As health care professionals, our duty is to do no harm to our patients and to provide the best care for them. Sometimes, that means using intervention methods to prevent patients from harming themselves or those around them.
The most common method is the use of restraints. This type of intervention is used in a number of specialities, not just psychiatric and mental health. Some may be commonly used on units where patients are confused or have difficulty moving in order to prevent falls or other issues.
However, restraints are not a go-to technique and should only be used when all other efforts fail to prevent harm. Here are some of the basics on using restraints.
When to Use Restraints
The ideal goal is to never use restraints for patients. The American Nurses Association encourages all registered nurses to reduce the use of restraints as much as possible, although the organization recognizes that there are instances when it’s necessary.
Once health care professionals exhaust all other possible interventions, using restraints is the last resort for protecting a patient and the people around them from harm. Some of the reasons restraints might be used include the following:
- To prevent confused patients from getting up out of bed
- To prevent patients from pulling out IV lines, catheters, or tubes
- To prevent violent behavior
- To prevent a patient from moving during a necessary procedure
- To prevent falls
Your facility will determine when and how restraints are used. Be familiar with those policies, including documentation requirements and how to get doctor’s orders for restraints.
If using restraints is the only other option available for protecting a patient, then remember not to jump immediately to the most restrictive option, even if it’s available.
Always start with the least restrictive restraint. For example, if mittens or wrist restraints will suit the purpose, then start with those before something more restricting like full-body restraints.
Additionally, restraints should never be used to punish or coerce a patient. These tools are only to be used when there’s immediate threat of harm to the patient and/or the people around them.
Facilities that are accredited under the Joint Commission must be familiar with and diligently enforce the Joint Commission’s standards and definitions for restraints. The standards include what qualifies as a restraint, when restraints can be used, evaluation and monitoring of patients on restraints, staff training, and reporting deaths or issues.
Alternatives to Try Before Restraints
Part of the process before using restraints on a patient is to try all other potential alternatives that are available. This requires critical thinking, using the nursing process, and working with the other members on the patient care team to come up with and try different solutions.
Every patient’s situation will be different, and each patient has different needs that might be aggravating or influencing their behavior. Before using restraints, consider alternative actions like these:
- Move the patient to a room near the nurse’s station; staff can keep a better eye on the patient and respond quickly to any issues
- For patients recovering from surgery, who are in a state of confusion, or are physically weak due to illness, keep the call button as close to them as possible at all times, and remind them to use it to call for help
- Use a chair or bed alarm
- Arrange a consultation with a psychologist or psychiatrist
- Redirect patients
- Assess a patient’s physical needs and comfort levels, such as their hydration, pain levels, or need to use the bathroom
- Use a calm voice and tone and don’t raise your voice
- If family are available, encourage them to sit with the patient often
- Decrease stimuli from the environment around the patient
- Reorient the patient
- Check if a patient’s medication is causing or contributing to the issues
Depending on your speciality and facility, you’ll likely have other specific options that you will need to try before using restraints.
Using Different Types of Restraints
Which restraints you’ll have available and be legally allowed to use is determined on your license and certification level, your facility’s policies and procedures, the doctor’s orders, and the patient’s situation.
Physical restraints are any mechanical restraint devices that are used to limit a patient’s mobility or freedom of movement.
There are many types of physical restraints that can be used depending on the threat to the patient’s safety and the wellbeing of the people around them. In the order of least restrictive to most reactive, physical restraints include the following:
- Full side bed rails
- Secured mitten restraints
- Vests, used to prevent falls and manage violent behavior
- Waist belts
- Canopy beds
- Hard or leather restraints
Chemical restraints are any drug or medication that’s used to manage or control a patient’s behavior if that behavior is violent or threatening to themselves or those around them.
Medication types include typical or atypical antipsychotic drugs or sedatives, like benzodiazepines.
Environmental restraints use the patient’s environment to restrict their movement. In particular, this type of restraint uses seclusion and isolation.
This method of restraint works by placing a patient in a room where doors are shut, preventing them from leaving the room freely. The intent is to cut off their access from other areas of the unit or building and from other people or activities.
Patients could be secluded or isolated in a dedicated isolation room or in their bedrooms or just preventing them from accessing an area they want to go to.
Your Responsibilities When Restraint is Used
If all other intervention methods have been exhausted and restraints are the only viable option left to prevent injury, then the first step is to make sure there is a complete doctor’s order in place for restraint use.
Before using restraints, read your facility’s restraint usage policy to know how often a staff member must check on a patient. Practice good and quality documentation techniques to protect not only yourself but your patient.
Once a restraint is applied to a patient, that’s just the beginning of the process. Exact processes, such as how often checks need to be made, may vary from facility to facility, but the general guidelines are the same.
Staff must check routinely for issues that might be caused by the restraint, such as skin breakdown, muscle pain, decreased blood flow, blood clots, elimination problems, or other issues, even death.
Some patients may also require one-on-one constant monitoring from a dedicated staff member as part of the process. Facilities should also have detailed procedures on how often staff are changed out and what they should do during monitoring.
All our patients have the right to safe and quality care, and part of that responsibility is being knowledgeable and well-versed on methods and techniques, like using restraints.