Physical Restraints and Ethical Decision-Making in Nursing

Patient-centered care is the foundation of the nursing practice, which may involve different interventions, including restraint application. Physical restraint might be utilized in acute and residential medical facilities to promote patient safety and facilitate the management of aggressive behavior causing physical or emotional harm to patients and medical staff. When it comes to decision-making regarding physical restraints, nursing professionals play a pivotal role as they initiate, maintain, and terminate the intervention or provide care for restrained patients (1). Despite being a common practice, the use of restrains may negatively impact patients’ health. Moreover, the practice might be viewed as inhumane and breaching basic human rights (2). The factors influencing nursing decisions to use or avoid restraints include professional knowledge, cultural background, nurses’ attitudes to the restraint use, and patients’ unique characteristics (1, 3). Thus, nurses should be cautious about their decision-making related to physical restraints, apply the evidence-based approach (EBP) to the practice, and analyze the issues associated with the measure.

Decisions about physical restraint use may be difficult since the practice is controversial and presents an ethical dilemma. On the one hand, physical restraint devices have their benefits as they facilitate therapeutic procedures, protect staff and patients from harm, and prevent potential harm-related liability lawsuits. It is vital to follow the manufacturer’s recommendations while employing physical restraints since the incorrect application of restraint devices can cause injury or death (4). The negative aspects may originate from the lack of awareness about the risks associated with restraints use, not the method itself (5). Based on that position, additional education and training can enhance nurses’ knowledge of restraint procedures and prevent accidents.

On the other hand, physical restraints may negatively impact patients’ health and well-being. There is evidence demonstrating that the correct use of restraints by nurses might still lead to physical injuries, mental issues, and death. The systematic review by Bellenger et al. (2) suggests that physical restraints can increase mortality and morbidity resulting from falls, cognitive issues, nerve injuries, and incontinence. Furthermore, the value of safety should not interfere with other core values, such as beneficence, dignity, freedom, and autonomy (1). Estevez-Guerra et al. (6) identified the psychological effects of restraints, including anxiety, fear, dignity loss, aggression, and social interaction problems. Nurses may acknowledge the negative outcomes of the use of restraints but prioritize residents/staff harm prevention and decreased liability risk in their decision-making. However, it should be noted that “restraint minimization studies have not demonstrated a change in the number of fall-related injuries” (2, p. 1043). Due to ethical and legal issues involved in physical restraints’ use, further research is needed to provide conclusive evidence, find effective alternatives to the method, develop restraint-free care models, and review patients’ perspectives.

The decisions about physical restraints place a considerable psychological burden on nurses who may experience guilt and conflict between their personal values and professional obligations or the value of safety. The nursing staff should be supported by a value-supportive environment and ethical leadership to provide evidence and reasoning for each intervention. The prevalence of physical restraints use may be explained by inadequate knowledge, so ethical leaders may prefer to conduct fall prevention and psychological support trainings to minimize the need for restraints (6). Ethical leadership may help nurses to make informed decisions and decrease the use of restraints or avoid frustration with their actions (7). The nursing decisions should be a balance of various opinions, core ethical principles, such as the ANA Code of Ethics, and respect for human dignity and worth (8). Additionally, organizational initiatives, such as Trust Before Restraint program introduced in Norway, help nurses identify and evaluate their patients’ needs and decrease the use of restraints (3). Value-supportive strategies might include questionnaires and staff interviews to assess personal values, ethical dilemmas, and misconceptions of nurses. Overall, value-based strategies can assist nurses in making informed choices between safeguarding and supporting the patient’s autonomy.


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