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Restraint Use: Evidence Based Practice

1.00 Contact Hour
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Kelley Madick (MSN/ED, PMHNP)

Outcomes

The purpose of this course is to present current evidence based practice for the use of restraint and seclusion.

Objectives

After completing this course, the learner will be able to:

  1. define restraints and seclusion,
  2. discuss nursing care of a patient in restrains or seclusion ,
  3. identify the consequences of the use of restraints and seclusion, and
  4. apply methods to reduce the use of restraints and seclusion.

Introduction

Restraining a patient should be considered a last resort. There are three types of restraints: physical, chemical, and seclusion.  The use of restraints can be a dangerous intervention if not done properly and by qualified staff. Improper use of restraints can cause death and serious injury (Use & Falls, 2011). The Center for Medicare and Medicaid defines a physical restraint as any manual, physical or mechanical device attached or adjacent to the patient that cannot be easily removed and restricts movement. This may include vests, straps, wrist ties, belts, bed-side rails and Geri-Chairs (Lai, Chow, Suen, & Wong, 2011; Barton-Gooden, Dawkins, & Bennett, 2013).  Also, holding a patient to restrict their movement is considered a restraint (Springer, 2015). Chemical restraints consist of the use of drugs for the purpose of controlling behavior or movement. Seclusion, on the other hand, is when the patient is in a locked room involuntarily (Springer, 2015). Restraints and seclusion are used for various reasons including aggression, violence or self-harm (such as pulling out medically needed devices or causing self-injury). However, the nurse must be aware of standards and regulations of agencies.

Regulatory agencies that provide standards for restraints and seclusion are the Center for Medicare, Medicaid, and the Joint Commission on Accreditation of Healthcare Organizations. Both agencies have standards that guide practitioners and nurses on how and when to use restraints. Other organizations that offer guidelines are the American Nurses Association (ANA) and the National Alliance on Mental Illness (NAMI). All standards and guidelines state that first and foremost restraints are use only when necessary and when all other forms of interventions have failed. The least restrictive methods of controlling behavior must be tried first before restraints are initiated. Restraints are to be time limited, have documented indications, and be re-evaluated frequently (Barton-Gooden, Dawkin & Bennet, 2013; Springer 2015). It is important to note that a restraint is in place when the patient is not able to free themselves from the restraint. This includes soft restraint and bed rails. However, an important distinction is that some forms of restraints such as bed rails can be used to help the patient get in and out of bed and may not be considered restraints.  It is up to the prescriber to make the use very clear in the documentation. Furthermore, unless the patient is being violent toward himself or others or places himself in danger, the patient can refuse restraints.

Regulations of Restraints

The Omnibus Budget Reconciliation Act (OBRA) of 1987 ruled that restraints should not be used for convenience or discipline. Restraints should only be used if the patient was causing harm to self or to others and that the ordering physician states duration and circumstances for restraints (Turnham). This rule also specifies that patients have the right to refuse treatment unless there is no other alternative, and all other least restrictive interventions have been tried unsuccessfully, and there is physician order. Furthermore, each state has provisions that also encompass this rule.

The Centers for Medicare and Medicaid (CMS) also published rules in 2006 and the Joint Commission followed in adopting the rules in 2007 (PC.12.90). The rules require face-to-face evaluations within an hour of the patient being restrained or secluded (Code of Federal Regulation, 2006). The evaluation is to be conducted by a physician or another independently licensed practitioner (Code of Federal Regulations, 2006). For hospitals, CMS states that all patients have the right to the least restrictive treatments. Restraints are only to be used when the patient has put himself or others in danger. Additionally, the restraints must be removed as soon as possible (centers for Medicare and Medicaid).  Documentation must include what other interventions were attempted and failed, the order for restraints that cannot be a standing or PRN order, and the restraint or seclusion intervention must be added to the patient’s plan of care. Staff must also receive training and demonstrate competency in restraint and seclusion care. The Joint Commission requires that hospitals have written policies and procedures including training for any staff who may be involved in a restraint or a seclusion (Joint Commission).

Chemical restraints are the use of medications that are not part of the patient’s treatment plan to calm the patient. These are usually antipsychotic medication or benzodiazepines such as Haldol or Ativan. Chemical restraints are also not part of the patient’s treatment plan and are never to be used for convenience per the CMS definition (Jacob, et. al, 2015). The CMS rules for nursing homes state that the resident is not to be given a chemical restraint for wandering, poor self-care, restlessness, impaired memory, anxiety, depression, nervousness, uncooperative or agitated behaviors that do not represent a danger (state operations manual). These events should be documented and plans of care initiated for the patient as well as other least restrictive interventions that did not work.

Restraint orders for non-violent patients can be renewed according to facility policy. However, if the patient is violent or shows self-harm and needs to be restrained or secluded orders are only in effect for 24 hours at which time the patient must be reassessed by the provider and write a new order. An assessment must also occur within one hour of initiating the restraints by an RN or a PA and reported to the provider as soon as possible (CMS). There must be 15-minute checks completed, a family member or caregiver must be contacted at the patients request, a debriefing must occur within 24 hours of all those involved including family members (Joint Commission).The following chart shows the renewal times for each group (CMS).

Age Renewal
Adult (over 18)4 hours
9-17 2 hours
under 91 hour

Patients who are restrained and/or in seclusion for violent behaviors or self-destructive behaviors are to be monitored on a one to one or face to face status by a trained staff member. This can be done via video and audio equipment as well by a staff member trained in this area.  The staff member must document the patients condition, any attempts at less restrictive intervention with results, a behavioral and medical evaluation, the response to the restraints and the reason to continue the restraints.

 If death should occur while a patient is being secluded or restrained, it must be reported to CMS within 24 hours per The Joint Commission and CMS. This includes deaths that occur while in seclusion or restraints excluding those in which only 2-point soft wrist restraints were used and the patient was not in seclusion at the time of death. Also any death that occurred after the patient was removed from restraints or seclusion up to one week and the restraint or seclusion is suspected to have directly or indirectly contributed to the death regardless of restraint type must also be reported (CMS-42 CFR 482.12(g) (Department of Health and Human Services, 2014). There should also be an internal reporting system at the facility.

The American Nurses Association (ANA) wrote a position statement regarding the use of restraints that addresses the role of the nurses in reducing the use of restraints and seclusion. The statement states that restraints and seclusion are a last resort and are only used when safety issues are impending. This statement parallels those of CMS and the Joint Commission as well as the National Alliance fro the Mentally Ill. ANA recommendations also include training of personnel, reviewing ethical issues that may occur, instituting a movement toward restraint free facilities, developing clear policies and accepted national standards, sufficient staffing levels, and environmental support.

Consequences of Restraints

Does the risk outweigh the benefit? The practice of using restraints in patient care has been an ongoing issue for over 200 years. Although significant strides have been made in education and training of health care workers, the controversy of whether to use restraints or not is still being asked. Of great concern is patient morbidity and mortality (Rakhmatullina & Jacob, 2013). In a comprehensive review conducted in 1994 by Fisher concluded that restraints although helpful for managing agitation and injury, could still cause significant harm, both physical and psychological harm to the patient such as aggression and demoralization (Goethals, Dierckx, etc., 2012). Additional studies show that neither seclusion or restraints have proven to be an effective intervention in research (NAMI). But are at times, required for the safety of the patient and the staff. Furthermore, patients may suffer from bedsores, falls, asphyxiation and death while in restraints.

Seclusion is seen as a therapeutic intervention among nurses. However, this intervention is seen as negative by the patient (Van der Merwe, 2013). Although seclusion is the number one therapy used for aggressive behaviors, patients reported feeling angry, abandoned, vulnerable, humiliated, worthless, depressed, trapped and not getting the attention, they needed (Van der Merwe). Other older studies however, reported that patients appreciated the staff taking control and being near during a time they could not control their behaviors (Heyman, 1987; Tooke 1992; Kjellin, 2004;, Kousmanen, 2007).

Chemical restraints involve the use of antipsychotic medications and/or benzodiazepines to decrease agitation. Typically, chemical restraints are used in emergency situations and have a history of being administered in nursing homes. However, there are side effects that need to be assessed. These include unsteady gait, postural hypotension, sedation, movement disorders, memory impairment, functional decline, withdrawal, EKG changes and agitation (Ang,2015). These adverse reactions are of particular concern when chemical restraints are used in the elderly population. The Omnibus Budget Act of 1987 clearly states that uncooperativeness, restlessness, wandering, and unsocial behavior are not justifiable reasons to use chemical restraints. Therefore, it is important to develop alternative strategies other than restraints, particularly in the geriatric population.

Nursing Responsibilities

Although restraint and seclusion practices have been employed as a means to deter aggressive and unsafe behaviors, research has shown that restraints are not only causing additional issues but the outcome is not always therapeutic (ANA, 2012). Nurses have an obligation to use the least restrictive intervention when working with patients.  The Position Statement by the American Nurses Association (ANA) states that nurses need to work toward reducing the use of restraints and seclusion as an intervention. The position statement further states that restraints are only to be used as a last resort when patient or staff safely is jeopardized (ANA, 2012). When restraints are used, best practice guidelines should be followed including documentation by more than one person.

Making the decision to use restraints or seclusion should not be taken lightly. The decision should be based on the assessment and the ability to pick up on cues related to the patient’s behavior. The nurse must then consider all alternatives prior to administering restraints or seclusion. Cues and assessment should center around the patient’s speech, mood and content of thought (Laio et al, 2013). Furthermore, the nurse must assess if safety to the patient or to the staff is likely to occur. Once in restraints the nurse must regularly assess the patient and provide basic needs such as toileting and washing (Kontio et al, 2012). The patient, when possible, should also be included in the treatment planning and allowed to discuss their experience in restraints (Kontio, 2012). These actions adhere to patient-centered care and should be documented.

Cues

  • Pacing, agitated
  • Grimace on face
  • Yelling
  • Being offensive
  • Clenching fists
  • Threatening other or self
  • Throwing items
  • Slamming doors

Using restraints and seclusion can be an issue for nurse as well as for the patient. Nursing ethics includes beneficence and non-malfeasance as a center concept. The nurse has to come the decision that although possible psychological and physical trauma may occur, restraining or secluding a patient is in the best interest and safety of the patient as well as staff and other patients on the unit (Laio, 2013). Nursing care should be dictated by the assessment and decision to protect the patient.

Nursing care includes treating the restrained patient with dignity and respect. Nurses are to be involved in the assessment, intervention and outcome planning of the restrained patient. Federal regulations, Centers for Medicare and Medicaid (CMS) and Joint Commission standards should be followed at all times. Joint Commission, the ANA and CMS standards include:

  1. An order for the restraint or seclusion must be obtained from a provider permitted to order restraints in the state within one hour of the restraint placement. If the order is not given face to face, a telephone order is acceptable.
  2. The reason for the one-hour interval between restraint placement and the order is documented.
  3.  An RN
  • assesses the patient until the provider arrives.
  • communicates with the family or legal caregiver about the need for restraints and procedure that will be followed.
  • explains to the patient the need for restraint or seclusion and attempts to solicit cooperation.
  • arranges for assistance from qualified staff to help with the restraints or seclusion as well as for care of the patient.
  • uses the least restrictive restraint while ensuring patient comfort and safety. No force should be used.
  • ensures privacy of the patient.
  • ensures continuous observation is maintained as well as ensures the patient is treated with dignity and respect.
  • attends to the psychological and physical needs of the patient at regular intervals.
  • assesses the restraints regularly. An attempt is made to discontinue the restraints or seclusion.
  • debriefs the patient and the family as needed.
  • documents the use of the restraints or seclusion and all assessments.
  • explores alternative interventions for the patient.
  • maintains competence and education on the use of restraints and seclusion.
  • decision to restrain or seclude a patient should take in to account the patient’s age and developmental status as well as medical health.

Alternative to Restraints

CMS, ANA and the National Alliance for the Mentally Ill (NAMI) support the use of restraints and seclusion by qualified, trained staff only in extreme circumstances to manage violent behavior. Alternative strategies should be tried and documented prior to restraining or secluding a patient when possible (ANA, NAMI, CMS). Alternative strategies include de-escalation, distraction, reassurance, or sitting with a family member or staff. Starting with the least restrictive intervention which is verbal interventions.  During interactions with the patient, the nurse needs to continue to assess and be aware of the patient’s actions and speech. Is the patient pacing, slamming doors, cursing, yelling or throwing things? The following are additional interventions (Richmond et al, 2012):

  1. Assess the environment. Is the patient agitated by something that can be removed?
  2. Approach in a calm manner with eye contact and a calm voice.
  3. Give the patient options to control their behavior such as walking the hall, talking about the issue in a calm manner, or doing a task. Let the patient know that if they cannot control their behavior staff will have to help them which may mean restraint or seclusion.
  4. Reassure the patient that you are here to help them and when they can control their behavior you will discuss their concerns with them.
  5. Maintain personal space when possible about 2 arm’s lengths away from the patient
  6. Speak in simple terms and repeat yourself if necessary.
  7. Identify the patient’s feelings
  8. Be sure to have others standing by for help if necessary.
  9. Let the patient know that harming themselves or others is not acceptable

One of the most important things to remember when dealing with an agitated or violent patient is that the behavior occurs as a progression, not as a sudden isolated incident (Robertson, 2012). By understanding this, nurses are in a far better position to assess a possible problem and break the progressive cycle before it gets to a point of restraint or seclusion.  For example, is the patient uncomfortable with the catheter or the wound vac? If so the nurse should assess frequently and check medications to see of there is a prn medication. The nurse must decide how often to assess the patient and what cues will indicate the need for a restraint. The assessment and planning ahead will help head off any potential problems.

Verbal de-escalation or talking the patient down is a collaboration between the nurse and the patient. The nurse can redirect the patient’s emotions toward a calmer state. The goal is to reduce anxiety and avoid any behavioral problems through therapeutic communication and assessment (Robertson, 2012). For example, careful addressing a patient that is becoming more agitated can help to identify stressors and redirect energy. The nurse may walk the halls with the patient while discussing what is upsetting the patient and help the patient to find alternatives to acting out.

Other recommendations for alternatives to restraint and seclusion are low stimulus areas that include soothing sounds, lights, pictures, or reading materials. Comfort rooms that have soft blankets, pillows, headphones, audio, or other items that are comfortable and soothing. Art activities is another option to help a patient communicate and calm themselves (Nami, 2003). The nurse should assess the appropriateness of each intervention.

The nurse is the most important tool in helping patients to de-escalate and avoid restraints or seclusions. By using skills such as one to one communication, recognize behaviors that may escalate, and therapeutic conversations, the nurse is a powerful reinforcer of appropriate behaviors. Present the patient with the opportunity to calm themselves first. Physical restraint or seclusion is a last resort.  Nurses should keep in mind that restraining or secluding a patient has not shown any therapeutic value and often impacts treatment negatively (NAMI, 2003).

References

American Nurses Association. (2012). Reduction of patient restraint and seclusion in health care settings. Retrieved from (Visit Source).

Ang, S. Y., Aloweni, F. A. B., Perera, K., Wee, S. L., Manickam, A., Lee, J. H. M., ... & Chan, J. K. (2015). Physical restraints among the elderly in the acute care setting: Prevalence, complications and its association with patients’ characteristics. Proceedings of Singapore Healthcare, 24(3), 137-143.

Barton-Gooden, A., Dawkins, P. E., & Bennett, J. (2013). Physical Restraint Usage at a Teaching Hospital: A Pilot Study. Clinical nursing research, 1054773813493112.

Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicare and Medicaid programs; hospital conditions of participation: patients’ rights; Final rule. Fed Regist. 2006;71(2236):71377-71428.

Department of Health and Human Services Centers for Medicare and Medicaid Services. (2014).

Fisher WA: Restraint and seclusion: A review of the literature. American Journal of Psychiatry

Goethals, S., Dierckx de Casterlé, B., & Gastmans, C. (2012). Nurses’ decision-making in cases of physical restraint: a synthesis of qualitative evidence. Journal of advanced nursing, 68(6), 1198-1210.

Heyman E. (1987) Seclusion. Journal of Psychosocial Nursing and Mental Health Services 25,

Jacob, T., Sahu, G., Frankel, V., Homel, P., Berman, B., & McAfee, S. (2015). Patterns of Restraint Utilization in a Community Hospital’s Psychiatric Inpatient Units. Psychiatric Quarterly, 1-18.

Kjellin, L., Andersson, K., Bartholdson, E., Candefjord, I. L., Holmström, H., Jacobsson, L. . . . Östman, M. (2004). Coercion in psychiatric care—Patients’ and relatives’ experiences from four Swedish psychiatric services. Nordic Journal of Psychiatry, 58(2), 153–159

Kontio, R., Joffe, G., Putkonen, H., Kuosmanen, L., Hane, K., Holi, M., & Välimäki, M. (2012). Seclusion and restraint in psychiatry: Patients' experiences and practical suggestions on how to improve practices and use alternatives.Perspectives in psychiatric care, 48(1), 16-24.

Kuosmanen, L., Hätönen, H., Malkavaara, H., Kylmä, J., & Välimäki, M. (2007). Deprivation of liberty in psychiatric hospital care: The patient’s perspective. Nursing Ethics, 14(5), 597–607. d

Lai, C. K. Y., Chow, S. K. Y., Suen, L. K. P., & Wong, I. Y. C. (2011). The Effect of a Restraint Reduction Program on Physical Restraint Rates in Rehabilitation Settings in Hong Kong. Rehabilitation Research and Practice, 2011, 284604.

Laiho, T., Kattainen, E., Åstedt-Kurki, P., Putkonen, H., Lindberg, N., & Kylmä, J. (2013). Clinical decision making involved in secluding and restraining an adult psychiatric patient: an integrative literature review. Journal of psychiatric and mental health nursing, 20(9), 830-839.

National Alliance for the Mentally Ill Policy Research Institute. (2003). Task force report on restraints and seclusion. Arlington, VA: Author.

Rakhmatullina, M., Taub, A., & Jacob, T. (2013). Morbidity and Mortality Associated with the Utilization of Restraints. Psychiatric Quarterly, 84(4), 499-512.

Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman, G. H., Zeller, S. L., Wilson, M. P., ... & Ng, A. T. (2012). Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1).

Roberton, T., Daffern, M., Thomas, S., & Martin, T. (2012). De-escalation and limit-setting in forensic mental health units. Journal of forensic nursing, 8(2), 94-101.

State operations manual. Appendix PP: guidance to surveyors for long-term care facilities. Centers for Medicare & Medicaid Services Web site (Visit Source) . Revised January 7, 2011

Tooke S.K. & Brown J.S. (1992) Perceptions of seclusion: comparing patient and staff reactions. Journal of Psychosocial Nursing and Mental Health Services 30, 23–26.

Turnham H. Federal Nursing Home Reform Act from the Omnibus Reconciliation Act of 1987 or simply OBRA 87 Summary. North Carolina Department of Health and Human Services Web site (Visit Source).

Use, R., & Falls, P. P. (2011). Joint Commission Resources Quality & Safety Network.

Van Der Merwe, M., Muir-Cochrane, E., Jones, J., Tziggili, M., & Bowers, L. (2013). Improving seclusion practice: implications of a review of staff and patient views. Journal Of Psychiatric & Mental Health Nursing, 20(3), 203-215.


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)

Topics:

CPD: Practice Effectively, CPD: Preserve Safety, Geriatrics, Medical Surgical


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