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Introduction

Patient restraint remains one of the key ethical and legal issues within the medical setting.  Restraint is largely defined as a deprivation of liberty or of freedom of movement. In various settings, there are several ways in which patient restraint can occur. It can be done in a physical manner, when individual’s movements are restricted by the others. It can also be implemented through the use of apparatus, such as cot sides, that keep an individual in a defined area (Ulrich et al. 2010). Moreover, patient restraint can be done through the use of medication which commonly results in the reduction of movement of any individual. In other cases, factors that enable the movement of an individual can be removed. The principle of autonomy, which requires an individual to make a serious decision, is at the center of most ethical issues when it comes to patient restraint (Cheung & Yam 2005). Ethically, patient restraint opposes this fundamental principle. Other ethical aspects that are affected by patient restraint include beneficence, which defines the duty of care aimed to maximize the benefits of the patients, maleficence, which refers to the right of an individual to receive care, and justice, which advocates equal care rights for all individuals (Cheung & Yam 2005). However, there are specific times when patient restraint in hospital settings is necessary for preventing any form of injury or alleviating the disease that the patient suffers from. In such situations, the law permits the patient to be restrained in hospital setting through the use of a variety of methods. Some of the important legal components that need to be addressed in regard to the patients being restrained include aspects such as the right to prohibit any form of torture or any method that degrades treatment (Department of Health 2012). Others include the right to liberty and security, and focus on the essential role that professional medical care providers have within their respective settings. Patient restraint remains a key ethical and legal issue in many settings that implement the management of the diseases.

Case Law

Patient X is a seven-year-old boy who arrived to the hospital setting complaining of severe fever and headache, confusion, prolonged vomiting, neck stiffness, and increased sensitivity to light. Other signs displayed by the child included changes in alertness, hallucinations, loss of energy, difficulty in talking, and speech changes. A careful analysis of the described condition revealed that the child displayed high incidences of unsteady gait, high lethargy levels, nausea, and vomiting. The child also showed high levels of irritability and fought with one of the nurses, claiming that he wanted to go back home. The parent accompanying the child indicated that Patient X had been previously diagnosed with encephalitis by another clinical setting. During the examination, the child's behavior was inappropriate and restless. He stood up on several occasions, crouched on the floor, lay down, sat up, and climbed on the scale even when not requested. Faced with the possibility that the child might have been suffering from any form of primary psychosis related to herpes encephalitis, lorazepam, acyclovir, and risperidone were prescribed. Acyclovir was discontinued after it had been discovered that the polymerase chain reaction had failed to detect any form of herpes simplex virus (Chen et al. 2012). However, even after this, the patient remained agitated, and his behavior was severely disorganized. One day, at his hospital ward, the patient attempted to run towards the window and almost jumped out of it. He was stopped by the hospital security guards who physically restrained him. Due to the psychomotor agitation showed by the patient, the use of intravenous aloperidol (5mg), IV propofol (30-50 mg), and IV diazepam (5-10 mg) was administered in order to reduce the instances of psychomotor aggression. Parental consent had been obtained before using any other patient restriction methods. During the admission phase, the patient was physically restrained on a hospital bed, with nurses getting help from the security guard. Proper head positioning was ensured during this process, and the restriction duration was one hour.

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Decision Made

In the aforementioned case, a decision was made to restrict the movement of the patient since he was not only a danger to himself, but also to other patients in the hospital setting. Due to the elevated aggression levels noted in the boy, it was necessary to ensure that they would not have a negative impact on health condition of the patients. Two methods were used to restrain the patient with the aim of preventing him from harming himself or causing any unnecessary disturbance in the clinical setting. The first method was the use of drugs that treated insomnia displayed by the patient, as well as drugs that reduced the levels of psychotic issues and induced sleep (P L Lindsey, 2009; Duxbury and Wright, 2011). Haloperidol, ziprasidone, and lorazepam were utilised as sedatives aimed to reduce aggression noted in the patient (Powney, Adams and Jones, 2012; Huf et al., 2016). The use of the above-mentioned drugs has been known to reduce acute agitation. The patient was also restrained in one of the hospital stretchers for one hour, as per regulations of the hospital (Pamela L Lindsey 2009; Oersakul et al. 2011). Disposable latex gloves and soft nylon leather restraints were used to restrain the patient, and adequate positioning was ensured during this process, with the head raised at 30 (Kunin et al. 2007; Mischke et al. 2014). The described activities ensured that the patient spent most of the time asleep as the required tests were being conducted. Physical restraint was implemented by the nurses and security guards on the first day after the patient had been admitted to the clinical setting. Since Patient X had previously shown high aggression and irritation levels, he was transferred to a different ward with less disturbance level. A nurse constantly checked the patient’s vitals to ensure that he was in the right condition. 

Professional Codes

Nurses across all settings are guided by a strict professional code of conduct (Perkins et al. 2012; Steckley 2012; Bray et al. 2004). Two important codes that are supposed to be followed by all medical representatives include the duty of care and addressing the needs of the patients. All registered nurses are bound by what is commonly referred to as duty of care (Brackett 2013; Griffith 2015). It requires them to protect the rights of the patient and ensure that the best interests of the patients are respected in the management of any disease and condition (Anderson 2014; Moylan ∓ Cullinan 2011). When restraining an individual incorporates the need to deal with small children, other laws, such as the Human Right Act, acquire authority. Duty of care requires nurses to make a sole decision that would ensure the improvement of the patient’s condition (Young 2009). In the regarded case, patient restraint as a method of handling Patient X was necessary, and in accordance with the rules, physical restraint had to be conducted over a short period of time. Nurses also administered the required drugs to the patient and ensured that his vital signs were maintained at the appropriate levels at all times. Furthermore, nurses allowed Patient X to be visited by family members, so they could ensure that the adequate treatment was being maintained in the provided framework (Griffith 2015; Brackett 2013). It is important to emphasise the fact that before the patient had been restrained, parental consent was sought.

The patient needs is the second key aspect that has to be addressed as a part of the professional code when dealing with issues related to patient restraint (Dalmau et al., 2011; Ramanathan et al., 2014). Nurses and other medical representatives could choose to extend the period in which the patient was to be restrained. This period is supposed to assist in maintaining the patients’ safety more easily, though it is not a prerequisite for the management of the condition described above, since some clinical officers may choose to restrain the patients to ease the process of conducting the required tests (Dalmau et al. 2011; Ramanathan et al. 2014; Carrera et al. 2013). Keeping patients restrained past the required hours is considered unlawful in the clinical setting, and therefore, the nurses must adhere to the minimum indicated period (Gudjonsson et al. 2004; Kirk et al. 2015; Zun 2003). Nonetheless, medical practitioners and nurses are allowed to restrain patients if it is needed to achieve clinical management objectives (Folkes, 2005). However, in case of the prolonged application of patient restraint, the elaborate reasons in writing should be provided to the head of the hospital unit and mentioned in the care plan of the patient, and the approval must be obtained from the physicians in charge (Brackett 2013; Griffith 2015). Since duty of care applies to all individuals providing help to the patient, it is essential to give all clinicians an opportunity to state their views in regard to what is the best approach in managing the condition in children (Folkes, 2005) . Furthermore, parental consent and implications of the practice should be discussed with the parents ( Romer, 2009; Wellesley and Jenkins, 2015).

Personal Values

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Several important ethical principles were applied in dealing with the regarded case. The principle of consequentialism, based on the principle of morality underlying all decisions, is ultimately built on the consequences of a given action (Gallagher 2011). The morality of patient restraint is under investigation. In the case of Patient X, high levels of aggression as well as irritability could have seriously affected the disease management process. Restraining the patient was a method used to reduce the effects of the disease condition in order to ensure that the patient fully recovered. In addition, the patient was not only a danger to himself, but also to his family members. Another ethical value that was utilised to define the aforementioned case was the deontology theory, which states that procedures should only focus on the laws that have been provided in clinical settings (Cheung & Yam 2005; Yönt et al. 2014). In the regarded case, all the procedures that were utilised in the management of the condition adhered to the mentioned principles. All the rules in regard to the utilised patient restraint were followed fully. The application of the required amounts of sedatives, the maximum period in which the patient was restrained, and the monitoring of all vital signs during the management of the condition were all implemented (Kontio et al. 2010; Gallagher 2011). Some important ethical principles that relate to the principles of care advocated in nursing were also applied, namely — the aspects such as maleficence and beneficence. Maleficence requires the care to be provided to all patients undergoing any form of treatment, while beneficence refers to the duty of care implemented in order to maximize positive health outcomes of the patient (Department of Health 2012; Visalli & McNasser 2000; Gallagher 2011). Ideally, the above methods are the only ones that should have been utilised to ensure that the patient recovered in the right manner. In this case, the unshakeable principles of autonomy were not incorporated in the management of the condition, since they would have given the patient an opportunity to decide whether any form of treatment should be applied by himself. Considering the principles of autonomy were not followed, the professional values were deemed to supersede personal values in the application of care, since the aforementioned professional codes were to be applied in the management of the above condition.

Laws Relevant

The Mental Health Act of 2001 outlines the code of conduct that has to be followed when any form of physical restraint is applied to patients. Physical restraint is only supposed to be applied if it does not interfere with the condition of the patient and when it does not pose any significant threat to them. All other interventions related to controlling aggression should be considered before using any outlined method of patient restraint (Morgan 2010). The codes state that the duration in which the patient is restrained has to be kept at the minimum in order to protect the patient from any adverse effects or any form of serious harm. Also, patient restraint is never to be applied in cases where the hospital staff has any form of operational shortages, including staff shortages (Department of Health 2012). Special consideration is supposed to be provided to the restrained patients. Any patient who has undergone any form of physical abuse or has a critical mental issue should not be restrained (Bray et al. 2004; Steckley 2012; ME 2005). Hospital codes require the process of restraining the patients to be only administered by registered medical health practitioners, such as registered nurses, present in the clinical setting, so the restraining technique could be implemented in the appropriate manner (Mooney 2008; Gudjonsson et al. 2004). Also, all other nurses and medical officers in the clinical settings are supposed to be notified of the condition of the patient. In addition, records are supposed to be kept of all patients who have been restricted. The consultant psychiatrists have to be informed of the condition of the restricted patients. Also, the codes require the maximum time of restraining a patient within the clinical setting to be three hours, after which the medical practitioner is supposed to apply a different treatment regimen (Department of Health 2012). The patient is also expected to be informed of the duration that they are most likely to be under physical restrains, unless the provision of such information may be detrimental to the condition of the patient or could affect their mental health (Boyle 2011; Cylus et al. 2015). In this case, if such information is not provided, the appropriate reasons should be recorded. The next of the kin of the patient is supposed to fill the consent forms, and this information must be placed in the file in the case of any form of future conflicts (Department of Health 2012). In cases where the patient is underage, parental consent forms are signed on the behalf of the patient (Bilston et al. 2008). The Mental Act functions in line with the Human Right Act. This right ensures that the human beings are treated in the required manner, as their rights are inherent. Patient restraint methods are not supposed to injure or affect the disease management process negatively.

The Children Act provides more elaborate information on how children should be managed in any healthcare setting. The Children Act allows a parent to act on the behalf of their children before they reach the legal age by providing their consent for any medical procedure to be applied to the child. In this case, before patient restraint measures are utilised, the parents are supposed to be informed of the procedure and to provide their consent. The Children Act necessitates that the views of the children must be taken into account based on their age and maturity (Hine 2007; Perkins et al. 2012). In essence, children are supposed to be provided with an opportunity to be a part of the decision-making process, unless they act in the way that could endanger their lives and the state of their condition (Morgan 2010). Children are supposed to receive all the appropriate information related to the management of their disease condition, while other aspects, such as their mental state, are expected to be monitored at all phases of the treatment. The Children Act is meant to protect the rights of the children and ensure that the treatment process is maintained at all times.

Decision

Patient restraint is a method used to safeguard the condition of the patient. The use of the methods mentioned above is applied in order to restrict the movements of patients who are primarily suffering from different conditions, including mental disorders, as in the case of Patient X. In such cases, patient restraint is the only method that can be used in the management of the disease condition. If such method is not applied, then the patient risks inflicting harm not only upon themselves, but also upon other patients in the same setting (Eren 2014; Folkes 2005).

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Nurses are bound by the obligation to follow the code. Ideally, they are supposed to provide adequate care to all patients and ensure that the patient recovers within the set timeline. Such code of conduct guides nurses and assists them in applying different treatment methods, including the use of techniques such as patient restraint (Griffith 2015). Before this approach is applied, it is important to note that all other factors are normally considered and proven to be valid. Parents are supposed to provide the required consent before their children are placed under any form of restraint (Young 2009). Also, in their individual care plans, nurses are supposed to indicate all the measures that they took while the patient was restrained. In addition, the mandatory number of hours of being restrained that a patient should be placed under must be strictly adhered to by all parties. In the regarded case, all of the aforementioned issues were resolved in accordance with the required standards.

Individual rights are supposed to be respected before the application of any form of restraint. In the regarded case, Patient X was not only a danger to himself, but also to other patients in the hospital setting. In addition, Patient X was too young to decide on the method or technique that could be used to control his condition, and as a result, one of his parents was tasked with making this decision for him. Parental consent must be obtained according to every law and in every case, unless the life of a minor is under threat. However, all methods of patient restraint should adhere to specific standards aimed to ensure that they do not in any way negatively affect or injure the patient. The use of leather gloves in cases with agitated patients, as well as the use of the disposable latex gloves, are vital in order to restrain an individual (Kunin et al. 2007; Mischke et al. 2014). In addition, patients are supposed to be restrained for a maximum of three hours in any setting, though the duration differs depending on the age of an individual. Prolonged use of patient restraint methods should be reduced or eliminated in most settings, since the law does not permit it (Lewis 2002; Knight et al. 2006). Therefore, the use of patient restraint methods in the above case was considered as one of the most effective ways to control Patient X.

Conclusion

In the regarded case, duty of care, which is a fundamental principle outlined in the professional code for nurses, was followed thoroughly, since nurses must provide care to all patients regardless of their personal values. In the case regarded above, the needs of the patient superseded the internal belief system of most nurses, thus making one of the discussed issues both an ethical and legal matter. The Children Act requires parents to be informed of the decision taken in regard to their children, on the basis of their mental state. In the aforementioned case, the disease affected the mental state of the patient, and therefore, he could not participate in the process of making a decision. For this reason, the parent had provided consent before the patient was restrained. The second option was largely associated with the Mental Act and the Human Act. However, this method had to be applied in conjunction with the wishes of the patient. Thus, the dilemma was in finding a balance between the needs of the patient and the duty of the nurse in providing care and respecting the wishes of the patient. Also, nurses had to choose between their own internal and personal values and upholding professional standards that required them to follow certain rules. In the end, the needs of the patient and the duty of care were more important as compared to wishes of the patient. By following the professional codes, nurses ensured that they could manage the disease condition effectively, which resulted in the improved condition of the patient.

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