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IMPORTANCE OF RESTRAINTS IN PERSPECTIVE OF PATIENT AUTONOMY

BY: ANILA MUHAMMAD

“Why Mr. X lying on floor without cloths and even uncovered private part? Why his body was restraint with chain treated by policeman? How cruel the staffs were? It’s really against human rights. It’s just because of his sin? I had asked myself isn’t it malpractice? I think they don’t have humanity”. These questions are always bother me and made me depressed. Physical restraints are always considered as an issue and nurses many times have concept about the use of restraints. This paper is all about a situation which I have observed during my clinical visit to one of the government psychiatric hospital. During round of the hospital I have observed that Mr. X was tightly tied up with chain on both hands and legs. He seems as he was mumbling for some help and I was shocked to see him in such condition. I had never seen this type of restraint patients in my previous bedside nursing, although, I had taken care of very agitated patients in neurology clinics. It made me and my colleagues depressed and even my faculty also felt the same. Then I had inquired by one of the doctor who was with us that, why the patient was lying on floor with out his cloths, I was informed that he was in this situation because of his sins and whenever, he shouts he has been treated very badly by several policemen and gives him injection to calm down. Other than that doctor informed that the prisoners feed him daily and he passes urine and stool in that top sheet. There was no care for these types of patients and all personnel were treating him like he is not a human being. Environment of that area in the hospital was like that that patients were treated as animals in the cage. No doubt it is nurses and doctors, whose obligation is to protect their patients from injury but restraints are not only the solution as in the above mention scenario, which tells us that the legal issues of our society and the poor illiterate patients who doesn’t know about patient cares and even do not aware of their rights. This incident was so disgusting that whenever I see any patient in restraining this incident triggered in my mind to think about it that why that patient was treated like this. This made me think that whether patients at agitated and aggressive state should restraint or not what could be other alternatives, what are the impacts of restraints on mental health. Therefore, this whole paper is revolving around with this issue in the reference of Pakistan and planning, implementation and evaluation of certain strategies to overcome this issue.

If we see the Pakistani context this issue is very significant because people have understanding that those patients should restraints that are mad and mentally ill. They could not accept that this is also one of the interventions to deal with aggressive and violent patients who try to harm themselves and others. That might be one of the reasons that the doctors of that hospital did not know about restraint. However, many health care personnel misuse the restraints like the same as that government hospital, where patients were really restraint like animals in suicide ward. . Nobody was realizing the impact of restraint on mental health of a patient in that particular situation. However they follow the criminal law for criminals in the jail but why they follow the same law in the mental health institute. Either they could not understand the what is mental health mean or they just follow whatever they taught previously from their followers. According to Iqbal, Naqvi, & Siddiqi (2006) “In Pakistan, where there is little regulation of psychiatric practice the potential of abuse of disturbed psychiatric patients by inappropriate, excessive and unnecessary use of both physical and chemical restrain is huge”(p.04).This is We can judge, what would be conditions of other hospitals in Pakistan because patients don’t argue with the treatment. They think restraint as part of the treatment and they don’t raise voices for their rights. As in the west people sue against nurses and hospitals for misusing restraints. According to Rogers & Bocchino (1999), “Researchers have shown that restrained patients are hospitalized twice as long as those who are not; that restrained patients are eight times more likely to die during hospitalization than are non restrained patients” (p.27). Although their no significant Pakistani data is available but we can make assumption on the basis of this data. Because what I have seen patients with physical restraint in government hospital it would be more than that. That is why this issue is very significant to be raised. Iqbal, Naqvi, & Siddiqi (2006) “Although various studies have been conducted on in patient violence, they lack methodological vigor and findings are contradictory. No study has been carried out in Pakistan” (P.01). In addition to it According to Iqbal, Naqvi, & Siddiqi (2006) “Unfortunately, the recently introduced Mental Health Ordinance, 2000 does not address the issue of physical and chemical restraint adequately” (P.04).

For analyzing we need to know what physical restraint is. Physical restraint defined by Stilwell, (1991) “Physical restraints are any devices, materials or equipment that are attached or adjacent to a person preventing free bodily movement.” Cited Yam, & Cheung (2005). (p.34) However, Lee, Gray, Gournay, Wright, Parr, & Sayer (2003) states, “Control and restraint are a set of formally taught techniques used to hold patients in an attempt to control and restraint potential or actual aggressive and for violent behavior in ward situation” (p.425). Perhaps it is questionable that whether restraint’s uses are for the benefit for the patients, the health care personnel or for policeman. Whenever I relate this question with my scenario, I could not get the answer. Mr. X was restraint because as he was agitate or violent behavior or because of its sin. According to Yam, & Cheung (2005) “physical restraint tended to be used more often in the most serious situations, i.e. when the patient was dangerously violent and there was fear of injury” (p.35). Still I think that why I didn’t used any other alternatives to control Mr. X, might be that time I was so confused and not familiar with the environment. It’s seems me that all patients are in the jail not in the mental health hospital. I have informed by a doctor who was with us during round that they are not following any guideline of restrain because they have to follow criminal law. For that they just treated the patient as criminal not as patient. Even they couldn’t realize the impact of restraint on Mr.X mental health.”

According to WHO (2001) “Many psychiatric hospitals retained the jail- like structure of their construction in colonial times. Patients were referred to as inmate and were for most of the day in the care of warders.”

Furthermore, in spite of practice myths among nurses that the use of physical restraint can protect patients from any harm or injury, a range of serious adverse effects and consequences are also associated with their use. There are negative psychosocial effects such as low social functioning, and adverse emotional reactions, associated with the use of restraints. The author has identified three categories injuries of the patient with restraint. The first category of physical injury is associated with the direct impact of the restraint device on the patient. According to (Evans et al., 2002). “These injuries include lacerations, bruises, nerve damage, ischemic injury, asphyxiation and even sudden death from strangulation.” Cited Yam, & Cheung (2005) (p.35). The second category is related to the injuries as a consequence of the enforced immobilization. According to Yam, & Cheung (2005) “These include reduced functional ability, loss of muscle tone and contractures.” (p.35).As said by author restraint patients also suffer from psychological harms associated with According to Yam, & Cheung (2005). “restraint reactions like anger, fear, humiliation, depression, agitation and regressive behaviors.” (p.35) Furthermore the author has been clearly reported that “the morbidity and mortality rates are eight times greater among restrained patients.” (p.35).When I reflect back to my scenario patient became affected the uses of physical restraints because he was badly restraint with chain and without cloths. He can have physically, psychologically, and emotionally injury because no nurse would take care of him. On the other hand I have also felt depressed. I didn’t able to concentrate on the round throughout of the hospital. No matter the patients restraint to control their aggressive behavior but I have remain fearful if patients harm themselves. No matter I was not direct care giver of that patient but I can understand the potential harm like accidentally he went into the respiratory distress. However nurses become more vigilant while taking care of violent and aggressive patients having restraints, ultimately nurse stress increases at work place. However, nurses should be aware of the adverse consequence of restraint on their patient, especially the psychosocial effects. According to Yam, & Cheung (2005) “For potentially violent patients, nurses experience a sense of fear, helplessness and hopelessness.” (p.36).

In addition, there are several strategies to deal with issue of physical restraint. Ethical consideration with the use of restraints conflict between patient’s safety and patient should be regarded as having worth, dignity and autonomy even on the event of possible physical risk. First of all, nurses should analysis the situation in reference of risk benefit of restraint’s use should always be a last resort. After careful consideration, nurse need to take precautionary measures which include: correction of underlying problems. Sometimes hypoxia, infection, medication toxicity, electrolyte imbalance, depression and pain can all contribute to confusion, agitation and aggression. Second is individualize approach, nurses should try to determine whether it is discomfort that is agitating the patient. Offering to help maintain simple but meaningful rituals may diminish agitation and eliminate the need to sedate or restraint. When patients are in agitation state, literature also supports that, reorient the patient frequently. Keep the patient warm, dry and comfortable. According to Rogers & Bocchino, (1999) “Establish eye contact; maintain a conversation even if the patient is confused. Listen and validate patient’s concern. Explain procedures before touching the patient. Human beings provide an important part of the sensory environment for most patients”. Chemical restraint it another strategy to save patients from physical restraint. In above mentioned scenario patient got chemical restraint beside physical restraint but not in a way that patient know about it that restraint is a part of treatment might he understand it’s a part of treatment to kept him chain and lying on floor. More over, some alternative steps to relax the patients can be utilized to prevent patients from aggression like massage, music therapy. By applying above mentioned alternatives can be relevant to deal with the issue of restraint to prevent mental health deterioration based on individual, group and institutional.

If I relate the scenario then following would be the planning process and implementation. The purpose of restraint is to facilitate optimal care of the patient. Use of restraint must not to be an alternative to control human behavior. Restraint should only be used when alternative therapeutic measures have proved ineffective to obtain the desires outcome. On behalf patient rights with full disclosure of the likely risks and benefits ratio so as to kin or proxy third party to make decisions obtain their informed consent before the use of restraints. According to Iqbal, Naqvi, & Siddiqi (2006) states,“At AKUH, policy and procedure documentation serves as a guideline in staff training and patient management.” All healthcare providers should understand the standards by which they will be judged and fulfilling their obligations for their patients. Media can also play an important role if channalize the information in right direction.

If nurses uses all above strategies, it can enhance mental health of patients ultimately nurses can also promote their mental health. As work load would be increase at work place so if nurses follow the proper use of restraint they control over that situation. After through assessment many patients might not require physical restraint and can be saved from further mental health deterioration. According to Iqbal, Naqvi, & Siddiqi (2006) “In physical restraint can not be initiated with comprehensive multidisciplinary risk assessment and patient-care’s involvement.” Ultimately by applying above strategies it will enhance mental health of people of Pakistan.

To summarize, physical restraint might cause many negative impact on patient Therefore, health care institutions should provide proper protocols to nurses. They should know how to manage agitated and aggressive patients and applying other alternatives to control patients in confusion state. Physical restraints should be used as a last resort. Institutional policies are most important factors contributing to prevent the misuse of restraint.

To conclude, education for the staff regarding chemical, physical and psychological restraint must encompass training and competency programs in all health care institution especially in hospitals. According to Yam, & Cheung (2005) “The awareness of patient’s rights and self determination has filtered through all medical, nursing and allied health education programs.” (p.38). Conduct ongoing education sessions for staff so they can aware of the policy and aware undesirable effect. Other than that no matter physical policy is their but the staff attitudes and some important factors contributing to its misuse.