Introduction
The use of physical and chemical restraints in acute and intensive care began ages ago. Of these two restraint methods, physical restraint has attracted the most negative attention and criticism from both the health care sector and the human rights organizations. However, both chemical and physical restraints continue to be used to a certain extent in countries across the globe. In the United States, for instance, acute and intensive care units use restraints as a therapeutic and moral method of minimizing accidents and injuries to both the patients and healthcare providers (Hamers, Gulpers, and Strik, 2004).
This is because the majority of patients in acute and intensive care settings may be emotionally, psychologically, or mentally unstable and are therefore in a position to inflict harm not only to themselves but also to others. Restraints have turned into a legal concern and some countries like the United States and England have laws that govern the extent and circumstances of their use. For instance, the Mental Health Act of 1983 identifies five circumstances under which restraints can be used.
These circumstances include: noncompliance with treatment, self-harm, and risk of a physical injury by an accident were the most relevant in critical care settings. Such legislation, in conjunction with advocacy from human rights organizations, has forced nurses and other healthcare providers to use the restraints taking into consideration the patients’ rights, potential complications, and ethical considerations. This paper aims to review several studies that discuss the use of chemical and physical restraints and the ethical issues that affect them.
Review of Literature
Physical restraints
A considerable number of patients in acute and intensive care settings are normally subjected to physical restraints. This number is said to range between 7% and 17% according to a research study done by Akansel (2007). Common types of physical restraints include wrist restraint, ankle restraint, chest restraint, chest and leg restraint, and whole-body restraints. Materials used to physically restrain patients include sheets, belts, and gloves.
The use of physical restraint on patients is associated with harm not only to the patients but also to their families. The harm done is not only physical but also emotional and psychological. The Food and Drug Administration estimates that the number of deaths resulting from physical restraint is at least 100. Other studies show that physical restraints cause “skin trauma, pressure sores, muscular atrophy, nosocomial infection, constipation, incontinence, limb injury, contractures, depression, anger, a decline in functional and cognitive state and increasing agitation,” (Cheney, Gossett, Fullerton-Gleason, Weiss, Ernst and Sklar, 2006, p.211).
The ratio of nurse to the patient increases the understanding of the utilization of physical restraint and the development of complications from the use of such restraints. A study conducted by Demir (2007) indicated that some intensive care units are understaffed. This limits the abilities of the nurses to pay close attention to the patients or to reassess the restraints. This occurred especially if the nurse in charge of a restrained patient has to leave the patient to attend to other patients. The absence of the nurse in the restrained patient’s room provides the patient with the opportunity to harm themselves as they try to free themselves from the restraints.
The researchers gave a good illustration of how patients can be harmed by physical restraints as a result of a low nurse: patient ratio. In one case observed by Demir (2007), a patient suffered from arm paralysis after being restrained. In this particular case, the nurse, being busy with other patients, had requested an inexperienced aide to restrain the patient in question but the nurse forgot to assess the patient for a whole weekend. When the nurse returned to work after the weekend she found the patient still restrained and suffering from paralysis. Besides this case, nurses in the study also admitted to finding patients suffering from armpit and chest ulcers due to prolonged restraints.
Complications resulting from physical restraints have also been reported by other researchers. Cheney et al. (2006) found that limb and vest restraints used on elderly patients caused atrioventricular irregularities. In addition, prolonged agitation resulted in tachycardia and deaths among patients. Mott et al. (2005) also found that physical restraints fail to completely play their purpose but instead enhance the risk of agitation.
Physically restrained patients are more likely than non-restrained patients to suffer from falls and strangulation. They are more likely to spend more time in hospitals, less likely to be discharged, and have higher risks of complications and death. Like Mott et al. (2005), Zun and Downey (2008) also found that patients who are physically restrained are normally agitated, acquire more complications, and fall more often as they try to free themselves from the restraints. The complications that arise from physical restraints may be grave and life-threatening. Most of the studies above found that hospitals and healthcare units that physically restrain patients lack standard material that is distinctively designed for physical restraint.
In the study by Demir (2007), for instance, the materials used for wrist and ankle restraint were produced by nurses themselves by making use of a roll of gauze directly or after placing some cotton in between the layers of the gauze. Only a handful of intensive care units studied above used standard restraint materials. Interestingly, none of the hospitals used in the above-mentioned studies had guidelines for the use of physical restraint on their patients.
The complications resulting from physical restraints are also linked to the lack of adequate care of the patients by the nurses in charge of them. The U.S. Center of Medicare and Medicaid Services states that the maximum number of hours that a restrained patient should go unobserved is two hours (cited in Moore and Haralambous, 2007). That is, restrained patients should not be left on their own for more than two hours without being reassessed or observed.
Unfortunately, most acute and intensive care settings do not comply with this rule. The majority of the studies mentioned above showed that restrained patients go for more than three hours – and in some extreme cases for days – without being reexamined and reevaluated. It is therefore important for nurses to continually observe and monitor restrained patients to ensure that self-inflicted harm and complications arising from the restraints are minimized as much as possible (Moore and Haralambous, 2007).
Chemical Restraints
Chemical restraints used in critical care are of three main types: sedation; neuromuscular or paralyzing agents, and anxiolytics drugs (Zun and Downey, 2008). Anxiolytics drugs are used purposely to manage nervous, highly confused, and delirious patients. These drugs include sedation and antipsychotic medications. Sedation is most used in critical care for mechanically ventilated patients. Sedation helps to relieve anxiety, give comfort and facilitate care such as ventilation. Sedation is a widely accepted restraint method but there are claims that some nurses tend to over-sedate patients.
Over-sedation can have substantial negative effects on patients that include: “hypotension, pulmonary vasculature, reduced rapid eye movement sleep, and reduced intestinal motility,” (Zun and Downey, 2008, p.62). Over-sedation is more likely to occur especially if the sedation is followed by pain relief therapy. The most favorable level of sedation for patients depends on the patients’ illness and the supportive therapies they need. The majority of the sedation examination tools strive for a sedation level that provides the patient with the least amount of sedation which makes it possible for the patient to be aware but also to be calm and tolerant of required treatments like mechanical ventilation (Happ, Tuite, Dobbin, DiVirgilio-Thomas and Kitutu, 2004).
Neuromuscular blocking agents are used to paralyze patients and are considered to be the most dangerous chemical restraints used in critical care. Because of their potential harm, neuromuscular blocking agents ought to be used as the last resort and in certain conditions such as: “increased intracranial pressure, muscle spasms, and to decrease oxygen consumption,” (Mott, Poole and Kenrick, 2005, p.98). However, other treatment options should be used before the neuromuscular blocking agents are used on the patients.
The second condition of the use of neuromuscular blocking agents is that they should be halted daily and only re-used when the patient’s condition needs it. Third, when infusing neuromuscular blocking agents in patients, nurses should make sure that the patients are well sedated to minimize the risk of awareness and paralysis of patient.
Ethical Considerations
Seriously ill patients rely on nurses and other healthcare professionals to care for their fundamental and complex needs. When patients become delirious, they may unintentionally interfere with their treatment and therapy devices thus endangering their lives. Protecting patients from dangers is one of the most essential responsibilities of nurses. The use of physical and chemical restraints is considered to be one of the simplest solutions to this challenge. However, the use of restraints is linked with potential and actual harm and hence the ability of the nurses to obtain consent from the patients is a requirement.
However, consent is rarely obtained by nurses when administering physical or chemical restraints on patients. This violates the Human Rights Act which states that human beings have the right to be free from unconstitutional force to limit their mobility unless they are subject to lawful imprisonment. Additionally, people should not be put through affliction or undignified treatment (Kielb, Hurlock-Chorostecki, and Sipprell, 2005).
Despite the human rights concerns, patients suffering from critical conditions may experience changes to their bodies and normal behavior as a result of their health conditions. Nurses and other healthcare providers in the critical care settings, therefore, face difficult decisions concerning the identification of the most effective tactics of preventing patients from inflicting harm on themselves and others. The quagmire faced by healthcare professionals in critical care units can be solved by following the United States Department of Health guidelines as well as the Nurses Code of Professional Conduct (Kielb, Hurlock-Chorostecki, and Sipprell, 2005).
The U.S. Department of Health guidelines stresses that consent is not a one-off procedure but rather is a continuous process that covers treatment, physical examination, and individualized care for patients. The need to respect patient freedom is generally supported as a determinant of professional practice. Nonetheless, it means that the patient should be competent enough to make such as decision. When competence on the part of the patient is lacking, nurses are allowed to follow the ‘reasonable person’ rule in which the nurse can take actions that are in the best interest of the patient by the socially and legally accepted standards (Kielb, Hurlock-Chorostecki, and Sipprell, 2005).
Conclusion
Restraint in critical and intensive care units is used to prevent patients from inflicting harm on themselves and others and also to enable the nurses to administer treatment to the patients. Whereas physical restraint is widely used, chemical restraint is less common and is only used when all other methods have failed. The grave complications that arise from the use of physical restraint on patients can be minimized by increasing the ratio of nurses to patients.
This will increase the frequency with which the restrained patients are assessed and monitored. Legal and ethical issues about restraint use arise from the need to obtain consent from patients before such methods are used on them. Unfortunately, the majority of patients in critical care units are not competent enough to give such consent. Nurses can address this challenge by following professional guidelines and code of conduct which will ensure that they act to serve the best interests of the patients while maintaining their professional standards.
There is also a need for healthcare organizations to train their nurses and other concerned healthcare professionals on the use of restraint, different types of restraint, complications resulting from their use as well as their ethical and legal considerations. This will minimize the cases of death or serious injuries that result from the use of restraint.
References
Akansel, N. (2007). Physical restraint practices among ICU nurses in one university hospital in Western Turkey. Health Science Journal 4, 1-8.
Cheney, P., Gossett, L., Fullerton-Gleason, L., Weiss, S.J., Ernst, A. & Sklar, D. (2006). Relationship of restraint use, patient injury, and assaults on EMS personnel. Pre-hospital Emergency Care 10(2), 207-212.
Demir, A. (2007). Nurses’ use of physical restraints in four Turkish hospitals. Journal of Nursing Scholarship, 39(1), 38-45.
Evans, D., Wood, J., & Lambert, L. (2003). Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing, 41(3), 274-282.
Hamers, J.P.H., Gulpers, M.J.M. & Strik, W. (2004). Use of physical restraints with cognitively impaired nursing home residents. Journal of Advanced Nursing 45(3), 246-251.
Happ, M.B., Tuite, P., Dobbin, K., DiVirgilio-Thomas, D. & Kitutu, J. (2004). Communication ability, Method, and content among non-speaking non-surviving patients treated with mechanical ventilation in the intensive care unit. American Journal of Critical Care 13(3), 210-220.
Kielb, C., Hurlock-Chorostecki, C. & Sipprell, D. (2005). Can minimal patient restraint be safely implemented in the intensive care unit? Canadian Association of Critical Care Nurses 16(1), 16-19.
Moore, K. & Haralambous, B. (2007). Barriers to reducing the use of restraints in residential elder care facilities. Journal of Advanced Nursing 58(6), 532-540.
Mott, S., Poole, J. &. Kenrick, M. (2005). Physical and chemical restraints in acute care: Their potential impact on the rehabilitation of older people. International Journal of Nursing Practice, 11, 95-101.
Zun, L.S. & Downey, L. (2008). Level of agitation of psychiatric patients presenting to an Emergency Department. Primary Psychiatry 15(2), 59-65.