Restraint Use for CNAs and HHAs

Proper restraint usage and safety are an important part of working as a certified nurse’s aide (CNA) or home health aide (HHA). Patients requiring restraints in an assisted living facility or home setting are extremely vulnerable and are often not mentally and/or physically able to communicate well or stand up for themselves. It is the responsibility of the CNA or HHA to make sure that the needs of the patient are met when restraints are applied. It is also the responsibility of the aide to communicate to the nurse and medical team any observed behavioral or mood changes a patient shows. The use of techniques to calm down a situation is important before restraints are used. Unsafe restraint practices can lead to physical injury and increased emotional distress for the patient. When restraints are not used when needed, harm to the patient and nearby staff can occur.

There are many legal considerations about the use of restraints that will be talked about later in the course. The bottom line is that a CNA or HHA cannot decide to use restraints. Proper documentation and a medical order must be placed by the proper physician or licensed medical practitioner, depending on state regulations (Nursing, 2023). Restraints should be used as a last resort when a patient is at risk of harming themselves or others. The patient may show increasingly aggressive behavior because of emotional distress, mental illness, or drug use. Sometimes, the patient may exhibit behavioral and/or mood changes, severe confusion, delusions, and hallucinations from dementia, Alzheimer’s, or delirium. In all these cases, the patient may attempt to pull out medical equipment that is necessary for their condition, try to climb out of bed when it is unsafe to do so, or attempt to run away.

Some patients may show irritation and nervousness at their baseline due to their medical condition. Usually, these patients’ behaviors are clearly reported in handoffs, and de-escalation techniques are well established. If you know about these behaviors ahead of time, it can help make them more manageable. Having a comprehensive care plan in place can also keep things from becoming worse. In other situations, a patient may be usually calm at baseline, and then seemingly out of nowhere become aggressive or severely confused. This may put them at risk for harm. This scenario can cause a lot of challenges since the behavior wasn’t expected.

As CNAs or HHAs, it is important to be familiar with your facility or agency’s policies, restraint protocol, and what resources are available to you. Many of the patients cared for by aides have some form of dementia (usually Alzheimer’s) or mental illness. As these diseases worsen over time, the risk of behavioral changes and cognitive impairment increases. If a patient ever shows concerning behavior, it should be reported as soon as possible to the registered nurse/supervisor and provider. Especially if the aid works in the home setting, it is important to have all the resources available to ensure patient and caregiver safety. The bottom line is that when patients show behaviors that put themselves or others at risk, restraints should be considered. Restraints should never be used as punishment, incentive, or convenience (Bray, 2024).

Dementia: Dementia is a more general term that describes a collection of symptoms associated with various brain disorders. It is not a normal part of aging. The symptoms involve a decline in mental ability that is severe enough to impact daily life. Patients with dementia experience memory loss, impaired judgment, disorientation, difficulty with language, and changes in personality and behavior (irritability, anxiety, depression, apathy) (Reuben et al., 2024).

Alzheimer's: Alzheimer's disease is the most common type of dementia. It is a progressive disease. This means it will continue to worsen over time. If a patient lives long enough with Alzheimer's, they will forget how to function entirely, losing their ability to eat, speak, and move functionally (Kumar et al., 2025).

Delirium: Delirium is a serious change in mental abilities involving confusion and impaired thinking ability (affecting memory, reasoning, language, and perception). It also involves emotional and behavioral changes such as agitation, anxiety, hallucinations, delusions, and withdrawal. The symptoms can come on suddenly and change over a short or long period. Patients with dementia, alcohol use disorder, and those taking certain medications are at risk of delirium. Other causes include acute illness, untreated pain, and surgery. Geriatric patients who spend any amount of time in the intensive care unit (ICU) are at an increased risk of what’s known as ICU-delirium (Ramírez Echeverría et al., 2022).

Alexa is a certified nurse’s aide who works in a skilled nursing facility (SNF). Today is the first day back at the facility after her scheduled vacation. She is assigned to her usual patients on the B Hallway. During her morning rounds, she notices Miss Kay is more confused than usual. Miss Kay is mumbling incoherently, unusually restless and fidgety, and seems anxious. Alexa pulls up Miss Kay’s chart and learns she was admitted to the hospital seven days ago and spent four of those days in the ICU. Today is Miss Kay’s first full day back at the SNF. Alexa is very fond of Miss Kay and hopes she can make her feel better.

De-escalation techniques are approaches for calming down a person who is agitated or aggressive. These techniques focus on managing the situation, not winning an argument. Various de-escalation techniques should be used before requesting restraint orders. Depending on what is driving the behavior changes, it may be possible to observe subtle escalation and stop it before it gets dangerous. There are recognized phases of escalating aggression, which include (University of Sydney Matilda Center, n.d.):

1. Trigger phase: The trigger phase is the initial stage where the patient experiences stress or anxiety, or an initial event triggers the patient. The initial signs are subtle and can include increased awareness, muscle tension, and increased heart rate.
2. Escalation phase: The escalation phase involves increased aggressive behavior that is more obvious to those around the patient (e.g., clenched fists, arms crossed, rapid speech, sarcastic comments, etc.).
3. Crisis phase: The crisis phase is the peak of violent conduct. At this point, the patient has lost control and is shouting, swearing, and potentially putting others at risk of harm.
4. De-escalation phase: The de-escalation phase is when the tension starts to decrease.
5. Recovery phase: During the recovery phase, the patient might still be slightly irritated, so it is important to be supportive.
6. Post-crisis depression phase. The post-crisis depression phase is when the patient might feel tired or guilty for the outburst. It is important that the CNA be supportive and understanding of the behavior.

It is important to understand that these phases don’t always happen in order. The phases can vary in intensity and duration depending on what is going on (University of Sydney Matilda Center, n.d.). The goal is to recognize the early signs and take them seriously.

When caregivers see increased anxiety or worry, there are several de-escalation techniques that should be used. Active listening is a great technique to use to get to the reason for a patient’s distress (Kaur & McNamara, 2025). When working with patients with special needs, dementia, or other conditions that impact the patient’s ability to express themselves, ensure the patient’s immediate needs are met. Is the patient hungry or thirsty? Does the patient need to use the bathroom or get cleaned up? Is the patient in pain? Pain is a crucial factor to rule out. It can be the whole reason for increased anxiety and agitation. The pain should be treated promptly (Husebo et al., 2022).

If the patient’s immediate needs are met and pain is not an issue, the next thing to consider is the patient’s environment. How could improvements to the environment impact the patient? Some patients respond well to the presence of familiar caregivers. If possible, swap assignments with an aide who is known for getting along with the patient and who might be best able to de-escalate the patient. If it is known that the patient responds well to having a family member present, contact that person and see if arrangements can be made. If staffing permits, advocate for a 1:1 sitter who can observe the patient and intervene as necessary (Kramer & Schubert, 2023).

Some patients respond well to soothing music, familiar television shows, pictures of their loved ones, animal therapy (when possible), or going outside on a nice, comfortable day. Alzheimer's, dementia, and delirium patients can benefit from using a busy board or fidget blanket to aid in distraction and prevent them from pulling on medical equipment (Mosley et al., 2020). It is important to be aware of the resources available in the facility or home setting prior to handling a real-world scenario.

Alexa makes sure that Miss Kay’s immediate needs are met. She refills her water and offers her breakfast. She takes her to the bathroom and gets her dressed for the day. Alexa knows Miss Kay benefits from routine, but today there is no sign of improvement. In fact, Alexa has never seen her this way. Alexa turns on Miss Kay’s favorite radio station. Aleza then documents her morning routine in the chart. She then leaves the room to report to the registered nurse covering Hallway B. Alexa explains the confusion, restlessness, and anxious behavior to the nurse. The nurse performs a detailed assessment and rules out pain. Alexa is advised to continue soothing the patient and keep a close eye on her.

The CNA or HHA will most likely see a change in a patient’s mood or behavior before anyone else on the medical team. This is because aides tend to spend the most time with patients. Mood or behavioral changes, especially sudden changes, can indicate a new or worsening medical condition. This could also be the result of medication changes. Because of this, it is important that aides report the mood or behavior changes that they have seen to the registered nurse or medical provider as soon as possible.

Remember, the goal of restraints is to treat the medical symptom(s). All other interventions must have been attempted or contraindicated before restraints can be considered appropriate. The underlying cause of the medical symptom(s) must be determined. The provider will ultimately place the order for the restraints. It is never acceptable to place restraints on a patient without the official medical order. A CNA or HHA should always try several de-escalation techniques and communicate what was done before. This must also be documented before expecting restraint orders. Be aware that the patient or legal guardian must provide consent prior to the placement of restraints (Bray, 2024).

Just before lunch time, Alexa suddenly hears yelling from Hallway B. She realizes the noise is coming from Miss Kay’s room. As she gets closer to the room, she sees another resident standing in the doorway, frantically yelling at Miss Kay to stop. Miss Kay is found pulling out the IV from her arm. She has blood down her gown. She isn’t wearing her oxygen either. Miss Kay appears very confused and doesn’t seem to recognize Alexa. Miss Kay grabs her cane and begins pointing it at Alexa, telling her to “go away!”. Alexa calls for help, and nearby staff appear by her side. It takes several minutes to calm Miss Kay down. Alexa knows Miss Kay is very fond of her granddaughter. Shortly after the incident, Alexa gets in contact with her and puts Miss Kay on speaker phone, so they can talk. Alexa also understands that a new care plan must be put in place to lessen this new behavior. Alexa seeks out the registered nurse and the provider covering Hallway B.

Restraints are used to restrict a person’s movement. There are several different types of restraints that can generally be categorized into three groups: physical, chemical, and environmental. Be aware of your state laws and regulations. Some forms of restraints are NOT permitted, including jackets, sheets, metal cuffs, belts, or mitts made of certain types of material like leather (Kaur & McNamara, 2025).

Using restraints when caring for patients in healthcare can negatively affect patients and staff. Consequences can be physical, social, and psychological. The patient may experience injury or even death as a result of the use of restraints. The patient may experience post-traumatic stress disorder, shame, guilt, or loss of dignity (Kaur & McNamara, 2025).

Restraint use can negatively affect staff, who might also sustain physical injury. Also, the staff might feel guilt because of internal conflict regarding the ethical responsibility when using restraints on a patient. These shared experiences might disrupt the therapeutic relationship between the provider and the patient (Kaur & McNamara, 2025).

The Joint Commission requires that a time-limited order be acquired by staff for the restraints. The length of time that the restraints are good for varies based on the age of the patient, state, and facility. If the restraints need to be used beyond the expiration of the order, a new order must be placed. After one hour of using the restraints, a face-to-face assessment must occur between the provider and the patient. The continued need for restraints must be assessed frequently. Depending on the behavior of the patient and policies of the facility, the restraints may need to be assessed as frequently as every 15 minutes or up to every hour. It is the responsibility of the registered nurse to maintain documentation reporting the need for restraints (Kaur & McNamara, 2025).

While the registered nurse or provider is responsible for monitoring a patient's restraints, CNAs and HHAs might be asked to check the patient's vital signs and skin at the site of the restraint. This monitoring needs to be frequent, at least every 15 minutes (Nursing, 2023).

Alexa shares her concerns regarding Miss Kay’s current behavior with the medical team. The provider on call diagnoses Miss Kay with delirium related to her stay in the ICU. The provider orders hand mitts and an anti-anxiety medication to be given until the delirium improves. Alexa knows the hand mitts are meant to protect the patient from further self-harm, but also understands the hand mitts could cause the patient other problems. Alexa knows the nurse will reassess the need for the restraints frequently, and it is up to Alexa to ensure Miss Kay’s immediate needs are being met, like using the restroom, drinking, and eating OK. Alexa also understands she must report new or worsening behavior to the nurse or provider.

• American Psychiatric Nurses Association [APNA]. (2025, April 14). APNA Standards of Practice: Seclusion and Restraint | APNA. APNA. Visit Source.
• Bray, M. (2024). Use of restraints in nursing homes and residential care facilities. Volume 135. Ohio Legislative Service Commission. Visit Source.
• Husebo, B. S., Vislapuu, M., Cyndecka, M. A., Mustafa, M., & Patrascu, M. (2022). Understanding Pain and Agitation Through System Analysis Algorithms in People With Dementia. A Novel Explorative Approach by the DIGI.PAIN Study. Frontiers in pain research (Lausanne, Switzerland), 3, 847578. Visit Source.
• Kaur, J., & McNamara, S. (2025). Patient Restraint and Seclusion. In StatPearls. StatPearls Publishing. Visit Source.
• Kumar, A., Sidhu, J., Lui, F., & Tsao, J. W. (2025). Alzheimer Disease. In StatPearls. StatPearls Publishing. Visit Source.
• Kramer, I., & Schubert, M. (2023). The use of patient sitters at a Swiss hospital: A retrospective observational study. PloS one, 18(6), e0287317. Visit Source.
• Mosley, B., Kroustos, K. R., Sobota, K. F., & Brooks, R. (2020). Enhancing student-pharmacists' professional development through community outreach with dementia population. The Mental Health Clinician, 10(1), 6–11. Visit Source.
• Nursing, M. S. R. M. B. R.-. O. R. F. (2023). 8.7 Restraints and Restraint Alternatives. Nursing Assistant. Visit Source.
• Ramírez Echeverría, M., Schoo, C., & Paul, M. (2022). Delirium. In StatPearls. StatPearls Publishing. Visit Source.
• Reuben, D. B., Kremen, S., & Maust, D. T. (2024). Dementia prevention and treatment: a narrative review. JAMA Internal Medicine, 184(5), 563-572. Visit Source.
• University of Sydney: Matilda Center. (n.d.). Phases of aggression. In Aggressive, angry, or violent behaviour. Comorbidity Guidelines. Visit Source.