5.7 Restraints

Definition of Restraints

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. See Figure 5.6^[1] for an image of a simulated patient with restraints applied.

Restraints include mechanical devices such as a tie wrist device, chemical restraints, or seclusion. The Joint Commission defines chemical restraint as a drug used to manage a patient’s behavior, restrict the patient’s freedom of movement, or impair the patient’s ability to appropriately interact with their surroundings that is not standard treatment or dosage for the patient’s condition. It is important to note that the definition states the medication “is not standard treatment or dosage for the patient’s condition.”^[2] Seclusion is defined as the confinement of a patient in a locked room from which they cannot exit on their own. It is generally used as a method of discipline for behavior that can cause harm to themselves or others, or as a method of decreasing environmental stimulation. Seclusion limits freedom of movement because, although the patient is not mechanically restrained, they cannot leave the area.

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.”^[3] 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.

Medical Restraints

Restraints used to manage nonviolent, non-self-destructive behaviors are referred to as medical restraints. Medical restraints may be appropriate to manage behavior such as the client attempting to remove life-sustaining tubes, drains, IV catheters, urinary catheters, or endotracheal tubes. These types of restraints often include hand mitts or soft wrist restraints. Medical restraints may also be used for clients attempting to get out of bed and as such are a high risk for falls. These types of restraints include siderails, vest restraints, and roll belts. Each facility is required to have a policy in place for the use of medical restraints. Policies typically include requirements for documentation of the reason for the restraint, alternative measures tried, type of restraint applied, behavioral criteria for removal of restraint, range of motion and cares while in restraints, and the date and time the restraint is applied or removed. A medical restraint requires a registered nurse to apply or supervise application of the restraint, a new order every 24 hours, and may never be issued as an as needed order. If the primary care provider did not order the restraint, they should be notified as soon as possible. Medical restraints are more commonly encountered in the general hospital setting rather than behavioral restraints.^[4],[5]

Behavioral Restraints

Restraints used to manage violent, self-destructive behaviors are referred to as behavioral restraints. Behavioral restraints are used when clients exhibit behaviors such as hitting or kicking staff or other clients, physically harming themselves or others, or threatening to do so. Behavioral restraints are used in emergency situations where safety concerns need to be immediately addressed to prevent harm. ^[6]

RNs need special training to apply behavioral restraints, including safe application of the restraint, maintaining personal safety, and techniques to de-escalate the violent or aggressive behavior. Behavioral restraints are typically used in mental health units, emergency departments, or critical care units. Similar to medical restraints, each agency must have a policy in place for the use of behavioral restraints. Health care facilities that accept Medicare and Medicaid reimbursement must also follow federal guidelines for the use of behavioral restraints that include the following:

Guidelines for the use of behavioral restraints 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.^[7]
• 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.^[8]

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, or to help the patient with repositioning, 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.^[9]

Hand Mitts, Soft Limb Restraints, and Vest Restraints

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^[10]:

• 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

Soft limb restraints are a type of medical restraint that is designed to immobilize either one or both arms or legs through application around the wrist(s) or ankle(s). The restraint is made of a soft material designed to minimize the risk of pressure injuries or other injuries. Soft limb restraints are implemented to prevent inadvertent removal of tubes, drains, catheters, or other medical equipment by the client.^[11]

Vest restraints are a type of mesh or cloth vest applied over the client’s chest and tied to an immovable part of each side of the bed. The purpose of vest restraints is to prevent a client from getting out of bed and injuring themselves. As with any restraint, vest restraints should only be used for impulsive or confused clients when other alternatives are not effective, and not as a means of convenience.^[12]

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, intentional rounding, frequent toileting, and effective pain management.^[13]

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.