Ethical Considerations of Selcusion and Restraints



Ethical Considerations of Seclusion and RestraintsLacey HastingsStenberg CollegeEthics and Law in HealthcareKyle TaylorEthical Considerations of Seclusion and RestraintsPsychiatric nurses have an ethical responsibility to uphold the values of: Respect for the inherent worth, right of choice, and dignity of persons; of their health, mental health, and well-being; and, and of quality practice (RPNC, 2010). Their code of ethics ensures that they use safe, competent and ethical practice, such as: committing to building therapeutic relationships and behaving in a manner that protects the integrity of those relationships; Ensures that one neither initiates nor participates in any practice that is considered harmful to the welfare of others; and Strives to maintain a level of personal health, mental health, and well-being in order to provide competent, safe, and ethical care (RPNC, 2010). Yet Psychiatric Nurses are also required by their competencies to have knowledge and ability of the ‘therapeutic’ use of seclusion and restraints (CRPNBC, 2001). However the term ‘therapeutic’ attached to seclusion or restraint has proved to be an oxymoron, since they involve several side effects, evidence shows they have no therapeutic value, and they actually cause further trauma and harm (Huckshorn, 2006; Stuart, 2009). This writer believes that the current use of seclusion and restraints in psychiatry prevents psychiatric nurses from living up to their ethical responsibility, and has more traumatic, damaging, harmful effects on patients than any positive ones. As such, this writer will review and analyze relevant literature to support my claim.Let’s take a closer look at definitions of seclusion and restraints for the use of this paper. Seclusion can be defined as “The involuntary confining of a person alone in a room from which the person is physically prevented from leaving” (Stuart, 2009, p.587). Restraints can be broken into physical “ any manual method or physical or mechanical device attached to or adjacent to the patient’s body that the patient cannot easily remove and that restricts freedom of movement or normal access to one’s body, material or equipment (Stuart, 2009). Or chemical “medications used to restrict the patients freedom of movement or for emergency control of behavior but are not standard treatments for the patients’ medical or psychiatric condition” (Stuart, 2009). Both seclusion and restraints continue to be widely used measures in psychiatric settings (Holmes, 2004; Kontio et al, 2011; Cutcliffe, 2005); however evidence is still lacking regarding their effectiveness in reducing patients’ aggressive behavior or alleviating serious mental illnesses (Sailas & Fenton, 2000; as cited in Kontio, 2011). Seclusions and restraints are said to be used as a last resort for controlling aggressive or violent behavior, as a security measure only, designed to protect patients and staff in instances where safety may be compromised; however there is little question that physical restraint and seclusion of a patient is a coercive and risky procedure that has been abused and misused (Cutcliffe 2005; Mohr, 2010). The use of seclusion rooms contains fascist elements; notably fear, force and fraud; and Cutcliffe (2005) suggests Psychiatry “uses this fear, force and fraud for the purposes of social control and punishment”. This coercion used for ‘aggressive’ behavior can be described as the coercion–aggression cycle; precipitating this cycle is often some directive on a caregiver's part to the patient, who may not comply, leading with an escalation of hostilities- the outcome of such a cycle is never in the patient's favor (Goren, Singh, & Best, 1993; as cited in Mohr, 2010). The health care provider holds the power, and therefor can use seclusion and restraints as a form of control and punishment. Seclusion and restraints are a violation of patient rights when used as a means of coercion, discipline or convenience for staff (Stuart, 2009).Let’s now look at the traumatic and harmful outcomes of seclusion and restraints. Seclusion and restraints are fraught with risks of various adverse effects, from patient’s deaths to deleterious physical and psychological effects (Kontio et al, 2011). These forms of coercion infringe on human freedoms and have negative consequences for the client. They can reactivate earlier traumatic events, rouse feelings of shame and abandonment, or foster a negative perception of the facility, thereby weakening the therapeutic alliance and resulting in a cessation of treatment compliance (Holmes, Kennedy, & Perron, 2004; Bonner, Lowe, Rawcliffe ,&Wellman, 2002; Steinert, Bergbauer, Schmid, & Gebhardt, 2007; as cited in Larue, 2010). Current literature continues to describe the physical and emotional damage that seclusion and restraint use can inflict upon patients; this emotionally stressful process may also hinder the therapeutic nurse-patient relationship and increase patient aggression in the unit (Ashcraft & Anthony, 2008; Moran, Cocoman, Scott, Matthews, Staniuliene, & Valimake, et.al, 2009; as cited in Bertram et al, 2012) . As noted above, “Seclusion and restraints may actually cause further trauma and harm to patients who have often experienced significant physical and psychological trauma in the past” (Huckshorn, 2006; as cited in Stuart, 2009, p.587). Therefor with the physical and emotional damage that accompanies seclusion and restraints, how are psychiatric nurses to abide by their code of ethics, of providing safe, and ethical practice, of protecting the integrity of therapeutic relationships, and of “Ensuring that one neither initiates nor participates in any practice that is considered harmful to the welfare of others” (RPNC, 2010).Let’s now look at the patients reported experiences of seclusion and restraints. Patients’ experiences of seclusion/restraint are mainly negative, harmful, or traumatic (Frueh et al., 2005; as cited in Kontio et al, 2011).Many patients do not know the reason why they are placed in seclusion or restraints and have experienced seclusion/restraint as a punishment or as a violation of their autonomy (Holmes,Kennedy,& Perron, 2004; Keski-Valkama, Koivisto, Eronen,& Kaltiala-Heino, 2010; Hoekstra,Lendemeijer, & Jansen, 2004; as cited in Kontio et al, 2011). Studies have shown that patient’s experiences of seclusion served as an intensification of already existing feelings of exclusion, rejection, abandonment, and isolation (Holmes 2004; as cited in Cucliffe, 2005). Seclusion/restraint-related negative emotions often mentioned by patients are anger, helplessness, powerlessness, confusion, loneliness, desolation, and humiliation (Hoekstra et al., 2004; as cited in Kontio et al, 2011). In seclusion more specifically patients indicated feeling angry secondary to the injustice of being locked up or because of the lack of care received while in seclusion (Holmes, 2004). By knowingly limiting contacts with secluded individuals (Neglecting), nursing personnel are contributing to intensifying the patients’ already existing feelings of abandonment and exclusion (Holmes, 2004).Seclusion and restraints aren’t just harmful and traumatic for the recipients, they have negative impacts on the health professionals implementing them as well (Stuart 2009; Larue, 2010; Mohr, 2010; Kontio et al, 2011). Nurses have reported that they prefer to use other means to manage aggressive behavior, that they are not altogether comfortable with restraint use, and that the process is as painful for them as for their patients (McCain and Kornegay, 2005 and Bigwood and Crowe, 2008; as cited in Mohr, 2010). Studies have shown that, at times, care providers, including nurses, feel shame, fear, and distress and are afraid of abusing their power during such episodes (Bonner, 2002; Marangos-Frost &Wells, 2000; as cited in Larue, 2010). The literature continuing to discuss the trauma that goes along with seclusion and restraints, generally group staff and patients together, as the physical and psychological damage can be caused to patient and staff alike (Morgan et al, as cited in Georgieva, Mulder, & Whittington, 2012). Therefor restraints and seclusion are causing more distressing conditions for patients and staff then any therapeutic conditions.Psychiatric nurses are required to “understand, promote and uphold the ethical values of the profession”; and to “use ethical principles to guide psychiatric nursing practice” (RPNC, 2010). Ethical values such as patient autonomy, empowerment, beneficence, ensuring respect, dignity and worth of the patient, and preventing harm- however as we have seen the use seclusion and restraints makes these values difficult to uphold. It has been stated that restraining or secluding patients/residents either directly or indirectly is viewed as contrary to the fundamental goals and ethical traditions of the nursing profession, which upholds the autonomy and inherent dignity of each patient or resident (ANA, 2012). Patient autonomy, being the patients choice and right to make decisions, their individual freedom (Mohr, 2010)- is undeniably rejected in the forced use of seclusion and restraints. The act of beneficence is a moral obligation on caregivers to act for the benefit of their patients, it can be viewed on a continuum from preventing or removing harm to facilitating good or promoting a person's welfare (Mohr, 2010). Some may say seclusion and restraints are doing so by ensuring the safety of the patient and further preventing harm to themselves or others, however beneficence requires a specific action which includes weighing all available options to facilitate maximal benefit to the patient; with respect to those actions, they should be therapeutic and promote well-being (Mohr, 2010). Thus following through on this line of reasoning requires us to ask whether restraints and seclusion are therapeutic (Mohr, 2010); and as reviewed previously, they have not proven to have anything therapeutic value (Stuart, 2009). When we look at concepts such as respect, dignity, and empathy, they are said to lose their meaning during interventions of this nature; as showing someone respect while placing them in the seclusion room or under restraints proves to be a difficult task (Lamothe, 1988; as cited in Holmes, 2004). In using these interventions, nurses are exerting power and control over patients, taking away autonomy, and dignity, and potentially causing more trauma and harm. However there is a reason this is a debated ethical dilemma. The ethical dilemma rises when there are times seclusion and restraints may be needed for the safety of the patient and staff, however one questions if it is worth the risk the goes along with using them. As nurses struggle to balance their responsibility to protect patients' rights of freedom with their obligation to prevent harm to patients and staff (ANA, 2012). As there can be times when physical restraint or seclusion is the only possible course of action open to caregivers, and holding or tying a patient down, or secluding them is a better alternative than allowing patients to injure themselves or compromise others' safety (Mohr, 2010). Knowing that restraint use may be dangerous and traumatic, however, puts thoughtful practitioners in a clinical quandary (Mohr, 2010). The issue therefor lies in the misuse of restraints and seclusion. As more efforts need to be made to ensure they are only being used in emergency situations, and as a last resort; there is also critical need for mandated monitoring of the use (frequency, methods, etc.) of restraint and seclusion (ANA, 2012). Focus needs to be on the training of staff on alternative methods, such as de-escalation techniques for aggressive and violent behavior, in an effort to reduce seclusion and restraint use (Bertram et al, 2012). Other more multifaced educational programs should also be introduced, as they not only educate staff, but also incorporate environmental, managerial, and regulatory unit changes, such as: leadership involvement, organizational and cultural change, policy change, debriefing, consumer/family involvement, and trauma-informed care (Johnson, 2010; Scanlan, 2010; E-Morris, 2010; Borckardt et al., 2011; Pollard, 2007; Gaskin et al, 2009; as cited in Bertram et al, 2012). That being said when interventions of this type are put in place, they require rigorous clinical reasoning on the part of nurses, and the mindfulness of the nurse to the potential danger they are submitting their patient too. When restraint and seclusion are absolutely necessary it is important to note that once implemented it is necessary that whenever possible the patient be treated with humane care that preserves human dignity (ANA, 2012).We can see that the use of seclusion rooms and restraints in psychiatry contradict the ethical responsibility of the psychiatric nurse. These forms of intervention prove to inflict physical and emotional damage upon patients, hinder the therapeutic relationship, and only increase negative emotions such as aggression (Ashcraft & Anthony, 2008; Moran, Cocoman, Scott, Matthews, Staniuliene, & Valimake, et.al, 2009; as cited in Bertram et al, 2012). Nurses continue to be in an ethical dilemma when it comes to the use of seclusion and restraints; and therefor efforts need to be made in further education of alternative interventions, decreasing the use of these coercion methods, and further awareness that the last resort use of seclusion and restraints remains an option only for unsafe situations that are unable to be resolved by other methods (Barton, Johnson, & Price, 2009; as cited in Bertram et al, 2012). In times where psychiatric nurses have no other choice but to use seclusion and or restraints, they need to continue to uphold ethical values to the greatest of their ability, by demonstrating respect, dignity, and compassion, ensuring the least amount of harm, and protecting the therapeutic relationship. ReferencesAmerican Nurses Association [ANA]. (2012). Reduction of Patient Restraint and Seclusion inHealth Care Settings. Retrieved from: , D., Kichefski, K., Paradis, S., Platon, C., Allen, D., & Sharp, D. (2012). Seclusion & Restraint Workgroup Report. American Psychiatric Nurses Association. Retrieved from: of Registered Psychiatric Nurses of British Columbia [CRPNBC]. Competency Profile for the Profession in Canada. Retrieved from: , J., (2005) Seclusion rooms; fascism and social control: Are there alternatives out there? Vancouver Coastal Health. Retrieved from: , I., Mulder, C. L., & Whittington, R. (2012). Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions. BMC psychiatry, 12(1), 54. Retrieved from: , D. (2004). THE MENTALLY ILL AND SOCIAL EXCLUSION: A critical examination of the use of seclusion from the patient’s perspective. Issues In Mental Health Nursing, 25(6), 559-578. Retrieved from , R., Joffe, G., Putkonen, H., Kuosmanen, L., Hane, K., Holi, M., & V?lim?ki, M. (2012). Seclusion and Restraint in Psychiatry: Patients' Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives. Perspectives in psychiatric care, 48(1), 16-24. Larue, C., Piat, M., Menard, G., & Goulet, M.H. (2010). The nursing decision making process in seclusion episodes in a psychiatric facility. Issues in Mental Health Nursing, 31(3), 208-215. Retrieved from , W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of psychiatric nursing, 24(1), 3-14. Retrieved from: Psychiatric Nurses of Canada [RPNC]. (2010). CODE of ETHICS& STANDARDS of PSYCHIATRIC NURSING PRACTICE. Retrieved from: . G. (2009). Principles and Practice of Psychiatric Nursing (9th ed). St. Louis, Missouri: Mosby Inc. ................
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