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LEARNING DISABILITY PRACTICE May 2016 | Volume 19 | Number 4 23

Art & science | physical interventions

NURSES FACE situations with ethical implications every day (Ulrich et al 2010) and they are often required to make complex decisions for which they are professionally and legally accountable.

Ethical issues arise in clinical situations when certain practices are judged as being in contravention of an approved professional or moral standard. For example, if a service user requires life-saving medication and is refusing it but does not have capacity to understand the consequences, or if he or she is engaging in challenging behaviour that puts themselves or others at risk of imminent harm, then the nurse has a moral obligation to ensure the person’s safety. Physically restraining the service user may be required, which may breach a moral imperative (strongly felt principle). Ultimately, the moral ‘transgression’ needed to resolve certain clinical situations can make nurses’ decision-making process difficult (Wilson et al 2008).

The use of restrictive practices is a difficult ethical issue that nurses often experience, and can include the following areas: ■■ Mechanical restraint. ■■ Psychological restraint. ■■ Physical restraint. ■■ Chemical restraint. ■■ Seclusion.

In recent years there has been greater awareness of issues raised by the use of physical restraint in intellectual disability services (Clarke 2011). Accordingly, this article focuses on physical restraint and explores its use and misuse in intellectual disabilities settings, as well as the ethical, legal and political issues associated with its use. Also considered is the consent of the person subjected to restraint, the wider aspect of human rights and the balancing of these rights with safety, ethical values and duty of care.

Layla Hughes and Paula Lane describe the implications of restraint procedure in intellectual disability practice in Ireland, and how policy changes affect nurses

Correspondence [email protected]

Layla Hughes is an intellectual disabilities nursing student

Paula Lane is a lecturer

Both at the School of Health Sciences, Waterford Institute of Technology, Ireland

Date of submission December 7 2015

Date of acceptance January 27 2016

Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software

Author guidelines journals.rcni.com/r/ ldp-author-guidelines

Use of physical restraint: ethical, legal and political issues

Abstract This article explores the ethicolegal and political factors associated with physical restraint in intellectual disability practice in Ireland.

The primary purpose of physical restraint in intellectual disability care is to prevent injury or harm to the service user or others, yet research evidence shows it can cause trauma and injury. Physical restraint is a controversial topic and it is important for nurses to remain up to date with clinical governance strategies, regulation and policy developments.

In recent years, there has been debate regarding the use and misuse of the restrictive practice of physical restraint, particularly in care settings where vulnerable clients reside. In intellectual disability

services, nurses face difficult decisions in caring for clients when managing challenging behaviour.

The protection and safety of the service user is of utmost importance and includes: legal considerations regarding professional duty of care and consent; political matters of advocacy and power; human rights; and ethical principles.

Ethics require a moral approach that ‘first does no harm’, engaging in beneficial practices that serve to uphold the best interests of service users and engender public trust.

Keywords ethics, intellectual disability, learning disabilities, physical restraint, restrictive practices, safety

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Feature Art & science | physical interventions

The independent Mental Health Commission (MHC) in Ireland defines physical restraint as ‘the use of physical force (by one or more persons) for the purpose of preventing the free movement of a resident’s body when he or she poses an immediate threat of serious harm to self or others’ (MHC 2009).

Research has shown that people with severe intellectual disabilities, those who engage in challenging behaviour and service users who have intellectual disabilities and are non-verbal, are particularly vulnerable to restrictive interventions (Merineau-Cote and Morin 2012).

The primary purpose of physical restraint is to prevent people with intellectual disabilities from harming themselves or others (Heyvaert et al 2015). However, physical restraint can be traumatic for all involved (Parish 2014) and, even when used correctly, there is a risk of injury (Williams 2009).

When older people with intellectual disabilities are subjected to physical restraint, the risk of injury is higher due to comorbidities associated with intellectual disabilities and age, such as epilepsy and cardiac abnormalities (Ridley and Jones 2012).

In addition to the risks of physical injury, the use of restraint can have a negative psychological impact on staff and service users.

Qualitative research has found that most nurses involved in a restraining incident experience negative feelings such as sadness, guilt and emotional distress (Chuang and Huang 2007), while service users who are subjected to restraint describe feeling anxious, angry, confused, powerless, vulnerable and dehumanised (Strout 2010, Heyvaert et al 2015).

The misuse of physical restraint can lead to the type of illegal abuse exposed in 2014 by Irish broadcaster RTÉ (Box 1).

The potential risk of physical and psychological harm associated with physical restraint makes its use controversial and ethically laden (Goethals et al 2011), and policies are now focused on eliminating or minimising the use of restraint (Rickard et al 2013).

Nursing falls under the domain of normative ethics – an approach to ethics that works from standards of right or good action; this is because nurses’ actions are guided by professional ethical values (Butts and Rich 2013). The use of physical restraint poses an ethical dilemma for nurses because it conflicts with certain ethical values, contravenes human rights and dignity, and potentially causes harm to service users (Rickard et al 2013).

Decision making about the use of physical restraint must involve an analysis of the alternatives, balancing ethical values and the value of safety (Goethals et al 2011).

Within normative ethics there are two broad schools of thought – duty theory and consequentialism. These theories can guide decision making by providing reasoned answers to ethical issues (Denieffe et al 2008). The main principles underpinning intellectual disabilities nursing are (Department of Health (DH) 2001): ■■ Rights. ■■ Independence. ■■ Choice. ■■ Inclusion.

Duty theory suggests these principles must be upheld, regardless of the consequences, whereas consequentialism determines whether an action is ‘right’ if the consequences outweigh the risk of harm (Butts and Rich 2013).

Thus physical restraint can be justified when the benefits of restraining a person, as well as the risk of harm if restraint is not used, outweigh the potential negative consequences.

Nursing codes of practice The International Council of Nurses’ (ICN) code of ethics (ICN 2012) stipulates that nurses have four fundamental responsibilities: ■■ To promote health. ■■ To prevent illness. ■■ To restore health. ■■ To alleviate suffering.

In Ireland, nurses’ and midwives’ actions are governed by a code of conduct and ethics from the Nursing and Midwifery Board of Ireland (NMBI), which establishes the ethical values and professional standards by which staff are required to conduct themselves (NMBI 2014).

The NMBI’s fitness to practise committee is comprised mostly of laypeople, and its fitness to practise inquiries are held in public.

Inherent in national and international codes is the professional responsibility on nurses to ensure the care they provide respects human rights,

Box 1 Physical restraint exposed on television

In December 2014, RTÉ’s Prime Time programme reported on Áras Attracta, a care centre for adults with intellectual disabilities in County Mayo, in the west of Ireland (Prime Time 2014). The documentary revealed an incident in which a 75-year-old woman with severe intellectual disabilities was physically restrained and force-fed by a staff member. Later footage showed the woman to be capable of feeding herself with little assistance.

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including the right to dignity, the right to be treated with respect, and the right to autonomy.

Autonomy refers to an individual’s ability to make choices based on their personal values, and acquiring informed consent is fundamental to respecting this principle. Respect for autonomy is embodied in the Irish code for nurses and midwives, which presumes every adult has the capacity to be autonomous.

Wilson et al (2008) acknowledge that promoting autonomy for some people with intellectual disabilities can be challenging, and highlight the importance of a close and enduring relationship between service users and caregivers.

If it has been determined that an individual lacks capacity, medical interventions must be discussed with the individual’s family members and other members of the multidisciplinary team.

Nurses have highlighted the importance of multidisciplinary input in lightening the ethical burden (Kontio et al 2010).

Legislation In Ireland, the Nurses and Midwives Act 2011 is the governing legislation for nurses and midwives, following the repeal of much of the previous Nurses Act 1985. The act brings the governance of nurses and midwives closer to that of other healthcare professionals, and increases protection of service users by ensuring nurses and midwives uphold their duty of care (Moore 2013) and adhere to local and national guidelines.

The Health Information and Quality Authority (HIQA), established under the Health Act 2007, is the statutory body responsible for promoting the quality and safety of health and social care services. The monitoring and inspection of intellectual disabilities care has been a positive step towards improving services, and has led to the development of national standards for residential services for children and adults with disabilities, as well as guidance on restraint procedures for designated centres.

The guidance emphasises the importance of assessment and planning to meet service users’ needs by focusing on positive behaviour supports, rather than physical interventions, to promote a restraint-free environment (HIQA 2014).

In Ireland, national policy on restraint requires care centres to establish a policy that adheres to national standards, legislation and defined principles (Box 2) (DH 2011).

The MHC was established under the Mental Health Act 2001 to develop guidelines for the act’s more complicated sections, such as section 69.

This section legislates for the use of restraint for the purposes of treatment, or to prevent the patient from injuring him or herself or others.

The act applies to people receiving care in an ‘approved centre’, such as a hospital or inpatient facility registered for the care and treatment of persons with a mental health disorder. However, despite the high prevalence of mental health problems among people with intellectual disabilities (Devine and Taggart 2008), there is only one approved centre for the treatment of people with a dual diagnosis of intellectual disability and a mental health problem in Ireland (Inclusion Ireland 2013).

In Ireland, people with intellectual disabilities receiving care in intellectual disabilities services are not protected by this law. This is unsatisfactory and the country’s Department of Health and Children (2006) highlighted the need for a legislative solution.

The Irish Constitution, Bunreachtnah Éireann (1937), is the fundamental law of Ireland. Article 40 of the constitution describes the fundamental rights of all Irish citizens, and these, as well as rights enshrined in the European Convention on Human Rights Act 2003, include: ■■ The right to be treated with dignity and respect. ■■ The right to freedom. ■■ The right to bodily integrity.

While the use of physical restraint infringes on these rights, Ireland’s government stipulates that the procedure may be justifiable if it is necessary to protect another constitutional right, for example to protect a person from imminent risk of harm.

However, the subjection of a service user to physical restraint for any reason other than

Intellectual disability nurses are in an ideal position to identify the negative and positive aspects of services

Box 2 Guidelines on physical restraint

■■ A staff member of the same sex as the service user must be present

■■ A doctor must examine the individual subjected to physical restraint within three hours of the incident

■■ The service user’s next of kin must be informed of the incident as soon as practically possible

■■ Following a physical restraint incident, it is compulsory for a psychiatrist to be informed immediately, and for the event to be documented in the service user’s clinical file. An episode of physical restraint must not exceed 30 minutes.

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Art & science | physical interventions

to protect him or her from imminent harm, or to administer treatment that is medically necessary, is in breach of Article 3 of the European Convention on Human Rights Act 2003, which provides for the right to be free from inhuman and degrading treatment.

The UN Convention on the Rights of Persons with Disabilities 2006 (United Nations 2006) is an international agreement that was signed by the Irish government in 2007. Its main objective is to ensure all human rights for persons with disabilities are respected without discrimination (Doyle and Flynn 2013). Article 12 of the convention protects the autonomy of people with disabilities, ensuring they are at the centre of decision making on issues concerning themselves.

However, the UN Convention on the Rights of Persons with Disabilities has still not been ratified in Ireland. The paternalistic ‘ward of court’ system derived from the Lunacy Regulation (Ireland) Act 1871, which remains in use (Doyle and Flynn 2013), has been highlighted as the major barrier to ratification of the convention by the Irish government.

To protect people who lack capacity, the Assisted Decision-Making (Capacity) Bill 2013 (Government of Ireland 2013) was approved by the Irish

government in 2013. It protects people with limited decision-making skills by ensuring their wishes and preferences are taken into account, and that they are supported in exercising their legal capacity. The Assisted Decision Making (Capacity) Act 2015 was passed in December 2015 and has now repealed the Lunacy Regulation (Ireland) Act 1871. As a result of this, it is likely that the UN Convention on the Rights of Persons with Disabilities will be ratified soon.

Political issues Politics affects every aspect of nursing at a macro and micro level. At the macro level, implementation of the capacity bill will see the outdated Lunacy Regulation (Ireland) Act 1871 and its ward of court system replaced by a more clearly defined act. This will protect people who lack capacity by ensuring their personal will and preferences are the main factors in decisions regarding themselves (Carey and Griffiths 2014).

At the micro level, Ireland’s Health Service Executive published the HSE National Policy on the Use of Physical Restraints in Designated Care Units for Older People (Health Service Executive 2010), which provides guidance on the use of physical restraint, and details the rare circumstances when the use of such restraint is permissible.

Bradbury-Jones C, Sambrook S, Irvine F (2008) Power and empowerment in nursing: a fourth theoretical approach. Journal of Advanced Nursing. 62, 2, 258-266.

Butts J, Rich K (2013) Nursing Ethics: Across the Curriculum and Into Practice. Jones and Bartlett Learning, Burlington, Massachusetts MA.

Carey E, Griffiths C (2014) The impact of Irish policy and legislation on how adults with learning disabilities make choices. British Journal of Learning Disabilities. 43, 1, 1-11.

Chuang YH, Huang HT (2007) Nurses’ feelings and thoughts about using physical restraints on hospitalized older patients. Journal of Clinical Nursing. 16, 3, 486-494.

Clarke Z (2011) Finding alternatives to restraint. Learning Disability Practice. 14, 2, 21-23.

Denieffe S, Denny M, Wells J (2008) Professional and ethical challenges in mental health nursing. In Morrissey J, Keogh B, Doyle L (Eds) Psychiatric/Mental Health Nursing: An Irish Perspective. Gill and Macmillan, Dublin.

Department of Health (2001) Valuing People – A New Strategy for Learning Disability for the 21st Century. DH, London.

Department of Health and Children (2006) A Vision for Change: Report of the Expert Group on Mental Health Policy. The Stationary Office, Dublin.

Department of Health (2011) Towards a Restraint Free Environment in Nursing Homes: A Policy Document. The Stationary Office, Dublin.

Devine M, Taggart L (2008) Addressing the mental health needs of people with learning disabilities. Nursing Standard. 22, 45, 40-48.

Doyle S, Flynn E. (2013) Ireland’s ratification of the UN convention on the rights of persons with disabilities: challenges and opportunities. British Journal of Learning Disabilities. 41, 3, 171-180.

Goethals S, Dierckx de Casterlé B, Gastmans C (2011) Nurses’ decision-making in cases of physical restraint: a synthesis of qualitative evidence. Journal of Advanced Nursing. 68, 6, 1198-1210.

Harrison T, Davies R (2009) Advocacy: time to communicate. Advances in Psychiatric Treatment. 15, 1, 57-64.

Health Information and Quality Authority (2014) Guidance for Designated Centres: Restraint Procedures. HIQA, Dublin. tinyurl. com/hrulw77 (Last accessed: March 30 2016.)

Health Service Executive (2010) HSE National Policy on the Use of Physical Restraints in Designated Care Units for Older People. HSE, Dublin. tinyurl.com/h9pprbb (Last accessed: March 30 2016.)

Heyvaert M, Saenen L, Maes B et al (2015) Systematic review of restraint interventions for challenging behaviour among persons with intellectual disabilities: focus on experiences. Journal of Applied Research in Intellectual Disabilities. 28, 2, 61-80.

References

LEARNING DISABILITY PRACTICE May 2016 | Volume 19 | Number 4 27

Inclusion Ireland (2013) Implementing the National Disability Strategy: Inclusion Ireland Position Paper. tinyurl.com/l5gl3ao (Last accessed: March 30 2016.)

International Council of Nurses (2012) The ICN Code of Ethics for Nurses. tinyurl.com/by8duos (Last accessed: March 30 2016.)

Kontio R, Välimäki M, Putkonen H et al (2010) Patient restrictions: are there ethical alternatives to seclusion and restraint? Nursing Ethics. 17, 1, 65-76.

Maryland M, Gonzalez RI (2012) Patient advocacy in the community and legislative arena. Online Journal of Issues in Nursing. 17, 1, 2.

Mental Health Commission (2009) Code of Practice on the Use of Physical Restraint in Approved Centres. MHC, Dublin.

Merineau-Cote J, Morin D (2012) Correlates of restraint and seclusion for adults with intellectual disabilities in community services. Journal of Intellectual Disability Research. 57, 2, 182-190.

Nursing and Midwifery Board of Ireland (NMBI) (2014) Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives. The Stationary Office, Dublin. tinyurl. com/zzbrfb9 (Last accessed: March 30 2016.)

Owen F, Griffiths D (2008) Challenges to the Human Rights of People with Intellectual Disabilities. Jessica Kingsley Publishers, London.

Parish C (2014) Advice on restrictive practices is ‘revolutionary’, say experts. Learning Disability Practice. 17, 5, 8-9.

Prime Time (2014) RTÉ investigations unit: inside bungalow 3. RTÉ One. December 9 2014.

Rickard E, Chan J, Merriman B (2013) Issues emanating from the implementation of policies on restraint use with people with intellectual disabilities. Journal of Policy and Practice in Intellectual Disabilities. 10, 3, 252-259.

Ridley J, Jones S (2012) Clamping down on the use of restrictive practices. Learning Disability Practice. 15, 2, 33-36.

Strout T (2010) Perspectives on the experience of being physically restrained: an integrative review of the qualitative literature. International Journal of Mental Health Nursing. 19, 6, 416-427.

Ulrich C, Taylor C, Soeken K et al (2010) Everyday ethics: ethical issues and stress in nursing practice. Journal of Advanced Nursing. 66, 11, 2510-2519.

Williams D (2009) Restraint safety: an analysis of injuries related to restraint of people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities. 22, 2, 135-139.

Wilson N, Clegg J, Hardy G (2008) What informs and shapes ethical practice in intellectual disability services? Journal of Intellectual Disability Research. 52, 7, 608-617.

The influence that health policy has on nursing has been acknowledged and as such nurses are exerting their influence on its development (Maryland and Gonzalez 2012). They are furthering their role as patient advocates, serving as a voice that can give expression to clients’ needs and perspectives.

Advocacy is an important part of the role of the registered intellectual disability nurse. Nurses need to be aware of the power they have and power imbalances within their multidisciplinary team if they are to advocate effectively on behalf of service users and act in a political manner to bring about changes in the healthcare system (Bradbury- Jones et al 2008).

As part of their responsibilities, advocates for people with intellectual disabilities should promote the person’s rights and safeguard autonomous decision making (Harrison and Davies 2009). Advocates should encourage individuals with intellectual disabilities to become actively involved in their health care, which will help to redress the imbalance of power between the individual and their doctor (Owen and Griffiths 2008).

Intellectual disability nurses are in an ideal position to identify the negative and positive aspects of services. By bringing these issues and

concerns to the attention of elected officials and other gatekeepers, nurses can successfully improve service provision and quality of care (Maryland and Gonzalez 2012).

Conclusion This article has discussed the ethical, legal and political issues associated with the use of physical restraint in intellectual disability nursing practice.

Physical restraint is a controversial topic and it is important for healthcare workers to be aware of its use and misuse. Nurses experience ethical dilemmas regarding the use of physical restraint because its use conflicts with ethical values and can infringe on service users’ human rights.

Knowledge and understanding of ethical principles and theories can assist nurses when making complex decisions in clinical practice.

It is also essential for nurses to continue refreshing their knowledge of legislation, national and local policies, and evidence-based practice guidelines.

Nurses are in a position of power and should use this power effectively to advocate at the individual level,and to influence government policy and improve care provision for people with intellectual disabilities.

If you are interested in this subject, turn to the inside back cover to find out more related articles from RCNi’s archive.

Conflict of interest None declared

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