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.
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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