interpersonal relationships or interaction. Therefore, physical restraints should be considered critically because ignorance of justice leaves patients vulnerable to prejudice and unfair treatment.³² Although the use of physical restraints in the care process is unavoidable in some cases, restrained patients should be treated as humans and their basic needs met.

There can be no objections to the statement that restraints may violate people’s rights.³³ However, does this mean it should never be used? The American Nurses Association (ANA) states that nurses must be compassionate and treat all patients with respect for their inherent dignity, value and unique attributes.²⁵ Research noted that effective care should pay attention to all aspects of the patient as a person, including physical, psychological and moral aspects.³⁴ However, the medical environment is complex, and sometimes, how to provide ethical care is unclear, especially when deciding the correct course of action is challenging, potentially leading to moral conflict.³⁵ For example, when patients are unable to make decisions or claim rights by themselves, their rights are easily violated. Therefore, nurses must understand the importance of human rights so that they can protect the rights of patients and provide ethical care in particular circumstances.³⁵

Legal Considerations of Physical Restraints

In addition to ethical considerations, the use of restraints is accompanied by legal constraints and norms. Studies^11,36 have shown that injuries caused by falls are the main reasons for the prosecution of nursing homes. Falls not only cause physical injury to the elderly but also result in nursing homes facing compensation claims for medical expenses. In 2000, Japan established long-term care insurance³⁷ to care for the elderly population. In addition, Japan’s Ministry of Health and Welfare passed legislation to prohibit the use of physical restraints among elderly patients with long-term care insurance. However, in terms of medical insurance, it is legal for medical workers to use restraints. This is because long-term care insurance is separate from medical insurance. The common reason for prosecution in disputes related to medical accidents is that the right of informed consent of family members is not guaranteed.¹¹ In the present study, we must highlight the right of informed consent of family members and the right of medical staff to provide treatment. In the nursing of elderly patients, staff have the right to decide their patients’ nursing plan. Therefore, when using physical restraints, the key factor is whether nursing staff have abused their power. Article 483 of Chapter 42 of the Federal Code of the United States³⁶ and the law on the reform of nursing homes³⁸ clearly stipulate that it is prohibited for caregivers to use physical restraints on elderly patients for the purpose of discipline or convenience, and the patient has the right to reject the restraints used. The establishment of these laws and regulations, to a certain extent, regulates the scope of the use of restraints and avoids the abuse of power by medical staff for convenience. Others have proposed that a restraints restriction order should be introduced to limit the use of restraints.³⁷ When assessing whether the elderly need to be restrained to support treatment, medical staff should carefully consider the potential hazards and consequences rather than simply using physical restraints for treatment purposes. The elderly need medical staff to take responsibility for the abuse of restraints. In 1974, US legislators became aware of the problems of restraints use in nursing homes and introduced a series of regulations for the elderly. However, many of these regulations have not been implemented. The right of informed consent of the family requires the caregiver to decide whether to strictly implement the obligation to inform or whether to explain the related adverse consequences of restraints use to the family members in detail as well as to consider the prevention and control measures for adverse consequences. If caregivers do not carefully observe the skin at the restraints site, the improper use of restraints can lead to related complications in elderly patients. Thus, the dereliction of duty can directly cause physical and mental damage.¹¹ Legal warnings and implementation help reduce the use of restraints. Studies have found that after the implementation of relevant laws, some nursing homes reduced the use of physical restraints, and caregivers became more cautious when using restraints.^39,40 The right of informed consent is the main manifestation of autonomy among the elderly and their families in relation to treatment. This not only requires legal protection but also caregivers to respect the rights and interests of the elderly and their families rather than facilitate their use of restraints on elderly patients.

As many countries call for a reduction in the use of restraints in nursing homes and the development of research on alternative forms of restraints, the use of restraints has been reduced¹¹ but not eliminated. In 2013, the Australian Evidence-Based Healthcare Centre published three principles of physical restraints: try not to use physical restraints, remove them as soon as possible and find alternative methods whenever possible. Nursing homes may not accept a reduction in the use of restraints because it will increase their costs.³² A consultation of a large amount of literature found that the physical and mental harm caused by restraints is undeniable and inevitable, and the occurrence of harm can only be minimised and reduced. Reducing the excessive use of restraints is more important than simply avoiding its use or reducing the restraints rate. Nursing of the elderly in nursing homes is essentially different from that of hospital patients, and nursing staff should be cautious in the use of restraints. Caregivers of elderly patients should change their view of restraints use and focus on nursing before considering restraints use. A reduction in predictive restraints can reduce restraints use. For elderly patients who require restraints, caregivers must prevent and treat any related physical injuries. In addition, caregivers should take measures to alleviate the negative emotions they experience when using restraints, for example, through psychological care, counselling and support. The cultivation of empathy among nursing staff can enhance the relationship between them and the elderly in their nursing duties and encourage elderly patients to actively cooperate with the implementation of nursing operations. Nursing staff should strengthen their communication with elderly patients, establish a positive relationship with them, observe and understand their wishes and needs, and take corresponding measures. Studies have shown that the education and training of nursing staff should be strengthened.⁴¹ However, it is not enough to address the issue only in this manner.¹⁴ Researchers have proposed alternative restraints methods to reduce restraints injuries, such as providing support for the self-care ability of elderly patients by improving environments that are potentially harmful to them, reducing the factors that induce mental disorders, enhancing training and encouraging active participation in daily life^41,42. In 2002, the Department of Health and Social Services in Quebec, Canada, drafted guidance for medical institutions on the use of alternative forms of restraints.⁴³ The guidance describes the issue of protecting the dignity of elderly patients while reducing the potential risks and injuries of physical restraints. However, alternative restraints methods cannot completely replace the role of restraints. In 2009, the Norwegian government introduced the Patients’ Rights Act. This Act stipulates that medical staff can use physical restraints when the method of alternative restraints is ineffective and the patient is unconscious. In addition, the use of restraints requires the advantages of restraints use to outweigh the disadvantages.⁴⁴ At present, China has no unified standard guidelines for the use of physical restraints.⁴⁵ Nursing homes developed later in China than in some other countries. Therefore, China must establish a set of standards specifically for the use of physical restraints for the elderly residents of these homes. There are relevant guidelines in other countries.⁴⁶ Nursing managers can refer to the existing literature, reports and other materials and consider China’s national conditions to formulate appropriate standards to guide the use of restraints for the elderly by caregivers.

Current Situation in China

In China, nurses face challenges and moral dilemmas when using physical restraints. Overall, for various reasons, China’s health services are not developing as fast as in Western countries. Moreover, although the population is large, the number of registered nurses in China is lower than the global average.⁴⁷ Understaffed healthcare institutions are faced with a patient load that exceeds their capacity, but they also need to provide nursing services that meet the standards. This leads to a heavy workload for nurses. Therefore, when faced with agitated patients, it is easy for nurses to physically resist aggression because other options consume resources (eg in terms of time and personnel), which is challenging in clinical situations.²

Nurses have a dilemma as to whether to use physical restraints, and they feel helpless and fearful when facing aggressive patients.⁴⁸ Nurses need to balance the ethical principle of beneficence, ensuring the safety of the patient, and the principle of autonomy of the person.⁴⁹ Whether to use physical restraints and the extent of use is determined by the nurse’s attitude and clinical culture.³² The ANA noted that imposing physical restraints on patients may be caused by peer pressure and demands,²⁵ and these intentions might not be in the interests or in line with the wishes of the patient. At present, being able to use physical restraints in harsh conditions is critical for medical staff. According to ethical principles, in cases where physical restraints cannot be eliminated, the focus should be on the method which was used. Therefore, moral considerations should be based on autonomy, beneficence, non-maleficence and justice.

Obtaining informed consent from patients is the basis for respecting patient autonomy. However, according to the Chinese Mental Health Commission (2009), in an emergency (for example, when the patient poses a direct danger to others), it is legal to use physical restraints without the patient’s consent.⁵⁰ Given that most patients admitted to hospital are ill and unable to determine what is in their best interests, the informed consent of close relatives is feasible in China because it is consistent with traditional beliefs. Moreover, when considering the possibility of doctor–patient disputes, informed consent is equally crucial for the protection of healthcare staff.

Suggestions for Clinical Practice

It was necessary for the elaboration and implementation of protocols on intervention to support decision making was observed.⁵¹ According to the Irish Mental Health Commission (2014), the principles and requirements that support physical restraint must be specified in an organisation’s guidelines to standardise and monitor nursing practices and ensure that treatment goals can be achieved.⁵² Only in this way can the binding treatment goals exceed the side effects of restraints use;⁵³ otherwise, illegal behaviour may result in abuse resulting from the use of physical restraints.³² Attitudes and experiences were the main determinants for restraint use. Nurses asked for more discussion about restraints in the team, for more support at an interprofessional level and for better guidelines to help with the decision-making process.⁵⁴ Employee training is a meaningful way to reduce the use of physical restraints and provide training to nurses to familiarise them with guidelines, respond to violent behaviours and regulate their behaviour. China’s National People’s Congress (2012) requires nurses to strictly abide by the National Mental Health Law – only after a comprehensive evaluation of the patient and the recording of the results in the electronic medical record can physical restraints be used.⁵⁵ Moreover, to reduce the side effects of restraints use, unless the restraints is removed, medical staff should conduct a medical examination promptly. The restraint-free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family.⁵⁶

Summary

The moral dilemma associated with physical restraints use is a double-edged sword, and the damage it causes to nurses both physically and mentally affects the quality of nursing. This has consequences for nursing objectives, forming a vicious circle. The use of physical restraints faces many challenges in terms of autonomy, beneficence, non-maleficence and justice. Although nurses played a crucial role in the decision-making process of using physical restraints, changing the healthcare climate and the hospital management mode for unplanned extubation are fundamental measures to reduce physical restraints use.⁵⁷ Many countries have developed guidelines and principles that regulate restraints use, reduce its physical and mental harm to patients and improve the moral dilemma of nursing staff. In China, nursing staff face more serious moral dilemmas related to restraints use. Therefore, China must develop guidelines for restraints use in response to the current situation in the country.

Conclusion

The moral dilemma faced by nurses regarding physical constraints was mainly based on four principles. At present, there was no clear evidence to support or not support the physical restraints behavior in the intensive care unit. This study focuses on how to consider the interests of patients and better implement physical restraints. Relevant agencies should develop clear guidelines for the use of physical restraints based on evidence-based practice. Guidelines for restraints use that are suitable for countries and regions can be developed based on four principles. Moreover, education and consultation programmes should be developed and implemented for nurses. For issues related to the use of physical restraints, the programme content should be based on ethical nursing practices, patient rights, physical restraints guidelines and legal management principles. The actions and beliefs of experienced practitioners should be carefully considered. Therefore, more attention should be paid to common methods of physical restraints in medical treatment. Attention should also be paid to the workload and psychological state of nursing staff, as these are related to their attitude towards patients and their judgement on whether to adopt restraints. This article critically examined the use of physical restraints through moral principles and discussed the moral dilemma of nurses in relation to this issue.