Running head: ETHICAL ISSUES SURROUNDING THE USE OF RESTRAINTS
Ethical Issues Surrounding the use of Restraints
Sasha Yunick
Stenberg College
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ETHICAL ISSUES SURROUNDING THE USE OF RESTRAINTS
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Ethical Issues Surrounding the use of Restraints
There are many ethical dilemmas that arise within psychiatric nursing. One of the biggest
dilemmas surrounds the use of restraints. Restraints can be divided into three main types which
include: physical, chemical, and environmental. Physical restraints restrict or control movement
and behavior, chemical restraints are medications used to modify or restrict behavior, and
environmental restraints change or modify a person’s surroundings to restrict or control
movement (Alzheimer Society of Canada, 2007). Restraints are used by psychiatric nurses in
scenarios where a person may cause harm to themselves or others. Restraints raise question
though, simply because they are typically used against someone’s will or consent. Butts and Rich
state, “Seclusion or restraint must never be used for staff convenience or to punish or coerce
patients” (Butts & Rich, 2005). All three types of restraints are only meant to be used when less
restrictive measures have proven to be ineffective. Physical restraints may look something like
the use of lap belts, vests, strait jackets, bed rails, sheets that are intentionally tucked in too
tightly, breaks on wheelchairs, and limb and/or waist ties (Davis, M., 2008). All of these things
are capable of creating physical barriers for a person. When psychiatric nurses use chemical
restraints they may use a form of tranquilizer or sedative to calm the patient down; while an
environmental restraint may consist of a person being placed in a locked unit, or in a seclusion
room that has a locked door. In the proper circumstance, each one of these restraints can be very
beneficial for patient, nurse and other surrounding patients. Ethical dilemmas arise on the topic
of people being restrained against their will or without consent, and also whether psychiatric
nurses are using restraints for strictly the patient’s well-being, or to meet their own needs instead.
Physical restraints refer to “a manual method or mechanical device, material, or
equipment attached or adjacent to the patient’s body that he or she cannot easily remove and that
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restricts the patient’s freedom or normal access to one’s body” (Davis, M., 2008). Physical
restraints are used by psychiatric nurses in many different settings such as in long-term care
facilities, hospitals, and mental health facilities. When a patient needs treatment, but they are too
aggressive and violent to be near or they may hurt themselves, the uses of physical restraints are
beneficial for nurse, patient, and surrounding patients. The psychiatric nurse cannot help treat the
patient if he or she cannot be near them. Ethical dilemmas arise with the use of physical
restraints because the patient’s body is being held against their own will without consent, and
there have also been many incidences of death due to physical restraint as well. Research has
proven that death by asphyxiation has been amongst the top reasons for death in patients who are
being physically restrained. (Mohr, W. K., Petti, T. A., & Mohr, B. D., 2003). Death by
asphyxiation is caused more commonly when a patient is in the midst of aggression and the
psychiatric nurses are trying to protect themselves against a spitting or biting patient. Many times
this is done by holding a towel over their mouth or by accidently obstructing the patient’s airway
with one of their own limbs during “takedowns” by staff members that are trained to restrain
combative patients. Not to say that a lap belt or a wheelchair could not cause death by
asphyxiation, but it is more common during “takedowns”. Though it doesn’t get much worse
than a patient dying because of a physical restraint, they are sometimes much needed to prevent
harm to the patient and others. According the Alzheimer Society of Canada, “An inappropriate
use of restraints occurs if restraints are misused or used too often” (Alzheimer Society of
Canada, 2007). Psychiatric nurses may become accustomed to using physical restraints for
certain patients who they have used them for previously, which is very wrong. Only in the event
that a patient is uncontrollably aggressive and violent should their body be physically controlled.
Research suggests that “There is, however, little scientific evidence to suggest that mechanical
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restraints significantly reduce risk or harm; indeed, using fewer mechanical restraints may even
reduce serious injuries in nursing home residents” (Andrews, G. J. (2006). An example of this
could be an elderly patient falling in between the bed and bedrail, causing suffocation. There are
definitely both positives and negatives that come along with the use of physical restraint, but
which one outweighs the other? This is where we have an ethical dilemma.
Chemical restraints are frequently used in psychiatric nursing to minimize aggressive,
violent and potentially dangerous behaviors. The main and only purpose of chemical restraints
should be to prevent the patient from being harmful to themselves, the nurse, and other patient’s
around them. The use of chemical restraints can be beneficial to the people surrounding the
patient who is aggressively acting out, and it has been stated that, “The failure to restrain some
patients may have adverse effects on other patients, for which practitioners and institutions will
also be liable” (Currier, G. W., & Allen, M. H., 2000). Patient’s behavior can be transferable,
and having a patient violently act out may put other patients in distress. Like physical restraints,
psychiatric nurses should only use chemical restraints when need be. One of the ethical issues
that arises, is what or when is considered need be? Has the psychiatric nurse done and tried
everything in their power besides restraint? One question psychiatric nurses may ask themselves
is whether a drug is being given as part of the patient’s treatment plan, or simply to control the
patient's behavior. If the drug is being given after assessment and rational plan of care, then it is
for the patient’s treatment. But if the medication is only being prescribed due to the reaction to
the patient’s behavior, it is considered to be a restraint (Currier, G. W., & Allen, M. H. 2000).
For elderly patients, chemical restraints can be dangerous causing them to be severely sedated
and non-functional. An example of this would be an elderly person with severe dementia who
has been given a restraint medication such as an antipsychotic and falls due to being heavily
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sedated. Any patient who is heavily sedated could fall, but it could be life threatening for an
elderly person if they break a hip or other extremities. Ethically, chemically restraining someone
can be questioned whether it is truly being used to prevent the patient from harming themselves
or others, but some question whether the psychiatric nurse is using them to fulfill their own
needs.
Environmental restraints are things such as seclusion rooms with locked doors, or units
and facilities that are locked where patients do not have the option to leave at will.
Environmental restraints are used for the same important reason as physical and chemical
restraints are, to prevent the patient from self-harm and harm of others. Seclusion is, “the
involuntary confining of a person alone in a room from which the person is physically prevented
from leaving” (Stuart, G., 2013). There are three main therapeutic principles for the use of
seclusion, which include containment, isolation, and decrease in sensory input. Containment
prevents a patient from harming themselves or others, isolation helps to distance patients from
relationships that are intense, and decrease in sensory input is for patients who have heightened
sensitivity to external stimulation (Stuart, G., 2013). Nursing shortages have led to higher
patient-to-staff ratios, creating an environment where the main goal is to keep the unit calm.
Patients who disrupt the milieu are at risk for being restrained (Green, C., 2010). Unfortunately
this becomes an ethical dilemma, because it raises question to whether someone actually needs to
be placed in seclusion for their own good, or rather to make things easier for the nursing staff. In
addition to seclusion, psychiatric patients may be placed in a locked unit for a range of time
anywhere from a couple days to months where they will receive treatment. Depending on the
level of observation of the patient, the patient may not be able to leave the unit if the mental
health practitioners do not believe it is safe. The ethical dilemma here is that patients are being
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held, some without consent, to one restricted area for an unknown amount of time. “The
environment is very important, as it can be manipulated to reduce the risk of violence” (Davison,
S., 2005). Patients may feel that they are trapped, that they have no rights, no freedom, etc. The
list goes on. Some patients need much more help and treatment than others before they are
stable. They would fly right out of those locked doors if they could. So here is the ethical
dilemma, who is to decide for someone else whether they should be confined to one area or not?
Would it be okay to leave the doors unlocked and have unhealthy, potentially harmful patients
leave as they wish? Should that be their right? Environmental restraints can be seen as without a
doubt needed, but they can also be seen as a loss of rights.
Restraints are one of the most controversial ethical dilemmas in mental health. They are
only to be used in the scenario that a patient has potential to harm themselves or others. Stuart
states, “They are viewed as a negative experience by staff and patients, have no therapeutic value
other than as a last resort to ensure safety, and often raise ethical issues for staff, patients and
families” (Stuart, G., 2013). Occasionally staff may become accustomed to using different forms
of restraint, which is unacceptable. Though many mental health nurses would probably argue
that the use of restraints helped in many situations, there is still the ethical question of whether
the use of restraints are for the patients best interest or the nurses. As stated earlier, “Seclusion or
restraint must never be used for staff convenience or to punish or coerce patients” (Butts & Rich,
2005). Ethical dilemmas arise on the issue of people being restrained against their will or without
consent, and also whether psychiatric nurses use restraints to meet their own needs rather than
strictly for the patient’s well-being. Although physical, chemical and environmental restraints are
all different from one another; their main purpose remains the same. The use of any type of
restraint should only be used for the best interest of the patient, and to protect them and others
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from harm. Restraints should only be used as a last resort when every other technique or strategy
has been unsuccessful. “The environment is very important, as it can be manipulated to reduce
the risk of violence” (Davison, S., 2005). With that said, is it okay for mental health workers to
manipulate the environment that surrounds patients with restraints if it reduces the risk of
violence? Ethical dilemmas will forever continue to surround the use of restraints in mental
health.
References:
Alzheimer Society of Canada. (2007). Restraints. Retrieved from
http://www.alzheimer.ca/~/media/Files/national/brochures-toughissues/Tough_Issues_Restraints_2007_e.ashx
Andrews, G. J. (2006). Managing challenging behavior in dementia: a person centered approach
may reduce the use of physical and chemical restraints. BMJ: British Medical Journal,
332(7544), 741.
Butts, J., & Rich, K. (2005). Nursing Ethics: Across the Curriculum and into Practice. Sudbury,
MA: Jones and Bartlett Publishers.
Chaimowitz, G. (2011). The Use of Seclusion and Restraint in Psychiatry. Canadian Journal Of
Psychiatry, 56(8), 1-2.
Currier, G. W., & Allen, M. H. (2000). Emergency psychiatry: physical and chemical restraint in
the psychiatric emergency service. Psychiatric Services, 51(6), 717-719.
Davis, M. (2008). The Use of Physical Restraints. Retrieved from http://www.ccbiutoronto.ca/documents/bioethic_matters/Bioethics%20Matters%20Vol%206%20_10%20
The%20Use%20of%20Physical%20Restraints.pdf
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Davison, S. (2005). The management of violence in general psychiatry. Adv Psychiatr Treat
11:362–70. Retrieved from http://apt.rcpsych.org/content/11/5/362.full#ref-list-1
Glezer, A. (2010). Beyond Emergencies: The Use of Physical Restraints in Medical and
Psychiatric Settings. Harvard Review Of Psychiatry (Taylor & Francis Ltd), 18(6), 353358.
Green, C. (2010). Moving toward a restraint-free environment. Vol. 5 No. 8. Retrieved from
http://www.americannursetoday.com/article.aspx?id=6984&fid=6848
Mohr, W. K., Petti, T. A., & Mohr, B. D. (2003). Adverse effects associated with physical
restraint. Canadian Journal of Psychiatry, 48(5), 330-337.
Sailas, E., & Fenton, M. (2000). Seclusion and restraint for people with serious mental illnesses.
Cochrane Database of Systematic Reviews, 2.
Stuart, G. (2013). Principles and Practice of Psychiatric Nursing (10th ed.). St. Louis, MI:
Elsevier Publishing.