Physical restraint using, autonomy, ethics among psychiatric patients in nursing practice in China

Jun‑Fang ZENG, Hong‑Tao CAI, Wei‑Ming LI,Cai‑Mei ZOU

1Department of Affective Disorder, Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China;2Department of Nursing Administration, The Third People's Hospital of Foshan, Foshan, China

ABSTRACT

The application of physical restraint for patients represents ethical dilemmas for psychiatric nurses in terms of maintaining the safety of all (clients and staff) while at the same time curtailing the individual’s autonomy.This article aimed to provide a sound knowledge of ethical positions and strategies for psychiatric nurses to address ethical issues of physical restraint according to the ethical principles of autonomy, beneficence,nonmaleficence, and ethical theories.Given that nursing workforce was limited and workload among psychiatric nurses was heavy, physical restraint was one of the coercive interventions managing aggressive behavior.In relation to address ethical dilemmas, it was proposed to acquire informed consent of physical restraint from the individuals and provide person‑centered care.Effective communication and negotiation with patients could help to strike a balance between patients’ autonomy and nurses’ accountability when using physical restraint.In addition, guidelines and targeted intervention strategies need to be developed to regulate and reduce the implementation of restraint.Finally, a collaboration among nurses, psychiatrists, and families is essential to protect patients’ autonomy concerning physical restraint use.

Keywords: Autonomy, ethics, nursing practice, physical restraint, psychiatric nurses

INTRODUCTION

Globally, physical restraint use is the subject of ethical debate and legal concern, for it is regarded as a practice violating patients’ autonomy and dignity both ethically and legally.[1,2]Undeniably, the application of restraint for patients is a complex process, representing ethical dilemmas for psychiatric nurses regarding maintaining patient safety while at the same time curtailing the individual’s autonomy.The Mental Health Commission of Ireland has clearly claimed several principles underpinning the use of physical restraints.[3]First, physical restraints must be employed in exceptional circumstances when the service users present an immediate danger to themselves or others.Second, restraint should be used in particular circumstances as a last resort only when all alternative nursing interventions have failed.Third, it should be utilized in a professional manner and based on an ethical and legal framework.According to the Code of Ethics and Standards of Psychiatric Nursing Practice in Canada,[4]psychiatric nurses should respect patients’autonomy and rights to self‑determination to uphold the patient’s legal and moral rights.Similarly, a guidance document regarding physical restraint use in Ireland also clearly states that medical personnel should use physical restraint following the ethical principles and respecting patients’ dignity.[5]However, the Mental Health Act of China issued in 2013 covered little about how to protect restrained clients’ autonomy and dignity.Moreover, the Chinese Nurses Ethical Code simply guides nurses to respect the human rights and dignity of patients in clinical practice.[6]Such general guidance and statements provide little help for Chinese psychiatric nurses in addressing the ethical issue in using physical restraint.Indeed, no guidelines or frameworks currently exist in China to assist psychiatric nurses to cope with ethical issues regarding physical restraint.Therefore,this article aims to provide a sound knowledge of ethical positions and strategies for Chinese psychiatric nurses to address ethical issues with regard to physical restraint, as there is no complete set of “rules” that can offer nurses for an answer to each dilemma.The author will critically analyze the ethical issue in conjunction with the ethical principles and relevant philosophical theories.Specifically, the principles of autonomy, beneficence, nonmaleficence, and ethical theories will be employed to discuss in this article.[7,8]

CHINESE NURSES’ ATTITUDES TOWARD PHYSICAL RESTRAINT

Undoubtedly, mental health‑care workers primarily involve psychiatrists and nursing staff.However, psychiatrists and nurses face patients in a quite different way since nurses are with the patients on the 24‑h basis, and thus, their ethical dilemmas in using physical restraint may be more challenging.[8]The concept “moral distress”, initially coined by Jameton,[9]describes the situation in which someone knows the morally right thing to do but cannot do due to various external constraints.A number of studies have revealed that restraint use may lead to nurses’ moral distress such as frustration, shame, guilt, and anxiety.[10,11]However, in a study identifying Chinese nurses’ attitudes and practice toward physical restraint, Jiang[1]concluded that most nurses regarded restraint as a routine practice and a necessary method to prevent patients from harm.Another survey[1]involving 172 Chinese nurses reported that 63.4% of participants did not feel guilty when they restrained a patient.[12]Many Chinese nurses believe that they need to put the safety of their patients first, rather than morality,human rights, and dignity.In addition, under the Chinese Mental Health Act,[13]when patients pose a severe threat to themselves or others, it is legal to conduct physical restraints without the consent of patients during an emergency; thus,the nurses play a crucial role in making decisions on the use of restraints.[1]Besides, the practice of informed consent for people with a mental health condition in China is family oriented.As most patients are involuntarily admitted, their relatives or next of kin play a pivotal role in decision‑making regarding physical restraint.[1]Most nurses may feel that it is unnecessary to acquire informed consent from the patients regardless of their level of capacity to judgment once the patients are involuntarily admitted.

The term “capacity” means the ability of an individual to understand the nature and consequences of a decision to be made by him or her in the context of the available choices at the time the decision is to be made.[14]Therefore, getting the informed consent of restraint from patient’s families makes the nurses feel less morally distressing when caring for restrained patients.Thus, the first ethical issue discussed in this article is whether the nurses are ethically right to just acquire the informed consent of physical restraint from families rather than patients themselves when the patients are capable of making their own decisions? Is the nurses’ behavior morally acceptable when their nursing role requires them to do more to advocate for psychiatric patients’ rights?

ADVOCATE ROLE OF PSYCHIATRIC NURSES

According to Scott,[8]acting as an advocate for the clients has become a significant part of the nurse’s role in the 21stcentury.The reasons are, on the one hand, clients’ rights need protecting; on the other hand, nurses are the health‑care professions who have the most constant contact with clients,particularly in the psychiatric environment where the patient–health‑care staff contact may reach over months and years.As maintained by Registered Psychiatric Nurses of Canada,[4]psychiatric nursing professionals should uphold patients’legal and moral rights.Similarly, Harnett and Greaney[15]stated that psychiatric nurses should articulate standards and critical competencies to create and support patients’autonomy.Given that people with mental disorders belong to a vulnerable group who are finding the concept of autonomy and self‑advocacy challenging to achieve, psychiatric nurses as advocates thus have an obligation to advocate for their clients’ rights and exercise ethics in the clinical practice.With regard to physical restraint for patients, it is true that the external constraints include workload, patients’ clinical characteristics such as severe aggression, and suicide can influence nurses’ attitudes toward physical restraint use.[16]However, as claimed by Cheung and Yam,[17]suffering from mental illness should not be taken as a reason to restrict a person’s autonomy.From this point of view, nurses’ failing to obtain informed consent from a competent patient before implementing restraint is morally wrong in terms of the nurses’ advocacy role, even though it is legal to do so under the protection of the Mental Health Act of China.

BENEFICENCE AND NONMALEFICENCE

However, if nurses should exercise moral judgment on restraint use in clinical practice, what standards can assist them to do so? The ethical principles of beneficence,nonmaleficence, and autonomy should be taken into consideration.[18]In the context of patient care, beneficence and nonmaleficence refer to actions taken by health‑care professionals to do good and avoid harm to the patients.Following the principle of beneficence, physical restraint is the direct method to limit patients’ body free movement in emergencies, particularly when they post a severe threat to their lives such as suicide and self‑harm.In addition, the empirical and clinical evidence has shown that medication is useful in the management of psychotic symptoms;hence, it is necessary for clients with severe mental health conditions to adhere to the treatment.[19]However, due to various reasons, many clients may refuse any medical interference; under such a situation, physical restraint, as one of the coercive measures, has to be applied to maintain the compulsory treatment and enable recovery.[20]From this perspective, physical restraints appear to be a practicable method to protect patients from injury and ensure the effectiveness of treatment.

Nevertheless, are these therapeutic effects of physical restraint evidence‑based? Some scholars argue that the evidence showing the therapeutic benefit of restraint is unconvincing because most publications on this subject are case reports or of poor quality.[21,22]Conversely, the empirical and clinical evidence has revealed that the application of restraint can cause considerably detrimental physical and psychological negative consequences for patients.It is argued that physical restraints can cause physical injuries such as skin damage, deep‑vein thrombosis, nervous system damage, or even death.[23‑25]This evidence suggests that health‑care providers should balance the therapeutic goals and adverse outcomes when using physical restraint.According to the guidelines on the use of restraint issued by the Irish Nurses Organization, it highlights the individualized and person‑centered care should be provided for restrained patients.As stated by Smith,[8]offering person‑centered care is essential for the psychiatric service user safety while at the same time maintaining the nurse–patient therapeutic relationship.

Therefore, according to the principles of beneficence and nonmaleficence and given the physical and psychological consequences of physical restraint, the author suggests that the basic needs of restrained patients must be satisfied and patient‑centered care should be provided to eliminate the adverse effects caused by restraint use.Moreover,postrestraint psychological care such as emotional support and humane care should be offered for the restrained person to help them to relieve psychological trauma, thus ensuring continuity of care and prevent recurrences.[20]

RESPECT FOR AUTONOMY

Autonomy is another principle of ethics which also could be used to guide medical staff to cope with ethical issues on physical restraint.In the context of patient care, autonomy refers to medical staff who respect the patients’ right to choose and act following their values, preferences.[14]A restrained patient’s autonomy and liberty have been taken away by the medical staff because of concerns for the person’s safety.In addition, informed consent is one central practical example of the principle of autonomy.[14]Obtaining informed consent from patients has been viewed as the basic requirement to respect and promote the autonomy of individuals.[25]A person with a mental disorder does not inevitably mean that he/she is incapable of making decisions and consent to treatment.However, as Hemet al.[26]emphasized if the patient cannot consent, a method to respect a patient’s autonomy is to involve his/her relatives or next of kin in representing the patient to get informed all the medical procedures.

Therefore, the author suggests that nurses should endeavor to obtain informed consent from patients no matter they were admitted voluntarily or involuntarily to respect their autonomy.[5]In addition, the reasons, potential dangers, and duration of restraint must be explained and illustrated to the clients and their relatives before acquiring the consent to restraint to protect patients’ autonomy.

VIEWS FROM PATERNALIST AND LIBERTARIAN

However, Harnett and Greaney[15]state that patients’ absolute autonomy to some degree may lead them to make poor decisions for themselves and thus cause consequent harm.As Greaney[8]argued, should health‑care professionals always avoid interfering with the choices of patients in order to respect their autonomy? If not, to what extent should medical professionals interfere? As two perspectives of autonomy,paternalists and libertarians have been arguing for a long time.From the paternalists’ point of view, health‑care staff,to some extent, can behave in a paternalistic manner (e.g.,overriding autonomy) to protect the best interests of patients’regardless of patients’ wishes.However, as explained by Dooley and McCarthy,[25]whether paternalistic actions taken by health‑care staff are morally acceptable depends on the degree of paternalism; the weak or justified paternalism which overrides a nonautonomous person’ (such as a psychotic individual) decision to protect them from harm is deemed ethically acceptable, while the strong paternalism which overrides an autonomous patient’ decision is considered to be ethically unacceptable.In contrast to the strong paternalism, the libertarian perspective highlights the individual’s role in making decisions and pursuing freedom of choice as well as maximizing autonomy.[25]Nevertheless,one limitation of the libertarian view is that, to some extent,libertarians are extraordinarily selfish as they consider their absolute freedom as the top priority.[27]Therefore, neither strong paternalism nor absolute liberalism is appropriate for mental health professionals to exercise ethical practice;rather, they should practice ethics in‑between the two to respect patients’ autonomy regarding physical restraint.

However, others may argue that most psychiatric patients may not have the capacity to express their preferences due to mental disorders; thus, mental health staff has to take responsibility for patients’ best interests.As Harnett and Greaney[15]suggested, patient autonomy is not absolute.The term “protective responsibility”, which refers to the particular responsibilities taken by an individual to care for the vulnerable patients, offers a suitable framework for a collaborative approach to care in psychiatric nursing.Similarly, Greaney and O’Mathúna[8]proposed that a process of dialog, effective communication, and negotiation with mentally ill patients could help to strike a balance between patients’ autonomy and nurses’ accountability.The authors also argued that despite the long‑standing influence of Confucian culture, Chinese people’s awareness of autonomy had increased significantly in recent years owing to the impact of globalization and western culture.Therefore,blindly using physical restraints in a strong paternalistic style without listening to the voice and needs of patients is morally unacceptable, and lacking negotiation and effective communication with patients are not in line with the practice of modern‑era society.Psychiatric nurses should act morally to strike a balance between patients’autonomy and nurses’ accountability when deciding to apply physical restraint.

ETHICAL THEORIES: UTILITARIANISM VERSUS DEONTOLOGY

Are there any other philosophical frameworks that could be used to guide nurses to deal with the issue of physical restraint use? Two philosophical theories can also be applied to provide different stances in answering this question, namely utilitarianism (consequentialism) and deontology (nonconsequentialism).[25]The utilitarian is concerned with the greatest benefit for the greatest groups,but it fails to address the individual’s value.They stress whether actions are acceptable or unacceptable depends on the consequences of actions.[25]In clinical practice, applying physical restraint for individual patient is a utilitarianism’s choice because nurses decided to retrain him or her to protect all staff and patients present from harm.However,patient’s individual needs and values were sacrificed, as being restrained is against his or her willing.

In contrast to utilitarian, deontology well supports the individuals’ interests and rights.[25]According to this theory,it can be argued that restraining a person without his or her permission is always morally wrong regardless of any reasons.However, although deontology advocates the individual’s choice of direction is upheld without discrimination using the principles of autonomy, one critique of deontology is that it can be brutal since it leaves no room for professional judgment and discretion.

Overall, it seems reasonable to propose that the underlying theory used in this case will shift to a utilitarian perspective.However, as Goodhall[28]emphasized, following closely one of the major ethical theories or principles would be seriously flawed because it would be neither entirely appropriate nor feasible in the complicated health‑care settings.Health‑care requires sensitivity, and the complexity of real life does demand the combination of rules, principles, and integrity rather than an absolutize method.[29]From this perspective,ethical theories or philosophical theories are useful as frameworks for clinical decision‑making, facilitating the multidisciplinary team to make the ethical decision through teamwork rather than collusion.[29]

SUGGESTIONS

Physical restraints have been forbidden for ethical reasons in some countries (e.g., the United Kingdom).[16]However, as Yeet al.[19]stated, due to the shortage of psychiatric nurses and the underdevelopment of mental health services in China, it is challenging to eliminate physical constraints in the short term.Given this, it is warranted to protect patients’ autonomy and eliminate the detriment of physical restraint.Psychiatric nurses should reflect and balance the ethical principles of beneficence, nonmaleficence, and autonomy when using physical restraint.Besides, providing patient‑centered care is critical to eliminating the physical and mental harm that physical constraints bring to patients.

Hawley[30] stresses that solving ethical dilemmas requires the whole team to be involved, including communication,reflection, and team debriefings to determine the best interest of patients.Thus, a collaboration among nurses, psychiatrists,and families is essential to respect psychiatric service users and protect their autonomy concerning physical restraint use.Furthermore, nursing leadership plays a vital role in fostering a patient‑safe ethical ward climate and changing nurses’behavioral pattern in clinical practice; more guidance and moral education should be provided for psychiatric nurses to cultivate and improve their ethical sensitivity and direct them to practice ethically regarding physical restraint use.[31]In addition, since employing restraint to prevent violence is a long‑lasting practice, nurses report ethical dilemmas over this practice, yet they failed to find alternatives.[4]Nursing leaders should provide more continuing education and training courses in the alternatives to restraint, such as de‑escalation techniques and effective communication skills to regulate and reduce restraint use and change nurses’ attitude toward physical restraint.Finally, through referring to the relevant guidelines of other countries, it is suggested to develop codes of conduct or ethical guidelines regarding physical restraint to guide psychiatric nurses to uphold patients’ moral and legal rights.[4]

CONCLUSION

This article has discussed how psychiatric nurses could apply ethical principles and theories to deal with the ethical issue of physical restraints.The awareness of protecting restrainted patients’ autonomy and dignity should be raised among nurses.In a Chinese psychiatric hospital context, acquiring informed consent from the individuals and providing person‑centered care are essential to respect patient autonomy and eliminate the detriment caused by physical restraint.Effective communication and negotiation with patients could help to strike a balance between patients’autonomy and nurses’ accountability.In addition, guidelines and targeted intervention strategies need to be developed to regulate and reduce the implementation of restraint.Finally, the ethical dilemmas of this ethical issue around psychiatric nurses have been discussed.Good leadership is of vital importance in fostering work ethical climate and nursing staff’ ethical sensitivity to ensure psychiatric nurses to practice ethically.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.