Restraints are measures used to restrict freedom, limit the activity, or control the behaviour of a person or a portion of their body. Restraints can be:
- Physical: Hands-on holding of the arms, legs or body.
- Chemical or pharmacologic: A drug that is not required for treatment but is given to manage or control behaviour or activity.
- Mechanical: Any device, material, or equipment attached to or near a person that limits movement and cannot be controlled or easily removed by the person including a lap belt, wrist ties or side rails.
- Environmental: Limits a person to a room or area by using a barrier such as a door the person can’t open.
In situations where the safety of the client or others is a concern, the nurse’s responsibility to prevent harm while balancing the person’s right to autonomy can create an ethical conflict. This requires nurses to reflect on the situation and give serious consideration to their role and responsibilities in the use of seclusion and restraints.
Risks of restraints
Restraints are often overused and can be harmful. There is ongoing recognition that seclusion and restraints are not grounded in research and are not therapeutic (World Health Organization, 2017).
Harmful effects include loss of bone and muscle mass, falls, skin breakdown, urinary incontinence, urinary tract infection, pneumonia, cardiovascular stress, injury and death. Restraints may also lead to emotional distress such as increased agitation, anxiety, anger, delirium, confusion, depression and mistrust of health-care providers.
What to consider before using restraints
Nurses play an essential role in providing safe care to people in all care settings. This role requires that nurses provide effective, evidence-based care, including comprehensive assessment, prevention and management of behavioral emergencies.
Although restraints are ordered by the most responsible health-care practitioner, the assessment of need, application and removal are primarily the responsibility of nurses. As a result, nurses play a critical role in reducing restraints through:
- Following all standards, guidelines and employer policy.
- Questioning policies and procedures inconsistent with therapeutic client outcomes, best practices and safety standards.
- Performing the appropriate client assessments, weighing the risks and benefits of restraint use and applying critical decision-making to ensure safe and ethical care of all clients.
- Recognizing and addressing all of the relevant ethical, legal and safety issues.
- Exhausting all possible appropriate alternative interventions and strategies before deciding to use a restraint in a non-emergency situation.
- Ensuring that prior to restraint use, conversations with the interprofessional team, client and family regarding are completed and documented.
- Ensuring that the most responsible health-care practitioner is involved in the decision to use restraints.
- Ensuring that nursing care and use of restraints is provided with the client’s informed consent or alternate decision maker.
- Ensuring that if restraints are required:
- The least restrictive restraint is used for the shortest time.
- Proper application, monitoring and reassessment is done.
- Appropriate restraint documentation is completed.
- Clearly documenting all nursing care in relation to the restraint assessment, screening, alternative interventions, communication with client and family and referrals made.
- Advocating for policy development and processes that identify least restraint, safe staffing levels, alternative measures appropriate to the practice setting, resources and education.
- Involvement in the assessment, implementation, and evaluation of restraint practices and promoting a least restraint culture for the practice setting.
- Ongoing learning of:
- best practices on restraints
- alternatives to restraints
- client safety and the right to autonomy
- interventions to reduce agitation, aggression and behavioural emergencies that may result in a decision to use a restraint
- Communicating essential information regarding restraints at transitional points in care.
- Never using restraints as a precautionary method, punishment or to address staffing shortages.
Alternatives to restraints
Restraints should only be used as a last resort. The least restrictive restraint is used for the shortest time in an emergency or when other interventions have not worked.
Nurses should question using antipsychotic medicine to treat behavioural symptoms of dementia and limit their use to cases where non-pharmacologic measures have failed. Responsive behaviors are a form of communication and are often the last means of expression for unmet needs, pain, or fear. Responsive behaviours are often misinterpreted as agitation, aggression, disruption and resistance to care (Choosing Wisely Canada, 2017).
Alternatives to restraints can include a variety of physical, physiologic, psychological and environmental approaches. They are tailored to the needs of the individual client and the practice setting. Examples include:
- Comprehensive assessments, prevention and management of behavioral emergencies.
- Intervening early with less restrictive measures.
- Offering choices in care.
- Choosing the least intrusive treatment possible.
- Involving family to participate in care.
Nurses can take responsibility for ongoing learning and professional development on reducing restraint use such as:
- Attending education sessions on interventions to reduce agitation, aggression and behavioural emergencies that may result in a decision to use a restraint.
- Understanding the balance between client safety and the client’s right to autonomy.
- Participating in training on non-coercive, de-escalation and nonviolent interventions.
- Participating in training on motivational interviewing, collaboration and negotiation.
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