Ethical Considerations IN THE Restriction OF Patients WITH Mental Disorders PDF

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Restraint has been defined as any manual method or physical or mechanical device, with the use of materials or equipment that immobilizes or reduces the ability of a person to move arms, legs, body and head freely. Historically, Martínez (12), refers that in the 19th century there was no clear diffe...

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ETHICAL CONSIDERATIONS IN THE RESTRICTION OF PATIENTS WITH MENTAL DISORDERS

Restraint has been defined as any manual method or physical or mechanical device, with the use of materials or equipment that immobilizes or reduces the ability of a person to move arms, legs, body and head freely. Historically, Martínez (12), refers that in the 19th century there was no clear difference between the means of punishment and the therapeutic measures, both consisted of similar treatments of coercion and restraint. The whip, chains, net and shackles were used to catch and restrain the patients. Then different devices were used such as the straitjacket, straps, force chair, force bed, means of irritation of the skin, bleeding and electricity, among others. At the global level, the Universal Declaration of Human Rights of 1948, (30) in its articles 3 and 4 establishes that everyone has the right to life, liberty and security. No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. Law 911 of 2004, (31) Code of Ethics for Nursing, is relevant to respect for life, dignity of human beings, rights, principles and fundamental values that guide the exercise of the profession. Mental Health Law 1616 of 2013, (32) establishes that patients have the right to receive comprehensive, integrated and humanized care, as well as that the interventions provided are the least restrictive. According to Tamyres et al. (7) Restriction is a method that is generally used in mentally ill patients, it has a prevalence rate that varies between 0.25% and 59% in countries such as: Italy, India, Finland, Germany, Switzerland and the United States. The lowest prevalence of its use is 0.25% in Italy, and the highest prevalence is 59% in the United States. Its use is prohibited in countries such as the United Kingdom and the Netherlands ”. Guevara et al. (9) They state that physical restraint is a practice widely used by health personnel in the treatment of violent patients, but many times its indications, contraindications, possible adverse effects and the way in which it should be carried out are not taken into account. cape. “Tailor and Campaign (11). They establish that in healthcare practice, mechanical restraint is carried out by the nursing team and when urgent situations of agitation occur, they are the ones who decide and carry it out in the first instance (11). According to Luengas (10) the use of this method is indicated in: psychomotor agitation, mental confusion, disorientation, risk of displacement of catheters, probes or

drains, high risk of physical self-harm or health personnel. Similarly, Fernández and Zabala (8) reiterate this information. It has been considered that the use of this method of physical restraint, if it does not respond to a correct indication and with inadequate technique, may violate some of the fundamental rights of the person. Tailor and Campaign (11) propose that whenever this method is applied, the ethical principles of nonmaleficence, justice, beneficence and autonomy must be taken into account; and special care with the privacy and vulnerability of the person. Hernandez (23). He refers that the family almost always claims a leading role in information and decisionmaking. Families have reported feelings of hopelessness and outrage when their relative is restrained. Therefore, it is necessary to evaluate the risk / benefit of its use and in consideration of the patient and / or their family. The purpose of this review is to identify the ethical considerations of the nursing professional in making decisions regarding the physical restraint of patients with mental illness. OBJECTIVES 2.1 GENERAL PURPOSE Identify the ethical considerations of the nursing professional in decision-making in the face of the physical restraint of patients with mental illness 2.2 SPECIFIC OBJECTIVES 

Describe the main ethical problems faced by the nursing professional with the use of physical restraint.



Identify the attitudes of the nursing professional in making ethical decisions, regarding the use of physical restraint.



Determine the mechanisms that the nursing professional uses to support decision-making on the use of physical restraint.

METHODOLOGY A review was made of the ethical considerations of the nursing professional regarding the use of physical restraint in the patient with mental illness. The search was made in the following databases: ProQuest, Scopus, Science Direct and PubMed. The descriptors in Health Sciences (DeCs) used were: Ethics ”“ Nursing ”“ Mental disorders ”and the keyword“ restraint ”. The review was carried out on articles published between the years 2010 to 2017. The exclusion criteria were: articles related to restriction to pediatric patients, press reports and forums. Abstracts and full texts of those who presented the topic of interest were read. According to the review, three categories of analysis were established: Ethical problems of the nursing professional in the face of the restriction method, Attitudes of the nursing professional towards this method and support mechanisms used by the nursing professional. The respective analysis subcategories were established. The following descriptors were taken from the ProQuest database: Ethics AND Nursing AND Mental disorders for a

result of 32,981 records; Therefore, the search was limited to other descriptors until 45 were obtained; From these, the full text of 8 articles included in this analysis was read. From the Scopus database: the descriptors were used: Ethics AND restraint AND mental disorders, years: 2010-2017. Language: Spanish, English and Portuguese. 33 articles were located, of which 8 were selected for analysis. From the PubMed database: Ethics AND restraint AND mental disorders descriptors were used, obtaining results from 82 articles, of which 5 met the inclusion criteria. From the ScienceDirect database the following descriptors are used: Nursing AND Ethics AND mental disorders AND restraint, 44 articles are obtained, of which 9 meet the criteria for this analysis. Finally 30 articles are completed for review, analysis and discussion. The other articles were used as a complement and contribution to the topic. LITERATURE REVIEW

The ethics of care is defined according to Alvarado (1) as: “discipline that deals with responsible actions and moral relationships between people, motivated by a request, and whose ultimate goal is to achieve the care of their peers or the his own. " In this sense, the nursing professional, according to Garzón (2), in their practice support each other to make the right decisions, especially those difficult to manage, which they are faced with on a daily basis, as is the case with patients with mental illness. . For decision-making, it must be taken into account that aspects such as: values, morals, duties, principles, needs and rights of patients, among others, intervene. In this sense, conflicts or different ethical problems arise that are generated, according to Gaitán (3) “when it is not possible to do what is believed to be done; or when there is doubt or disagreement about what is right or wrong ”. One of the problems that occurs in the care of these patients is coercion, defined by Vuckovich (53) as “the act of forcing a person by legal authority or physical force to do what that person refuses to do”. Isolation according to Cleary (52) "is the supervised confinement of a patient only in a closed room, from which the patient cannot leave by himself, at any time and for any duration and for any purpose" as opposed to restraint physical or mechanical restraint Fernández and Zabala (8) define it as "a therapeutic measure used with some frequency for the management of agitated patients or in those patients who potentially pose a risk to the physical integrity of themselves or those around them." Faced with these situations, professionals generally ask themselves: Gaitán (3) What should be done? what not to do? What can be done or not done? The foregoing requires that the nursing professional carry out a careful analysis of the situations, for which he must know the different ethical problems, the attitudes and the mechanisms that must be assumed. According to Garzón (2), more attention should be paid to solutions than to limitations 5. Because the patient with mental illness is vulnerable and has characteristics that limit their participation, Garzón (2) states that “it is necessary to review the regulations on nursing professional practice in order to ensure the quality and ethics involved in this process ”. In accordance with the above, the Pan American Health Organization (PAHO) (4) mentions that professionals must rely on knowledge, other health professionals and current regulations to avoid sanctions imposed by the Ethical Court of Nursing , which include: verbal reprimands or suspension of professional practice.

According to Tamyres et al (7) "Nursing is in direct and continuous contact with the patient" so it is involved in decision making. For which it is essential that the acts that are derived are supported by ethical considerations. "Fernández and Zabala (8) affirm that the task of nurses consists of" ensuring the promotion, protection and care of health and guaranteeing the safety of the people under their care. " Beauchamp and Childress, established Principalism, which is based on the principles of autonomy, beneficence, non-maleficence and justice. According to Sastre and Campaña (11), the main conflict in non-voluntary restraints arises between the ethical principle of autonomy, because they limit the movements of the person, and the principle of beneficence, aimed at protecting the person. Finally Vitolo (22) refers: “If the nursing staff uses physical restraint in an unjustified or unsafe way, they may be accused of moral or physical damages resulting from that action. On the other hand, if the patient is not physically restrained when the situation warrants it and he suffers an injury due to a lack of restraint, the institutions may be sued for damages resulting from their lack of diligence ”.

DISCUSSION AND RESULTS According to the bibliographic review about the ethical problems presented by the nursing professional when faced with the use of the restriction method, they are related to the violation of autonomy, decisionmaking on the appropriate time to perform it, the duration and the safety of the patient and other people. Anger, regret, lack of pity and fear are the attitudes that most frequently appear in the face of restriction. The results of the review are presented below, with the percentage reported in the 30 articles selected according to the categories and subcategories that were identified for the analysis. (See table 1) Table 1: Ethical problems, attitudes and support mechanisms used by the nursing professional in the face of the restriction of the patient with mental illness. CATEGORY

SUBCATEGORY

Autonomy Vs Charity Start of restriction Ethical problems of the nursing professional in the face of the restriction method.

NUMBER OF REPORT S 4

PERCENTA GE

7.54%

5

9.43%

Duration of restriction

6

11.32%

Security

14

26.41%

twenty -one 3

39.62%

Acceptability of restriction method Caring for others patients

53

5.66% 100%

Nursing professional attitudes towards the restriction method.

Support mechanisms used by the nursing professional against the restriction method

Cognitive aspect

10

35.71%

Positive feelings

3

10.71%

Negative feelings

10

35.71%

Behavioral

5

17.85%

28

100%

Ethics Committee

0

Most important

1

0 % 3.22%

Work team

6

19.35%

Normativity

3

9.67%

Family or caregiver

3

9.67%

Patient

7

22.58%

elev en 31

35.48%

Alternatives

100%

Category: Ethical problems of the nursing professional in the face of the restriction method. Subcategory: Autonomy Vs Charity: According to Korkelia et al, (15) 47.3% of the nurses say that isolation / restriction (S / R) does not violate the autonomy of the patient. According to Kwisoon et al, (37) the restriction is enforced without considering the human rights of patients. Graziani et al, (29) state that the main ethical problems in restriction are the limitation of autonomy and the need to avoid harm. According to Lam et al, (26) healthcare personnel must guarantee the autonomy, dignity and comfort of patients. Therefore the use of restraint works against it, there is limited evidence to support its use. Subcategory: Start of restriction Pettit et al, (14) found that personnel less critical of the containment method, tolerate more extreme behaviors of the patient, react more slowly and therefore do not restrict it. When an isolation room is not available, staff take more time before initiating restraint. Kontio et al, (13) identified that the decision to perform the restriction should be as quick as possible in aggressive patients, there is no time to discuss the decision. Perkins et al, (34) refer that more personnel are required, even from other services, because this must be systematic, gradual and progressive. Landeweer et al, (19) identified that nurses waited too long to perform it and did not use coercion. Graziani et al, Subcategory: Duration of the restriction.

McCann et al, (16) consider that the aspects that generate conflict in the face of the restriction is to think about the time required to remain in it. Kontio et al, (13) found this same concern. korkelia et al, (15) state that the nurses disagreed that it should be used for a very long time. Graziani, et al (29) found a restriction time between 6 min to 48 hours. Goulet et al (46) an average of 7.5 hours. Kwisoon et al, (37) identified that the staff considered it natural to apply restrictions for longer than recommended, even a nurse stated: "Why am I worrying about this patient? I think that if the patient is forced to suffer, it is a deserved result and correct treatment ”. Subcategory: Security. Goulet et al, (46) found that this method was applied more to men aged 18 to 35 years with psychotic disorders and who are assumed to be a security threat. Benedictis et al (45) found a tendency to perceive restriction as an adequate method of patient safety, in the same way McCann et al, (16) affirm that patients were generally restricted for their own safety. Korkelia et al (15) identified that nurses agree to restrict a patient to take control of the situation when the patient acts against others. Kontio et al, (13) report concerns about restriction: safety of other patients, staff, and a peaceful therapeutic environment. Winkler et al, (35) reiterate that restraint is used when the person poses an acute threat to himself or others. Kwisoon et al, (37) state that mandatory restraints are the best treatment for patients prone to hurting themselves or others. On the contrary, in a study carried out by Landeweer et al, (19) they identified that nurses no longer consider control and safety as fundamental values. In research by McCann et al, (16) found that when patient aggression occurs, it is more likely to target nurses. According to Carr et al (18), there were more than 200 assaults on personnel in a period of 3 months. Graziani et al, (29) report that there are risks for the patient and staff, including: fractures, abrasions, blows, kicks and strangulation of staff. Perkins et al, (34) refer that the protection of the patient and other people from any physical damage was used as justification for its use. Swgun Fariña et al, (49) describe that the use of restraints is provided to reduce falls and prevent treatment interference. In this regard, Molewijk et al. (50) found that the respondents considered coercion necessary for reasons of care and safety. On the other hand, Lejman et al, (39) report that when there was a potential risk of harm, the nurses never mentioned obtaining the consent of the patients. The patients were tied up in their wheelchair due to lack of staff, the consequences of falls and injuries were considered to be worse than those of physical restraint. Subcategory: Acceptability of the restriction method. Carr et al, (18) state that indications of the restriction method are part of a short-term therapeutic intervention, reducing the risk for the individual. Simpson et al, (28) analyzed a total of 5,335 encounters with patients, of which 746 resulted in restraint or confinement. Reitan et al (38) found that annually, an average of 40 people were exposed to the restriction and more than half of the cases, the restriction was mechanical.

Van Doeselaar et al, (41) found that more than half of the nurses practiced restriction. Lam et al, (26) in their study reported that the rate of use of physical restraint increased from 52.68% in 2005 to 70.24% in 2015. Kuivalainen et al, (27) identified that the prevalence of Isolation and restriction ranged from 49.79 days / 1000 patients to 58.4 days / 1000 patients. This prevalence was statistically significantly lower in winter than in other seasons. The above is related to the theory of "Temperature Aggression", which explains that the highest prevalence of violence occurs during times of hot weather. Reitan et al, (38) reported that the use and type of restriction varied significantly by seasonal time. In summer the mechanical restraint was the most used. Pettit et al, (14) found that intermittent and constant observations and manual restraint were more used than mechanical restraint. The most acceptable was hospitalization in psychiatric intensive care units. In the study carried out by Graziani et al, (29) it is reported that (93.1%) of the participants had specific training on physical restriction and felt prepared to do it (100%). It was considered as an undesirable method, an irrational, primitive, fighting and defensive act, but very necessary to control the aggressive behavior of patients. Mechanical restraint and isolation showed the greatest variability in passing scores. In this regard, korkelia et al, (15) found that there is greater acceptance of the use of S / R. The nurses stated that its use is not improper and it is not done frequently. However McCann, et al, (16) in their findings, indicate that restraint and seclusion is used more often than necessary. According to Jalil Rahul et al, (25) found that the anger of the nursing staff was positively correlated with the approval of the physical restraint measure. In this way, the higher the level of guilt experienced, the lower the level of approval of the restriction. Benedictis et al, (45) reported that a greater expression of anger and aggression on the part of the staff was associated with a greater use of the restriction, on the contrary, a greater order and organization among the staff with less use of the restriction. Huf et al, (51) identified that some aggressive patients who were assigned with isolation, had to receive double intervention, that is: seclusion and later restriction. Kwisoon et al, (37) in their study found that restraint was used even when the patient could be easily controlled. Staff fail to recognize that mandatory restraint could become an ethical issue in itself. Landeweer et al, (19) state that coercive interventions can be seen as tragic interventions, surrounded by ambivalences, they are experienced as necessary but incorrect. Perkins et al (34). In their study, nurses viewed restriction as a necessary evil, justified in mental illness and the environment in which they worked. Lejman et al, (39) in their study, the participating nurses described that restrictions s...