Ethical Dilemma Factor in Regarding Physical Restraints to Elderly of Female Nurses with the Living Together Experience

doi:10.4236/ijcm.2012.35064

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International Journal of Clinical Medicine, 2012, 3, 328-334

http://dx.doi.org/10.4236/ijcm.2012.35064 Published Online September 2012 (http://www.SciRP.org/journal/ijcm) 1

Ethical Dilemma Factor in Regarding Physical Restraints

to Elderly of Female Nurses with the Living Together

Experience

Miwa Yamamoto1, Shizue Mizuno1, Masako Aot a2

1Department of Nursing, Kyoto Koka Women’s University, Kyoto, Japan; 2Department of Nursing, Meiji Univesity of Intergrative

Medic ine, Kyot o, Japan.

Email: [email protected]

Received May 22nd, 2012; revised June 24th, 2012; accepted July 4th, 2012

ABSTRACT

Purpose: The aim of this study was to illuminate the connotation of “dilemma” regarding the use of physical restraint

on elderly patients as represented by female nurses working in general wards at community hospitals who also live with

elderly adults at home. Method: The study used the questionnaire method with an independently prepared question-

naire. Participants: The objective of the stud y was exp lained to th e persons in ch arge of nu rsing in th e selected 17 hos-

pitals, and 1929. Finally, this stud y of participants were 524 female nurses working in general 54 ward s (excluding the

emergency wards of psychiatry, pediatrics, obstetrics, outpatients, operating rooms, and intensive care units) at commu-

nity hospitals who also live with elderly adults at home. Results and Conclusions: Cronbach’s overall coefficient for

the 20 items of dilemma was high (0.78) and the factor analysis extracted four dilemma factors as having a characteris-

tic value of 1 (Kaiser-Meyer-Olkin measure value = 0.81) with a cumulative contribution ratio of 64.5%. The high

Cronbach’s for these items (0 .86, 0.88, 0.87 and 0.81) conf irmed the internal consisten cies. W ith respect to the dilemma

where nurses working in general wards at community hospitals who also live with elderly adults at home are faced with

the physical restraint of elderly persons, four factors in the clarification of the dilemma were extracted: accomplishment

of medical-treatment and accident prevention, characteristic features in nursing for elderly patients with dementia,

healthcare professional relations hip in nursing for elderly patients with dementia, and priorities on the accident prev en-

tion for elderly patients with dementia. Therefore, the constr uction of four systems to cope with these dilemmas is sug-

gested. These systems would enable practising nurses to: 1) institution of policies to encourage discussion between

nurses and other medical staff to reach consensus on treatment; 2) allocating elderly care specialists to ward s to promote

alternatives to restraints; 3) establishment of safety standards to define nurses’ responsibilities; and 4) institution of con-

tinuous ethical ed u ca tion for nurses.

Keywords: Ethical Dilemma Factor; Physical Restraint; The Living under with Elderly People Experience

1. Introduction

What Are the Ethical Implications of Physical

Restraints for JAPANESE Nurses?

In 2000, Japan established long-term care insurance, a

system created in response to a growing societal concern

regarding the delivery of care to the aging population.

This system was established to assure that citizens will

receive care and be supported by society as a whole.

Long-term care insurance is separate from medical care

insurance, and was set up as a first step towards revising

the structure of social security. In addition, the Ministry

of Health, Labour and Welfare passed a bill prohibiting

the physical restraint of older patients receiving treatment

under the long-term care insurance program. As a result,

those caring for older patients became legally prohibited

from physically restraining them. At many general hos-

pitals in Japan, however, physical restraint remains a

legal option when treating patients under medical care

insurance. In general wards where regulations do not

specifically prohibit physical restraint, nursing care con-

tinues to include this practise, [1] partly due to a lack of

effective alternative options. Thus, the practice of physi-

cal restraint is likely to continue, as cures and effective

treatments for dementia remain on the distant horizon . A

patient with dementia hospitalized in a general hospital

differs from a senior citizen who enters an institution for

medical caretaking. Restraints are often employed when

extra care is required to prevent a dementia patient from

injuring him/herself by removing IV tubing or other

Ethical Dilemma Factor in Regarding Physical Restraints to Elderly of Female

Nurses with the Living Together Experience 329

equipment.

On the other hand, several trials have demonstrated

that physical restraints, rather than pro tecting the patient,

often cause undue harm [2,3]. Therefore, this phenome-

non—whereby restraints are actively used for practical

purposes, but are not in compliance with current regu-

lations—leaves nurses facing an ethical dilemma [4,5].

Several scholarly articles have addressed the challenges

and conflicting feelings faced by nurses in restraining

elderly patients. The placement of physical restraints by

nurses has been accompanied by feelings of frustration,

guilt, and ambivalence [6-9]. Matthiesen et al. studied

the perspectives on restraint use among nurses who had

experience living with an elderly relative [10]. They

found that nurses who liv ed with elderly family members

were significantly more likely to believe that restraints

exacerbate dementia. Their findings suggest that nurses’

personal experiences may influence feelings of moral

obligation toward their pa tients, and highlight th e need to

consider nurses’ personal experiences when developing

programs to overcome dilemmas inherent in restraining

the elderly.

2. Objectives

The purpose of this study was to further clar ify the n atur e

of the dilemma faced by nurses who live or have lived

with an elderly family member. We developed a ques-

tionnaire for nurses to explore these issues.

2.1. M Hypothesis

2.1.1. Conceptua l Framework

We based our study on the MORAL model offered by

Crisham [11,12]. A dilemma occurs in the setting of con-

flicting goals and ethical considerations . In this situation,

we assumed that the following five considerations were

in conflict: 1) the practise of nursing for elderly patients

with dementia; 2) the h ealthcare p rofessional relation ship

in nursing for elderly patients with dementia; 3) the ful-

fillment of obligation in safe treatment; 4) the nursing

moral; and 5) the nursing of elderly patients with demen-

tia. The study was performed using an independently

prepared 20-item questionnaire, developed using previ-

ous research of Crisham’s [11,12] and Kojima et al. [13].

The survey was comprised of four questions for each of

the five dilemmas (Table 1).

Table 1. 20 Dilemma items.

Classification No. Dilemma Items

1 Physical restraint of elderly patients may be allowed if there is another patient in critical condition.

2 Physical restraint of elderly patients may be allowed if nurses are busy under practices of ADL assistance and routine practices.

3 Physical restraint of elderly patients may be allowed if frequent observation is unavailable due to structure of wards.

A/Nursing

practice

4 Nursing without physical restraint is desirable, and when no other option is available, carrying out physical restraint is hard.

1 When another option is possible or when it has to be done, but deemed unnecessary due to doctor’s orders, nurses feel let down.

2 When another option is possible or when it has to be done, but deemed unnecessary due to orders of the nurse in charge, nurses

feel let down.

3 Physical restraint of elderly patients is questionable when insufficient discussion between nursing staff has taken place.

B/Cooperative

relationship

4 Physical restraint under the direction of a senior associate is questionable when deemed unnecessary or anot her method may be

available.

1 Physical restraint may be deemed necessary for elderly patients trying to remove infusion tub e s f o r drip infusion or tube feeding

for maintenance of life and physical strength.

2 Physical restraint may be deemed necessary for elderly patients trying to remove therapeutic drip infusions or tubes (including

balloon catheters).

3 Physical restraint may be deemed necessary for security reasons for elderly patients at risk of falling out of the bed.

C/Treatment

·security

4 Physical restraint may be deemed necessary for security reasons for elderly patients at risk of falling out of a wheelchair.

1 Physical restraint of elderly patients may be allowed for medical treatment purposes, despite the patient’s own refusal.

2 Physical restraint of elderly patients at a family member’s request is deemed questionable when the patient refuses.

3 Physical restraint of elderly patients is hard when the patient has limited consciousness or understanding.

D/Individual

nurse’s sense

of values

4 Physical restraint of elderly patients who have violent tendencies may be allowed for the security of other pa tients and nursing

staff.

1 Physical restraint greatly affects dementia symptoms of elderly patients, and a desire to find an alternative method exists.

2 Physical restraint reduces the QOL of elderly patients, and a desire to find an alternative method exists.

3 Physical restraint causes diseases, including chronic diseases, and a desire to find an alternative method exists.

E/Nursing of

the elderly

4 Physical restraint accelerates the decline in mental and physical aging, and a desire to find an alternative method exists.

*A five-poin t Likert scale, with the higher score meaning the more likely that nurses would have mixed feelings.

Ethical Dilemma Factor in Regarding Physical Restraints to Elderly of Female

Nurses with the Living Together Experience

330

2.1.2. Definition of Ethical Dilemma

An ethical dilemma is defined as a state in which one

must select between two or more equally unacceptable

adoptions, where there is “conflict between two or more

nursing ethical principles and each solution may contain

unpleasant outcomes for one or more involved parties”

[12,14].

2.2. Participants

The grade to which one feels a dilemma differs for each

nurse and differs with educational background, past

clinical experiences, personal life experiences, and one’s

nursing moral [12,14]. Nurse participants were des igna ted

from hospitals in Kansai area Japan using the purposive

selection method [15]. Participants were registered

nurses working at hospitals that ad apt the following rules:

1) having a nursing division or department at the hospital

under nursing management; 2) holding training programs

for nurses continually; 3) having nearly identical em-

ployment terms for nurses; and 4) being a community

hospital. The participants and method of the study were

guided by nursing administrators in the selected 17 hos-

pitals, and a total of 1929 questionnaires were distributed .

There were 1771 responses (91.8% response rate). Par-

ticipants were 1463 female nurses working in 54 wards

(excluding surgical, intensive care units, emergency,

psychiatry, paediatric, obstetric, and outpatient depart-

ments). Participants were asked the following question:

“Have you ever lived with elderly person?” Among re-

spondents, 524 female nurses answered yes to this ques-

tion.

3. Methods and Statistical Analysis

The study used the questionnaire method with an inde-

pendently prepared questionnaire from Conceptual

framework. It was further assumed that the dilemma

could be measured by a five-point Likert scale, with the

higher score meaning the more likely that nurses would

have mixed feelings. Request sheets disclosing the objec-

tive of the study, the methods of distribution and retriev al

of the questionnaires, and the addresses of the investiga-

tors were distributed, and the details of the study were

explained to persons in charge of nursing in the targeted

hospitals/wards. A request sheet was sent to individual

nurses defining the terms, “physical restraint” and “eld-

erly patients”, how to fill out the questionnaires, the pe-

riod of response, and the objective of the present study.

A preliminary test was carried out with 10 nurses work-

ing in orthopedic surgery wards in community hospitals

(general hospitals with 400 beds) and the results obtain ed

were used to improve expression of dilemma items. The

resulting revised questionnaire was used in this investi-

gation. The internal consistency and reliability of the

constructed items of dilemma were examined using

Cronbach’s coefficient with a criteria set at a coefficient

of 0.6. The construction validity was assessed using fac-

tor analysis [16]. The factor structure was confirmed

after exploratory factor analysis (maximum likelihood

method: promax rotation) to construct validity. The crite-

ria of sample validity for the factor analysis aimed at a

Kaiser-Meyer-Olkin measure value of 0.6 and a cumula-

tive contribution ratio of 60% [17]. The inclusion of

items was applied to a factor loading of 0.4 without any

difficulty in interpretation.

Ethical Considerations

The questionnaire was designed to ensure privacy and

anonymity while allowing participants to complete the

form themselves. Participants inserted and sealed the

completed questionnaire into an envelope that was pro-

vided in advance. The study was conducted with the ap-

proval of the ethics committee at Meiji University of

Oriental medicine.

4. Results

4.1. Participants’ Characteristics

Eligible Participants were 524 female nurses working in

general wards at community hospitals who also live with

elderly adults at home and were enrolled. The average

age of participants was 29.7 years (±7.6, Minimum = 21,

Maximum = 58) and the average nursing experience was

7.6 years (±6.6, Minimum = 1, Maximum = 35). Public

Health Services Statistics and Information Department

recently reported that only 20.4% of nursing staff were

between 25 and 29 years old. Thus, our sample of par-

ticipants was relatively young compared to the national

average, and the having dilemmas identified in our sam-

ple might not be entirely representative of the identifica-

tion exhibited by all Japanese nurses.

4.2. Reliability and Validity of 20 Dilemma Items

The internal consistency of the 20 independently pre-

pared items of dilemma was tested with Cronbach’s co-

efficient and a value of = 0.78 (except for no answer:

eligible number = 524) was obtained.

4.3. Validity of Item Selection and Dilemma

Factors

The items were subjected to a factor analysis (maximum

likelihood method: promax rotation) for the clarification

of the dilemma factors. Four factors had a factor from

remaining 17 items, thus: one items of 20 items was

loading of 0.4 o r a difficulty in interp retation. As results,

Ethical Dilemma Factor in Regarding Physical Restraints to Elderly of Female

Nurses with the Living Together Experience 331

3 items were uninterprettable from the 20 items. There-

fore, the remaining 17 items were used for analysis. Four

items with a characteristic value of 1 were extracted and

a Kaiser Meyer-Olkin measure value of 0.82 and a cu-

mulative contribution ratio of 64.5% resulted. Cron-

bach’s coefficient for composing items and cumulative

contribution ratio of each factor were first factor = 0.86%

and 28.2%, second factor = 0.88% and 21.4%, third fac-

tor = 0.86% and 11%, and forth factor = 0.81% and 3.9%.

4.4. Interpretation of Each Extracted Factor

Interpretation of each extracted factor showed the fol-

lowing characteristic features. Factor 1, execution of

treatment and security, accounted for 25.9% of the cu-

mulative variance. Most items were related to dilemmas

occurring in the treatment practises and the security of

elderly patients while executing treatment. Factor 2,

characteristic features in the nursing of elderly patients,

accounted for 46.6% of the cumulative variance and was

composed of items expressing characteristic features in

the practical nursing of elderly patients. Factor 3, a co-

operative relationship in nursing, accounted for 57.4% of

the cumulative variance and was composed of items con-

sidered to express dilemmas with staff members in nurs-

ing. Finally, factor 4, priorities in nursing, accounted for

64.5% of the cumulative variance and was comprised of

items related to dilemmas in tryin g to smoothly carry out

duties for the elderly, among patients of various ages

(Table 2).

5. Discussion

Cronbach’s overall coefficient for the 20 items of di-

lemma was high (0.78) and the factor analysis extracted

four dilemma factors as having a characteristic value of 1

(Kaiser-Meyer-Olkin measure value = 0.81) with a cu-

mulative contribution ratio of 64.5%. The high Cron-

bach’s for these items (0.86, 0.88, 0.87 and 0.81) con-

firmed the internal consistencies (Table 2).

The 4 dilemma factors, 1) execution of treatment and

security; 2) characteristic features in the nursing of eld-

erly patients; 3) cooperative relationship in nursing; and

4) priorities in nursing, represented serious dilemmas

faced by nurses regarding the physical restraint of an

elderly person. The findings from this study provided a

greater understanding about immediate countermeasures

and indicated the following:

1) Execution of treatment and security: practising nurses

are expected to secure the elderly patients, but they

are also expected to follow physicians’ orders even

though they feel that physical restraint might cause

harm to the elderly. The strategy for this could be that

the nurses should communicate with comedical work-

ers, discuss patients’ care, and reach a consensus. In

addition, the nurses should explore alternatives to re-

straint devices.

2) Characteristics in the nursing of elderly patients: al-

though the nurses try to avoid restraining elderly pa-

tients as much as possible, they might hold a myth

about physical restraints, that is, they might think th at

the elderly should be restrained; otherwise, they

might fall and hurt themselves. The implication for

this is to allocate elderly care specialists in each ward.

Consequently, the nurses might acquire the skill to

care for the elderly without restraint.

3) Cooperative relationship in nursing practise: pr actis ing

nurses are responsible for clinical decision-making,

but they hav e substantially less autho rity than physic-

cians to assist patients. Nurse administrators should

be sensitive to quality patient care regarding physical

restraints. The administrators also should understand

the situations in which nurses experience a dilemma

in the use of physical restraints. The strategy to assist

nurses is to ensure the existence and use of institu-

tional policies and safety standards. Toward this end,

the administrators might need to arrange for the

health-care organization to be objectively evaluated.

4) Priorities in nursing: when nurses take more time to

care for acutely ill patients than for elderly patients,

they are likely to think that the use of physical res-

traints for the elderly is needed. This might mean that

the nurses are upholding the individual ethics code or

that they are required to choose the institutional po-

lices. In either case, the nurses might report their

feelings of confusion or uncertainty. Continuing edu-

cation helps nurses to improve their skills in making

ethical decisions. The most important component of

educational programs is that nurses can recognize the

ethically difficult situatio n in which they are involved .

Therefore, the constru ction and implementa tion of th e

four factors to cope with these dilemmas is recom-

mended.

These results are similar to those in studies and re-

search on the dilemmas felt by nurses in all clinical fields

[5,18] and might be deemed as actual dilemma factors

that are felt by nurses working in general wards. How-

ever, Factor 2, characteristics in the nursing of elderly

patients, reveals factors that also appear in gen eral wards

for adult and acute-phase patients.

Practising nurses are expected to behave in a moral

manner on a daily basis, but they continue to report con-

fusion and uncertainty regarding how to act in ethically

difficult situations because of restraints of the elderly in

general wards. It is to suggest that the four systems

would enable nurses to cope with these dilemmas; for

example, by having a conference with comedical workers

in which they share their judgments and attitude toward

Ethical Dilemma Factor in Regarding Physical Restraints to Elderly of Female

Nurses with the Living Together Experience

332

Table 2. Factore analysis of nurses’s dilemma for pyhsical restrainted elderly patientes with dementia.

Factor

1 2 3 4

Dilemma items Execution

of treatment

and security

Characteristic features

in the nursing of

elderly patients

A cooperative

relationship

in nursing

Priorities in

nursing

C-2 Physical restraint may be deemed necessary for elderly

patients trying to remove the rapeutic drip infusions or

tubes (including balloon catheters). 0.90 –0.02 –0.02 –0.10

C-1 Physical restraint may be deemed necessary for elderly

patients trying t o remove infusion tubes for drip infus ion or

tube feeding for maintenance of life and physical strength. 0.80 0.00 –0.06 –0.06

C-3 Physical restraint may be deemed necessary for security

reasons for elderly patients at risk of falling out of the bed. 0.78 0.05 0.01 0.01

C-4 Physical restraint may be deemed necessary for security

reasons for elderly patients at risk of falling out of a

wheelchair. 0.74 0.03 0.06 0.07

D-1 Physical restraint of elderly patients may be allowed for

medical tre atment purposes, despite the patient’s own

refusal. 0.52 –0.05 –0.02 0.15

D-4 Physical restraint of elderly patients who have violent

tendencies may be allowed for the security of other

patients and nursing staff. 0.45 0.04 0.07 0.13

B-2 When another option is possible or when it has to be done,

but deemed unnecessary due to orders of the nurse in charge,

nurses feel let down. –0.07 0.92 –0.04 0.06

B-1 When another option is possible or when it has to be done,

but deemed unnecessary due to doctor’s orders, nurses feel

let down. –0.02 0.81 –0.05 0.04

B-4 Physical restraint under the direction of a senior associate is

questionable when deemed unnecessary or another method

may be available . 0.03 0.78 0.04 –0.05

B-3 Physical restraint of elderly patients is questionable when

insufficient discussion between nursing staff has taken place.0.10 0.71 0.05 –0.10

E-4 Physical restraint accelerates the decline in mental and

physical aging, and a desire to find an alternative method

exists. 0.05 –0.05 0.87 –0.07

E-2 Physical restraint reduces the QOL of elderly patients, and a

desire to find an alternative method exists. 0.03 0.09 0.83 –0.01

E-3 Physical restraint causes diseases, including chronic

diseases, and a desire to find an alternative method exists. 0.05 –0.12 0.80 0.01

E-1 Physical restraint greatly affects dementia symptoms of

elderly patients, and a desire to find an alternative method

exists. –0.16 0.10 0.69 0.10

A-2 Physical restraint of elderly patients may be allowed if

nurses are busy under practices of ADL assistance and

routine practices. –0.04 –0.02 0.01 0.89

A-1 Physical restraint of elderly patients may be allowed if there

is another patient in critical condition. 0.08 0.01 0.04 0.67

A-3 Physical restraint of elderly patients may be allowed if

frequent observation is unavailable due to structure of wards.0.20 –0.02 –0.05 0.63

Cumulated contribution ratio ( %) factor 1 - 4 28.2 49.6 60.6 64.5

Reliability Coefficients α 0.86 0.88 0.87 0.81

KMO value = 0.82, Bartlett’s sphericity test; ***(P < 0.001).

Ethical Dilemma Factor in Regarding Physical Restraints to Elderly of Female

Nurses with the Living Together Experience 333

physical restraints for elderly people. Having a confer-

ence is not costly and cou ld easily “start tomorrow”. The

results from this study need further consideration in the

future as being faced with dilemmas on a daily basis is

not a favorable working environment for nurses. When

faced with these dilemmas, every nurse should carefully

reconsider the customary use of physical restraints on the

elderly, not just to overcome the situation, but to view it

as a chance to reflect on the active improvement of the

quality of care and quality of life of the elderly. Few

studies have been carried out in Japan to examine the

conscience of nurses regarding the physical restraint of

elderly patients and a comparative investigation and

study has not yet occurred. The dilemmas that occur in

the conscience of a person are likely to be influenced by

many factors, including differences over time. The pre-

sent study examined no factors that influence an individ-

ual nurse’s sense of value or individual experiences and

attributes, such as educational background, religious

standpoint, nursing experience, and the distinction of

gender [14]. In addition, the questionnaires were com-

pleted only once during the study period. A detailed

analysis of changes in conscience over time remains one

of the problems to be investigated in the future. In addi-

tion, the questionnaires were analysed without regard to

gender in this stu dy. As a result of the very small n u mber

of male participants, it was difficult to assess gender dif-

ferences. Even so, the results of this research are useful

in coping with dilemmas regarding the use of restraints.

6. Conclusions

With respect to the dilemma where nurses are faced with

the physical restraint of elderly persons, four factors in

the clarification of the dilemma were extracted: execu-

tion of treatment and security, characteristic features in

nursing, cooperative relationship in nursing, and priori-

ties in nursing. Therefore, the construction of four sys-

tems to cope with these dilemmas is suggested. These

systems would enable practising nurses to: 1) communi-

cate with comedical workers in order to reach a consen-

sus about the elderly’s care; 2) avoid restraining the eld-

erly by allocating elderly care specialists to them; 3) es-

tablish institutional policies and safety standards that

establish the nurses’ responsibilities for patients’ deci-

sion-making; and 4) receive continuous and timely edu-

cation about ethics. The limitation of the study is the re-

sults from this study need further consideration in the

future, as being faced with dilemmas on a daily basis is

not a favorable working environment for nurses. When

faced with these dilemmas, every nurse should carefully

reconsider the customary use of physical restraints on the

elderly, not just to overcome the situation, but to view it

as a chance to reflect on the active improvement of the

quality of care and quality of life elderly.

7. Acknowledgements

The authors are very grateful to all the respondents from

the hospitals, as well as to the administrators, who

greatly contributed to this study.

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