Posted: June 13th, 2022
The use of any form of restraints, whether in minors or adults, should always remain as the last measure implemented in patient care, as there are legal and ethical implications that must be considered. In fact, the ethical and legal basis for using restraint interventions as a last resort is founded on eight crucially important overarching principles, which include the fact that such interventions shall never be used as a means for punishment or humiliation, and that a real possibility of harm to the person or others is imminent if no action is undertaken and that the chosen form of restraint being used is proportionate to the risk of harm while remaining as the seriousness of that harm. Any action taken to restrict a client’s freedom of movement must always be the least restrictive option for meeting that need, among others (Ridley et al., 2019).
When used in children, the most important aspects pertaining to the moral and ethical implications resulting as the aftermath. Aspects that are highly significant to consider are the possible resulting physical and psychological harm that may result from their use. One meta-analysis found that a potential relationship between physical restraints being used for more than 15 minutes in children or adolescents resulted in increased risk for physical injury while demonstrating a lack of therapeutic effect which potentially resulted in worsening behaviors(Nielson et al., 2020). This worsening behavior can only be interpreted as a worsening emotional state being experienced by the minor and may cause traumatic memories. Based on this information, PMHNPs must be completely aware of the minor’s condition and what led to the event requiring restraints, as well as all pertinent client health information, to ensure that restraints are only used as a last resort when all other options to deescalate the client have been exhausted. Furthermore, Florida practicing providers must also take into account that legalities on physical restraint use limitations exist by client age; for example, anyone ages 9 – 17 may only remain restrained for a maximum of two hours, whereas in adults 18 and over the limit is four hours (Disability Rights Florida.org, 2022). Just as with adults, provider orders for the restraint must be obtained within 15 minutes (preferably prior to their application), but in the case of a minor, their parent/guardian must also be notified.
In terms of ethical and legal considerations regarding adults 18 years and older, providers must also follow the same rules of implications for their use and application, with the best ethical justification behind the notion that such restraint use will result in self-harm (Crutchfield et al., 2019). However, when dealing with adults, particularly seniors, providers must first consider their mental state, and any prior existing medical conditions which may exacerbate under the use of restraints, and which then may result in physical harm, or even death, to the client (Ye et al., 2018). In Florida, PMHNPs must remain aware of the requirements of meeting the client’s needs while in restraints, including that of physically monitoring and documenting on the client every 15 minutes, while offering fluids and comfort measures as stipulated (Disability Rights Florida.org, 2022).
Crutchfield, P., Gibb, T. S., Redinger, M. J., Ferman, D., & Livingstone, J. (2019). The conditions for ethical application of restraints. Chest, 155(3), 617–625. https://doi.org/10.1016/j.chest.2018.12.005
Disability Rights Florida.org. (2022). Rights in a statewide inpatient psychiatric program (sipp) for children under 21 – disability rights florida. https://disabilityrightsflorida.org/disability-topics/disability_topic_info/rights_in_a_statewide_inpatient_psychiatric_program_sipp_for_children_under
Nielson, S., Bray, L., Carter, B., & Kiernan, J. (2020). Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis. Journal of Child Health Care, 25(3), 342–367. https://doi.org/10.1177/1367493520937152
Ridley, J., Leitch, S., & Restraint Reduction Network (RRN) Training Standards 2019. (2019). Ethical training standards to protect human rights and minimise restrictive practices. (1st Edition). Birmingham: BILD Publications.
Ye, J., Xiao, A., Yu, L., Wei, H., Wang, C., & Luo, T. (2018). Physical restraints: An ethical dilemma in mental health services in china. International Journal of Nursing Sciences, 5(1), 68–71. https://doi.org/10.1016/j.ijnss.2017.12.001
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