Kately Sylvia Week 2 Main Discussion Post COLLAPSE
Week 2: Main Discussion Post
The topic selected is the use of physical restraints on children/adolescents and adults with psychiatric health disorders. Hospital settings still frequently use physical restraints on patients, for example, who are agitated and at risk for self harm or harm to others. Physical restraints do not allow patients to freely move their body by often restraining arms, legs or both. There are other restraints as well such as raising all 4 bedside rails and covering a patient with tightly tucked sheets to prevent movement. There has been a decrease in the use of physical restraints because of the adverse effects. The benefits of using physical restraints should outweigh the adverse effects.
Ethical Issues Related to Physical Restraints
The ethical issues of applying physical restraints to children and adolescents with mental health conditions are the physical consequences are understood, but the psychological consequences of the restraints are poorly understood (Nielson et al., 2020, p. 342). The systematic review by Nielson et al. (2020) found that “little is known about children and adolescents’ first-hand experiences of physical restraints,” and more research is needed to address the first-hand experiences of physical restraints (p. 342). According to Ridley and Leitch (2019), health care providers need to understand children/adolescent consequences of physical restraints on their mental and physical well-being (as cited in Nielson et al., 2020, p. 343). Further research needs to be done on the psychological adverse effects of physical restraints on this population.
In the article by Ye et al. (2020), the ethical issues of applying restraints to adults with mental health disorders are the principles of autonomy, justice, beneficence and non-maleficence. First, the lack of autonomy violates the patient’s freedom to make decisions about their care. The least restrictive means should be used for patients who pose harm to themselves or others. If patients cannot speak for themselves about having physical restraints applied, the patient’s next of kin should give permission to do so because the patient’s autonomy will not be breached (Ye et al., 2017, p. 69). Second, justice is for providers to always treat patient’s as humans and not as “insane” humans, and physical restraints should always be used as a last resort while their basic needs are being met (Ye et al., 2017, p. 69). Third, beneficence is the best course of action for patients. If a patient does require restraints a provider has to assess the patient every 4 hours and nurses every 2 hours for skin assessment and circulation where the restraints are applied (Ye et al., 2017, p. 69). Four, non-maleficence means to do no harm to patients. Physical restraints often have adverse side effects, and “therefore, the author of this article asserts that the therapeutic goal of physical restraints should outweigh their adverse effects in nursing practices” (Ye et al, 2017, p. 70).
Legal Issues Related to Physical Restraints
According to the article by A. Preisz and P. Preisz (2019), the legal issues of applying unnecessary restraints to children and adolescents with health and mental health conditions done by force is assault and can have legal ramifications (p. 1116). On occasion, it may be necessary to restrain a child or adolescent to do a procedure or because of self harm or potential harm to others. “At other times, the least restrictive form of restraint, whether by chemical or physical means, should be adopted to allow for effective assessment, management and monitoring” (A. Preisz & P. Preisz, 2019, p. 1116). For young people and adults, restraints should never be used for such things as discipline or convenience (Disability Rights Maryland, 2020). Furthermore, another legal issue related to children/adolescents being physically restrained is that it can have both physical and psychological harm (Nielson et al. 2021, p. 363).
According to the article by Ye et al. (2017), legal issues related to the use of physical restraints in adults and possibly children are adverse effects such as skin injury, nervous system damage, deep vein thrombosis and death (pp. 69-70). Other adverse effects such as malnutrition, contractures, worsening behavior and bed sores can occur while the patient is in physical restraints (van Gemert et al., 2015; V & VN, 2013; Heinze et al., 2012 as cited in de Bruijn, 2020, p. 2). Checking patients while in restraints to prevent physical and psychological harm is mandatory to have best patient health outcomes.
Application of Physical Restraints in Clinical Practice
Restraints are ordered by a licensed health care provider for emergency situations, and a patient’s personal representative may sign informed consent before application of physical restraints, if available (Altunkeser & Korhan, 2019, p. 1). Studies examined reasons why physical restraints have adverse effects. First, the physical restraint was not necessary to use at that time; second, the appropriate physical restraint was not chosen; third, the restraint was applied “too tight or too loose, and the patient is not watched regularly sufficiently and the required interventions are not carried out” (Altunkeser & Korhan, 2019, pp.1-2). The purpose of the study by Altunkeser & Korhan (2019), was to develop a “Physical Restraint Application and Evaluation Scale” to help providers and nurses to manage a better outcome for the application of physical restraints (p. 2). The scale was found to have acceptable levels of reliability and validity for nurses and providers to use in managing the care of patients in physical restraints (Altunkeser & Korhan, 2019, p. 7). The scale consists of 55 items using a Likert Scale with 1 meaning “I totally disagree” and 5 meaning “I totally agree” (Altunkeser & Korhan, 2019, p. 3). The scales highest score is 275, and the lowest score is 55; the higher the score using the scale means that applying physical restraints are necessary ((Altunkeser & Korhan, 2019, p. 3).
Specific Implications for Restraints in Maryland
Physical restraints must be ordered by a licensed practitioner, and must be used appropriately for emergency safety precautions. In the state of Maryland the use of restraints is in compliance with 42 CFR 483.352–483.376 for children under age 21 years old (Disability Rights Maryland, 2020, pp 1-2).
In compliance with 42 CFR 483.356 include the following: one, physical restraints may not be used for “coercion, discipline, convenience, or retaliation” (Disability Rights Maryland, 2020, p. 2). Two, restraints may not result in harm to the patient, and restraints and seclusion may not be used at the same time. Three, the restraint may no longer be used if a patient is not a harm to themselves or to others even if the order has not expired (Disability Rights Maryland, 2020, p. 2).
In compliance with 42 CFR 483.358, the order for restraints may not be used longer than needed. Also, restraints under no circumstances should not be used longer than the following duration: first, young adults 18-21 year olds must not have physical restraints applied longer than 4 hours; second, children/adolescents 9 to 17 years old may not have physical restraints applied longer than 2 hours; and, children under 9 years may not have restraints applied longer than 1 hour (Disability Rights Maryland, 2020, p. 2). Also, the name of the ordering provider, the date and time the restraint was ordered, the expiration of the restraint, and the restraint used should be documented. Furthermore, a provider should assess the patient in person 1 hour after the restraint has been applied to assess the patient’s physical, psychological status, behavior, appropriate intervention and complications of the restraint (Disability Rights Maryland, pp. 2-3).
In compliance with 42 C.F.R. 483.362, restraint monitoring and assessing during an emergency situation should be continuous to ensure the patient’s physical and psychological well-being. (Disability Rights Maryland, 2020, p. 3). Moreover, when the restraint is immediately removed a provider must assess the patient and the effects of the intervention (Disability Rights Maryland, 2020, p. 3).
Last, in compliance with 42 CFR 483.372 is the medical staff is obligated to document in the patient’s record all injuries sustained during emergency applied physical restraints to patients and any injuries to staff members. In addition, the “staff must meet with supervisory staff and evaluate the circumstances that caused the injury and develop a plan to prevent further injuries” (Disability Rights Maryland, 2020, p. 5).
Altunkeser, E. B., & Korhan, E. A. (2019). Application of physical restraints and developing a rating scale. International Archives of Addiction Research and Medicine, 5(1), p. 1-7. doi: 10.23937/2474-3631/1510030
de Bruijn, W., Daams, J. G., van Hunnik, F. J. G., Arends, A. J., Boelens, A. M., Bosnak, E. M., Meerveld, J., Roelands, B., van Munster, B. C., Verwey, B., Figee, M., de Rooij, S. E. & Mocking, R. J. T. (2020). Physical and pharmacological restraints in hospital care: Protocol for systematic review. Frontiers in Psychology, 10(921), pp. 1-10. doi: 10.3389/fpsyt.2019.00921
Disability Rights Maryland. (2020). Restraint & seclusion legal requirements. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://disabilityrightsmd.org/wp-content/uploads/Restraint-Seclusion-Legal-Requirements-Handout-1.pdf
Nielson, S., Bray, L., Carter, B., & Kiernan, J. (2021). Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis. Journal of Child Health Care, 25(3), 342–367. https://doi.org/10.1177/1367493520937152
Preisz, A. & Preisz, P. (2019). Restraint in paediatrics: A delicate balance. Journal of Paediatrics and Child Health, 55(10), pp. 1165-1169. doi.org/10.1111/jpc.14607
Ye, J., Xiao, A., Yu, L., Wei, H., Wang, C., & Luo, T. (2017). Physical restraints: An ethical dilemma in mental health services in China. International Journal of Nursing Sciences, 5(1), 68–71. https://doi.org/10.1016/j.ijnss.2017.12.001