Nursing Reflection: Incident Analysis and Therapeutic Use of Self

This assignment presents a nursing reflection on a clinical incident in a geriatric ward, utilizing Borton's reflective model. The reflection centers around a situation involving a dementia patient and the potential application of restraints for feeding. The student nurse describes the incident, including the patient's agitation, the nurses' initial approach, and the student's intervention. The reflection delves into the ethical implications of restraint use, the importance of patient-centered care, and adherence to nursing standards. The analysis considers the 'what, so what, and now what' of the incident, exploring the student's feelings, the ethical dilemmas, and potential improvements in practice. The student nurse reflects on the consequences of restraint application, the role of compassion and empathy, and the importance of training and knowledge in providing optimal care. The reflection also references relevant literature to support arguments and recommendations for future practice, including the need for alternative interventions and adherence to ethical guidelines.

Running head: NURSING REFLECTION
NURSING REFLECTION
Name of the Student
Name of the University
Author Note

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Diary entry
I will use Borton’s three levels of reflection in order to reflect on the incident that
occurred during my first placement in the geriatric department of the hospital. The Borton’s
model of reflection generally uses three steps for analysing the incident that has taken place,
what had happened, gives the account of the feelings and the lessons that has been learnt after
the incident. Nurses working in the geriatric ward, often have to deal with elderly patients
who had been suffering from dementia. Nursing dementia patients are quite challenging as
many of the patients come up with several behavioural challenges and often show aggressive
behaviours, show self-destruction attitude and violence towards the nurses. Such challenges
hinder the type of care. However, while I was in care for my patient, I witnessed one of my
peer nurses seemed too much anxious with her patient who had dementia. On asking, it was
known that the 65 years old patient suffering from progressive dementia has not been
receiving his food since, last night and is verbally abusing any nurses who is trying to go near
him. Since, the patient had been diabetic and needs to take meals after every 3- 4 hours. I
heard that the nurses wanted the authorities to grant them with the permission to the apply
restraints for nasal feeding. The patient was becoming more and more agitated each time the
nurses are trying to hold their hands. However, I suggested the nurses to leave him for a
while for giving him the chance to calm down. After few hours, I went to the patient for
pacifying him and to convince him to have food. Somehow, I managed to make the patient
eat some food, without applying any restraints.
Level 1
What?
The issue was about the application of restraints on a dementia patient, in order to apply the
nasal feeding for the enteral feeding. The problem was that restraint is generally applied as

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the last resort as long the clinicians are not left with any other options. But in this case the
restraint was applied even without trying all the feasible alternatives like trying empathetic
words, giving comfortable backrubs, taking the patient for a walk before the lunch or the
dinner. This incident came to my notice when I was taking care of my own patient. I
immediately intervened between the entire situations and eventually reported this matter to
the higher authority. I had been mindful enough to check to report this matter and fully
helped the administrators to the resolve the issue. Being a novice, I was not very sure to
interrogate the nurses but I tried to inform them about the pitfalls of the application of
restraints and the legal ramifications that might follow. However, the nurses had admitted
that they had been busy these days and cant afford to spend so much time on only one patient,
as the concerned elderly patient used to take long hours to eat.
The bad thing about this entire incident is that I was anxious by this situation, that
how would, the other nurses react to my action. But to my surprise, my mentor and the other
peer nurses appreciated my deed and asked me to be more careful to prevent other such
“misses” in the future. My mentor commented on what I did tight and what I could have
done. I would not deny, that this has helped me to understand my feelings, strengths and
weaknesses.
Level 2
So what?
I felt ashamed and angry to see that my peer nurse is experienced enough not to act
such callously. I was even surprised to see that none of the nurses who was witnessing this
entire things also did protested at the time of this incident. I was perturbed and anxious as the
patient was shouting, which was obviously disturbing the other members. I was even fearful
of the fact that the patient might inflict harm to the other patients present or might indulge in

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some self-harming behaviour as she was becoming agitated seeing all the nurses approaching
towards him. The only good that happened in this entire incident is that the patient finally
agreed to have food and he became calm after sometimes and no restraints have to be put on
the patient. This information has been escalated to higher authority. I personally explained to
the nurse as what dangerous could have been happened. Physical restraints could have caused
psychological issues in the elderly patient, the patient could have hurt the nurse or the other
nurses that were present. Forceful feeding could have caused difficulties in aspiration or
choking of food. A health care professional should be knowledgeable about the restraint
policies and the laws of the particular organisation. Restraints should be minimum and needs
to be applied only after the approval of the doctor.
Normally, the staffs have a false sense of security as they apply restraints on the
elderly. But no researches could find out that restraints could manage the behavioural
symptoms in the dementia patients, instead usage of the physical restraints have led to a
threefold increase in the agitation of the dementia patients.
I believe that provision of restraints applied on elderly person can give rise to several
ethical issues. According to Simpson, Joesch, West and Pasic (2014), the research and the
clinical practice affected by dementia and their families present a set of complex ethical
issues. Putting on restraints might restrict the autonomy of the patient and he might feel that
his life will be threatened or that he cannot rely on the health care professionals. In health
care, it is the duty of the health care workers to act for the benefits of the patient maximizing
the utility of the patient considering the benefits and risks of the patient. Non-maleficence
ethics on the other hand means no harm and facilitate good to the patient (Yönt et al., 2014).
Hence, it is the duty of the nurse to estimate the severity of the harm that can be inflicted
upon the patients. The beneficence principle to an agitated patient is actually absolute, as it is
not clear whether the restraints can actually confer safety to the concerned patient. I should

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not deny the fact, that there are situations where restraints have to be applied, in case the
patient is in imminent danger, at that time restraints might become unavoidable. But, it will
only be used in extreme situation or for the best interest of the patients own health or health
of the others. Here the argument goes that the patient might be benefitted from the restraints,
justifying the risk of harm and this leaves a complex moral in order to do right for the
patients.
One of the thing that really surprised me, is the attitude of the other staff nurses, none
of whom even resisted or went to seek approval from the doctor. During, out nursing the
studies we had learned about the nursing standards of NMBA, where the standards have
stated that the nurses are obligated to provide a comprehensive and safe quality nursing for
the elderly patients and they should always practice within their scope of practice. Hence, it
was the basic responsibility of the other nurses to speak up against this and take appropriate
actions, but nothing has been done. The standard 6 of NMBA also states that nurses are
ethically and are legally obligated to work in accordance with the relevant policies, guidelines
and the standards, but it seems that no such thing has taken place.
Furthermore, I also believe that nurses should have some personal ideologies which
are upheld while caring for patients. Some of this attributes are compassion, empathy,
honesty and respect for the patient. While caring for the patient, I always feel that they are in
the vulnerable position and any mistake from our end with result in adverse outcome for the
patient. Hence, one has to remain careful and empathetic while caring for the patient, such
that they feel valued and can solely rely on the health care professionals. Hence interventions
like using empathetic words during feeding the patient or engaging them in activities that can
keep them distracted is an actual example of a patient centred care. Such approaches not only
establishes a therapeutic relationship between the patients and the nurses but also helps the
patient to remain adhered to the treatment regimen.

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Years ago, use of the restraints were common and included the use of restrictive
restraints about the use of vests and the straight jackets, although these are not used
nowadays. However, restraints should only be applied f all the other alternatives has already
been tried out or the person on whom the restraint will be applied possess the capacity to bear
the restraints (Hofmann & Hahn, 2014). Being a nurse, it should be known to all, that there
are several consequences of restraint application. It affects a person’s mobility greatly, as the
person might need to visit the washroom or he might be feeling hungry or he might have to
stretch the legs. As stated by Hofmann and Hahn, (2014), restraints largely affects the
psychological health of the patients. People who have been restrained have displayed feelings
of depression, feelings, anger, humiliation and helplessness. A person might also experience
from a significant amount of negative reactions to restraints like screaming, fighting and
extreme agitation that can be traumatic both for the person and the caregivers
(Rakhmatullina, Taub & Jacob, 2013). As per the journal of medical ethics, the negative
consequences of restraints are bruises, the decubitus ulcers, and respiratory complications,
increased dependence in the activities of living, increased dependence of the activities of
daily living, impaired balance and increased chance of falls, decreased cardiovascular
endurance, increased violence and agitation. According to Nakanishi, Okumura and Ogawa,
(2018), restraints have been associated with strangulation and frequently ineffective and has
not been found to be effective in reducing any form of aggression and violence.
Level 3
Now what?
The main implication of this experience is that this incident will provide a learning
lesson for the novice nurses who tends to apply nurses, just to reduce their burden or to get
their work done in less time. Dementia might trigger some challenging behaviour like

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aggression and catastrophic reactions ad restraints have been used at times in the past for
helping to prevent injuries to that person and others around them.
Keeping in mind, the disadvantages of applying restraints, the nurses can take up
certain essential steps like managing the type of behaviour that can lead to consider the use of
the restraints. Individual care plans having psychosocial interventions like the anticipation of
the needs, various physiological needs like the management of pain, activities that are
planned the and some of the environmental interventions like low beds, contoured chairs has
been found to be effective in reducing the use of the restraints (Hofmann & Hahn, 2014).
Furthermore, it should be noted that many of the nurses does not have enough knowledge
about restraints protocols of the institutions. It is necessary to provide training to the nurses
about the use of the restraints. The health care staffs should be trained about the restraint
hazards, minimizing the risk of the falls, understanding and responding to the behaviours.
Gerontological trained nurse can be helpful in reducing the use of the restraint (De Bellis et
al., 2013). Medical interventions like the feeding tubes and oxygen tubes needs to me
minimised or has to be disguised for the reduction of the comfort and the distraction of the
patient (Simpson, Joesch, West & Pasic, 2014).
The nurse and clinicians often might face with ethical dilemma regarding the
application of restraints on the dementia patient. While some might think that restraints
greatly breaches the autonomy of the patient. Each and every patient has the right to take
decisions of their own treatment, unless they are physically and mentally capable of doing so.
In people suffering from dementia, a progressive loss in the decision making capacity is
witnessed in people with dementia (Peisah & Skladzien, 2014). In such cases, in order to
make a decision on the medical treatment, it is the role of the health care providers to ensure
that the families get enough medical information for taking a decision. Restraints in elderly
destroys their self-respect and dignity of the elderly and makes them feel more vulnerable to

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malpractices and tortures (Lee & Kim, 2016). It is the duty of the nurses to advocate for the
elderly patients such that their dignity and the integrity are not breached. It the duty of the
nurses to work as per the nursing ethics of beneficence and autonomy.
The health care workers are to act as per the best interest of the patients, maximizing
the utility the, taking in to account the consequences of the steps taken. Non-maleficence in
ethics refers to no harm and facilitate good. Physical restraints have been seen to be causing
more harm than the benefits. Hence, all the ethical principles needs to be considered while
making an ethical decision making for these patients. According the NMBA codes of ethics
nurses should value the ethical management of decisions. They should value informed
decision making, preserving the dignity and the integrity of the patient (NMBA, 2018).
In conclusion, it can be stated that the physical and chemical restraints are often used
in geriatric wards and mental health wards. However, researches have continued to show that
physical restraints are not safe and can be extremely harmful for them patients. Application
of restraints on the concerned patient could have been extremely harmful for this patient. This
act could have harmed the patient. On injury, the patient’s family could have brought about
legal lawsuit against the nurse. Furthermore, application of restraints is against breaching the
nursing principles of the autonomy and beneficence. This, incident has made me feel ore
empathetic towards the elderly patients, who are vulnerable to all sorts of malpractices or are
more susceptible to receive appalling standards of care. I intend to remain updated about the
restraint protocols of the organisation, and carry on with my personal evidence based
researches for caring for the dementia patients. Physical restraints should be eliminated from
the care regimen of the elderly. The risk of the application of the restraints greatly outweigh
the benefits. Careful, individualised care plan and assessment addresses the requirements of
elderly. Education and training from a specialised trained nurse has been shown to be

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successful. A restraint free environment for care is only possible under the initiative of the
organisation.

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References
De Bellis, A., Mosel, K., Curren, D., Prendergast, J., Harrington, A., & Muir-Cochrane, E.
(2013). Education on physical restraint reduction in dementia care: A review of the
literature. Dementia, 12(1), 93-110.
Hofmann, H., & Hahn, S. (2014). Characteristics of nursing home residents and physical
restraint: a systematic literature review. Journal of Clinical Nursing, 23(21-22), 3012-
3024. https://doi.org/10.1111/jocn.12384
Lee, H., & Kim, K. H. (2016). Perceptions and intention of nurses in using physical restraints
for dementia patients in geriatric hospitals. Journal of Korean Gerontological
Nursing, 18(3), 159-171. DOI: https://doi.org/10.17079/jkgn.2016.18.3.159
Nakanishi, M., Okumura, Y., & Ogawa, A. (2018). Physical restraint to patients with
dementia in acute physical care settings: effect of the financial incentive to acute care
hospitals. International psychogeriatrics, 30(7), 991-1000. doi:
10.1017/S104161021700240X
NMBA, (2018). Registered nurse standards for practice. Access date: 22.3.2020. Retrieved
from:https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/
Professional-standards/registered-nurse-standards-for-practice.aspx
Peisah, C., & Skladzien, E. (2014). The use of restraints and psychotropic medications in
people with dementia. Alzheimer's Australia.
Rakhmatullina, M., Taub, A., & Jacob, T. (2013). Morbidity and mortality associated with
the utilization of restraints. Psychiatric Quarterly, 84(4), 499-512.
Ihttps://doi.org/10.1007/s11126-013-9262-6

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Simpson, S. A., Joesch, J. M., West, I. I., & Pasic, J. (2014). Risk for physical restraint or
seclusion in the psychiatric emergency service (PES). General hospital psychiatry,
36(1), 113-118. https://doi.org/10.1016/j.genhosppsych.2013.09.009
Yönt, G. H., Korhan, E. A., Dizer, B., Gümüs, F., & Koyuncu, R. (2014). Examination of
ethical dilemmas experienced by adult intensive care unit nurses in physical restraint
practices. Holistic nursing practice, 28(2), 85-90. doi:
10.1097/HNP.0000000000000013