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Moving toward a restraint-free environment


Moving toward a restraint-free environment

A behavioral health nurse provides guidance on how to eliminate the need for physical restraints in acute-care behavioral health facilities

Sherry, age 17, is admitted to a behavioral health residential facility by her adoptive parents. She has mild mental retardation and attention deficit hyperactivity disorder. Recently, she reported having flashbacks of a house fire that her biological mother set intentionally, which led to the deaths of three of Sherry’s siblings. Memories of other physical and sexual abuse inflicted by her biological mother and her mother’s boyfriends have led to a diagnosis of posttraumatic stress disorder, manifesting in outbursts of physical aggression.

On the residential unit, Sherry frequently fails to adhere with her treatment plan—rejecting her medications, yelling and screaming, kicking staff members and furniture, running up and down the hallways, and refusing to do her daily goal work. As a result, she has been physically restrained more than 100 times. Her adoptive mother, a psychiatric nurse, wonders if these restraint episodes have impeded Sherry’s treatment and if they could have been avoided.

A restraint is a physical or mechanical device used to limit a person’s movement, physical activity, or normal access to the body for the purpose of protecting the patient or others from injury. At most healthcare facilities, physical restraints involve the use of Velcro® locked devices for the wrists and ankles and a locked waistband secured to bed frame slats. A chest restraint may be added if the patient is extremely out of control.

Use of physical restraints has led to serious patient injuries and even deaths. The Joint Commission stipulates that restraints can be applied only when adequate clinical justification exists and all other interventions have failed. Commonly, a facility’s restraint policy states that restraints should be used only as a last resort when all other less restrictive measures have been exhausted and the safety of the patient or other persons on the unit is in jeopardy.

But it’s not always easy to determine when all other measures have been exhausted. In most cases, it’s a judgment call based on the healthcare providers’ perception of the situation. In fact, most patient incidents can be averted without using restraints. Because of physical and psychological trauma reported by patients, many acute-care behavioral health units have begun to institute a restraint-free environment.

Factors that increase restraint use

The decision to use physical restraints is multifaceted. With shorter patient stays and increased inpatient acuity due to stricter insurance reimbursement guidelines, behavioral health facility staff may be more likely to resort to restraints. Nursing shortages have led to higher patient-to-staff ratios, creating an environment where the main goal is to keep the unit calm. Patients who disrupt the milieu are at risk for being restrained.

Also, high staff turnover in some facilities can cause difficulty retaining personnel trained in deescalating aggressive patients. Unskilled staff members may be quick to use physical restraints to try to keep themselves and others on the unit safe.

Risks of restraints

Restraints pose many physical risks. An investigative report conducted by the Hartford Courant, a Connecticut newspaper, estimated that 50 to 150 deaths occur annually across the nation due to patient restraints or seclusion. Most of these deaths stem from asphyxiation or thrombosis. Other less serious injuries also are common. Abrasions and bruising may occur as patients struggle to remove restraints. I have witnessed staff injuries resulting from aggressive, frightened patients struggling while being placed in restraints.

In interviews, some patients who’ve been restrained reported that the episodes caused psychological and emotional trauma, including triggering memories of sexual abuse and childhood trauma. Many expressed feelings of helplessness, loss of integrity, fear, and increased anxiety. None described being restrained as a positive experience. Several believed they’d been restrained because staff were trying to demonstrate their power, and that the experience damaged the provider-patient alliance. Most patients who’d been restrained said that if staff had communicated openly with and listened actively to them, their behaviors wouldn’t have escalated to the point where staff thought restraints were needed.

Creating a restraint-free environment

A restraint-free environment epitomizes the concept of patient-centered care. To create this environment, the facility must develop a new organizational culture that is supported at all hierarchical levels. For the impetus to continue, staff must be rewarded for successful efforts.

Here are some basic guidelines for creating a restraint-free environment.

Identify violence-prone patients

Staff members should be capable of identifying violence-prone patients—for instance, by reviewing medical records to gain insight into previous restraint episodes. On admission, the patient should undergo a thorough psychiatric and medical evaluation to give staff a comprehensive picture of patient-specific behaviors, triggers for problem behaviors, and early warning signs of increased stress or aggression. The healthcare team should incorporate these factors into the patient’s treatment plan.

In addition, personnel need to be trained to recognize early warning signs of aggressive behavior. Typically, patients display the following aggressive behaviors (listed in ascending order of seriousness) before becoming physically violent:

  • exhibiting low-grade hostility
  • displaying loud and demanding behaviors
  • approaching individuals in a threatening way
  • verbalizing threats without a plan to inflict harm
  • touching another person in a threatening way
  • making a verbal threat with a plan to inflict harm
  • inflicting low-grade harm requiring no medical care
  • inflicting serious harm necessitating medical care.Recognizing these warning signs gives staff time to intervene before physical violence that would warrant restraint use occurs.

    Train staff and patients in de-escalation and crisis intervention techniques.

    Open communication, nonconfrontational body language, and active listening skills strengthen the patient-staff alliance. Staff gain confidence as they acquire new skills, making them less likely to turn to physical restraints to maintain a safe environment. Patients, for their part, require instruction and guidance in recognizing their anger and the external manifestations of aggression. They need to learn how to communicate their feelings in an appropriate way. Staff can help them develop positive coping skills, such as walking, keeping a journal, and getting involved in a hobby.

    All staff members must develop and support a therapeutic environment that promotes patient recovery.


    To create a therapeutic environment, staff should encourage patient input and feedback about their treatment, show respect for patients as individuals, and develop appropriate plans of care tailored to each individual. Management should encourage creative alternatives to restraints, as by distributing restraint-free tool kits. These kits commonly contain safe diversionary items, such as Play-Doh, word-search games, puzzles, and coloring books. Other methods that promote a calm, therapeutic environment include relaxation methods, pet therapy, music therapy, and visual imagery.

    Reinforcing patient-centered care

    The use of physical restraints has been controversial for years. Many behavioral health units have created restraint-free environments with positive results. Rather than taking a reactive approach—using restraints to control patient behavior—these environments foster strong patient-staff alliances through the development of individualized plans of care.

    For Sherry, early recognition of her aggressive behavior triggers and development of an individualized plan of care centering on her mental and emotional needs might have eliminated the need to restrain her in many—perhaps most—instances.

    Colleen Green is a patient care specialist at Lehigh Valley Health Network Behavioral Health Science Center in Bethlehem, Penna.

    Selected references

    Barton SA, Johnson MR, Price LV. Achieving restraint-free on an inpatient behavioral health unit. Journal Of Psychosocial Nursing. J Psychosoc Nurs Ment Health Serv. 2009;47(1):34-40. Accessed July 18, 2010.

    Curran SS. Staff resistance to restraint reduction: identifying and
    overcoming barriers. J Psychosoc Nurs Ment Health Serv. 2007;45(5):45. Accessed July 18, 2010.

    Luiselli JK. Physical restraint of people with intellectual disability: a review of umplementation reduction and elimination procedures. JARID. 2009;22(2):126-134. Accessed July 18, 2010.

    McCue RE, Urcuyo L, Lilu Y, Tobias T, Chambers MJ. Reducing restraint use in a public psychiatric inpatient service. J Behav Health Serv Res. 2004;31(2):217-224.

    Rutledge D, Pravikoff D. Use of restraints. Part 2. Restraints and seclusion in psychiatric institutions. OJCI. 2003;6(3):1-56.

    Wynn R. Psychiatric inpatients’ experiences with restraint. J Forens Psychiatry Psychol. 2004;15(1):124-144.

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