Nurses face critical challenges throughout their roles and responsibilities in the workplace. For many nurses working with vulnerable patients who require restraints, it is necessary to develop and maintain ethical appropriateness while using these devices. Nurses play a role in preparing patients for restraints and in ensuring that their needs are met in an effective and suitable manner. These decisions must be consistent with the practices and recommendations set forth by nursing governance organizations and healthcare policies. It is the responsibility of nurses to demonstrate their understanding and willingness to cooperate in the treatment of all patients requiring restraints in order to support guiding nursing principles and frameworks for this specific patient population. The following discussion will address the role of nurses in treating patients requiring restraints in greater detail and will emphasize the importance of specific principles and guidelines to promote ethical responsibility and awareness of this population and its clinical, psychosocial, and emotional needs during this difficult time.
There are many perspectives surrounding the ethical nature and appropriateness of restraints for vulnerable patients who may pose a danger to themselves or to others. This population group already faces numerous challenges; therefore, it is the responsibility of nurses to work collaboratively in order to achieve optimal patient care and treatment in this setting. The use of restraints is a form of patient restriction, whereby a patient exhibits potentially aggressive forms of behavior that may pose a threat to the patient and to others (Kontio et.al, 2010). In this capacity, it is important to determine the ethical appropriateness of restraints and to determine if this is the most feasible option for the care and treatment of a patient demonstrating this type of behavior (Kontio et.al, 2010). Making decisions regarding the use of patient restraints requires nurses to demonstrate their knowledge and understanding of restraints and how this impacts patient care and treatment in different ways (Kontio et.al, 2010).
Much of the discussion surrounding restraints involves the understanding of a patient’s aggressive behavior and what might happen if a patient continues to be aggressive without being restrained (Kontio et.al, 2010). There is always concern for the safety of the patient and those that surround him or her, whether or not restraints are used; furthermore, the patient must be properly evaluated in order to ensure that all possible causes and/or explanations of aggressive behavior are addressed prior to making any decisions regarding the use of restraint devices (Kontio et.al, 2010). However, this discussion leads to many important questions regarding the care and treatment of aggressive patients and whether or not restraints are the appropriate option to consider (Kontio et.al, 2010). For many nurses, there is an ethical dilemma in place with the possible use of restraints, noted as follows: “Medical and nursing ethics both emphasize respect for the autonomy and dignity of patients by promoting choice, rather than paternalistic practices” (Kontio et.al, 2010, p. 66). This is an important step to remember because it reflects upon the aggressive behavior itself and the option to use other resources and only use restraints in extreme cases as a last resort (Kontio et.al, 2010). These efforts must demonstrate the important nature of ethical concerns regarding the use of restraints for patients who exhibit one or more forms of aggressive behavior (Kontio et.al, 2010). It is recommended that in mental health settings, “Mental health care staff thus need to be encouraged and educated in the use of alternative methods for the prevention of assault and harm to themselves or others. To be more successful, these efforts should be complemented, for example, by programmes in clinical leadership, change management, monitoring of seclusion and restraint episodes, and of schange to a more therapeutic environment” (Kontio et.al, 2010, p. 66). This type of reflection encourages nurses to discuss their concerns regarding the possible use of restraints and the development of new ideas and approaches to improve patient outcomes in other ways that are less restrictive and more appropriate for a patient’s needs (Kontio et.al, 2010).
Nursing staff members may possess their own perspectives regarding the use of restraints that may interfere with their ability to use this approach for their patients without question. The American Nurses Association Center for Ethics and Human Rights addresses some of the most important ethical and moral issues associated with this practice for nurses and for patients in a variety of healthcare settings (Nursingworld.org, 2012). In this context, it is observed that there are significant factors associated with the use of restraints because it poses many ethical questions regarding this practice (Nursingworld.org, 2012). The organization’s position is as follows: “Restraining or secluding patients/residents either directly or indirectly is viewed as contrary to the fundamental goals and ethical traditions of the nursing profession, which upholds the autonomy and inherent dignity of each patient or resident” (Nursingworld.org, 2012, p. 2). As a result, it is important to recognize the value of existing nursing practice guidelines and frameworks in an effort to achieve positive outcomes for patients facing these risks (Nursingworld.org, 2012).
For patients who have no other option but to be restrained, nurses performing this duty must be apprised of the guidelines regarding restraints, including the documentation that is required, along with the requirement to have multiple witnesses at the time that the action is taken (Nursingworld.org, 2012). These actions are imperative because they demonstrate the importance of ethical protections and appropriateness to ensure that patient safety is maximized at all times (Nursingworld.org, 2012). In all cases, “the patient should be treated with humane care that preserves human dignity” (Nursingworld.org, 2012, p. 2). This practice must be evaluated on a consistent basis so that patients are protected from any unnecessary risks or harm in this case. With this perspective in mind, there are considerable challenges associated with the use of restraints in patient care settings, and as a result, many questions are raised regarding this practice, particularly if it is utilized more frequently than desired.
The use of restraints in nursing practice settings also emphasizes limited mobility, whereby patients are restrained to protect their own safety (Gastmans and Milisen, 2006). In this context, it is likely that there are significant ethical factors that must be considered prior to restraining patients, particularly in settings where other options are available (Gastmans and Milisen, 2006). Therefore, it is necessary to consider whether or not restraints are the optimal choice for these patients, particularly in nursing home settings (Gastmans and Milisen, 2006). Nurses must explore these options and communicate with their colleagues in regards to the development of new perspectives to protect patients from unnecessary risks with the use of restraints (Gastmans and Milisen, 2006).
There are a number of physical challenges associated with restraints, including but not limited to possible bruising, ulcers, and reduced muscle strength and wasting (Gastmans and Milisen, 2006). Therefore, an individual with the capacity to require restraints in the first place is likely to be physically and/or mentally impaired or face other concerns that are difficult to overcome, thereby creating an environment in which restraints are perhaps too restrictive and physically limiting (Gastmans and Milisen, 2006). However, for patients who are competent or conscious and are aware of restraints and their significance, there is a potentially terrifying series of events that will occur under these conditions (Gastmans and Milisen, 2006). Patients who are fully aware of the restraints may find themselves in a very difficult emotionally charged situation that may or may not be necessary in the first place (Gastmans and Milisen, 2006). Therefore, it is imperative to address these concerns and to perhaps consider other alternatives prior to using these restraints for this patient population (Gastmans and Milisen, 2006).
From an ethical point of view, the use of restraints may interfere with the ability of patients to remain autonomous and as independent and mobile as possible (Gastmans and Milisen, 2006). This is critical in order to enable patients to experience as much freedom as possible, given the circumstances of their condition (Gastmans and Milisen, 2006). Patients who experience any degree of impairment, such as confusion, dementia, or other conditions, they are subject to exhibit abnormal or potentially aggressive behaviors, some of which may require the possible use of restraints (Gastmans and Milisen, 2006). Unfortunately, this condition leads to critical concerns and challenges regarding how patients are treated when they face physical or mental impairments and have little ability to communicate for themselves (Gastmans and Milisen, 2006). Therefore, it is the responsibility of nurses to address these concerns and to develop strategies with their colleagues in order to determine different methods of managing their patients without compromising their integrity and autonomy in the process (Gastmans and Milisen, 2006).
According to Horsburgh (2003), “it is arguable that in care settings, there is an ethical requirement not only to avoid harm, but also to create benefit for the client. This principle is beneficence…The ethical principles of non-maleficence and beneficence might be used as justifications for overriding autonomy.” Under these conditions, it is expected that there will be significant questions raised when patients are being evaluated for the use of restraints in a given patient care setting (Horsburgh, 2003). However, this should not lead to ethical compromises that could pose significant injury and harm to patients (Horsburgh, 2003). There are important factors to consider in this process in adhering to patient protocols and other requirements as established by nurses (Horsburgh, 2003).
In the United Kingdom, a four-perspective approach to restraints is often utilized in order to determine how to best approach the use of restraints for patients who might require them (Gallagher, 2011). This is best accomplished using the following themes: 1) medical indications, whereby patients’ medical conditions are described; 2) patient preferences, whereby prior discussions or directives are considered; 3) quality of life, which represents a means of evaluating current and future health status; and 4) and contextual issues, which are primarily concerned with culture, family, religion, and other issues (Gallagher, 2011). These questions are important because they address some of the most relevant concerns surrounding the use of restraints for a specific patient and whether or not this is the optimal choice (Gallagher, 2011). It is imperative that the ethical nature of this decision is considered by all involved parties working with the patient, including nurses, so that the appropriate options are taken as necessary (Gallagher, 2011). There are considerable discussions required to determine if restraints are the most optimal ethical choice for a patient who has either become aggressive or is exhibiting some other type of behavior that makes it difficult to maintain control in other ways (Gallagher, 2011).
Nurses may find it very difficult to make decisions regarding patient restraints due to the challenging nature of this practice and how it limits their freedom and independence in most cases (Goethals et.al, 2012). In general, “The lack of evidence supporting the use of physical restraints, the negative consequences of restraint for patients, and the low availability of alternatives obviously complicate the decision-making” (Goethals et.al, 2012, p. 1198). It is imperative that nurses address the alternatives for patients who face these types of risks so that all possible concepts are explored in a manner that is consistent with recommended practice methods and principles (Goethals et.al, 2012). There is a necessity for nurses to exercise sound and reasonable ethical judgment at all times when working with these patients because there is considerable potential to compromise patient care in a negative manner when the wrong decision is made (Goethals et.al, 2012). Since there is limited evidence that already exists regarding the effectiveness of restraints for patients as well as other feasible alternatives, this often leaves nurses no other choice but to restrain patients who face these risks (Goethals et.al, 2012). Nonetheless, it is also important to identify the challenges that exist in the development of new ideas and approaches to patient care that impact and even compromise their wellbeing, which includes the use of restraints (Goethals et.al, 2012). It is anticipated that additional measures must be considered and future research must be conducted that will play an important role in improving the decision-making process in regards to patient restraints within a given patient population (Goethals et.al, 2012). Nurses must ultimately make the most appropriate decisions for their patients that will not compromise their ethical integrity and patient wellbeing in the process with a primary emphasis on safety concerns for these patients, as well as those that surround them (Goethals et.al, 2012).
The American Medical Association has developed its own perspectives regarding the use of restraints in daily practice settings, such as nursing homes. In accordance with these guidelines, it is imperative that the risks associated with restraint use must be considered, including physical and psychological risks (American Medical Association, 1989). In the nursing home setting, it is imperative that “The right of nursing home residents to be free from unreasonable bodily restraint also requires that care be provided in the environment that offers the fewest possible restrictions on mobility and independent action. The type of restraint selected should therefore permit the maximum degree of mobility that is compatible with therapeutic goals” (American Medical Association, 1989, p. 3). These guidelines are critical to the success and wellbeing of patients in these settings and require a greater understanding of the challenges and limitations that restraints may bring to the lives of these patients (American Medical Association, 1989).
Although restraints are typically viewed as physical objects in nature, chemical restraints are also common, such the use of sedatives and anti-psychotic medications to calm patients down (American Medical Association, 1989). Regardless of the circumstances, it is evident that there are many significant factors to consider with the use of restraints, including the type of restraints that might be used and their impact on patient care and wellbeing (American Medical Association, 1989). If the potential outcomes are not appropriate, then other alternatives must be considered in order to protect these patients from any form of unnecessary risk or harm in these settings (American Medical Association, 1989). In addition, if restraints are the final choice, they should not be used out of spite or as a form of punishment for patients, as this is in clear violation of ethical principles and frameworks set forth to protect patients in healthcare settings (American Medical Association, 1989). Also, it is expected that for patients who are restrained, informed consent from the primary responsible party must be provided at all times to protect nurses and the organization from any type of unnecessary risk or damage to their reputations (American Medical Association, 1989).
Nurses who use restraints for their patients may also face legal risks associated with this practice under some conditions. Therefore, it is important to develop the proper protocols and the type of documentation that is necessary to utilize this practice properly and without additional forms of risk. With this perspective in mind, it is important to determine how healthcare organizations might work with their nursing staff members to effectively create protocols that will have a positive impact on the lives of their patients and that will only use restraints under extreme circumstances under conditions where no other options are available. This is imperative to the development of new ideas and opportunities that reflect upon the challenges of patient care and wellbeing, particularly when patients exhibit aggressive behaviors and pose a danger to themselves or to others. These factors play a role in shaping outcomes for patients and in enabling nurses to make the appropriate decisions that will have the best possible impact for their patients at all times.
The ethical principles associated with nursing practice require that nurses demonstrate and understand tolerance, patience, beneficence, and autonomy, amongst others. These concepts are important indicators of the development of new opportunities for nurses to consider other feasible alternatives to treat their patients with respect and to protect them from any form of unintentional risk or harm. It is expected that nurses will adhere to the guidelines set forth by the leaders in this field in order to ensure that patient care is of primary concern and that restraints are only utilized under extreme circumstances when no other alternatives are available. In this context, patient care and wellbeing must be protected at all times through nursing decision-making that demonstrates ethical appropriateness and responsibility under a variety of patient care conditions.
Finally, the unique nature and focus of nursing practice and the decisions that must be made by new and experienced nurses lead to many questions regarding the use of restraints for patients in vulnerable population groups, given that nurses should attempt to prevent additional harm to their patients. Since the risks associated with restraints are high, additional considerations must be made that will emphasize the importance of measures that will improve patient outcomes rather than prohibit positive results for these patients. Therefore, the use of restraints must be minimized and supported by other factors that are likely to play a role in the development of these decisions to protect all patients, regardless of their health and mental status.
Nurses are required to make important decisions on a regular basis. The use of restraints for patients who exhibit aggressive behaviors may be essential to protect these patients, as well as those around them from unnecessary risk or harm. However, this decision is not made without many different complications, such as the ethical integrity of this type of decision and its impact on patient care and wellbeing. These factors are critical to the success of patient care and treatment in a variety of settings, which may include nursing homes and mental health facilities, amongst others. It is necessary that nurses must collaborate and openly communicate regarding these decisions in order to accomplish the desired objectives, while also considering other directives that may be less invasive and less challenging to these patients.
The principles of ethics and morality are critical to any decisions that are made regarding restraints because this practice leads to many difficult and challenging outcomes when the desired objectives are not met. Therefore, it becomes necessary to address the important aspects of care and treatment for patients with issues that may require the use of restraints, including the ethical principles of autonomy and beneficence. These decisions must explore the short and long-term impact of restraints on the lives of these patients in order to determine if the risks associated with the use of these restraints is worth it and that the desired benefits are achieved. Therefore, careful and thoughtful considerations must be made prior to making any final decisions regarding the use of restraints in many patient care settings.
American Medical Association (1989). Guidelines for the use of restraints in long term care facilities. Retrieved from http://www.ama-assn.org/resources/doc/code-medical-ethics/817a.pdf
American Nurses Association (2012). Reduction of patient restraint and seclusion in health care settings. Retrieved from http://nursingworld.org/restraintposition
Gallagher, A. (2011). Ethical issues in patient restraint. NursingTimes.net, retrieved from
Gastmans, C., and Milisen, K. (2006). Use of physical restraint in nursing homes: clinical- ethical considerations. Journal of Medical Ethics, 32(3), 148-152.
Goethals, S., de Casterie, B.D., and Gastmans, C. (2012). Nurses’ decision-making in cases of physical restraint: a synthesis of qualitative evidence. Journal of Advanced Nursing, 68(6), 1198-1210.
Horsburgh, D. (2003). The ethical implications and legal aspects of patient restraint. Nursing Times.net, retrieved from