Restraints are devices used in health care settings to prevent patients from causing harm to themselves or others when alternative interventions have not been effective. A restraint is a device, method, or process that is used for the specific purpose of restricting a patient’s freedom of movement. While restraints are typically used in acute care settings, they may be used in some circumstances in long-term care settings for safety purposes. However, restraints restrict mobility and can affect a client’s dignity, self-esteem, and quality of life; every possible measure to ensure safety should be considered before a restraint is implemented. An order from a health care provider is required to implement a restraint, and agency policy must be strictly followed.^[1]

Restraints include physical devices (such as a tie wrist device), chemical restraints, or seclusion. The Joint Commission defines a 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.” 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, convenience, or coercion. Seclusion limits freedom of movement because, although the patient is not mechanically or chemically restrained, they cannot leave the area.^[2]

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, in some cases, 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.^[3]

Restraint Guidelines

The American Nurses Association (ANA) has established evidence-based guidelines that a restraint-free environment is considered the standard of care. The ANA encourages the reduction of 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.^[4]

The ANA provides the following guidelines: When restraint is necessary, documentation of application of the restraint 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 regarding appropriate use of restraints and seclusion.^[5]

Nursing documentation is vital when restraints are applied and 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. Frequent monitoring according to agency guidelines and provision of basic needs (food, fluids, and toileting) must also be documented.^[6]

Any health care facility that accepts Medicare and Medicaid reimbursement must follow federal guidelines for the use of restraints. These guidelines include the following^[7]:

• 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.
• The patient in seclusion or restraints must be routinely monitored according to agency policy. Generally, the best practice for physical restraints is continuous visual monitoring or visual checks at least every 15 minutes. Some agencies require a 1:1 patient sitter when restraints are applied. Physical restraints should be removed every 1 to 2 hours for range of motion exercise and skin checks.
• 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.

In addition to continually monitoring the site of a physical restraint for skin issues, a physical restraint should only be secured to the bed with a quick-release knot in case of emergency.

Side Rails

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.” 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.^[9]

Full side rails are generally only found on beds in acute care. In long-term care, beds usually have a transfer loop that is a much smaller side rail. The transfer loop allows the resident to support themselves while repositioning in bed and standing up from the bed. The smaller size of this type of side rail reduces the risk of the resident becoming entrapped and injured from the device. Full side rails may be ordered by the physician if they allow the resident to reposition independently. If a resident’s bed in a long-term care setting has full side rails and they are not used for repositioning, they should always be lowered when care is complete, and a staff member is no longer present in the room. Acute care settings have different regulations regarding full side rails; review specific agency policy.^[10]

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 such as a catheter, feeding tube, or intravenous (IV) catheter. See Figure 8.23^[11] for an image of a hand mitt. Hand mitts are considered a restraint by The Joint Commission if they are used under these circumstances:

• Pinned or otherwise attached to the bed or bedding
• 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 by the patient in the same manner it was applied by staff, considering the patient’s physical condition and ability to accomplish this objective

Vests

A vest restraint is worn on the upper body and has ties that secure it to a chair or bed frame, allowing the restrained person to sit or lie in bed.

Other Restraints

Common items can be considered restraints when used improperly. A general rule is if any device limits the mobility, freedom of movement, or access to one’s body, it is considered a restraint. The resident must be able to independently remove any device that is utilized when directed to do so. This action shows that the resident can cognitively and physically control their environment. Here are some examples of how common devices can be considered a restraint:

• Wheelchair brakes that are left on with a resident who cannot independently release them are considered a restraint because it prevents the resident from moving freely throughout their environment.
• Lap trays (used for meals or supporting an immobile limb) are considered a restraint if it impairs the resident’s ability to move.
• Self-release seat belts can be used to keep a resident positioned properly in their wheelchair, but the resident must be able to remove the seat belt if asked to do so.
• Gait belts must be removed after residents have completed a transfer. They should not be left on during meals or activities for convenience because they can cause discomfort.

Restraint Alternatives

There are many interventions available to keep residents safe without applying restraints. When a potentially unsafe behavior is occurring, the health care team should look at all the factors surrounding the behavior to determine the root cause. After the root cause is determined, the staff can implement appropriate redirection. Common risks and appropriate interventions include the following:

If a resident continues to attempt to self-transfer without assistance:

• Offer toileting every hour
• Offer the opportunity to lie down after meals
• Assist in ambulation (if their condition permits) throughout the day
• Place a motion alarm in the doorway or near the foot of the bed
• Use a pressure or tab alarm in the wheelchair

If a resident is agitated or aggressive towards other residents:

• Offer an individual activity such as board games, crafts, or movies
• Ambulate or take them for a walk in their wheelchair
• Give them something to hold such as a stuffed animal
• Offer a blanket
• Ask about pain, hunger, or toileting needs

If a resident wanders or wants to leave the facility:

• Allow them to self-propel in wheelchair in a safe area
• Offer an individual activity such as board games, crafts, or movies
• Ambulate or take them for a walk in their wheelchair
• Apply a wanderguard to the wheelchair or their wrist or ankle

Motion sensors, pressure or tab alarms, and wanderguards are all alarms. There are many facilities that choose not to use alarms because they can be disruptive to the environment due to the noise and can reduce the dignity of the resident. If implemented incorrectly, they may not deter the unsafe behavior but merely notify staff the behavior is occurring or has occurred. If an alarm is indicated in the care plan, the NA is responsible for making sure the alarm is functioning and properly placed as indicated in the care plan. Behavioral and environmental interventions, as previously discussed, should be considered before alarms are put in place.