RESTRAINTS IN NURSING CARE
RESTRAINTS
Definition of Restraints
are devices used in health care settings to prevent patients from causing harm to themselves or others when alternative interventions are not effective. A restraint is a device, method, or process that is used for the specific purpose of restricting a patient’s freedom of movement without the permission of the person.
Although restraints are used with the intention to keep a patient safe, they impact a patient’s psychological safety and dignity and can cause additional safety issues and death. A restrained person has a natural tendency to struggle and try to remove the restraint and can fall or become fatally entangled in the restraint. Furthermore, immobility that results from the use of restraints can cause pressure injuries, contractures, and muscle loss. Restraints take a large emotional toll on the patient’s self-esteem and may cause humiliation, fear, and anger.
Restraint Guidelines
The American Nurses Association (ANA) has established evidence-based guidelines that state a restraint-free environment is the standard of care. The ANA encourages the participation of nurses to reduce patient restraints and seclusion in all health care settings. Restraining or secluding patients is viewed as contrary to the goals and ethical traditions of nursing because it violates the fundamental patient rights of autonomy and dignity. However, the ANA also recognizes there are times when there is no viable option other than restraints to keep a patient safe, such as during an acute psychotic episode when patient and staff safety are in jeopardy due to aggression or assault. The ANA also states that restraints may be justified in some patients with severe dementia or delirium when they are at risk for serious injuries such as a hip fracture due to falling.
The ANA provides the following guidelines: “When restraint is necessary, documentation should be done by more than one witness. Once restrained, the patient should be treated with humane care that preserves human dignity. In those instances where restraint, seclusion, or therapeutic holding is determined to be clinically appropriate and adequately justified, registered nurses who possess the necessary knowledge and skills to effectively manage the situation must be actively involved in the assessment, implementation, and evaluation of the selected emergency measure, adhering to federal regulations and the standards of The Joint Commission (2009) regarding appropriate use of restraints and seclusion.”Nursing documentation typically includes information such as patient behavior necessitating the restraint, alternatives to restraints that were attempted, the type of restraint used, the time it was applied, the location of the restraint, and patient education regarding the restraint.
Any health care facility that accepts Medicare and Medicaid reimbursement must follow federal guidelines for the use of restraints. These guidelines include the following:
- When a restraint is the only viable option, it must be discontinued at the earliest possible time.
- Orders for the use of seclusion or restraint can never be written as a standing order or PRN (as needed).
- The treating physician must be consulted as soon as possible if the restraint or seclusion is not ordered by the patient’s treating physician.
- A physician or licensed independent practitioner must see and evaluate the need for the restraint or seclusion within one hour after the initiation.
- After restraints have been applied, the nurse should follow agency policy for frequent monitoring and regularly changing the patient’s position to prevent complications. Nurses must also ensure the patient’s basic needs (i.e., hydration, nutrition, and toileting) are met. Some agencies require a 1:1 patient sitter when restraints are applied.
- Each written order for a physical restraint or seclusion is limited to 4 hours for adults, 2 hours for children and adolescents ages 9 to 17, or 1 hour for patients under 9. The original order may only be renewed in accordance with these limits for up to a total of 24 hours. After the original order expires, a physician or licensed independent practitioner (if allowed under state law) must see and assess the patient before issuing a new order.
Side Rails and Enclosed Beds
Side rails and enclosed beds may also be considered a restraint, depending on the purpose of the device. Recall the definition of a restraint as “a device, method, or process that is used for the specific purpose of restricting a patient’s freedom of movement or access to movement without the permission of the person.” If the purpose of raising the side rails is to prevent a patient from voluntarily getting out of bed or attempting to exit the bed, then use of the side rails would be considered a restraint. On the other hand, if the purpose of raising the side rails is to prevent the patient from inadvertently falling out of bed, then it is not considered a restraint. If a patient does not have the physical capacity to get out of bed, regardless if side rails are raised or not, then the use of side rails is not considered a restraint.
Hand Mitts
A hand mitt is a large, soft glove that covers a confused patient’s hand to prevent them from inadvertently dislodging medical equipment. Hand mitts are considered a restraint by The Joint Commission if used under these circumstances:
- Are pinned or otherwise attached to the bed or bedding
- Are applied so tightly that the patient’s hands or finger are immobilized
- Are so bulky that the patient’s ability to use their hands is significantly reduced
- Cannot be easily removed intentionally by the patient in the same manner it was applied by staff, considering the patient’s physical condition and ability to accomplish the objective
It is important for the nurse to be aware of current best practices and guidelines for restraint use because they are continuously changing. For example, meal trays on chairs were previously used in long-term care facilities to prevent residents from getting out of the chair and falling. However, by the definition of a restraint, this action is now considered a restraint and is no longer used. Instead, several alternative interventions to restraints are now being used.
Alternatives to Restraints
Many alternatives to using restraints in long-term care centers have been developed. Most interventions focus on the individualization of patient care and elimination of medications with side effects that cause aggression and the need for restraints. Common interventions used as alternatives to restraints include routine daily schedules, regular feeding times, easing the activities of daily living, and reducing pain.
Diversionary techniques such as television, music, games, or looking out a window can also be used to help to calm a restless patient. Encouraging restless patients to spend time in a supervised area, such as a dining room, lounge, or near the nurses’ station, helps to prevent their desire to get up and move around. If these techniques are not successful, bed and chair alarms or the use of a sitter at the bedside are also considered alternatives to restraints.
- “PinelRestraint.jpg” by James Heilman, MD is licensed under CC BY-SA 4.0 ↵
- The Joint Commission. https://www.jointcommission.org/ ↵
- American Nurses Association. (2012). Position statement: Reduction of patient restraint and seclusion in health care settings. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/reduction-of-patient-restraint-and-seclusion-in-health-care-settings/ ↵
- Moore, G. P., & Pfaff, J. A. (2022, January 12). Assessment and emergency management of the acutely agitated or violent adult. UpToDate. Retrieved February 23, 2022, from https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult?csi=49b96b98-3589-484d-9a71-5c7a88d4fb72&source=contentShare ↵
- HealthPartners. (n.d.). Patients’ bill of rights (federal). https://www.healthpartners.com/care/hospitals/regions/patient-guest-support/federal-rights/ ↵
- The Joint Commission. (2020, June 29). Restraint and seclusion - Enclosure beds, side rails, and mitts. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/provision-of-care-treatment-and-services-pc/000001668/ ↵
- The Joint Commission. (2020, June 29). Restraint and seclusion - Enclosure beds, side rails, and mitts. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/provision-of-care-treatment-and-services-pc/000001668/ ↵
- Raveesh, B. N., Gowda, G. S., & Gowda, M. (2019). Alternatives to use of restraint: A path toward humanistic care. Indian Journal of Psychiatry, 61(Suppl 4), S693–S697. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482675/ ↵
Definition
Restraint application is a technique of physically restricting a person’s freedom of movement, physical activity or normal access to his body. A physical restraint is a piece of equipment or device that restricts a patient’s ability to move. It is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.
The definition of restraint is based not on the equipment or device but rather on the functional status of the client. If the client cannot release himself from the device physically, then the said device is considered a restraint.
Purpose of Restraint Application
Restraints are used to control a patient who is at risk of harming him or her self and/or others. In some cases, restraints are also used for children who are not capable of remaining still when they are frightened or in pain during administration of medication or performing other procedures. However, using restraints in any health care facility should be used as the last option in dealing with patients.
When to use restraints?
Physical restraint should be used only when other, less restrictive, measures prove ineffective in protecting the patient and others from harm.
Types of Restraints
- Soft restraints. This type of physical restraint device is used to limit movement of patients who are confused, disoriented or combative. The main goal of using this restraint is to prevent the patient from injuring him or her self and/or others.
- Vest and Belt Restraints. In using this device full movement of arms and legs are permitted. This is used to prevent the patient from falling from bed or a chair.
- Limb Restraints. Patients who are removing supportive equipments such as I.V. lines, indwelling catheters, NGTs and etc. are placed on limb restraints. This device allows only slight limb motion.
- Mitts. This device prevents the patient from removing supportive equipment, scratching rashes or sores and injuring him or herself and/or others.
- Body restraints. When patients become combative and hysterical they can be controlled by applying body restraints. This immobilizes almost all of the body.
- Leather Restraints. This restraint is only used when soft restraints are not sufficient to control the patient and when sedation is either dangerous to the patient or ineffective.
Precautions of Restraint Application
- Before applying restraints it is important to try other methods of promoting patient safety. Alternative methods that might be effective are reorientation of the patient to the physical surroundings, moving the patient’s room near to the staff members, teaching relaxation techniques in order to decrease anxiety and fear and decrease overstimulation.
- Documentation of any alternative method used is extremely important. Restraint application should be documented thoroughly.\
Situations that Requires Restraint Application
- Confused client tries to endanger him or herself
- Confused client attempts to remove supportive equipments such as necessary tubes, IV lines or protective dressings.
- The client is at risk for falls.
- The client is suicidal.
- The client poses harm or threat of inflicting harm to health care staff, other clients and/or visitors.
- A child is unable to remain still during a minor surgical procedure.
Equipments
Soft restraints
- Vest restraint
- Limb restraint
- Mitt restraint
- Belt restraint
- Body restraint as needed
- Padding if needed (large gauze pads can be used)
- Restrain flow sheet (washcloth can be used)
Leather restraints
- Two wrist and two ankle leather restraints
- Four straps
- Key
- Large gauze pads – this is used to cushion each extremity
- Restraint flow sheet (washcloth can be used)
Restraint Application Key Steps
- Make sure that the restraints are correct size for the patient’s build and weight.
- Explain the need for restraint to the patient. Assure him or her that they are used to protect him from injury rather than to punish him. It is necessary to inform the patient of the conditions necessary to release him or her from restraints.
- Restraints are ONLY used when all other methods have failed to keep the patient from harming himself or others. Restraints used should be least restrictive to the patient.
- Obtain adequate assistance to manually restrain the patient.
- After an hour of placing a restraint, the patient should be evaluated by a licensed independent practitioner and an order must be written for restraints.
- The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9 to 17 years old; 1 hour for patients younger than 9 years old.
- The original order expires in 24 hours. Thus, the same order cannot be used the following day.
- To promote safety and ensure the patient is not harmed with restraint application, the patient should be assessed every 2 hours or according to the facility policy.
- In cases where the client consented to have his family informed of his care, the family should be notified of the use of restraints.
When and how to use restraints
Few things cause as much angst for a nurse as placing a patient in a restraint, who may feel his or her personal freedom is being taken away. But in certain situations, restraining a patient is the only option that ensures the safety of the patient and others.
As nurses, we’re ethically obligated to ensure the patient’s basic right not to be subjected to inappropriate restraint use. Restraints must not be used for coercion, punishment, discipline, or staff convenience. Improper restraint use can lead to serious sanctions by the state health department, The Joint Commission (TJC), or both. Use restraints only to help keep the patient, staff, other patients, and visitors safe—and only as a last resort.
Categories of restraints
Three general categories of restraints exist—physical restraint, chemical restraint, and seclusion.
Physical restraint
Physical restraint, the most frequently used type, is a specific
intervention or device that prevents the patient from moving freely or restricts normal access to the patient’s own body. Physical restraint may involve:
- applying a wrist, ankle, or waist restraint
- tucking in a sheet very tightly so the patient can’t move
- keeping all side rails up to prevent the patient from getting out of bed
- using an enclosure bed.
Typically, if the patient can easily remove the device, it doesn’t qualify as a physical restraint. Also, holding a patient in a manner that restricts movement (such as when giving an intramuscular injection against the patient’s will) is considered a physical restraint. A physical restraint may be used for either nonviolent, nonself-destructive behavior or violent, self-destructive behavior. (See What isn’t a restraint?)
Restraints for nonviolent, nonself-destructive behavior. Typically, these types of physical restraints are nursing interventions to keep the patient from pulling at tubes, drains, and lines or to prevent the patient from ambulating when it’s unsafe to do so—in other words, to enhance patient care. For example, a restraint used for nonviolent behavior may be appropriate for a patient with an unsteady gait, increasing confusion, agitation, restlessness, and a known history of dementia, who now has a urinary tract infection and keeps pulling out his I.V. line.
Restraints for violent, self-destructive behavior. These restraints are devices or interventions for patients who are violent or aggressive, threatening to hit or striking staff, or banging their head on the wall, who need to be stopped from causing further injury to themselves or others. The goal of using such restraints is to keep the patient and staff safe in an emergency situation. For example, a patient responding to hallucinations that commands him or her to hurt staff and lunge aggressively may need a physical restraint to protect everyone involved.
Chemical restraint
Chemical restraint involves use of a drug to restrict a patient’s movement or behavior, where the drug or dosage used isn’t an approved standard of treatment for the patient’s condition. For example, a provider may order haloperidol in a high dosage for a postsurgical patient who won’t go to sleep. (If the drug is a standard treatment for the patient’s condition, such as an antipsychotic for a patient with psychosis or a benzodiazepine for a patient with alcohol-withdrawal delirium, and the ordered dosage is appropriate, it’s not considered a chemical restraint.) Many healthcare facilities prohibit use of medications for chemical restraint.
Seclusion
With seclusion, a patient is held in a room involuntarily and prevented from leaving. Many emergency departments and psychiatric units have a seclusion room. Typically, medical-surgical units don’t have such a room, so this restraint option isn’t available. Seclusion is used only for patients who are behaving violently. Use of a physical restraint together with seclusion for a patient who’s behaving in a violent or self-destructive manner requires continuous nursing monitoring.
Determining when to use a restraint
The patient’s current behavior determines if and when a restraint is needed. A history of violence or a previous fall alone isn’t enough to support using a restraint. The decision must be based on a current thorough medical and psychosocial nursing assessment. Sometimes, addressing the issue that’s underlying a patient’s disruptive behavior may eliminate the need for a restraint.
Also, caregivers must weigh the risks of using a restraint, which could cause physical or psychological trauma, against the risk of not using it, which could potentially result in the patient harming him- or herself or others. Input from the entire care team can help the provider decide whether to use a restraint.
Alternatives to restraints
Use restraints only as a last resort, after attempting or exploring alternatives. Alternatives include having staff or a family member sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications.
If appropriate alternatives have been attempted or considered but have proven insufficient or ineffective or are deemed potentially unsuccessful, restraint may be appropriate. A provider order must be obtained for patient restraint. Be sure to update and revise the care plan for a restrained patient to help find ways to reduce the restraint period and prevent further restraint episodes.
Reducing restraint risks
Restraints can cause injury and even death. In 1998, TJC issued a sentinel event alert on preventing restraint deaths, which identified the following risks:
- Placing a restrained patient in a supine position could increase aspiration risk.
- Placing a restrained patient in a prone position could increase suffocation risk.
- Using an above-the-neck vest that’s not secured properly may increase strangulation risk if the patient slips through the side rails.
- A restraint may cause further psychological trauma or resurfacing of traumatic memories.
To help reduce these risks, make sure a physical restraint is applied safely and appropriately. With all types of restraints, monitor and assess the patient frequently. To relieve the patient’s fear of the restraint, provide gentle reassurance, support, and frequent contact. Monitor vital signs (pulse, respiration, blood pressure, and oxygen saturation) to help determine how the patient is responding to the restraint.
Changing the culture
The American Psychiatric Nurses Association’s position statement on the use of restraint suggests a unit’s philosophy on restraint use can influence how many patients are placed in restraints. Interacting with patients in a positive, calm, respectful, and collaborative manner and intervening early when conflict arises can diminish the need for restraint. Facility leaders should focus on reducing restraint use by supporting ongoing monitoring and quality-improvement projects.
To help ensure a restraint is applied safely, nurses should receive hands-on training on safe, appropriate application of each type of restraint before they’re required to apply it. Such training also should occur during orientation and should be reinforced periodically.
The goal is to use the least restrictive type of restraint possible, and only as a last resort when the risk of injury to the patient or others is unacceptably high. Consider using restraint only after unsuccessful use of alternatives, and only as long as the unsafe situation occurs. Remember—restraint use is an exceptional event and shouldn’t be a part of a routine protocol.
Selected references
American Psychiatric Nurses Association. APNA Position Statement on the Use of Seclusion and Restraint. Original 2000; revised 2007; revised 2014. www.apna.org/i4a/pages/index.cfm?pageid=3728. Accessed November 4, 2014.
American Psychiatric Nurses Association. Seclusion & Restraint Standards of Practice. May 2000; Revised May 2007; revised April 2014. www.apna.org/i4a/pages/index.cfm?pageid=3730. Accessed November 4, 2014.
Federal Register. Part II; Department of Health and Human Services, Centers for Medicare & Medicaid Services; Medicare and Medicaid Programs. 42 CFR Part 482; Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights; Final Rule. December 8, 2006. www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/downloads/finalpatientrightsrule.pdf. Accessed November 26, 2014.
Joint Commission, The. Hospital Accreditation Standards. Provision of Care, Treatment and Services. Standards PC.03.05.01 through PC.03.05.19. 2010.
Joint Commission, The. Sentinel Event Alert. Issue 8, November 18, 1998. Preventing Restraint Deaths. www.jointcommission.org/assets/1/18/SEA_8.pdf. Accessed November 4, 2014.
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