NUR 4013 Module 5 Ethics and Communication Paper Example

A Daughter Asks for Restraints: Ethics and Communication in a Night-Shift Disagreement Over a Delirious Older Adult

Student Name

American College of Education

NUR4013: Transition to Professional Nursing: Issues and Concepts

Module 5 Assignment

Instructor Name

February 9, 2026

The Disagreement

At 0230 on the third night after surgical repair of a hip fracture, an 84-year-old retired machinist became acutely confused, pulled out his peripheral intravenous line and tried twice to climb over the bed rails. His daughter, who was staying overnight, asked the nurse to tie his wrists to the bed so that he would not fall or pull out his urinary catheter. She was frightened and exhausted, and she said that her father would never forgive her if he broke his other hip. The on-call hospitalist, reached by phone for a new intravenous site order, offered to add a restraint order if the nurse thought it was needed. The patient, family and unit described here are invented composites, not real people or places.

The nurse did not think restraints were the right answer, but she could not say that the daughter was wrong to be afraid. This is the kind of disagreement that has no clean answer: every option carries a real risk to the same patient, and the people disagreeing all want to protect him. This paper analyzes the dilemma using four ethical principles and the Code of Ethics for Nurses, reviews the evidence on restraints and delirium, describes how the nurse communicated with the daughter and the hospitalist, and considers what remained unresolved when the shift ended.

The Principles in Tension

Beauchamp and Childress (2019) set out four principles that bedside ethics leans on: justice, beneficence, nonmaleficence and respect for the patient's autonomy. In this case, autonomy is the principle most compromised and least available. A patient in active delirium cannot weigh the risks of restraint against the risks of falling, and his wishes in the moment, to get up and go home, are not an expression of his settled values. His daughter can speak to those values, and she believes he would want to be kept from another fracture. Respect for autonomy here becomes respect for the person he was before tonight, which is the daughter's strongest argument.

Nonmaleficence and beneficence pull in opposite directions depending on which harm is in view. A fall could cause a second fracture, a head injury or death, and preventing it is a clear benefit. Physical restraint, however, carries harms of its own. A systematic review of restraint-related injury found reports of asphyxiation, strangulation and other serious injuries, as well as indirect harms such as pressure injuries and loss of function (Evans et al., 2003). Restraints can also worsen agitation in a person who does not understand why he cannot move, and delirium itself is associated with longer stays, functional decline and higher mortality in older adults (Inouye et al., 2014). The principle of doing no harm does not choose between the options; it only insists that the harms of each be counted honestly.

Justice enters through resources. A one-to-one sitter would allow the patient to move with someone at his side, but the unit had one sitter on the night schedule, already assigned to a patient at risk of self-harm. Whether a restraint is used can depend less on the patient's needs than on what the staffing grid allows at 0230, which is an uncomfortable fact for any analysis that treats the decision as purely clinical.

The Code of Ethics and the Evidence

The Code of Ethics for Nurses asks nurses to honor the inherent dignity and worth of each person in their care and to promote and protect each patient's rights, health and safety as an advocate (American Nurses Association [ANA], 2015). Both obligations apply here. Tying an older man's wrists to a bed rail while he calls out for his wife, who died six years ago, is hard to reconcile with dignity. Leaving him free to fall is hard to reconcile with safety. The Code does not choose between them, but it does place the nurse in the role of advocate for the patient rather than for the family's peace of mind or the unit's convenience.

The evidence on restraint use by nurses helps explain why restraints remain common despite these concerns. A systematic review of nurses' attitudes toward physical restraints in the care of older adults found that many nurses believed restraints prevented falls and protected patients, even though the evidence does not show that restraints reduce falls or injuries, and that nurses often described feeling conflicted when using them (Möhler & Meyer, 2014). That finding describes the nurse in this case exactly: her instinct told her the daughter's request might be reasonable, and her reading told her it probably would not achieve what the daughter hoped.

The Conversations

The nurse spoke to the daughter first, in the hallway so that the patient would not hear. She began by naming the fear rather than the request: that the daughter was afraid her father would fall and be badly hurt, and that the fear was reasonable. She then explained, in plain words, that restraints do not reliably prevent falls in confused patients and can cause injuries and make confusion worse, and she asked what usually calmed her father at home. The daughter said that he listened to baseball games on the radio every night and that he always slept with a light on. The question turned the daughter from the person asking for restraints into the person who knew what her father needed.

The nurse then called the hospitalist back. Using a structured format, she described the situation, gave her assessment that the confusion was new and likely delirium, and recommended evaluation for causes such as pain, urinary retention, infection and medications before any restraint was ordered. She stated her concern directly: she was uncomfortable with a restraint order at this point because less restrictive options had not yet been tried. The hospitalist agreed to review the medication list, ordered a bladder scan and asked the nurse to call back in two hours or sooner if the patient's behavior escalated.

The plan that followed used the daughter's knowledge and the unit's limited resources. The nurse lowered the bed to its lowest position, placed floor mats, turned on a small lamp, found a baseball broadcast on the daughter's phone and moved the patient to the room nearest the nurses' station. The bladder scan showed 640 mL of retained urine, which was drained and reported. The daughter agreed to sit with her father until 0600, when a sitter would become available from the day schedule. No restraint was applied, and the patient did not fall during the shift.

What Remained Unresolved

The outcome was good, but the paper would be dishonest if it treated the case as settled. The plan depended on a daughter willing to stay awake until morning, a hospitalist willing to take a second call and a sitter who happened to be free at 0600. On a night without those conditions, the same nurse might have faced the same request with fewer options, and a restraint might have been the least harmful choice available. The ethical question also did not end with the shift. If the patient's delirium continues, the team will need to plan with the daughter for the next night, and her view may change as her exhaustion grows.

What the case does show is that a disagreement with no clean answer can still be handled well. The nurse treated each person's concern as legitimate, used the principles to name what was at stake rather than to declare a winner, and turned the disagreement into a shared plan. That is a realistic standard for ethical practice at the bedside, where the choice is rarely between right and wrong and more often between two imperfect ways of protecting the same person.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Nursesbooks.org.

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Evans, D., Wood, J., & Lambert, L. (2003). Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing, 41(3), 274-282. https://doi.org/10.1046/j.1365-2648.2003.02501.x

Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922. https://doi.org/10.1016/S0140-6736(13)60688-1

Möhler, R., & Meyer, G. (2014). Attitudes of nurses towards the use of physical restraints in geriatric care: A systematic review of qualitative and quantitative studies. International Journal of Nursing Studies, 51(2), 274-288. https://doi.org/10.1016/j.ijnurstu.2013.10.004