Ethical and clinical aspects of restraint in neurosurgical care

Abstract: Background: Compulsory care, manifest in the form of restraint measures, is common in somatic healthcare settings and occurs in many countries. However, studies of restraint use in somatic care in Sweden are scarce and have mostly focused on geriatric care. What we do know from these studies is that restraint actually occurs in somatic healthcare settings in Sweden, and, that there seems to be a gap between regulation and practice. Furthermore, despite the limited research concerning restraint use in neurosurgical care, the use of restraint in neurosurgical settings is well known and described in nursing literature and early research on neurosurgical nursing. There is therefore a need for a better understanding of the circumstances surrounding the restraining events for these patients. Aim: The overall aim of this thesis is to investigate the ethical and clinical aspects of restraint in neurosurgical care. This thesis is based on four studies: Study I aimed to investigate the extent to which restraint is used in neurosurgical care, under which circumstances, and how it is documented. The study was a mixed-methods study where a study-specific questionnaire was distributed to nurses and electronic medical records of restrained patients were reviewed. The analysis showed that restraint occurs in neurosurgical care in Sweden, that it is rarely documented and used when patients were considered to be a danger to themselves or to others. Study II described nurses’ experiences of using restraint in neurosurgical care. Nurses (n=15) from three neurosurgical departments in Sweden were interviewed. Nurses' experience restraint in neurosurgical care as a multi-layered struggle, ranging from inner doubts to practical issues. They described an inner resistance to using restraint and that the use of restraint conflicted with their inner values such as, respect of autonomy. They also voiced concerns of when and how to use restraint and felt unsure if restraint were the best option. Study III used the same sample as study II. The aim was to understand nurses’ justification of restraint in neurosurgical care. The nurses’ reasoning was based on a consequentialist approach where different options were balanced against each other to assess which option would induce the least suffering. Restraint was considered legitimate if the benefit exceeded the suffering, but decisions on which restraint measures to use and when to use them depended on the values of the individual nurse. Study IV discussed arguments and concepts from the bioethical debate, relevant policy documents, and results from the empirical investigations in studies I-III. The aim was to analyse regulations of restraint in somatic healthcare. This was done according to standard methods in analytical philosophy, with a main focus on reflective equilibrium. In summary, it was argued that restraint regulation should incorporate an assessment of decision-making capacity and only be done if it is in the best interest of the patient. Conclusion: This thesis adds to the understanding of when, how, and why nurses in neurosurgical care use restraint. Furthermore, it also adds to the knowledge of restraint used in Swedish healthcare and the theoretical understanding of restraint. Moreover, it adds to the normative analysis of justified restraint and the regulation thereof.