The Absolute Last Resort: When Restraints Are Necessary
Restraints are never a first-line intervention and should only be considered when all less-restrictive alternatives have been exhausted. The decision to use a restraint is a grave one, made in emergencies to prevent immediate and serious harm. A nursing assistant (NA) does not make this decision alone but follows strict orders from a physician and facility protocol.
Protecting the Patient from Self-Harm
One of the most common reasons for a restraint is to prevent a patient from harming themselves. This is particularly relevant for those with cognitive impairments or altered mental states. A confused or disoriented patient might attempt to pull out life-saving medical devices, such as intravenous (IV) lines, catheters, or feeding tubes. In such a situation, a provider may order a restraint to protect the patient's immediate health and safety.
Preventing Harm to Others
In rare cases, a patient's behavior may become violent or aggressive, posing a threat to staff, other patients, or visitors. If de-escalation techniques fail and the patient presents a clear and present danger, a physician-ordered restraint may be necessary to ensure the safety of everyone in the vicinity. This is a critical safety measure, not a punitive one.
The Legal and Ethical Framework
Federal regulations, such as those governed by the Omnibus Budget Reconciliation Act (OBRA) of 1987, provide a clear legal framework. Restraints cannot be used for staff convenience, punishment, or discipline. Before a restraint is even considered, less invasive interventions must be attempted and documented. The use of a restraint must be explicitly ordered by a physician for a specific, limited duration, and the NA must be trained in its proper application.
Exhausting Alternatives Before Restraint
Prior to applying a restraint, NAs and the care team must diligently attempt and document various alternatives. These proactive strategies help maintain patient dignity and autonomy.
Some effective alternatives include:
- Relocation or redirection: Moving the patient to a calmer, quieter environment or engaging them in a different activity to redirect their focus.
- Bed or chair alarms: These devices alert staff when a patient attempts to get up, allowing for immediate intervention without restricting movement.
- Increased supervision: Providing one-on-one observation or repositioning the patient closer to the nurses' station for closer monitoring.
- Addressing underlying causes: Sometimes, agitation is caused by pain, hunger, thirst, or the need to use the restroom. The NA should assess and address these needs first.
- Family presence: Encouraging family members to be present can provide reassurance and reduce anxiety.
Types of Restraints and Safe Application
Physical restraints come in various forms, and their use is governed by strict protocols. The NA must use the least restrictive restraint possible for the shortest duration necessary. Common types include soft wrist or ankle ties, hand mitts, and vests. Proper training is essential to prevent injury. A two-finger rule (being able to fit two fingers under the restraint) is often used to ensure proper circulation. The restraint must always be tied to a stable part of the bed or chair frame using a quick-release knot, never the side rail.
A Comparison of Approaches: Alternatives vs. Restraints
| Aspect | Restraint Alternatives | Restraints (as last resort) |
|---|---|---|
| Goal | Prevent agitation, manage behavior, protect autonomy | Ensure immediate safety in an emergency |
| Approach | Proactive, patient-centered, environmental modification | Reactive, medically-ordered, temporary restriction |
| Patient Autonomy | Preserved and promoted | Restricted |
| Associated Risks | Minimal, if any | Physical harm (e.g., skin tears, circulation issues), psychological trauma, functional decline |
| Required Order | Often based on care plan and nursing assessment | Explicit physician's order for a specific duration |
| Monitoring | Routine checks based on care needs | Continuous, frequent monitoring (e.g., every 15 minutes to 2 hours) |
The Importance of Meticulous Documentation
When a restraint is used, exhaustive documentation is required. The NA plays a vital role in this process, providing a detailed record for the medical team. This includes:
- The specific patient behaviors or events that necessitated the restraint.
- All less-restrictive alternatives that were attempted and the patient's response.
- The type of restraint used and the time of application.
- The physician's order, including the start time and duration.
- Regular assessments of the patient's condition, including mental status, skin integrity, circulation, vital signs, and range of motion.
- Care provided while restrained, such as offering fluids, toileting, and repositioning.
- The time of removal and the patient's subsequent behavior.
Continuous Monitoring and Reassessment
Restraints are not set and forgotten. The NA is responsible for constant observation and frequent checks of the restrained patient. This monitoring ensures the patient's physical and emotional well-being is not compromised. A patient's status must be reassessed regularly to determine if the restraint is still necessary. As soon as the patient is no longer a danger, the restraint must be removed. The ultimate goal is always to reduce and eliminate restraint use whenever possible, focusing on a restraint-free environment as the standard of care.
Conclusion
In summary, a nursing assistant should only use a restraint in very limited and exceptional circumstances, following a physician's order and institutional policy. The primary justification is to prevent immediate, serious harm to the patient or others, and only after all less-restrictive measures have failed. The entire process—from considering alternatives to application, monitoring, and removal—must be meticulously documented. This ensures patient dignity, safety, and compliance with ethical and legal standards in senior care. For more information on patient safety and the responsible use of restraints, NAs should consult reputable training resources like the American Nurse Journal.
