Skill 4-3

Implementing Alternatives to the Use of Restraints

Restraint-free care is the standard of practice and an indicator of quality care in all health care settings (American Nurses Association, 2012; Touhy & Jett, 2018, p. 210). Physical restraints do not prevent falls, and they increase the possibility of serious injury due to a fall (Taylor et al., 2023). Additional negative outcomes of restraint use include skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration, and respiratory difficulties, and even death (Taylor et al., 2023). Federal guidelines reinforce that in all settings, the primary responsibility is to protect and promote patient's rights and that restraints may only be used to protect the patient, staff, or others (Taylor et al., 2023). Federal and state mandates as well as the Joint Commission recommend that acute care facilities use restraints only as a last resort (CMS, 2020a; Taylor et al., 2023). The current standard for long-term care facilities is to provide safe care without the use of physical or chemical restraints (Taylor et al., 2023).

Careful nursing assessment is the key to identifying appropriate alternatives to restraint use and finding an individualized solution (Taylor et al., 2023). The American Nurses Association (ANA, 2012) has approved a position statement defining the nurses' role in reducing restraint use in health care. Their recommendations are included in Box 4-2. Restraints should be used only after less restrictive methods have failed. The following skill outlines possible alternatives to restraint use.

Delegation Considerations

After assessment by the RN, activities related to the use of alternatives to restraints may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

PPE, as indicated
Additional intervention tools, as appropriate (refer to sample intervention equipment in this skill)

Assessment

Assess the patient's status. Determine whether the patient's pattern of behavior (wandering, fall risk, interfering with medical devices, resistive to care, danger to self or others) increases the potential need for restraint use. Assess to determine the meaning of the behavior and its cause. Assess for pain. Assess respiratory status, vital signs, blood glucose level, fluid and electrolyte issues, and medications. Assess the patient's functional, mental, and psychological status. Evaluate the patient's environment, including noise level, lighting, floor surfaces, design/suitability of equipment and furniture, visual cues, barriers to mobility, space for privacy, and clothing. Assess and evaluate the effectiveness of restraint alternatives.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Acute confusion
Injury risk

Outcome Identification and Planning

The expected outcome to achieve when implementing alternatives to restraints is that the use of restraints is avoided, and the patient and others remain free from injury.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Explain the rationale for interventions to the patient and family/caregivers.	Explanation helps reduce anxiety and promotes engagement and understanding.
4. Include the patient's family and/or caregivers in the plan of care.	Promotes person-centered, individualized care and engagement, continuity of care and understanding.
5. Identify behavior(s) that place the patient at risk for restraint use. Assess the patient's status and environment, as outlined above.	Behaviors, such as interference with therapy or treatment, risk for falls, agitation/restlessness, resistance to care, wandering, and/or cognitive impairment, put the patient at risk for restraint use. Assessment and interpretation of patient behavior identifies unmet physiologic or psychosocial needs, acute changes in mental or physical status, provides for appropriate environments and individualized care, and respects patient's needs and rights.
6. Identify triggers or contributing factors to patient behaviors: Assess respiratory status, vital signs, blood glucose level, fluid, and electrolyte issues (Taylor et al., 2023). Evaluate medication usage for medications that can contribute to cognitive and movement dysfunction and to increased risk for falls (Taylor et al., 2023).	Changes in physiologic status and prescribed medications can be triggers and/or contributing factors. Removal of underlying issues triggering or contributing to patient behaviors can decrease or eliminate the need for restraint use.
7. Assess the patient's functional, mental, and psychological status and the environment, as outlined above.	Assessment provides a better understanding of the reason for the behavior, leading to individualized interventions that can eliminate restraint use and provide for patient safety.
8. Provide adequate lighting. Use a night light during sleeping hours.	Appropriate lighting can reduce disruptive behavior related to fear in an unfamiliar environment.
9. Consult with the health care team regarding the continued need for treatments/therapies and the use of the least invasive method to deliver care.	Exploring the possibility of administering treatment in a less intrusive manner or discontinuing treatment no longer needed can remove the stimulus for behavior that increases risk for the use of restraints.
10. Assess the patient for pain and discomfort. Provide appropriate pharmacologic and nonpharmacologic interventions. (Refer to Chapter 10.)	Unrelieved pain can contribute to behaviors that increase the risk for the use of restraints.
11. Ask a family member or caregiver to stay with the patient.	Having someone stay with the patient provides companionship and familiarity.
12. Reduce unnecessary environmental stimulation and noise.	Increased stimulation can contribute to behaviors that increase the risk for the use of restraints.
13. Provide simple, clear, and direct explanations for treatments and care. Repeat to reinforce, as needed.	Explanation helps reduce anxiety and promotes engagement and understanding.
14. Distract and redirect using a calm voice.	Distraction and redirection can reduce or remove behaviors that increase risk for the use of restraints.
15. Increase the frequency of patient observation and surveillance; utilize 1- or 2-hour patient care rounds/intentional rounding (hourly/nursing rounds), including pain assessment, toileting assistance, patient comfort, keeping personal items in reach, and meeting patient needs.	Patient care rounds/intentional rounding (hourly/nursing rounds) improve identification of unmet needs, which can decrease behaviors that increase risk for the use of restraints.
16. Implement fall-precaution interventions. Refer to Skill 4-2.	Behaviors that increase risk for the use of restraints also increase the risk for falls.
17. Camouflage tube and other treatment sites with clothing, elastic sleeves, or bandaging.	Camouflaging tubes and other treatment sites removes stimulus that can trigger behaviors that increase risk for the use of restraints. Assess sites regularly for complications (Taylor et al., 2023).
18. Investigate possibility of discontinuing bothersome treatment devices (e.g., IV line, catheter).	Remove invasive devices as early as possible (Lawson et al., 2020). Removes stimulus that can trigger behaviors that increase risk for the use of restraints.
19. Ensure the use of glasses and hearing aids, if necessary.	Glasses and hearing aids allow for correct interpretation of the environment and activities to reduce confusion.
20. Consider relocation to a room close to the nursing station.	Relocation close to the nursing station provides the opportunity for increased frequency of observation.
21. Encourage daily exercise/provide exercise and activities or relaxation techniques.	Activity provides an outlet for energy and stimulation, decreasing behaviors associated with increased risk for the use of restraints.
22. Make the environment as homelike as possible; provide familiar objects.	Familiarity provides reassurance and comfort, decreasing apprehension and reducing behaviors associated with increased risk for the use of restraints.
23. Allow restless patients to walk after ensuring that the environment is safe. Use a large plant or a piece of furniture as a barrier to limit wandering from the designated area.	Activity provides an outlet for energy and stimulation, decreasing behaviors associated with increased risk for the use of restraints.
24. Consider the use of a patient attendant or sitter.	An attendant or sitter provides companionship and supervision.
25. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the use of restraints has been avoided, and the patient and others remained free from injury.

Documentation

Guidelines

Document patient assessment. Include appropriate interventions to reduce the need for restraints in the plan of care. Document patient and family/caregiver teaching relative to the use of interventions. Document interventions included in care.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Interventions to distract no longer effective. Patient continues to pull at IV site and tubing: Reevaluate need for IV fluid infusion. Consult with health care team regarding possibility of converting to intermittent access. Reevaluate patient and environment; attempt additional/different interventions as outlined above.

Special Considerations

An alternative approach for temporary restraint is therapeutic holding (hugging), which makes use of a secure, comfortable, temporary holding position that provides close physical contact with the parent or caregiver for 30 minutes or less (Kyle & Carman, 2021; Perry et al., 2018).
Enclosure beds are a possible option for physical restraints (Kim et al., 2018). Enclosure bed can be used as part of a patient's plan of care to prevent falls and provide a safer environment (Harris, 2015). An enclosure bed is considered a restraint because it limits the patient's ability to get out of bed but is less restrictive than other types of restraints (Harris, 2015).
Use of mechanical restraint in acute psychiatric/behavioral health environments can be reduced through increased frequency of direct registered nurse surveillance and assessment of restrained individuals (every 15 minutes to continue surveillance) (Allen et al., 2020).

EVIDENCE FOR PRACTICE

Minimizing Restraint Use

These resources summarize current best evidence on the topic of interventions to be used as alternatives to the use of restraints, as well as minimizing and eliminating the use of restraints.

American Nurses Association (ANA). (2012). Reduction of patient restraint and seclusion in health care settings. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/reduction-of-patient-restraint-and-seclusion-in-health-care-settings/
American Psychiatric Nurses Association. (2018). Positionstatement on the use of seclusion and restraint. https://www.apna.org/resources/apna-seclusion-restraint-position-paper/
Centers for Medicare & Medicaid Services (CMS). (2020a). Department of Health and Human Services. CMS manual system. Pub. 100-07. Appendix A. Survey protocol, regulations and interpretive guidelines for hospitals. §482.13. Conditions of participation: Patients' rights. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf
Centers for Medicare & Medicaid Services (CMS). (2020b). Department of Health and Human Services. CMS manual system. Pub. 100-07. Appendix PP. Guidance to surveyors for long term care facilities. §482.10. Resident rights. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Cotter, V. T., & Evans, L. K. (2021). Consult Geri. Try this: Series. Avoiding restraints in patients with dementia. Issue #1 of dementia series. The Hartford Institute for Geriatric Nursing. https://hign.org/consultgeri/try-this-series/avoiding-restraints-patients-dementia
Grover Snook, A. (2017, March 31). Physical restraint use. CINAHL Information Systems. https://www.ebscohost.com/assets-sample-content/Physical_Restraint_Use.pdf
Registered Nurses' Association of Ontario (RNAO). (2012). International affairs & best practice guidelines. Promoting safety: Alternative approaches to the use of restraints. https://rnao.ca/bpg/guidelines/promoting-safety-alternative-approaches-use-restraints

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Skill 4-3

EVIDENCE FOR PRACTICE