Discuss about the Ethical Alternatives to Seclusion and Restraint.
The following essay is based on the case study of Sam, a 21 year old boy who has been admitted to inner city hospital with acute abdominal pain and has previous reported cases of drug related psychosis. This essay will shed light on the ethical dilemma experienced over the act of restrain in nursing care.
According to the nursing professional code of ethics, nurse must value quality nursing care for all the patients. This code of ethics is at stake in this case because Julia, the nurse in the charge shift is advising Camilla to focus caring on other patients, neglecting Sam. Here, Julia as a nurse is not valuing quality care for all the patients while refusing to accept the accountability for the standard nursing care. Camilla when raised her concern regarding the negative effects of restraining on patients like Sam, Julia overlooked it completely. She is only focusing over other patients and advising her fellow colleagues to do the same. The concept of restraining also conflicts value statement 2 of Australian nursing code of ethics (Nursing and Midwifery Board of Australia, 2017). According to this code, nurses must have respect for their patient while recognizing their capacity for active and informed participation. This act of participation can only be acknowledged via preserving the dignity of the people through practised kindness while skilfully indentifying the vulnerability and powerlessness of the patients who are under their care. In this case, Sam is refusing to participate in the process of diagnosis but in order to keep his violently activity under control; he has been put under restrain. Now the act of restraining is hampering his dignity and thereby posing a negative impact on his physical and mental health condition. Nursing and Midwifery Board of Australia also states that nurses must value proper management of the ethical information. Here the statement of Julia is sounding judgemental as she stated that, “patients like Sam are a waste of our time..”. Sam has previous reported cases of drug related psychosis and the disease condition is still prevailing and this can be gauzed from his violent and non-corporative activity. He thus he needs special care and proper counselling and not restraining as it will again increase the chance of self harm as quoted by Camilla (Nursing and Midwifery Board of Australia, 2017).
According to the Nursing Professional Code of Conduct, nurses must practise in a safe and competent manner. Here Sam, is endangering the lives of other fellow patients along with healthcare professionals. He is also getting victim of self-harm, when the medical team has arrived Sam has been found pulling out his IV cannula while verbally abusing Camilla. So in order to maintain the safety of the other patients, Sam was put under the order of restrain. Moreover, professional code of conduct also states that nurses must practise in accordance with the nursing standards while maintaining broader health system. Here Sam was planned to put under restrain for broader health benefits. But while doing this, nursing care is not supporting the health and the well-being of Sam which has been stated in the conduct statement 7 and hence giving rise to conflicts under nursing codes of professional conduct (Nursing and Midwifery Board of Australia, 2017). Since Sam is suffering from drug related psychosis, he must be treated with trust and confidence and this will help Sam to share his physical condition with Camilla while gradually decreasing his violent and self-harming activity. Moreover, the code of professional conduct also states that in situations where a patient is unwilling or unable to speak or decide independently, it is the endeavour of the nurse to ensure that their perspective is clearly represented by an appropriate advocate. Here Sam is refusing to communicate with Camilla. He is calling out and is unable to answer question asked by Camilla in a rational manner. So it is the duty of the attending nurse to represent her perspective via an allocating an advocate and not via putting the patient under restrain (Nursing and Midwifery Board of Australia, 2017).
The ethics deals with the moral dilemmas, which are generating out of the conflicts in the duties or obligation and the other faced consequences. In case of Camilla, the principal moral dilemmas faced by her are utilitarian approach and deontology. The statement of Julia is supporting the concept of utilitarian approach. According to utilitarian approach, the consequence of an action should promote well being and happiness to the majority of the people (Johnstone, 2016). How much the action is beneficial for the mass is of greatest importance, regardless of the harm or the needs of the minority. Restraining order of Sam is beneficial for the mass as it is decreasing harm to the other fellow patients and the health care professionals moreover; it is also decreasing self-harm of Sam. However, deontology contradicts utilitarian approach. Deontological theory of ethics consider the rights and the interest of individuals and consider it be of primary importance (Freegard, 2012). In case of Sam, argument can come from the underlying principal of deontology as restraining is going against the concept of deontology and hence, breaching of the ethical theories. Camilla’s is inclined towards the concept of deontology and hence is concerned about the patient. The ethical principal of liberty also directs Camilla mindset. Liberty is the basic right of every individual. Restraining physical activities of Sam will go against his right of liberty and will lead a negative impact on his mental status, making the scenario further complex (Kontio et al., 2010).
The act of non-maleficence both justifies and opposes the physical restrain on Sam. The act of non-maleficence means not to harm the patient so physical restrain can be treated to be unethical however, non-maleficence also means prevention of harm so following restrain over a drug addicted boy is ethical (Beauchamp & Childress, 2012). However, the act of beneficence goes against the order of restraining. It confers moral obligation upon the caregivers to act for the benefit of the concerned patient. Sam is agitated since from the time of admission in the hospital and was refusing to cooperate with the Camilla. He was again found pushing and verbally abusing Camilla, hampering her human dignity. Her principle of beneficence promise maximum benefits to Sam in regards physical injury or self-harm (Kerridge, Lowe & Stewart, 2013).
According to the nursing professional code of conduct, nurses must not contravene the law or breach the human rights of any patients assigned under their care. It is the moral duty of the nursing professionals to skillfully recognize the universal human rights of their patients in order to safeguard their inherent dignity. This is due to the fact that there lies a critical relationship between the health and human rights. Lack of attention in the domain of human rights and impose serious health threats. This existence of inherent relationship is reflected under the concerns of Camilla who is of the opinion that the act of restrain as imposed on Sam will increase the chance of self-harm. It is the duty of the nurse to safeguard the rights of all the patients at highest achievable standards of health. However, the act of restraining is going against the human rights (Lin, Watson & Tsai, 2013). Though restrain was done to prevent him from self-harming but it is going against his human rights. But on the other hand, if Sam is set free, then his agitated activity will not only cause self-harm but also will harm other fellow patients who also have equal share of staying fit and well (Nursing and Midwifery Board of Australia, 2017).
The first recommendation, which I would like to suggest in this case, is through research to develop safe alternatives to restraints so that it does not harm patient’s dignity and act of libertarianism and autonomy. Moreover, I strongly feel that there is an immediate requirement for proper development of personalized, trauma-informed interventions. Such interventions will be extremely helpful for patients like Sam who has drug related psychosis and demands expert level care, not just restraining. Such alternative and personal level care would serve as a substitute for the current authoritarian medical practice. Another recommendation which I would like to cite is proper elaborative discussion of threats associated with the act of restraining in the scientific literature. This will help the nurses to evaluate the consequences of restraining before passing down the final orders. Here in case of Sam, the order of restraining was taken with a one sided approach that is for the betterment of other patients. The restraining order failed to consider the ethical complication that can arise on the ground of libertarianism and egalitarianism. However, I feel that the statement of Julia, “patients like Sam are a waste of our time. Besides, we haven’t got enough staff rostered on today to be worried about him”, is a breach of the duty of care. As per the ethical theory, code of professional conduct of nursing and human rights, every patient has equal rights to recover from the diseased condition. Low patient: nurse ratio can never be cited as an excuse of negligence in nursing care. However, there still lies a conflict of interest issue among Sam, other fellow patients and health care professionals (Mohr, 2010).
References
Beauchamp, T. L., & Childress, J. F. (2012). Principles of Biomedical Ethics (7th ed.). New York: Oxford University Press
Code of Ethics for Nurses in Australia. (2005) (2nd ed., pp. 1-6). Melbourne. Retrieved from https://www.nursingmidwiferyboard.gov.au
Code of Professional Conduct for Nurses in Australia (2017). Melbourne. Retrieved from https://www.nursingmidwiferyboard.gov.au
Freegard, H. (2012). Ethical practice for health professionals. (2nd ed.). Melbourne: Cengage. Available at: https://ebookcentral.proquest.com/lib/acu/detail.action?docID=4814208
Johnstone, M. (2016). Bioethics : A Nursing Perspective. (6th Ed.). Chatswood, NSW: Elsevier.
Kerridge, I., Lowe, M., & Stewart, C. (2013). Ethics and Law for the Health Professions (4th ed.). Sydney: The Federation Press.
Kontio, R., Välimäki, M., Putkonen, H., Kuosmanen, L., Scott, A., &Joffe, G. (2010). Patient restrictions: are there ethical alternatives to seclusion and restraint?. Nursing ethics, 17(1), 65-76.
Lin, Y. P., Watson, R., & Tsai, Y. F. (2013). Dignity in care in the clinical setting: A narrative review. Nursing Ethics, 20(2), 168-177.retrieved from https://journals.sagepub.com/doi/abs/10.1177/0969733012458609
Mohr, W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of psychiatric nursing, 24(1), 3-14.
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