Kristen Trunkey
Philosophy
11/28/2022
During my clinical rotations I was assigned to a patient whom I will refer to as “X”. X had been
admitted to the emergency department for a head injury incurred during a fall brought on by a
hypoglycemic episode. X suffered from schizoaffective disorder with both hallucinations and delusions.
Due to this disorder, X was chronically confused and oriented only to self.
I truly enjoyed caring for X. Outside of the emotional outbursts and sometimes violent
aggression, X was very pleasant. I appreciated X’s delight with the staff’s company and care when he
was in a receptive mood. There was no account of X’s behavior prior to the hospital stay, so I had been
unable to verify if X’s agitated episodes were baseline behavior or if their onset occurred in the hospital.
Over the two months I spent on the renal unit, however, every outburst did seem to correspond to X
adamantly expressing the desire to “escape”. Though X’s perturbed states were likely a product of his
mental illness, the safety measures taken to ensure X’s safety undoubtedly contributed, at least in part,
to his agitation.
X’s confusion and chronically unstable blood sugars put him at high risk for another fall. In cases
such as these, patients’ bed alarms are activated. Bed alarms detect motion and will alert staff when a
patient gets up from their bed. Patients deemed a high-fall risk are asked to call the nurse’s station
before getting up for any reason, such as using the restroom or opening the blinds. X had been unable
to fully understand this process and the concept of fall risk. According to other nurses’ reports, during
the first two days of X’s stay on the renal unit he had made countless attempts to get up and walk
around unsupervised. Despite the bed alarm and repeated efforts to explain the call light function and
its significance, X did not comply. To prevent X from falling again, the nurse manager was compelled to
use restraints. Except for staff-assisted bathroom visits or walks, X was confined to a Posey Bed, a
rectangular tent-like structure containing a mattress that is locked from the outside, or his chair to
which he was placed in a lap belt restraint.
I internally struggled with the use of X’s restraints. Each afternoon X had moments of
awareness to his surroundings, to which he then reported feeling “trapped” and wanting to “escape”.
Though paranoia can indeed be a symptom of schizoaffective disorder, when considering the imposed
restrictions on X’s ambulation, the feeling of being held captive seems logical. These instances of
perceived entrapment preceded X’s agitated states and frequently led to violent fits and the use of
profanity and/or vulgar language directed toward staff. Again, I am unaware if X had been prone to
aggression prior to his hospital admittance, but research has demonstrated hostile behavior to be an
adverse effect of employing seclusion and restraints in behavior management (Chieze et al., 2019). X’s
aggression was quite possibly a response to forms of psychological harm these safety interventions can
cause, such as fear, anxiety, and general distress (W. Haugom et al., 2019). Additionally, the use of
seclusion and restraints has been demonstrated to cause a lack of trust between patients and their
practitioners (Myers, 2009). As trust is an essential aspect of effective patient-nurse relationships, I
worried X’s restraints were negatively impacting therapeutic efficacy.
After discussing my concerns over X’s psychological wellbeing with my preceptor, I learned
these feelings were shared. X had been in the hospital for three months prior to the start of my clinicals.
As such, most of the entire unit had already been struggling with this ethical quandary. The staff and I
morally battled between the need for safety interventions and the impingement on personal autonomy
these measures caused, as well as the emotional trauma they led to. Implementation of seclusion and
restraints presents a conflict between three of the four ethical principles on which biomedical ethics is
founded, including nonmaleficence, beneficence, and autonomy.
Patient safety is of the utmost priority in hospitals, and according to the principal of beneficence
(Beauchamp & Childress, 2019), preventing harm is not only a priority but a duty for medical
practitioners. X’s high-fall risk status and incompliance to ambulation instructions indicated the use of
medical restraints for prevention of falls and injury. His unpredictable moods and behavior further
warranted these safety interventions for the protection of other patients and staff. Therefore, the use
of restraints in X’s case could be regarded as an act of beneficence toward X and all other on the unit.
Unfortunately, this “beneficial act” also served as a detriment to X.
The use of seclusion and restraints impaired X’s autonomy and inflicted emotional harm. Under
the principle of respect for autonomy (Beauchamp & Childress, 2019), patients must have the capacity
for self-determination, acting without constraints or influence from those assigned to their care.
Confining X to a Posey bed and chair blatantly violated this maxim. Despite having full use of his legs, X
was not free to move about, nor could he even go to the bathroom without the staff’s assistance. Such
restrictions would be distressing for any individual, but for someone suffering from schizoaffective
disorder the negative psychological impact can be far worse (Steinert et al., 2007).
X’s violent outbursts and verbalized distress were frequently associated with feelings of
entrapment, evidencing the emotional trauma the restraints and seclusion caused him. Consequently,
these safety interventions directly violated the principle of nonmalificence. Nonmalificence holds that
medical practitioners are sworn not to inflict harm, either physical or psychological, on those in their
care. The observable harm to X’s psyche made it difficult not to object to his restraints. Every time I
went into X’s room I couldn’t help but feel personally responsible for his loss of autonomy and distress.
The Posey bed in particular made X look, and probably feel, like a caged animal. The use of restraints
and seclusion seemed an iniquitous solution for maintaining safety, but despite my discomfort with this,
I also knew it had been a last resort measure taken.
Safety interventions for ambulatory high-fall risk patients are implemented on a scale from least
restrictive to most restrictive. Bed and chair alarms are instituted first, but X’s confusion made it
impossible to utilize these effectively. When staffing allows, the next intervention would be 24-hour
supervision from a patient safety attendant (PSA). Unfortunately, all units in the hospital had been
suffering severe staffing shortages and had not been able to make the allowance for a PSA. Since all
other options for fall and elopement prevention had been explored, the ethical dilemma of maintaining
safety at the cost of violating X’s autonomy and causing emotional distress became a choice between
the lesser of two evils, a decision well-explained through the principle of double effect. According to
this principle (McIntyre, 2018), there are some instances in which it is acceptable to achieve a goal using
measures that may cause harm as a side effect so long as those measures are not the means by which
the goal is achieved. X was admitted to the hospital for a head injury sustained from a fall. Falls such as
these can be life threatening. As such, falls hold the potential to do more harm than the psychological
damage incurred from restraints and seclusion. For X, the Posey bed and chair restraint were found to
be the only successful means of fall prevention. Despite my moral quandary over the intense distress
these interventions caused, they were only temporary measures taken until X could be discharged.
Were restraints not used, a potential fall could have been fatal.
References
Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics. Oxford University Press.
Chieze, M., Hurst, S., Kaiser, S., & Sentissi, O. (2019). Effects of seclusion and restraint in adult
psychiatry: A systematic review. Frontiers in Psychiatry, 10.
https://doi.org/10.3389/fpsyt.2019.00491
Haugom, E., Ruud, T., & Hynnekleiv, T. (2019). Ethical challenges of seclusion in psychiatric inpatient
wards: A qualitative study of the experiences of Norwegian Mental Health Professionals. BMC
Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4727-4
McIntyre, A. (2018, December 24). Doctrine of double effect. Stanford Encyclopedia of Philosophy.
Retrieved December 4, 2022, from https://plato.stanford.edu/entries/double-effect/
Myers, S. (2009). Seclusion: A last resort measure. Perspectives in Psychiatric Care, 26(3), 24–28.
https://doi.org/10.1111/j.1744-6163.1990.tb00313.x
Steinert, T., Bergbauer, G., Schmid, P., & Gebhardt, R. P. (2007). Seclusion and restraint in patients with
schizophrenia. Journal of Nervous & Mental Disease, 195(6), 492–496.
https://doi.org/10.1097/nmd.0b013e3180302af6