Introduction

Nursing is a very rewarding career, but it also puts nurses at risk for injury, especially when patients become violent. According to the Occupational Safety and Health Administration (OSHA), roughly 75% of workplace violence occurs in medical settings (7). Additionally, healthcare workers face a 20% higher risk of being victimized in the workplace versus other professionals in other industries (7). Physically restraining patients, whether for the patient’s safety or the safety of the nurse, is an intervention that nurses must be prepared to implement.

Restraints are used to prevent patients from harm, such as falls, removing endotracheal tubes, and dislodging intravenous lines. Restraints are also used to protect healthcare staff and visitors from the patient when the patient is physically aggressive. (5) However, restraint use claims 23% of nursing time and $1.4 million in staff costs, equaling 40% of hospitals’ inpatient operating budget (8). Additionally, 80% of healthcare providers have limited knowledge and skills surrounding restraint use in hospitalized patients (9). This lack of knowledge negatively impacts patients and leaves nurses vulnerable to legal and ethical ramifications.

Research indicates that restraints are used regularly in the hospital setting, and older adults are three times more likely to be restrained than other adults (9). The most plausible explanation for this is that aging is associated with chronic health conditions that require frequent hospitalizations.

Studies also show that African Americans, patients without private insurance, and patients from lower socioeconomic backgrounds experience restraint use while hospitalized more than their counterparts from less vulnerable patient groups (5). One explanation for the inequity is that patients from vulnerable groups do not receive consistent healthcare before hospitalization, including access to behavioral health and psychiatric treatment (5).

Nurses have a duty to protect patients when the patients are at risk of harming themselves through impaired cognitive function, impaired mobility, or general interference with the treatment plan (3). Nurses must use their critical thinking skills and judgment to implement patient measures that provide a safe patient care environment.

In an effort not to harm patients, nurses must use physical restraint only as a last resort, and restraints should never be implemented as a means of punishment or convenience or due to staffing shortages (2, 7). Restraints should be administered in a professional and humane manner, and preserving the patient’s dignity should be a major goal (6).

Definition and Historical Background

Physical restraint is any item that restricts a patient’s movement and can include mittens, vests, belts, bed rails, and geriatric chairs with tables (4, 5). The Centers for Medicare and Medicaid Services (CMS) define a physical restraint as “any manual method, device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, or head freely” (1, 12).

In the mid-1900s, many hospitals began using physical restraints, including bedside rails, to prevent patient falls (4). This was to curtail liability issues, and eventually, policies were implemented to standardize their use. Restraints were most commonly used to prevent falls, wandering, and disruption of therapy (4).

Low body weight, frailty, older age, impaired cognition, and functional challenges were risk factors for restraint use in the mid-1900s (4). Today, research indicates that restraint use may pose serious safety hazards to patients and cause complications, such as joint contractures, muscle weakness, immobility, incontinence, deconditioning, delirium, and psychological distress (4).

Researchers and policymakers do not advocate for using physical restraints on patients today. However, the use of restraints to temporarily control violent patients to prevent the removal of critical equipment like endotracheal tubes, catheters, and intra-arterial devices is acceptable (4).

Hospitals can save resources and increase the quality of care when they don’t rely on restraints.

For example (8):

• Florida State Hospital reduced restraint use by 54%, saving the institution $2.9 million in reduced workers’ comp claims, staff injuries, and length of stay costs.
• The University of Massachusetts reduced patient restraint use by 98%, yielding an 86% decrease in staff member sick time.
• The Massachusetts statewide restraint prevention initiative, which focused on children and adolescents, reduced restraint use by 89%, saving $1.33 million annually.

Types of Restraints

Physical restraints include hand mittens, vests, belts, soft material limb restraints, leather limb restraints, bedrails, enclosure beds, and geriatric chairs with tables (4, 5, 7, 10).

Here is a closer look at the type of physical restraints according to The Joint Commission (10):

• Enclosed bed: An enclosed bed or net bed that restricts the patient’s ability to exit the bed freely is a type of physical restraint. The exception is the use of an age-appropriate crib for infants and toddlers.

• Bed siderails: Siderails on a patient’s bed are considered a restraint when they restrict the patient’s ability to exit the bed voluntarily. Bed rails are a restraint when all four segmented side rails are raised. If fewer than four segmented side rails are raised, this is not considered a restraint because the patient has a clear exit from the bed. In beds with only two non-segmented side rails, the side rails are restrained when both are raised. If only one non-segmented side rail is raised, this is not considered a restraint. If the patient cannot get out of bed due to physical or cognitive limitations, raising both non-segmented or all four segmented side rails is not a restraint because the side rails do not impede the patient’s ability to move. Siderails are also not considered a restraint when the patient is sedated, recovering from anesthesia, experiencing involuntary movement, on a stretcher, or in a therapeutic bed used to prevent the patient from inadvertently falling out of bed. Siderail restraints can cause entrapment, entanglement, or falling from a greater height due to the raised siderail.

• Hand mitts: Hand mitts are considered a restraint if used in conjunction with wrist restraints, pinned to the bed or bedding, secured so tightly that they restrict the patient’s finger or hand movement, bulky to the point of restricting movement, or cannot be intentionally removed by the patient.

Some hospitals consider bed and chair alarms a type of physical restraint (11).

Indications

Several hospital diagnoses are associated with increased restraint use. These are (in rank order) (5):

• Sepsis
• Respiratory failure
• Cerebral vascular accident
• Pneumonia
• Acute renal failure
• Urinary tract infection
• Acute coronary syndrome
• Alcohol withdrawal
• Chronic obstructive pulmonary disease (COPD) exacerbation
• Benzodiazepine poisoning

Restraints should not be used for delirium management because the risk of agitation and injury increases in the presence of immobility (9).

Patient agitation has been shown to escalate when interpersonal communication is challenged, waiting times to receive care are increased, and drug and alcohol intoxication and/or withdrawal are present (7). Medical conditions that can increase patient agitation include hypoglycemia, hypoxia, infection, dementia, stroke, schizophrenia, psychosis, and personality disorder (7).

The downside of physical restraint use is that it can increase the incidence of delirium, pressure ulcers, fractures, deep vein thromboses, cardiac dysrhythmia, neuromuscular injuries, ventilator use, asphyxia, strangulation, fecal and urinary incontinence, nosocomial infections, pneumonia, and mortality, as well as make patients feel a loss of dignity (4, 5, 7, 9).

Additionally, physical restraint use is associated with increased incidence of post-traumatic stress disorder (PTSD), anxiety and depression, social isolation, and impaired therapeutic rapport between the patient and healthcare providers (5). Restrained patients can experience anger, aggression, frustration, fear, humiliation, and low self-confidence (9). Restraint can also cause nurses guilt and moral distress (9).

Nurses should be aware that a patient’s history of violence is the best predictor of future violence (7). When caring for a violent patient, whether the patient is restrained or not, the nurse should always remain between the patient and the entry/exit door so that a quick, unencumbered getaway is possible (7). The nurse should be aware of the patient’s escalation of violent behavior: provocative acts, posturing, pacing, angry outbursts, and aggressive actions. The Overt Aggression Scale (OAS) can help nurses measure the patient’s verbal and physical aggression (7).

Implementation of Restraints

After receiving an order to administer restraints, the nurse should share the order information with the other patient-care team members. When restraining a patient, a team of five people should be present, and one of the five people should be a team leader. If the patient is female, one of the team members should be female to decrease the potential for sexual assault allegations. All team members should be trained in de-escalation strategies and restraint use.

If the patient is extremely violent, the nurse should not risk being harmed and should notify hospital security and/or law enforcement for assistance.

Regardless of which type of restraint is used, nurses should execute these steps (1, 6, 7):

1. Attempt to verbally de-escalate and verbally restrain patients before implementing physical restraints.
2. Before implementing restraints, attempt standard treatment of underlying medical or psychiatric conditions.
3. Use an individualized approach to restraining the patient and execute restraint use in a way that attempts to maintain the patient’s privacy and dignity.
4. Use the least restrictive restraint method possible for the patient’s and other’s protection.
5. Ensure the patient is in the supine position before applying restraints. Restraining a patient who is in a prone position can result in death.
6. Avoid placing restraints in a manner that will impede access to the patient, interfere with patient evaluation, or harm the patient or nurse.
7. Avoid placing restraints around the neck or in a manner that restricts the patient’s airway.
8. Place restraints in a manner that leads to immediate removal, if necessary.
9. If a patient who is physically restrained continues to be aggressive and combative, consider implementing chemical restraint measures to prevent the risk of cardiac arrest. Chemical restraints include benzodiazepines and antipsychotics.
10. Handcuffs and zip ties should only be placed by law enforcement personnel, if warranted.
11. If transporting a restrained patient, notify the receiving unit or facility about the situation that precipitated using restraints.
12. Adhere to accreditation standards, laws, regulations, and facility protocols regarding restraint use.

Additional components the nurse should consider when using restraints are (9):

• The patient’s chair or bed should be locked and set at the lowest possible height.
• To prevent neurovascular injuries, the patient should be positioned in proper body alignment.
• The restraint should be the correct size and fit the patient appropriately.
• Only two limbs should be restrained at a time; all four limbs should never be restrained simultaneously.
• Pads should be used to protect bony prominences and prevent tissue injury.
• Restraints should not be attached to catheters or other tubing.
• Restraints should be loose enough to move freely when the head of the bed is raised and lowered.

After restraint placement, the patient should be monitored every hour and repositioned to prevent pressure ulcers, nerve damage, and rhabdomyolysis. The patient’s range of motion should be assessed, skincare should be provided, and assistance with activities of daily living should be offered (4).

Restraints should not be implemented for longer than four hours for adults (18 years and older), two hours for adolescents and children (9 to 17 years), and one hour for children (less than 9 years) (7). Restraint orders should be renewed every 24 hours after a physician’s evaluation of the patient (4).

Documentation

Ideally, the nurse should have the patient sign a consent form prior to implementing restraints. Still, the reality is that most cases that require restraint use are due to the patient’s aggressive behavior that is not conducive to receiving explanations or signing paperwork (7).

Research indicates that complete documentation related to restraint use occurs in only 64% of cases, highlighting that legal and ethical regulations regarding restraints are lacking in the hospital setting (11). In many cases, documentation of restraint use is incomplete or missing altogether, which leads to a lack of evaluation of the use of restraints.

When implementing restraints for a patient, the nurse must document the situation thoroughly to avoid any legal ramifications. The documentation should include the patient’s diagnosis, precipitating event, type of restraint used, patient’s reaction to the restraint, and length of time the restraint is implemented. The nurse should include detailed anecdotes and patient quotes in the documentation to clearly demonstrate the need for restraint use.

A checklist should be utilized by all nursing staff who have contact with the patient to remind staff to monitor the restraint’s effectiveness, the patient’s skin condition and vital signs, and risk factors for potential adverse events, such as paresthesia (7). The patient’s psychological and emotional state should also be monitored (6).

The nurse must document the length of time the restraint remained in place and its removal (7).

Here is an example of poor nursing documentation when caring for a patient who requires physical restraint:

• 0700: Patient agitated and physically and verbally abusive towards staff. Restraints placed.
• 0800: Patient resting comfortably. Skin is intact and clear.
• 1100: Patient resting comfortably. Skin is intact and clear.

This is not adequate documentation because it does not present the situation in detail, explain why restraints were required, or list the patient’s diagnosis, the type of restraints used, or where they were placed. If the patient is resting comfortably at 0800, then the nurse should consider removing the restraints. If removing the restraints is not advised, the nurse should monitor and document the restraint use every hour. Instead, the nurse did not assess the patient between 0800 and 1100, which is too long of a gap in care.

Here is an example of adequate nursing documentation when caring for a patient who requires physical restraint:

• 0700: A patient with a diagnosis of COPD experienced extreme agitation when O2 saturation levels dropped to 85% on room air. The patient received 3L O2 but removed the nasal cannula, causing desaturation. The patient hit and kicked at the nursing staff when the staff attempted to replace the O2 nasal cannula on the patient. The patient thrashed about in the bed and started shouting, “Get away from me! You’re all trying to kill me!” The nurse attempted to reorient the patient using therapeutic communication without success. Educated patient on safety and explained that restraints would be implemented for patient’s and staff’s safety if aggressive behavior did not de-escalate. The patient continued to hit, kick, and scream at the staff. I informed the provider of the situation and received an order to place restraints. Attempted to obtain consent for restraints from the patient, but due to patient’s aggressive nature, was unable to do so. Due to the immediate risk of injury, soft cloth wrist restraints were applied to the patient’s right and left wrists as ordered and secured to the bed frame. A nasal cannula was placed on the patient, and O2 saturation returned to 96% on 3L O2. Skin assessment reveals clear and intact skin and capillary refill at 1+ bilateral during restraint placement.
• 0800: Restraints x 2 intact for the past hour. Skin clear, intact. cap refill 1+ bilat. O2 sat 97% on 3L O2. The patient is resting calmly. Restraints removed. The patient remained calm during and after restraint removal.
• 0900: Patient is eating breakfast while quietly watching television.

In this scenario, the nurse detailed the event leading to restraint placement, the patient’s response to the intervention, and ongoing patient monitoring. The nurse also determined to remove the restraints once the patient exhibited calmness, since restraints should not remain in place longer than necessary (7).

Legal Considerations

Prior to implementing restraints, the nurse should attempt to obtain consent from the patient or a family member. Then, the nurse should explain to the patient and family the rationale for the restraint’s use, the type of restraint being used, and the length of time the restraint will be used (2).

In situations where the patient poses a significant danger to self or others, involuntary restraint is acceptable. However, the least restrictive restraint should be used and removed as soon as it is no longer required (2). The nurse should regularly assess the patient’s need for ongoing restraint and document it appropriately in the patient’s medical record (2).

The American Nurses Association (ANA) has a position statement regarding ethical restraint use for nurses, and the key language is:

Nurses promote and advocate for the protection of patients from harm and from the potential for harm that could result from the use of physical restraints. While patients may be restrained to prevent them from harming themselves or others, this practice could result in patient harm. Previous ANA position statements have addressed the role of nurses in reducing or eliminating patient restraint practices.

Therefore, nurses have an important role in creating a safe environment for patients, loved ones, health care professionals, all members of the care team, and themselves. Knowledge and awareness of situations where the use of restraints is appropriate and indicated are necessary for nurses to create such an environment (3).

Strategies that can help reduce the need for restraints in the med-surg setting include (4, 9):

• Exercise programs
• New hospital beds or bed modifications
• Increase staff awareness of individual patient needs
• Use of assistive devices: hearing, visual, mobility aids
• Improved comfort in bed with extra pillows, cushions, wedges, and pads
• The physical environment is designed so that staff may closely observe patients
• Fall prevention programs: improving lighting, eliminating fall hazards, and using alarms
• Effective patient pain management

Lowering bed height and implementing trapezes, transfer poles, bed handles, assist bars, and patient lifts reduce bed-related falls (4).

Nurse leaders can help resolve adverse outcomes surrounding restraint use by (8):

• Hiring staff members with previous mental health experience
• Educating staff about patient signs that can indicate escalating aggressive behavior
• Educating patient-facing staff, including security personnel, on steps to take to build therapeutic rapport with patients
• Implementing post-restraint use of staff debriefings to explore the effectiveness the restraints have on patients
• Stocking units with items that can help de-escalate patients, such as drinks and snacks, music, books and magazines, personal journals, stress balls, coloring books, and play dough
• Ensuring that units are staffed sufficiently to manage necessary preventative care
• Training staff to safely implement, monitor, and discontinue restraint use

Staff nurses and nurse leaders should work together to improve clinical workflows, focusing on patient comfort and safety to decrease the need for restraints and, thus, potential complications relating to restraint use.

Research Findings

Government agencies and professional organizations have been advocating for the abolishment of physical restraints in the hospital setting, especially since many organizations utilize video-sitters, sedation for patients on ventilators, behavioral response teams, and enhanced understanding and management of substance withdrawal symptoms (5).

Patients who are physically restrained during their hospitalization have increased length of stay and mortality rates compared to patients who do not (5). Total hospital charges are higher for those patients who require physical restraint, and the odds of being discharged home following hospitalization are lower in patients who require restraints (5).

Physical restraint use is more prevalent in hospitals in the western United States versus other areas of the country due to the inconsistent adoption of evidence-based practices at large healthcare systems in the West (5).

PTSD has been reported in 25% to 47% of patients following restraint interventions (7). In the case of patient falls, restraint use can lead to delirium, reinforcing current research that finds restraint use is not effective in preventing patient falls (11). Research indicates that nurses consider alternatives to restraints (such as fall prevention strategies) in only 37% of cases, even though it is a legal and ethical requirement that nurses consider all other options before using restraints (11).

Case Study

B.B. is a 78-year-old female who is hospitalized in the med-surg unit of a major metropolitan hospital system for acute renal failure management. During morning rounds, the nurse assigned to B.B. approaches the bed to assess the patient’s catheter and drainage bag. B.B. becomes agitated and starts shouting at the nurse. The nurse attempts to calm the patient by smiling, speaking soothingly, and reminding B.B. they are the nurse assigned to her. B.B. raises up on her elbows and starts screaming, “I don’t know you! Who are you? Get out of my room!”

The nurse continues to speak with B.B. calmly but does not move closer to the patient. Suddenly, B.B. throws her cell phone at the nurse, who narrowly misses making contact with the nurse’s head.

The nurse leaves the room and assembles a team of three certified nursing assistants (CNAs) and an additional female nurse. The nurse explained the situation to the team, and they implemented a strategy for approaching and potentially restraining B.B.

As the team enters the room, the nurse explains to B.B. the need to assess the catheter and drainage bag. Again, B.B. starts screaming at the nurse and hurls a banana from her breakfast tray at the nurse. As the nurse attempts to de-escalate the situation by explaining that no one will hurt her, the other four team members slowly start to circle the bed. Two team members are now on the far side of the bed and surreptitiously grab B.B.’s right arm and leg while the other two team members who are closest to the door grab B.B.’s left arm and leg.

The nurse quickly administers a soft cloth wrist restraint to B.B.’s left arm and ties it to the bed frame. He then races to the far side of the bed administers the second restraint to B.B.’s right wrist, and fastens it to the bed frame. The team raises both non-segmented side rails and steps away from the bed as B.B. kicks her legs and continues to scream. After several seconds, B.B. becomes fatigued and stops thrashing and screaming.

Once she is calm, the nurse approaches the bed and states, “I’m sorry, B.B., but we’ve had to restrain you for our safety and yours. We understand that you are upset about being hospitalized, but we are trying to help you get better. Once you are calm and safe, we will remove the restraints. However, if you become combative again, we will replace them. Do you understand the situation and what I’m saying to you? Can you please describe to me what I’ve just explained to you?”

B.B. nods her head sheepishly and states, “I’m sorry. I really am. You’ve tied me up because I threw things at you. I get so confused and miss my home and cat so much.”

The nurse tells B.B. that he’s going to check her over and that if B.B. allows that, the team will then leave her to rest. B.B. nods her assent.

The nurse checks the restraints and ensures they are not too tight around B.B.’s wrists. He checks B.B.’s radial pulses, capillary refill, and range of motion in B.B.’s wrists and fingers. The nurse ensures that the restraints are tied with a slipknot and that the head of the bed can be lowered and raised easily. The nurse also places the call light and tray table within B.B.’s reach. Once the nurse is satisfied that B.B. is safe and comfortable, the team leaves the room. The team debriefs, during which they develop a plan for monitoring B.B.

Thirty minutes later, the nurse and one of the CNAs checked on B.B. and found her resting comfortably. The nurse asks B.B. if she will remain calm and permit future care if the nurse removes the restraints. B.B. assents. The nurse removed the restraints, but B.B. remained docile.

The nurse documents the situation in B.B.’s medical record and explains the episode to B.B.’s daughter when she visits that afternoon.

Conclusion

Even though physical restraint use is necessary to protect patients and nurses from harm, the use of restraints is associated with patient injury and even death, as well as increased healthcare costs. Nurses must educate themselves on the ethical and legal ramifications of physical restraints, including implementing proper documentation.

If restraints must be used, it is the nurse’s responsibility to ensure that the least restrictive restraint is utilized for a minimum amount of time and that the patient’s comfort and safety are maintained while the restraints are in place.