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Title: Nurses' ethical reasoning and behaviour in cases of physical restraint in acute elderly care in Flanders: a qualitative emperical study
Other Titles: Het ethisch redeneren en handelen van verpleegkundigen in situaties van fysieke fixatie in de acute ouderenzorg in Vlaanderen: een kwalitatief empirische studie
Authors: Goethals, Sabine
Issue Date: 9-Dec-2013
Abstract: IntroductionToday’s healthcare systems are characterized by rapid change, a high tech environment, cost efficiency and limited care capacities. These developments contribute to increasingly complicated situations and a more complex role for nurses in a stressful work environment. This evolution requires that nurses have a good ethical awareness as well as the creativity to search for care solutions that contribute to the well-being of the patient. Unfortunately, nurses working in this complex environment often give priority to technical care interventions which may jeopardize the development of a personalized caring relationship.Research shows that nurses experience difficulties in the ethical reasoning process as well as in implementing decisions in the clinical environment. As a result, nurses tend to conform expectations and requirements of the context, rather than undertake a critical ethical search for a particular tailored care solution. The importance of reasoning and acting in the patient’s best interest is all the more important in acute care for older people. Particularly in acute elderly care, where most of the patients have impaired physical and mental abilities and limited capacities to express their personal needs and wishes, the vulnerability of the patients increases. To deal appropriately with this vulnerability, nurses need to be able to critically observe and interpret patients’ signals in order to provide ethical care in order to respect the older patient’s individuality, dignity and autonomy.The difficulties nurses experience in their ethical practice are mostly related to ethically laden nursing practices such as the case of physical restraint in daily care for older people. Ethically oriented literature with regard to physical restraint stresses the importance of an ethical evaluation of the situation by means of balancing and weighing the different ethical values involved. Empirical research concerning nurses’ ethical reasoning and behaviour in cases of physical restraint is limited. Despite the growing evidence concerning the negative consequences of restraint use on patients, it remains a common and widespread measure in acute and residential health care facilities in many countries. Protecting the physical integrity of the patient and his environment is often mentioned as the reason for this common practice.The overall objective of this dissertation is to explore, understand and describe nurses’ ethical practice (reasoning and behaviour), specifically in the case of physical restraint in acute care for older people. Literature reviews A review of the literature including 39 empirical studies (13 quantitative, 19 qualitative and 7 mixed method design) published between January 1988 and September 2008 has led to a more nuanced understanding of nurses’ ethical practice. Nurses’ ethical reasoning starts from their ethical awareness with the intention of ‘doing good’. The caring relationship forms the context for the ethical assessment, wherein a decision is taken. Nurses take the patient’s life history, feelings, wishes, intentions, and integrity into account. Here, given the important contextual embedded of nurses’ ethical reasoning and decision making, it cannot be reduced to its cognitive dimension. To justify their decisions, they rely on medical knowledge, personal values and experiences. Their reasoning process is also influenced by the vision of other colleagues of the team, the wishes of the family members as well as the culture and traditions of the ward. In many cases nurses forsake their values and principles in order to adapt to the opinions and expectations of others. Nurses’ decision-making is often the result of a difficult process whereby nurses experience tension between their personal values, professional ideals, and the expectations of others. Literature describes how nurses have difficulties in implementing their decisions in practice. Being ignored and not being respected in their ethical practices can hinder nurses from acting as they would like and are the most important cause of moral distress and burn-out. A synthesis of qualitative evidence including twelve empirical studies published between January 1990 and January 2010, concerning nurses’ decision-making process in cases of physical restraint was carried out. Nurses’ decision-making in cases of physical restraint varies from case to case but is influenced by patient- nurse and context related factors. The patients’ behaviour forms an important argument of the decision-making. The complexity of the decision-making depends also on nurses’ willingness to take risks and the view of the others involved. Nurses are strongly committed to ensuring the safety of patients, of staff and of the environment in which they work. A thoughtful decision requires the balancing of other values involved like psychological integrity, freedom of movement and respecting autonomy. This process of balancing values can be experienced as a dilemma. Where the majority of the included studies focus on elements supporting the complexity of decision-making, only two studies described the entirety of the decision-making process. The phases of initiation, evaluation and adaptation of the decision-making characterizes the trajectory of the decision-making. The qualitative empirical studyIn the original empirical study-with a qualitative research design-by means of semi structured interviews we explored nurses reasoning and decision-making processes. Next to the exploration of the process of decision-making, we also explored the values involved and balanced in nurses’ decision-making. Also the context as well as the influencing role of the context was studied and described in a nuanced way. Based on the interviews, decision-making in situations of physical restraint are- mostly- the result of an intensive process of observing, analyzing the situation. In the first time nurses try to wait and give chances before physical restraint is applied. In most of the cases, nurses adapt a restraint measure when alternative solutions are insufficient. Physical restraint is often applied in order to guarantee the physical integrity of the patient and his environment. The interviewed nurses describe the application of physical restraint as a last resort and experience this measure as a necessary evil. Most of the taken decisions are ones or more evaluated, adapted and stopped. As a result decisions related to the application of physical restraint are characterized as temporal and reversible. A decision-making that supports the well-being of the patient is based on a correct and complete picture of the patient that is underpinned with rational arguments. Nurses’ decision-making in cases of physical restraint is characterized as an ethical deliberation process, whereby the goal of ‘doing good’ is the central idea Whereby a minority of the interviewed nurses explicitly articulate the goal of ‘doing good’ the majority of the nurses realize this goal by their processes of reasoning and behaviour. The identification of the different ethical values and the process of balancing these values form the essence of ethical deliberation. As the main values all interviewed nurses want to protect for their patients—both restrained and other patients—are physical integrity followed by psychological integrity. Nurses protect these values by undertaking many actions in order to avoid physical and psychological adverse effects of restraints. Driven by the overwhelming goal of protecting physical integrity, nurses took into account the values of dignity and justice more implicitly and less dominantly. Decision-making implies that nurses have to choose which values receive priority in the process, which in turn implies that not all values can be respected to the same degree. Depending on the situation, circumstances, and nurse involved, decision making can be experienced as difficult, even as a dilemma. According to the interviewees, decision-making in cases of physical restraint is a complex process. This complexity is largely due to the interplay of diverse contextual factors that influence decision-making. Relationships with nursing colleagues, other care providers such as physiotherapists, occupational therapists and physicians, and the patient’s family form the inter-personal network. The inter-personal network is the central forum wherein consultation, verification and decision-making takes place. Nurses also point the importance of the procedural-legal context as expressed in an institutional ethics policy and procedures, or through legal requirements concerning physical restraint. Further, the architectural structure of a ward, the availability of materials and alternatives for restraint use (the material-physical context), can be decisive in nurses’ decision-making. All interviewed nurses highlighted the unquestionable role of the practical context of care, specifically time of day and staff-related factors that contribute to the experienced work pressures. Also, the interviewed nurses reported that their decisions may vary according to the time of day (morning, noon, evening, night) and the presence or absence of nursing colleagues, other care providers and family. The work pressure experienced by nurses is often decisive in their decision-making.
Publication status: published
KU Leuven publication type: TH
Appears in Collections:Academic Centre for Nursing and Midwifery
Interfaculty Centre for Biomedial Ethics and Law
Field of Study Health Care Odisee

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