Ethical Dilemmas In Nursing: Analysis Of A Surgical Unit Experience

The Scenario

Question:

Discuss about the Health Ethics for Dignity and Human Rights.

Nurses working in health care setting are often confronted by daily ethical challenges in the delivery of care. According to the professional and ethical code of conduct in nursing practice, nurses are often required to uphold the moral values and principle to create an environment of trust with patients and avoid ethical conflicts. Adherence to ethical code of nursing practice is also necessary to develop trust with patient. However, nurses often face ethical challenges in the provision of care (Ulrich et al., 2010, pp. 2510-2519). To understand the kind of ethical issues experienced by nurses in daily practice, the report mainly analyzes the  experience of Camilla’s, a nurse while working on a surgical unit with Sam, a 21 year old man with acute abdominal pain. Based on the identification of ethical issues in the scenario, further discussion is presented with support from several ethical theory, ethical principles & values, professional code of ethics. It also provides recommendation about the strategies that nurse can employ to overcome the ethical challenges in the care process.

The nurse Camilla faced challenges in completing the vital sign assessment process for Sam because he was very aggressive and resistive during the procedure. Sam was also verbally abusing Camilla and pulling out the IV cannula. The medical team had ordered that physical restraints be applied on Sam, however as Camilla was worried this might cause further harm to patient, she took advice from the nurse-in charge Julia regarding the issue. Julia also favored medical team’s order and asked Camilla to focus on other patient and apply physical constraint on him. The main ethical dilemma in the case scenario is the conflict between the ethical principle of beneficence and non-maleficence. According to the principle of non-maleficence, (avoid unnecessary harm to patients or other during care), the action of physical restraint was justified. However, due to the use of physical restraint, there is high possibility of patient being more aggressive and harming himself and others. Hence, the use of physical restraint is in violation of the ethical principle of beneficence (promote well-being of patient) (Luk et al., 2014). It is an ethical decide for Camilla to decide whether priority should be given to non-maleficence principle or beneficence of patients and she should go ahead with physical restraint for Sam or not.

The above dilemma of exercising physical constrain on Sam is an ethical dilemma for the nurse, Camilla. Physical restraint is defined as the use of any device or equipment around the patient’s body to deliberately control their free movement. This type of constraints is mainly applied for older patients with functional disabilities or patients with cognitive disturbance or behavioral problem (Heeren et al., 2014). Use of physical restraint was proposed for Sam considering his aggressive behavior and past medical history of multiple hospital admissions for drug related psychosis. However, use of physical restraint is considered as an ethical issue for nurses because of the physical risk to patient. For example, physical restraint is associated with physical harm to patients such as bruises, increased agitation, undernutrition and many others. It increases the chance of conflict for nurse because use of physical constraint does not meet therapeutic needs of patients (Hofmann & Hahn, 2014). Hence, reconsidering the need for physical constraint is necessary for nurses because of the chances of harm for patient.

Ethical Issues and Analysis

Considering the requirements of ethical justice in using physical constraint is also necessary for nurse according to the virtue theory. The Virtue theory emphasizes on the individual character of the person on ethical thinking. This means that while doing professional duty to achieve good consequences for any person, the character traits of a person must be analyzed (Bell, Dyck & Neubert, 2017). Hence, the virtue theory mainly supports the fact that universal principles cannot be applied in all moral situations and impact of any actions must be evaluated on the basis of individual character of patient. Therefore, Camilla’s worry for safety of patient is justified according to the virtue theory because physical constraint may further cause harm to Sam. However, the medical team and the nurse leader’s decision to proceed with physical restraint seem to go with the deontological theory. This is because deontology theory judges the morality of an action based on established rules and the nurse leader may justify her action by stating that it is a usual norm to use physical restraint on patient who is aggressive (Lazar 2017).  Use of deontological theory is not favored for moral decision making in Camilla’s case because such theory lacks justified decision making and has many risk and uncertainty with the decision.

The ethical issue in using physical constraint for Sam can also be explained by the ethical principle of beneficence. According to the ethical principle of beneficence in nursing practice, the nursing action must be such that it promotes well-being for patien. In accordance with this principle, a nurse has the responsibility to prevent harm in patient and defend the rights of other by analyzing the benefits against possible risk of an action. Hence, Camilla’s action of clarifying the use of physical restraint for Sam is a morally sound action by her because she weighed the intervention against harm for patient. Moghadam, Khoshknab & Pazargadi, (2014) also supported the fact that although physical restraint is used to manage maladaptive behavior and reduce aggression, however negative effects of aggression such as stimulation of aggression and damage to therapeutical relationship with patient is also a possibility. Hence, instead of physical restraint, the medical team could have also advised the nurse to use other interventions like giving antipsychotic drugs like Olanzapine to patient to manage aggression. This intervention can reduce aggression in patient as well as promote safety of patient and other staffs (Gobbi,  Comai, & Debonnel, 2014). According to the value of humaneness too, the act of using physical restraint is not ethical action as it violates equal treatment and cause physical risk and injury to patient (Brophy et al., 2016). In addition, medical team’s decision of ordering physical constraints is also a disrespectful action as all patients irrespective of their illness deserves to be cared with dignity and respect. Restraint is seriously detrimental to the dignity of patient and is considered to reflect therapeutic practice (Petrini, 2013).  Hence, another ethical perspective to the Camilla’s scenarios is that ethical challenges are present in the case study due to the conflict between divergent values and value of respectfulness for patients.

Physical Restraints: An Ethical Dilemma

Apart from the clinical responsibility of caring for patient, nurses also have the obligation to comply with human rights and human dignity in practice setting. According to ANA Position Statement (2017), nurse must always advocate for human rights protection and respect inherent dignity, worth and human rights of all individuals. According to this action, the nurse must always refuse a practice that would negatively influence the quality of care and leaded to human rights violation. In the case scenario of Camilla too, the medical team’s order of applying physical constraint on Sam is a situation of human rights violation. Physical restraint by the use of device to restrict movement of patients strips them of all dignity and right to be involved in treatment. However, using this strategy to control aggressive and uncooperative patient is an indication that health staffs lack training to work with such patient. Hence, to protect harm to patient, the nurse Camilla must analyze the action on ground of human rights and human dignity and take the step to deny such practice. This is within the provision of nursing practice. In addition, she can also take alternative option possible to minimize negative ethical consequence and harm to patient.

According to the Code of Ethics for Nurses in Australia, they must value access to quality nursing care for all people. In the context of valuing quality nursing care for all people, it means that nurse must accept their moral and legal responsibilities to provide safe and competent care and have all the right to question any nursing intervention that is potentially unethical or illegal (Code of Ethics for Nurses in Australia, 2017). In this context, it can be said that the nursing intervention of using physical restraint for Sam is an unethical issue as it will lead to harm for patient and violate the requirements for safe and competent care. There are high chances of patient safety related issues in using physical restraint as it will increase agitation, cause skin injuries or restrict circulation and lead to self-harm consequences (Hughes & Lane, 2016). Hence, according to the code of ethics, Camilla has all the rights to question such treatment and consider the safety of patient above all things. Another important value statement of the Code of ethics is that nurses must value kindness and respect for self and others. According to this statement, the nurse have the obligation to respect and preserved the dignity of people by practicing kindness and recognizing vulnerability of the patient (Code of Ethics for Nurses in Australia, 2017). From this perspective too, the act of using physical restraint is an ethical issue as it will give feelings of disrespect to Sam and it will be harsh method of nursing care. According to Möhler & Meyer, (2014), nurse often decide in favor of using restraint when they are in doubt and lack skills to handle aggressive patient. They also use strategies to cope with negative feelings of patients. For Camilla, using other intervention will save her from ethical issues while on duty.

The Virtue Theory and Universal Principles

The principle of health care ethics is mainly centered around the factor of autonomy, beneficence, non-maleficence and justice to ensure optimal safety and care for patient. Autonomy is related to giving right to patient to take part in decision making for treatment options. Beneficence is the responsibility to put best effort for the benefit of patient and non-maleficence is related to ultimate goal of causing no harm to patient during the care process. The principle of justice demand elements of fairness in all kinds of decision making (Holmes, 2016). By comparing and evaluating the Camilla’s experience based on the principle of health care ethics, it can be said no principle of ethics is followed in going forward with physical restraint. Firstly, principle of autonomy will be violated because the medical team has not taken consent from Sam’s relative while deciding to use physical restraint. Secondly, beneficence principle is violated because physical restraint is not a therapeutic care option and develops negative feelings and behavior in patient such as isolation, resentment and aggression. Justice is also denied because according to human rights principle, no person has the right to be restricted and all must be treated equally.  

Based on the identification of several negative ethical implication for Camilla in using physical restraint for Sam, the recommendation for nurses like Camilla is that they must first identify the goal of the health care intervention and its benefit for patient. According to medical team’s order, physical restraint is necessary to save others from harm. However, as the nursing care is mainly centered around the patient related outcome, Camilla must also weigh the benefits and risk of physical restraint for Sam. Considering his mental condition, if using physical restraint is a necessity, then she must follow ethical process of taking consent from patient or his family members to make them aware of the need for such act. This will prevent any future issue in the future. However, as there is many evidence to provide harm and negative experience for patients is using physical restraint, Camilla must also identify other alternative intervention physical restraint is associated with increased risk of injury to both hospital staffs as well as patients. For example de-escalation technique can be used to avert violence and regain calmness of patient. However, as this requires complete verbal and non verbal communication skills by nurse, Camilla can also consider pharmacological treatment option to control aggression in patient (Spencer & Johnson, 2016). This will ensure that fairness is maintained in decision making and patient dignity and respect is preserved during the delivery of care.

Ethical Principle of Beneficence in Nursing Practice

Conclusion:

The essay summarized the ethical issue faced by Camilla in applying physical restraint and likelihood of ethical implications in practice due to risk of harm to patient and violation of dignity and respect of patient. Considering the risk of harm and negative consequences of physical restraint for patient, it can be said that the use of physical restraint is not effective nursing intervention. This is explained with support from ethical theory, principles of ethics in health care and code of ethics for nursing practice. The main recommendation for professional practice in dealing with such scenario is that benefits and risk of physical constraint must be weight for patient and ethical process must be followed in implementing it such as taking informed consent and using least restrictive methods to minimize injury in patient. It is also proposed to find alternative interventions to curb the practice of using physical restraint for mentally aggressive patient.

Reference

ANA Position Statement (2017). The Nurse’s Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity, and Human Rights in Practice Settings. Retrieved 23 October 2017, from https://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Position-Statements/NursesRole-EthicsHumanRights-PositionStatement.pdf

Brophy, L. M., Roper, C. E., Hamilton, B. E., Tellez, J. J., & McSherry, B. M. (2016). Consumers and their supporters’ perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups. International journal of mental health systems, 10(1), 6.

Code of Ethics for Nurses in Australia. (2017). Retrieved 24 October 2017, from https://file:///C:/Users/User00/Downloads/5_New-Code-of-Ethics-for-Nurses-August-2008.PDF

Gobbi, G., Comai, S., & Debonnel, G. (2014). Effects of quetiapine and olanzapine in patients with psychosis and violent behavior: a pilot randomized, open-label, comparative study. Neuropsychiatric disease and treatment, 10, 757.

Heeren, P., Van de Water, G., De Paepe, L., Boonen, S., Vleugels, A., & Milisen, K. (2014). Staffing levels and the use of physical restraints in nursing homes: a multicenter study. Journal of gerontological nursing, 40(12), 48-54.

Hofmann, H., & Hahn, S. (2014). Characteristics of nursing home residents and physical restraint: a systematic literature review. Journal of clinical nursing, 23(21-22), 3012-3024.

Holmes, D. (2016). Critical interventions in the ethics of healthcare: Challenging the principle of autonomy in bioethics. Routledge.

Hughes, L., & Lane, P. (2016). Use of physical restraint: ethical, legal and political issues. Learning Disability Practice, 19(4), 23.

Lazar, S., 2017. Deontological Decision Theory and Agent-Centered Options. Ethics, 127(3), pp.579-609.

Moghadam, M. F., Khoshknab, M. F., & Pazargadi, M. (2014). Psychiatric Nurses’ Perceptions about physical restraint; a qualitative study. International journal of community based nursing and midwifery, 2(1), 20.

Möhler, R., & Meyer, G. (2014). Attitudes of nurses towards the use of physical restraints in geriatric care: a systematic review of qualitative and quantitative studies. International journal of nursing studies, 51(2), 274-288.

Petrini, C. (2013). Ethical considerations for evaluating the issue of physical restraint in psychiatry. Annali dell’Istituto Superiore di Sanità, 49(3), 281-285.

Luk, E., Sneyers, B., Rose, L., Perreault, M. M., Williamson, D. R., Mehta, S., … & Burry, L. (2014). Predictors of physical restraint use in Canadian intensive care units. Critical Care, 18(2), R46.

Bell, G. G., Dyck, B., & Neubert, M. J. (2017). Ethical leadership, virtue theory, and generic strategies. Radical Thoughts on Ethical Leadership, 113.

Spencer, S., & Johnson, P. (2016). De?escalation techniques for managing aggression. The Cochrane Library.

Ulrich, C. M., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010). Everyday ethics: ethical issues and stress in nursing practice. Journal of advanced nursing, 66(11), 2510-2519.