Discussion two:– “Restraints are defined as act carried out with the purpose of restricting an individual’s movements, liberty and/or freedom to act independently and comes in many forms including, chemical, mechanical and physical forms of control, coercion and enforced isolation, also known as ‘restrictive interventions (Pértega & Holmberg, 2023, p. 1).” The use of restraints is contentious and is regulated by a strict set of laws (Pértega & Holmberg, 2023). The Mental Health Act declares that the use of restraints or seclusion must be therapeutic and used when necessary to prevent the patient from harming themselves, others (Keywood, 2005). There are many ethical issues that come with the use of restraints relating to trauma. For example, even in the event where the use of restraints is needed or considered “appropriate” it may result in the patient feeling depressed and dehumanized (Peterson, 2016). Another problem is the deaths and injuries that may be caused by restraints being used improperly (Peterson, 2016). Therefore, there were objectives set in place by the Hospital CoPs final rule, the first one being that the restraint or seclusion must be ordered by a doctor or nurse practitioner that is responsible for caring for the patient (Peterson, 2016). The second objective states that the restraint order must be exclusive to the event of a crisis and must be clear and measurable and visible in the patient’s chart (Peterson, 2016). The third states that if the restraint is used in an emergency and initiated prior to the order being placed by the provider, a doctor’s order must be placed as soon as possible (Peterson, 2016). The fourth objective states that the restraints must be discontinued as soon as the patient is no longer an imminent danger to themselves or others regardless of the length of the order placed by the provider (Peterson, 2016). The fifth objective is that the patient in restraints must be intermittently monitored by a staff member and the required interval is determined by the institutions policy (Peterson, 2016). The sixth objective states that a physician or registered nurse must see the patient within an hour of the restraints being initiated (Peterson, 2016). The last two objectives involve reporting (Peterson, 2016). Staff must provide information such as alternatives provided, such as the use of de-escalation and least-restrictive measures prior to resorting to restraints. Lastly, staff members must be provided training on recognizing and acting on signs of physical and psychological distress as well as signs of de-escalation. There is an ethical issue in the way that these objectives are stated, however. This is due to their lack of clarity and measurability and may be left up to interpretation (Peterson, 2016). Children and Adolescents Laws pertaining to the psychiatrist commitment of children and adolescents vary greatly from state to state (Kennedy & Mohr, 2001). Overall, children do not have the same constitutional protection as adults (Kennedy & Mohr, 2001). In 1979, the U.S. supreme court ruled that the involuntary commitment of a child is not a violation of their constitutional rights if the legal guardian consents and the provider agrees for the continued need (Kennedy & Mohr, 2001). Each state can grant rights to their citizen in addition to those granted by the federal constitution (Kennedy & Mohr, 2001). One ethical concern regarding the use of restraints in children is that informed consent is usually required in order to use restraints as a therapeutic intervention, however when treating a child who is considered “insufficiently mature” legal guardians can provide the consent (Pértega & Holmberg, 2023). The topic of restraints in children becomes more complicated because in other pediatric mental health visit, the treatment plan is a partnership between the child, the guardians, and the provider, but in the case of urgency in the inpatient setting, the child is violated, and the parents are not a part of the decision making for emergency restraint use (Pértega & Holmberg, 2023). The use of restraints causes many ethical concerns for children such as re-traumatization of a child who already has a history of trauma, physical discomfort, anxiety, humiliation and feeling isolated as well as potential for serious physical injury such as asphyxia and other unexpected deaths (Kennedy & Mohr, 2001). Applying information to Clinical Practice This information greatly applies to my clinical practice as it is vital as a provider to be aware of the laws and regulations relating to the use of seclusion and restraints since nurse practitioners have the authority to order such treatment interventions. As mentioned earlier, although there are general objectives put in place that provide guidelines for the use of restraints, specific policies and laws are specific to each state and/or institution, therefore it is important to be aware of those that effect the state and institution you work for (The New Jersey Hospital Administration, 2012). More specific guidelines for use of restraints in the state of New Jersey include; the hospital must have written policies that are reviewed at least every three years, the patient must be seen by a provider and an order must be placed within one hour of initiation, the clinical presentation of the patient should be assessed and documented every two hours, the provider responsible for the patient must visualize the patient every 24 hours to assess for any changes to the patient’s condition and documented, if the order was placed by the physician another order is not required as long as it is the same intent as the original order and within hospital policy (The New Jersey Hospital Administration, 2012). Specific guidelines for nursing personnel include; the assessment and documentation or patient presentation reevaluated for need for continued restraints every two hours, toileting offered at least every two hours, monitor and document vital signs and repositioning every 2 hours, continued or intermittent visual observation based on patient presentation, offering and monitoring for fluid intake and nutrition at regular intervals, offering assistance with bathing once daily, offering ambulation every four hours if clinically feasible (The New Jersey Hospital Administration, 2012). This information of the ethics surrounding the use of restraints in children and adults applies to my clinical practice because it is important to be aware of the ethical issues so that as a provider, I can identify and mitigate these issues when I come across similar cases in practice and respect the rights of my patients during my decision-making process. After learning about the potential for trauma in the use of restraints, I will pay close attention to patients’ history and weigh the risks and benefits before ordering restraints or seclusion as it may not be the best choice for every aggressive patient and could cause more harm than good. This information also reinforced the importance of accurate, detailed and thorough documentation of the events and behavior that preceded the use of restraints, the alternatives used to prevent the use of restraints, as well as the patient’s presentation before, during and after the restraints are discontinued and the care that was offered in between. discussion one:-Child and Elder Abuse Reporting According to Kohl, Sanders, and Blumenthal (2012), child and elder abuse are common problems in the United States and other countries around the world. 1 in 4 children in the United States get some form of maltreatment during their lifetime (Ho, Gross & Bettencourt (2017). Similarly, many elderly Americans are violated by their people in their communities. The abuse comes in different forms such as physical abuse, emotional abuse, financial abuse. Each of these forms of abuse is very devastating to the individual and their families. They also note that, in most cases, the abuse involves a family member. In every civilized society where the protection and safeguards of all individuals are important, reporting such abuse becomes a civic mandatory responsibility. As such, healthcare workers including physicians, practitioners, nurses are mandatory reporters. Ho, Gross & Bettencourt (2017) have examined the universal mandatory reporting policies and the odds of identifying child physical abuse. They conclude that universal mandatory reporting may not be the only answer for strengthening the protection of children and elderly victimized by physical abuse. Implementation of child and elderly protection policies must be exercised according to evidence to exert the fullest impact and benefit of these laws. Reporting of child and elderly abuse is the duty of everyone. Adames, Chavez-Duenas et al., (2023) and Berthold, Clemens et al., (2022) have written on the reporting of child and elderly abuse. Physicians, nurses, dentist, psychologists, social workers, mental health counselors, coaches, administrators, faculties, therapist, police officers, teachers are all mandatory reports. What must be reported include all the evidence of abuse. The time frame for the report is within 1 day for an oral report and 48 hours after the oral report. Dow, Gahan et al., ( 2020), have examined the barriers to reporting child and elderly abuse. The perpetrators are always related to the victim and because of this relationship, victims are always reluctant to report and seek help. The challenges of reporting child and elderly abuse are many. First many perpetrators themselves are family members. Also, because many of the victims love their family, they are hesitant or refuse to come forward. Kohl, Sanders, and Blumenthal (2012), note that even people closest to the problem at state and local levels grapple with uncertainties about how best to respond to problems of child and elderly abuse. As such, there is no proper law enforcement and coordination of the services related to child and elderly abuse. They conclude that state, federal, and local agencies should do more. Ethical and legal issues are involved in the reporting of child and elderly abuse. There are specific laws at state and federal level related to reporting of abuse. Also child and protective services have been put in place to protect children and the elderly as examined by Zeranski & Halgin (2011). As a registered nurse and a subsequent practitioner, I am a mandated reporter and the information gleaned in these articles is very useful and helpful to me. As nurses, we sometimes see cases that rise to abuse and neglect and raise eyebrows. It is our duty to report it and it is important to understand the legal and ethical issues as well as know the chain and method of reporting. This information therefore equips and puts me ready as a mandated reporter.
Restraints in healthcare are actions taken to restrict an individual’s movements, liberty, and freedom to act independently. They encompass various forms, including chemical, mechanical, and physical means of control, coercion, and enforced isolation, often referred to as ‘restrictive interventions’.
The Use of Restraints in Adult Patients
The Mental Health Act emphasizes that restraints should be employed therapeutically and only when necessary to prevent harm to the patient or others (Keywood, 2005). However, ethical dilemmas arise as the use of restraints may lead to patients feeling depressed and dehumanized (Peterson, 2016). There are also concerns about injuries or deaths resulting from improper restraint use (Peterson, 2016).
To address these issues, several objectives have been established, including the need for a doctor or nurse practitioner’s order (Peterson, 2016), clear and measurable restraint orders (Peterson, 2016), prompt discontinuation of restraints when no longer needed (Peterson, 2016), intermittent patient monitoring (Peterson, 2016), and timely physician or nurse assessment (Peterson, 2016).
Restraints in Children and Adolescents
Laws governing the use of restraints in children vary by state (Kennedy & Mohr, 2001), with children generally having fewer constitutional protections than adults (Kennedy & Mohr, 2001). In cases where a child is deemed “insufficiently mature,” legal guardians can provide consent for restraint use (Pértega & Holmberg, 2023). However, this raises ethical concerns, particularly regarding trauma, physical discomfort, anxiety, humiliation, and isolation (Kennedy & Mohr, 2001). Children may also face the risk of serious physical injury (Kennedy & Mohr, 2001).
Application to Clinical Practice
This information is highly relevant to healthcare providers, especially nurse practitioners who may have the authority to order restraint interventions (The New Jersey Hospital Administration, 2012). It highlights the importance of awareness regarding the laws and regulations governing restraint use, which can vary by state and institution (The New Jersey Hospital Administration, 2012).
Detailed documentation, assessment of patient history, and consideration of alternatives are essential in making informed decisions about restraint use, while prioritizing patient safety and well-being (The New Jersey Hospital Administration, 2012). Moreover, it is crucial for healthcare providers to receive training on recognizing and acting on signs of physical and psychological distress, as well as signs of de-escalation, to provide the best possible care to patients (Peterson, 2016).
Child and Elder Abuse Reporting
Child and elder abuse are pervasive issues in society, with devastating consequences for victims (Ho, Gross & Bettencourt, 2017). Healthcare workers, including nurses, play a crucial role as mandatory reporters in identifying and reporting cases of abuse (Adames, Chavez-Duenas et al., 2023; Berthold, Clemens et al., 2022).
Universal mandatory reporting policies exist, but their effectiveness in protecting vulnerable individuals varies (Ho, Gross & Bettencourt, 2017). The reporting of abuse is a collective responsibility, involving professionals from various fields, and should encompass all evidence of abuse.
Challenges to Reporting
Reporting abuse can be challenging, as perpetrators are often family members (Dow, Gahan et al., 2020), and victims may be hesitant due to emotional attachments (Dow, Gahan et al., 2020). Uncertainties about how to respond effectively to abuse cases persist at both state and local levels, leading to inadequate law enforcement and service coordination (Kohl, Sanders, and Blumenthal, 2012).
It is imperative that healthcare professionals, as mandated reporters, overcome these challenges through education and training (Dow, Gahan et al., 2020). Recognizing the signs of abuse and neglect and understanding the reporting process are vital to fulfilling the ethical and legal duty to protect vulnerable individuals.
Ethical and Legal Considerations
Specific laws at the state and federal levels govern the reporting of abuse (Zeranski & Halgin, 2011), and child and protective services have been established to safeguard children and the elderly (Zeranski & Halgin, 2011). As a registered nurse and practitioner, understanding these legal and ethical issues is crucial, as nurses are mandated reporters (Zeranski & Halgin, 2011).
Compliance with reporting requirements is not only a legal obligation but also an ethical imperative to ensure the safety and well-being of vulnerable populations. Recognizing the signs of abuse, knowing the reporting process, and understanding the importance of reporting are essential responsibilities for healthcare professionals (Zeranski & Halgin, 2011).
The use of restraints in healthcare and the reporting of child and elder abuse are complex issues that demand careful consideration from healthcare providers. Ethical and legal considerations must guide the use of restraints, with a focus on patient safety and well-being. Similarly, healthcare workers must fulfill their mandatory reporting duties to protect vulnerable populations from abuse and neglect. By addressing these issues, healthcare professionals can contribute to a safer and more ethical healthcare environment.
In conclusion, ethical considerations surrounding the use of restraints and the reporting of abuse are pivotal aspects of healthcare practice. These topics require continuous attention and awareness from healthcare providers to ensure that patient safety, dignity, and rights are upheld. Fulfilling these ethical and legal responsibilities is integral to providing quality care and safeguarding vulnerable individuals in healthcare settings.
Frequently Asked Questions (FAQs)
1. What are the primary forms of restraints used in healthcare, and why are they employed?
Restraints in healthcare encompass various forms, including chemical, mechanical, and physical means of control. They are employed with the purpose of restricting an individual’s movements, liberty, and freedom to act independently. Their use is often necessary to prevent harm to the patient or others.
2. What ethical concerns arise from the use of restraints in healthcare, particularly in children and adolescents?
Ethical concerns related to restraint use include the potential for trauma, physical discomfort, anxiety, humiliation, and isolation, especially in children. Restraints may re-traumatize children with a history of trauma and pose a risk of serious physical injury.
3. How do healthcare providers ensure ethical and legal compliance when using restraints in clinical practice?
Healthcare providers must follow established objectives and guidelines, such as obtaining a doctor or nurse practitioner’s order, clear and measurable restraint orders, prompt discontinuation of restraints when no longer needed, intermittent patient monitoring, and timely physician or nurse assessment. Additionally, they should receive training on recognizing signs of distress and de-escalation.
4. What is the role of healthcare professionals in reporting child and elder abuse, and why is it essential?
Healthcare professionals, including nurses, have a duty as mandatory reporters to identify and report cases of child and elder abuse. Reporting abuse is crucial to protect vulnerable individuals from harm and neglect. It is both a legal obligation and an ethical imperative.
5. What challenges do healthcare workers face when reporting cases of child and elder abuse, and how can these challenges be addressed?
Challenges in reporting abuse often stem from emotional attachments, reluctance to accuse family members, and uncertainties about the reporting process. To address these challenges, healthcare professionals should undergo education and training on recognizing abuse signs and understanding the reporting process, enabling them to fulfill their ethical and legal responsibilities effectively.
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