Keywords: Restraint/Ethics/Mental Practice health/Dementia/Stroke care Discussion ●This article has been double-blind Restraint peer reviewed How to use the “four-quadrant” approach to analyse different restraint situations Ethical issues in restraint

These comments suggest how chal- In this article... lenging the issues are; the head of patient The use of restraint in nursing practice safety at the National Patient Safety The four-quadrant approach to analysing ethical dilemmas Agency acknowledges that there are situa- tions when nurses have to intervene to Using this model to analyse different restraint situations prevent harm to a patient (Healey, 2010). However, according to Healey, vests, as well as belt and cuff devices are unaccept- Author Ann Gallagher is a reader in nursing by restraint by describing a “posey vest”. able and have resulted in deaths and ethics, director of the International Centre This fits over a patient’s clothing and has a serious harm. for Nursing Ethics, University of Surrey, and zip at the back and cloth ties at either side. As well as an ethical imperative to pre- editor of Nursing Ethics. Arms and legs can move freely, and the vent unjustifiable restraint, there is also a Abstract Gallagher A (2011) Ethical issues waist ties are attached to a bed or chair to legal framework that includes: Offences in patient restraint. Nursing Times; 107: prevent the patient from getting up. Against the Person Act 1961; the Mental 9, 18-20. Ms Morgan concluded: “I would rather Capacity Act 2005; Adults with Incapacity This article examines the ethical issues that have a conversation with a patient or their (Scotland) Act 2000; Human Rights Act arise in relation to restraint in mental health, family about why a posey vest is a good 1998; and the Mental Health Act 1983 (see dementia care and stroke care. The themes idea, than have to explain afterwards why a Royal College of Nursing, 2008). can, however, be applied to all areas of hip fracture occurred in the middle of the healthcare. The article also discusses how night.” She expressed surprise at UK Types of restraint “four quadrants” of practice situations – nurses’ reticence to use restraint when Let’s Talk about Restraint: Rights, Risks and medical indications, patient preferences, they are so concerned about patient safety. Responsibility (RCN, 2008) identified five quality of life and contextual features – can Responses from UK nurses revealed types of restraint: physical, chemical, be used to analyse three different restraint diverse views about the role and ethics of mechanical, technological and psycholog- situations. restraint: ical. Physical restraint involves holding down or physically intervening to recent opinion piece about the “A blanket system (either yes or no to stop them from leaving an area. Chemical role of restraint in UK nursing restraint) is not the best way.” restraint is when a restless patient is practice (Morgan, 2010), pub- sedated as a form of restraint. Alished on the Nursing Times “Dignity has to be our guiding principle. The posey vest described earlier is a website, generated a great deal of discus- Please explain to me what is dignified form of mechanical restraint. Other exam- sion and dissent among readers, particu- about confused or aggressive patients ples include bedrails and baffle locks, but larly in relation to patient safety. These creating mayhem on a ward or in a furniture, such as tables and chairs, posi- comments prompted the question: “In nursing home, upsetting all the other tioned in such a way as to restrict freedom what circumstances, if any, might restraint confused patients and putting staff on edge of movement are also forms of mechanical in care be justified?” as they try to ‘think around the problem’.” restraint. The author, American nurse Sara Technological developments have Morgan, expressed surprise that UK nurses “To see your mother bruised and bloodied resulted in more sophisticated forms of concerned with patient safety should be because she has lost her faculties and restraint such as tagging, door alarms and against restraint. She stated: “In the US, become a danger to herself is awful. I’ll be closed-circuit television. What is called nurses and doctors were pragmatic about honest, if someone had talked to me about technological surveillance amounts to this and we happily used whatever tools we restraint I would have agreed.” restraint when the technology results in could get our hands on to stop confused people being prevented from leaving an patients from getting out of bed without “I work with [older people] and area or having their movement controlled. help. Yes, this included restraints.” dementia patients. The idea of physical or Psychological restraint deprives She went on to qualify what she meant chemical restraint is abhorrent to me.” patients of choices and involves them

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diagnosis of dementia and is becoming 5 key fig 1. analysing ms morgan’s increasingly frail. She wanders continu- points situation ously around the home and repeatedly goes There are five to the front door and says she wants to go 1types of Medical indications Patient preferences home. One of the staff tells her: “You cannot restraint: physical, What are the goals of Does Ms Morgan have go home today. It’s Sunday and there is no chemical, care and treatment for Ms capacity? If so, what does she transport.” Mrs Jamison accepts this and mechanical, Morgan? Is her diagnosis of want? If not, has she continues to wander from room to room. technological and bipolar disorder correct? expressed preferences in an Staff discuss how to manage Mrs Jam- psychological What are the probabilities of advance directive (Atkinson, ison. Her husband is particularly anxious Restraint is different interventions (least 2011). Is she willing or that she remains safe; he tells staff when 2not a panacea coercive first) achieving the unwilling to cooperate with she was at home he had to ensure doors and can present goals of treatment and care? care and treatment? Why? Is were locked and she had a table fixed on significant risks her autonomy respected? her chair to prevent her from getting up so to patients she could rest. He suggests staff might use The four- Quality of life Contextual features a tracking device that will sound an alarm 3quadrant What distress is Ms Morgan What family issues might if she attempts to leave the home. approach is a experiencing? Will her quality influence decision-making? Is helpful framework of life after intervention be there a staff member, family Scenario analysis for ethical analysis acceptable to her? Or might member or friend Ms Morgan Each of the scenarios is analysed using the of situations intervention compromise the trusts who could help to gain four-quadrant approach in Figs 1-3 (Jonsen involving restraint success of future care? What her cooperation? What et al, 1992). This is used in clinical ethics Understanding interventions will enhance her religious, cultural or legal and is outlined by the UK Clinical Ethics 4the legal quality of life? How can issues need to be taken into Network (2011) as a “series of questions requirements of intervention benefits be account? Are there conflicts that should be worked through in order”: healthcare practice maximised and harms of interest? What 1. Indications for medical intervention is necessary to minimised? After the acute interventions, for example, are – what is the diagnosis? What are the protect patients episode, how can nurses in her best interests if she treatment or intervention options? What from unjustifiable collaborate with her to lacks capacity? Are staff is the prognosis for each of the options? restraint minimise the chances of such working within the law? 2. Preferences of the patient – is the patient Restraint situations happening again? competent? Does he/she have capacity 5should be to make a decision about treatment and considered as a care? If so, what does he/she want? If last resort and Scenario 1 not, what is in his/her best interests? practitioners Charlotte Morgan is an inpatient on an 3. Quality of life – will the proposed should consider acute mental health unit and has a diag- treatment or intervention improve the alternative nosis of bipolar disorder. She is experi- patient’s quality of life? Or will the interventions to encing psychotic symptoms and is burdens or risks of the intervention promote safety refusing oral medication, fluids and nutri- outweigh the benefits? and respect the tion. Ms Morgan is overactive, appears 4. Contextual features – what cultural, dignity of the dehydrated and has not slept for at least religious, contextual or legal factors person three days. Nurses are concerned her affect decision-making? physical health will deteriorate further being told they are not permitted to do and are considering whether they should Chemical and physical restraint in something; setting limits on what they can restrain her and give her medication mental health do, such as times to go to bed; and without her consent. The four-quadrant approach can help with depriving them of the means to be inde- analysing the ethical issues and decision- pendent. This can include keeping them in Scenario 2 making processes involved in Ms Morgan’s nightwear and not letting them have out- Ronald Freeman has been admitted to hos- case. Patterson (2011) describes such a case door clothing, walking or visual aids. pital after a stroke. He has been assessed as one where “restraint, seclusion or rapid and it is agreed that his swallowing is tranquilisation may be warranted in Restraint in nursing practice impaired. He is restless and has communi- exceptional circumstances”. If Ms Morgan The following three scenarios, drawn from cation difficulties. His family agree with continues to refuse, staff are considering anonymised practice examples, show the healthcare professionals that he should physical and chemical restraint with a complexity of this issue in everyday prac- have enteral feeding via a nasogastric tube. view to enabling her to have rest, fluids tice. Put yourself in the position of the Mr Freeman pulls out the first two tubes so and nutrition. Staff should consider the nurse then respond to these questions: nurses are now considering whether they questions in Fig 1. » Can the nurse’s actual or expected should use mittens or a nasal loop or bridle intervention be described as restraint? to hold the tube in place. Mechanical restraint in stroke care » If so, what type of restraint? In Mr Freeman’s case, nurses and family » What ethical arguments can be presented Scenario 3 members have agreed that he should have for and against the intervention? Cora Jamison recently moved from her enteral feeding via a nasogastric tube. » What alternatives are there? home to a nursing home. She has a However, he pulls out the first two tubes

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Fig 2. analysis of scenario 2 fig 3. analysis of scenario 3

Medical indications Patient preferences Medical indications Patient preferences What are the goals of care Does Mr Freeman have What are Mrs Jamison’s Does Mrs Jamison have and treatment for Mr capacity? If so, what does he capabilities in the context of capacity? (It should not be Freeman after his stroke? want? If not, has he her dementia? What are the assumed she has not.) If so, “The first question should be expressed prior preferences, goals of her care? What other what does she want? If not, ‘what are we trying to for example in an advance interventions might be has she expressed prior achieve?’” (Royal College of directive? Is he willing or considered that support her preferences about care? Is Physicians and British Society unwilling to cooperate with and her family, for example, she willing or unwilling to of Gastroenterology, 2010). care and treatment? Why? Is person-centred care, cooperate with care? Why? Is Crucially, is mechanical his autonomy respected? and supportive her autonomy respected? restraint necessary? What are care? (Nuffield Council on the alternatives? Bioethics, 2009)

Quality of life Contextual features Quality of life Contextual features What impairment and What family issues might What distress, if any, is Mrs What are the family issues distress is Mr Freeman influence decision-making? Jamison experiencing? Will that might influence decision- experiencing? Will his quality What are the religious, cultural her quality of life after making? Mrs Jamison must of life after intervention be or legal issues? Are there intervention be acceptable to be involved. What legal, acceptable to him? Will the conflicts of interest? Who is her? What interventions will religious or cultural issues long-term benefits outweigh best placed to contribute to a enhance her quality of life? must be taken into account? the short-term discomfort? “best interests” assessment if Will the benefits of a tracking Are there conflicts of interest, What interventions will Mr Freeman lacks capacity? device outweigh the loss of for example, between her enhance Mr Freeman’s Are practitioners working privacy and freedom? and her carers? Are staff quality of life? within the law? acting within the law?

and there is a question as to what he is deter her from attempting to leave the may be the easiest option but it is rarely communicating (is he, for example, home by saying: “You cannot go home the most ethical. Restraint represents a refusing feeding or demonstrating irrita- today; it’s Sunday and there is no trans- compromise as it has the potential to tion and a lack of understanding about the port.” This may appear innocuous but is undermine the values of nursing. More purpose of the tube?) and how to proceed nonetheless deceptive and dishonest. The creative, collaborative and respectful ethically. Also under consideration is what second consideration relates to technolog- responses to care are required. NT can be described as mechanical restraint in ical surveillance, in the form of a tracking the form of mittens or a nasal loop or device that will sound an alarm should References Atkinson J (2011) Advance directives. In: Barker P bridle to keep or hold the tube in place. Mrs Jamison attempt to leave the home. (ed) Mental Health Ethics: The Human Context. Hand-control mittens make it more The Nuffield Council on Bioethics (2009) London: Routledge. difficult for patients to pull out their states: “These technologies may also be of Healey F (2010) UK nurses do care deeply about patient safety – which is why they don’t use nasogastric tube. Williams (2010) con- significant benefit to carers in terms of restraining vests. Nursing Times. tinyurl.com/ cluded that mittens “have a place in clin- reassurance as to the wellbeing and state of care-patient-safety ical practice” but their use should be in health of the person for whom they care.” Jonsen A et al (1992) Clinical Ethics: A Practical accordance with a clear protocol and deci- The focus of the report is on supporting Approach to Ethical Decisions in Clinical . New York, NY: McGraw Hill. sion-making process, and that “older people with dementia, promoting their Morgan S (2010) Nursin’ USA – Why do UK nurses people and their next of kin must be autonomy and wellbeing, and also consid- consider restraints unacceptable? Nursing Times. informed about the use of mittens and ering the interests of carers. tinyurl.com/restraints-unacceptable Nuffield Council on Bioethics (2009) Dementia: involved as fully as possible in the deci- In relation to Mrs Jamison, the ques- Ethical Issues. London: Nuffield Council on sion-making process”. tions in Fig 3 should be considered. Bioethics. Nasal loops or bridles involve securing a Patterson B (2011) Restraint. In: Barker P (ed) nasogastric tube to a patient’s septum with Conclusion Mental Health Ethics: The Human Context. Abingdon: Routledge. a tape. This can also be labelled mechanical Sara Morgan’s views about UK nurses’ Royal College of Nursing (2008) Let’s Talk about restraint and is ethically more problematic reluctance to embrace restraint in care Restraint: Rights, Risks and Responsibility. London: as it involves an invasive and uncomfort- stimulated much-needed discussion RCN. tinyurl.com/rcn-restraint Royal College of Physicians and British Society able procedure. Analysing Mr Freeman’s about this contentious issue. As responses of Gastroenterology (2010) Oral Feeding situation using the four-quadrant to her piece highlighted, restraint is Difficulties and Dilemmas: A Guide to Practical approach suggests asking the questions in not a panacea and can present significant Care, Particularly Towards the End of Life. London: Fig 2. risks to patients. It should always be con- RCP and BSG. UK Clinical Ethics Network (2011) The Four sidered a last resort as it presents a signifi- Quadrant Approach. tinyurl.com/fourquadrant Psychological restraint and technological cant threat to human rights, dignity, Williams J (2010) Ethical dilemmas in maintaining surveillance in dementia care autonomy and wellbeing. Nurses must enteral feeding: the use of hand-control mittens. In: Hughes R (ed) Rights, Risks and Restraint-free Mrs Jamison’s case suggests psychological guard against choosing restraint, particu- Care of Older People. London: Jessica Kingsley and technological restraint. Staff try to larly when staff resources are limited. It Publisher.

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