Ethic is the branch of philosophy that deals with how we ought to live, with the idea of the good and with concepts such as right and wrong. Ethics is the study of good and bad, of moral duty and moral obligations and concerned with doing good and avoiding harm(Pojman2009). We, healthcare professionals encounter ethical issues which are not new for all of us. It is important for nurses to understand the ethics and appreciate the value of ethics in their work as they can deliver well with professional care.
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Ethical issues and dilemmas abound in the area of nursing, is a big challenge to balance the client’s right to autonomy, the rights of others and the legal concepts relevant to nursing care (Funnell et al 2009). In this case, SN A has right to restrain the patient? Is it appropriate ways of approaching to Mdm B? The author will discuss more in advanced nursing practice using the physical restrain.
Principles of ethics:
Beauchamp (2001) stated that ethical principles are the fundamentals of ethical study because each theory tries to achieve in order to be successful.
(Sullivan 2005) stated that rational people should be allowed to make their own decisions. Autonomy, self-determinations, and respect for persons are important notions in medical ethics. Several important legal decisions, say that respect for the autonomy of the patient should take priority over the beneficence of the physician trying to save the patient’s life (Pojman, L 2009).
From the scenario above, Mdm B has rights to make decisions without interference from medical professions. The Mental Capacity Act (2005) in England, states that patients’ who are mentally competent have the right to personal autonomy and to make decisions as any other person with mental capacity. She was begging SN A to release her physical restrain with possibility of insecure feeling and unable to mobilize her body parts freely. (Dimond 2008) stated that a person should not be considered as unable to understand the information relevant to a decision if she is able to understand an explanation in a way that is appropriate to her circumstances by using simple language or visual aids.
From the SN A perspective, autonomy refers to the liberty of nurses to make unrestricted and obligatory decisions within her scope of practice (Lewis, 2006).Mdm B was appeared to be confused, disorientated and attempted to climb out of bed few times. There are various equipment or devices for treatment purpose in HDU which are dangerous for Mdm B (Mental Health High Dependency Units in Queensland).
Each person has the autonomy to make their decision but sometimes it fails to consider the affect one person’s choice has on others (Shell, 2009). (Dimond 2008) stated that it is very important the patient be fully informed when involved and engaged in the process, which could resolving the disagreement since the patient’s involvement could be crucial to a good outcome or result. Instead, SN A should approach Mdm B in a caring and calm manner with explanation of the reason why the restraint had been applied and what had been done to her, so that she will be free from fear and restless and cooperate.
Beneficence refers to the act that is done for the benefit of others. In other words, it is explained as taking positive action to help others or desire to do well (Beauchamp, 2009). It can also can be defined as the nursing ethics based on the beliefs that the health-care providers to provide do not harm, avoid harm, diminish accessible harm and endorse the good and best interest service to the patients.
From Mdm B perspective, she should be respected and treated as same by not ended up being restrain as the action taken toward the patients should be in their best interest. (Frengley 1986) stated that use of restraint can prolong the length of hospitalization and long term restraint will lead to more harm, such as higher mortality, physical trauma and psychological trauma to patient than benefit.
SN B used physical restrain as a tool to protect the patient from removing all the medical equipments while receiving medical therapy and prevent fall to avoid arising further complications. According to (Yarmesch 1984), two most common reasons of restraining were to protect the patient and to protect others. (Strumpf and Evans1988) did a study to search for the main reasons given by nurses for restrain: were changes in the patient’s mental status (65%), prevention of falls (60%), protect others’ safety (55%), facilitate treatment (40%) and noncompliance (10%).
The principle of beneficence related to attitude by generating more good than wicked in the world which based on the belief that people benefit the most good (Beauchamp, 2009). If absolutely necessary, physical restraint is beneficial applied for medical treatment if patient is temporarily uncooperative or highly agitated only. However, before restrain is applied, SN A should explain to Madam B the reason for the restrain and enlist her cooperation.
Non-maleficence refers to cause no harm or harm the fewest people (Beauchamp, 2009). In overall, do no harm to others such as not to deliver harm but providing helps to one’s welfare and well-being.
From Mdm B’s perspective, her well-being is being compromised because nurse applied her on physical restraint and not respecting her autonomy and take priority over her decision could lead to harm. (Minnick et al 2001) stated that those who had been restrained felt their lives had been in danger or threat. Broadly, the patient has the right to be treated well by medical staffs because restraint will cause more harm than good. (Ilminen 1999) stated that restraint can direct result a potentially serious result to physical, and well-being such as circulatory impairment, abrasions, bruises, skin tears and aggression as restraint can cause frustration and anger.
From SN Gee’s perspective, overlapped with beneficence, nurses must not do anything that would intentionally harm patient without the act being balanced by comparative benefit because physical restraint can cause more harm than good. The restraint might cause physical trauma (Jones & Kroese, 2006) and psychological trauma (Johnson, 1998) to patient instead. Nurses’ duty of care to a patient is to ensure that the patient is benefits from the therapies given.
SN B should assess the need for restrain by not denying Mdm B goods of life because nurse’s duty is to care for the patient. Besides, nurses should take ethical reflections by ensuring that there is a legitimate or legal need to restrain and well-being, comfort, dignity and bodily and mentally needs of a patient on restrain are maintained (CGH Patient Restraint Policy, 2011).
Beauchamp (2009) stated that the word justice is closely attached with the legal system. However, the word refers to the fact that decisions should be based on fairness, equitably and distribute benefits to all people. Preference should follow ethical theory except if circumstances value is difference.
As a patient, Mdm B has responsibility to cooperate with doctors, nurses, and healthcare staffs in their efforts to care for her by following their instructions and medical orders including accept the medical consequences if she does not follow the care, service, or treatment plan provided to her. In this case Mdm B should be treated fairly as she has the right to receive a good quality care ( Green, 1996).
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SN Gee should assess the safety measures of restraint after getting consent from doctors and patient’s family members instead of patient due to her incapable of giving informed consent. After that well-documented patient records including why, how, where and for how long the restraint was used. After physical restrain applied, nurses should put patient under close observation and examination and standard assessment based on the hospital policies (CGH Patient Restraint Policy, 2011). Moreover, more concern and empathy should be shown to Mdm B by providing information concerning physical restraint during and after its use, share time to talk to patient and not letting the patient feels or experiences that restraint is a punishment and imprisonment. Besides, (Kerridge et al 2009) stated that physical restraint should not be used unless necessary or when in the patient’s best interests and safety measures should be considered before applying restrain.
The principle of justice in this scenario was one person has a duty of care towards another person and each party to be treated based on fairness. Physical restrain should not be used for punishment or convenience. It only used when non-restrain approaches are ineffective.
Ethical theories are the fundamentals of ethical study because they are the perspectives from which direction can be achieved along the pathway to a decision.
Butts (2008) stated that utilitarianism is a theory which addresses what is the best for most people. The value of the action is decided by its worthiness, with the main emphasis on the outcome consequences. In addition, Bentham (2009) stated that utilitarianism refer as a standardizing ethical theory which disposition of right and wrong exclusively based on the results and the consequences by performed that act over other acts. By definition, it steps further the possibility of his/her own welfare or happiness and towards others’ welfare or happiness.
In utilitarianism theory, nurses are accountable for their ethical conduct including perform duties that she wants or does not wants to act upon, such as not every patient has to be restrained by nurses and nurses need not have to restrain all the patients. In this case, SN A’s action was to protect the patient from removal all medical devices and disturbances of on-going therapy or treatment and prevention of falls due to her medical condition and it can lead to unwanted complications.
(Dennett 1995) stated that the limitation of utilitarianism is it cannot predict the future, and cannot balance the consequences. In others words, utilitarianism may not necessarily result in happiness as happiness is an individual choice because something that makes one person happy may not make another happy. The nurse’s duty is to provide the standard of care by ensuring patient’s safety during hospitalization and ensure the patient is receiving the therapy or treatment as prescribed by doctors but they foresee that restraint might cause physical and/ or psychological trauma to patient. However, patient might not trust or lose faith in nurses thereafter.
Kerridge et al (2009) stated that deontology is a duty based theory that highlights that every single person has to act good by binding one’s duty to one’s duty as being moral means acting from a sense of duty. Nurses duty is to provide compassionate and competent nursing care to meet each patient’s needs, give correct information and education to each patient according to the needs, get involved appropriately and promptly to prevent complication and evaluates each patient’s response to treatment at regular intervals (Schroeder, 1991). For nurses, commitment can be perceived as a duty to care and directed by an ethic of care because commitment is essential to care (Mayeroff 1972).
In this case, physical restrain was applied to a patient who required due to the medical condition. But restrain should be discontinued when or once the patient regains her ability to follow instructions and no interference with medical treatments.
(Penslar 1995) states that the limitations of deontology is there is no logical basis for defining duty. Nurses’ duty is to do good to patient but by applying restrain on patient is considered harming the patient. As per (Penslar 1995) deontology does not approach how to handle conflicting duties and also does not concerned for the welfare of others.
The role of ethics is very essential in today’s society because it provides guidance in decision making, choices and actions which individuals make every day. In nursing, ethics refer to the fundamental responsibility of the nurse. Ethics provides a framework for nurses to have critical thinking when delivering better and quality care to patient. Each ethical principle guides to moral decision making, moral action and moral judgement in nursing practices (Beauchamp, 2001). Each ethical theory emphasizes dissimilar point of views to reach a correct decision even though each ethical theory has its own limitation. SN A has done duty of care from prevent further complication by restraining patient. However SN A should consult physician and family members to get approval of consent as the patient is appeared confused. In addition, she has responsible to explain, warn and access further behaviour of Mdm B and to restrain if necessary in a good manner. To ask from ward manger to get more manpower if necessary. Lastly, nurses should identify the needs and urgency of restrain and assess accurately patients who are at risk for use of physical restraint as it will be used only as a last resort. Before the act is done, or the purpose for which it is needed can be effectively achieved in a way that is less restrictive of the patient’s rights and autonomy of action. For future practice, by applying nursing ethics in clinical practices, nurses should be able to assess the needs of restrains and carry out high quality of care to patients, so that it may improve both the patient’s and nurses’ overall satisfaction.
Description of a practical situation which raised ethical issues:
In accordance with the Singapore Nursing Board (SNB) Code of Ethics and Professional Conduct (p. 5), it is a duty of confidentiality where nurses are obligated to ethical codes and all names are changed in protecting the identity of person’s involved. Staff nurse (SN) A was assigned to work in a High Dependency unit (HDU). One other Register Nurse (RN) called for MC (medical certificate) and the unit was short-staffed. Madam (Mdm) B, a 75 year-old patient was confused and disorientated. As a result she was found repeatedly climbing out of bed over the side rails. The nurses had placed her in a body vest restrain safety device to prevent her from removing medical devices and therapy and from falling out of bed.
Should SN A restrain Mdm B?
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