Running head: CHILD RESTRAINTS

Child Restraints Shy Wegiel Kapiolani Community College November 30, 2012

CHILD RESTRAINTS Child Restraints The use of restraints on children during medical procedures is a widely used and

controversial practice. It raises the question of whether or not it is justifiable to restrain children. The term restraint usually refers to the use of force, with or without consent, to restrict a childs movements (Darby & Cardwell, 2011). It is used interchangeably with therapeutic, supportive, or clinical holding (Brenner, 2007). These types of holding may be defined as positioning a child so that a medical procedure can be carried out in a safe and controlled manner (Hull & Clarke, 2010). There are no definitive guidelines differentiating between the use of restraints and supportive holding. This may cause some confusion among healthcare workers. In order to fully explore the use of restraints on children, several issues must be addressed. Restraint use is often part of the pediatric nurses role and is frequently required to ensure many procedures are successfully completed (Darby & Caldwell, 2011). Restraints may be physical or chemical. Depending on the situation, these restraints may include: seclusion, restrictive devices, sedation, and physical restraint. Nurses are expected to practice in accordance with the law and their duty of care (Jeffery, 2010). There is a lack of research concerning the use of restraints on children. With this in mind, nurses should be guided by the principals of care (Darby & Cardwell, 2011). These ethical responsibilities include: autonomy, beneficence, non-maleficence, and justice (2011). Autonomy reflects the individuals right to make decisions concerning their care. Restraint use must be based on the principle of beneficence, or doing good (2011). There is a high incidence with the use of restraints linked to convenience, staff shortages, and uneducated staff (Brenner, 2007). These are inappropriate rationales for restraining children

CHILD RESTRAINTS and may be seen as unethical. The use of restraints should only be implemented when are no other alternatives and is in the best interest of the child. The decision to restrain children generally depends upon the necessity of the procedure, the childs safety, type of procedure, the

childs level of agitation, childs age, parents opinion, childs consent, and staff safety (Brenner, Parahoo, & Taggart, 2007). Physical restraints should only be used when they are justifiable and reflect the beneficence of the individual (Lloyd, Law, Heard, & Kroese, 2008). An example would be wound care, the procedure is likely to upset children, but is essential to their health (Darby & Cardwell, 2011). The benefit of wound care outweighs the negative aspect of restraining the

child. As patient advocates, nurses should continuously act in the best interest of their patients. Children often react to painful or unwanted procedures with feelings of anxiety, agitation, distress, crying, resistance, and aggression (Lloyd et al., 2008). The act of being restrained may be worse for children than the actual procedure (Jeffrey, 2010). It has also been proposed that there are potential psychological and physical consequences associated with the use of restraints (Brenner et al., 2007). These consequences may include: future fears, difficulty forming trusting relationships, and increased stress affecting the disease process (2007). It has also been suggested that a negative healthcare experience may have potential long-lasting effects (2007). This makes future healthcare visits increasingly difficult. There is a lack in research addressing these possible issues. When implementing the use of restraints, nurses need to ensure they are aware of the national and local guidelines for restraining and holding children (Hull & Clarke, 2010). They should also receive training in these techniques (2010). In a survey, less than 17 percent staff

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reported having formal training on holding techniques and more than 90 percent identified a need for more formal guidelines and education (Brenner, 2007). Nurses are often directly involved in restraining children. Restraining a person can be a highly emotional experience (Lloyd et al., 2008). Nurses who have used restraints have reported experiencing feelings of anxiety, inadequacy, frustration, and guilt (2008). These emotions could be related to the lack of training related to the practice (Darby & Cardwell, 2011). Many healthcare providers lack the confidence and skills to restrain children (2011). Many of the techniques used to restrain children are learned on the job (Brenner et al., 2007). It is a potential violation of the nurses duty of care to implement techniques that have not proven to be effective (2007). Nurses should constantly be concerned with the rights of children when employing both the use of restraints and alternative interventions (Darby & Cardwell, 2011). The use of restraints could be viewed as a violation of rights and as a form of abuse. It is imperative to obtain consent on the use of restraints prior to treatment (2011). Formal consent is generally provided by the parent or legal guardian of the child (Hull & Clarke, 2010). Children are not deemed suitable to provide legal consent for medical procedures and often dont have a voice when it comes to their care (Jeffrey, 2010). Children should, however, be included as much as possible in the decision-making process (Darby & Cardwell, 2011). Explanations for the procedures should be presented in a way that is easy for the child to understand. The childs fears and ability to cope should also be addressed prior to the procedure. This task enhances the childs sense of control, promotes compliance, and is recognized as the best practice for procedures (2011).

CHILD RESTRAINTS It is also beneficial for the nurse, child, and family to build a trusting therapeutic relationship (Darby & Cardwell, 2011). This partnership will help ease concerns pertaining to procedures. By having a voice and relationship with the nurse, children may feel more

comfortable and require less restraint use. Providing children with some control over their health care choices also protects their autonomy (2011). The impact of child restraints on parents is another area of neglect in research. According to Brenner et al. (2007), many parents felt that they were not given choices in participating in the restraining process. Many parents have also reported feeling emotionally and physically stressed. It is possible that parents may not be receiving sufficient information about procedures, their potential involvement, or the use of restraints (2007). As advocates for their childrens healthcare, parents should be well informed of procedures so that they are able to make appropriate decisions for their children. Parental involvement in restraining their child is not for everyone. Some parents do not wish to participate, while others feel challenged and emotionally traumatized from restraining their children (2007). Managing children who require invasive medical procedures can be challenging (Lloyd et al., 2010). Nurses are responsible for promoting and protecting the dignity of their patients. It is often insisted that nurses explore and consider alternative interventions that are suitable to each individual childs needs (Darby & Cardwell, 2011). The alternatives to physical restraints vary depending on the age of the child. These interventions can be pharmacological or non-pharmacological. Pharmacological interventions include the use of: chloral hydrate, ethyl chloride spray, ketamine, midazolam, nitrous oxide and oxygen, and topical anesthetic cream (Darby & Cardwell, 2011). If the pharmacologic

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intervention is a sedative, it can also be defined as a restraint. With that in mind, more emphasis should be placed on the use of non-pharmacological interventions which include: administration of sucrose, breastfeeding or non-nutritive suckling, play and distraction, swaddling, touch and stroking by parents or nurses (2011). Time is a potential factor that may prevent nurses from implementing interventions in place of restraints. The use of play therapy has proven to be an effective intervention for children. This type of procedure allows children to interact at their own cognitive level (Hull & Clarke, 2010). Play therapy can be used to prepare children for procedures and in many cases to gain their consent for clinical holding (2010). For example, after play therapy, a child could agree to an injection, but may still require some clinical holding during the procedure. The use of play therapy bridges the gap between the mindset of children and medical procedures. Contemporary nursing practice involves the use of evidence based clinical guidelines to justify their actions and clinical decisions (Darby & Cardwell, 2011). There is a deficit in research concerning the use of restraints on children in the healthcare setting. The potential detrimental effects may not only affect the child but the parents and healthcare workers. These concerns cast doubt upon the moral basis of the practice. It also questions the safety and rights of patients as well as the accountability of healthcare professionals (2011). The use of interventions in place of restraints should be considered throughout the healthcare field. It is part of the nurses role to act within the principals of care and protect their patients rights. By implementing the use of interventions, nurses are able to respect their patients rights while promoting health in a way that it beneficial to both the patient and their

CHILD RESTRAINTS families. It is important that restraint use on children be further explored to address the lack of research concerning its use.

CHILD RESTRAINTS Resources

Brenner, M. (2007). Child restraint in the acute setting of pediatric nursing: an extraordinarily stressful event. Issues in comprehensive pediatric nursing, 30 (1-2), 29-37. doi:10.1080/01460860701366658. Brenner, M., Parahoo, K., & Taggart, L. (2007). Restraint in children's nursing: addressing the distress. Journal of childrens and young peoples nursing, 1(4), 159-162. Retrieved from http://www.academia.edu/321592/Restraint_In_Childrens_Nursing_Addressing_the_Dist ress Darby, C., & Cardwell, P. (2011). Restraint in the care of children. Emergency nurse, 19 (7), 1417. Hull, K., & Clarke, D. (2010). Restraining children for clinical procedures: a review of the issues (cover story). British journal of nursing, 19 (6), 346-350. Retrieved from http://web.ebscohost.com/ehost/detail?vid=4&hid=19&sid=7ff16755-5258-4d18-85d3291de0fd92f6%40sessionmgr4&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl #db=hch&AN=48867425

Jeffery, K. (2010). Supportive holding or restraint: terminology and practice (cover story). Paediatric Nursing, 22(6), 24-28. Retrieved from http://web.ebscohost.com/ehost/detail?vid=6&hid=19&sid=7ff16755-5258-4d18-85d3291de0fd92f6%40sessionmgr4&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl #db=hch&AN=52060554

Lloyd, M., Law, G., Heard, A., & Kroese, B. (2008). When a child says 'no': experiences of nurses working with children having invasive procedures. Paediatric nursing, 20 (4), 29-

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34. Retrieved from http://web.ebscohost.com/ehost/detail?vid=8&hid=19&sid=7ff167555258-4d18-85d3291de0fd92f6%40sessionmgr4&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl #db=hch&AN=34014132