What alternatives to restraints are to be tried before applying restraints?

According to a systematic review published by the National Institutes of Health, over 90% of emergency department staff consider using alternatives to restraints before application. Prioritizing less restrictive measures is a fundamental principle of modern healthcare and human services. Before applying restraints, it is crucial to understand what alternatives to restraints are to be tried to ensure patient and staff safety while upholding dignity and respecting individual autonomy.

Quick Summary

This article outlines a tiered approach to preventing the need for restraints, beginning with person-centered strategies like verbal de-escalation and addressing underlying needs. It details how environmental modifications can create a safer atmosphere and compares different alternatives. The piece also covers behavioral interventions, sensory modulation, and the role of ongoing assessment in minimizing restraint use.

Key Points

• Verbal De-escalation: Start with calm, empathetic communication, respecting personal space, and offering choices to help an agitated individual regain control.

• Address Underlying Needs: Check for basic physiological needs like pain, thirst, hunger, or toileting, which are common drivers of agitation.

• Modify the Environment: Reduce sensory overload by lowering noise and light, creating a predictable and safe space, and removing potential hazards.

• Utilize Diversional Activities: Provide engaging distractions like music, games, or tactile objects to redirect an individual's focus away from agitation.

• Consider Sensory Modulation: Use techniques like weighted blankets, soothing textures, or pleasant scents to help a person self-regulate and find calm.

• Provide Consistent Presence: Use dedicated staff companionship and supervision to reassure and closely monitor individuals prone to agitation.

• Implement Behavioral Plans: Conduct thorough assessments to identify triggers and develop individualized, non-coercive strategies for managing challenging behaviors.

• Ensure Staff Training: All personnel should be trained in verbal de-escalation, crisis prevention, and trauma-informed care to effectively implement restraint alternatives.

A Tiered Approach to Alternatives: Prioritizing Least Restrictive Measures

Restraint should always be considered a last resort, used only when an individual presents an imminent and serious danger to themselves or others and other less restrictive interventions have failed. A structured, tiered approach ensures that alternatives are systematically attempted first. This process begins with understanding the root cause of agitation, such as pain, confusion, or unmet needs, rather than focusing solely on the behavior.

Tier 1: Person-Centered and Verbal Strategies

The first line of defense involves non-invasive, communicative techniques aimed at de-escalating the situation and building a therapeutic rapport. These strategies are often most effective when implemented early.

• Verbal De-escalation: Use a calm, reassuring, and non-confrontational tone. Respect the individual's personal space and avoid provocative body language. Offer choices rather than demands and set clear, simple limits in a non-threatening manner. Active listening is crucial for identifying underlying emotions and needs.
• Meet Basic Needs: Many behaviors that lead to restraint are rooted in unmet physiological or psychological needs. Addressing thirst, hunger, toileting, or pain can often resolve agitation. Providing opportunities for socialization and meaningful activities is also beneficial.
• Therapeutic Presence: Simply having a staff member or trained companion sit with the individual and offer a calming, consistent presence can be highly effective. This dedicated supervision can provide reassurance and allow for rapid intervention if the person becomes agitated.

Tier 2: Environmental and Behavioral Adjustments

When verbal interventions are insufficient, modifications to the immediate surroundings and daily routines can help calm an individual and prevent escalation.

• Environmental Modification: Reduce noise, bright lights, and excessive stimuli. Create a safe, comfortable, and predictable environment. For an individual who wanders, a safe, enclosed area can be designated, or a wanderguard system can be utilized. For fall risks, using bed alarms or placing the bed in its lowest position can be effective.
• Diversional Activities: Engage the person with meaningful activities to distract them from their source of agitation. Examples include listening to favorite music, watching a movie, or engaging in simple crafts. Sensory aids like weighted blankets or stress toys can also provide a calming distraction.
• Consistency and Routine: Minimize changes to daily routines, as predictability can reduce anxiety and confusion, especially for individuals with cognitive impairments. Having consistent staff members can also help build trust and rapport.

Tier 3: Advanced Behavioral and Medical Interventions

If the situation continues to escalate, these interventions require careful assessment and planning by a multi-disciplinary team.

• Behavioral Assessment and Planning: For individuals with chronic behavioral issues, a detailed behavioral assessment can identify triggers and help develop individualized crisis prevention plans. Family and patient input is invaluable for identifying historical coping mechanisms.
• Sensory Modulation: Use a variety of sensory inputs to help the individual regulate their emotional state. This can include multisensory rooms (snoezelen rooms), tactile objects, or specific scents. These techniques can help ground and soothe a person experiencing high distress.
• Medication Review: In some cases, agitation can be a side effect of medication or an underlying medical condition. A medical review can help identify if a change in medication or treatment could reduce the need for restraints. Pharmacological options for agitation are also available and should be carefully considered by qualified personnel, typically after other methods have failed.

Comparison of Restraint Alternatives

The choice of intervention depends on the specific situation, the individual's needs, and the care setting. Here is a comparison of different alternatives:

Alternative	Best For	Considerations	Potential Downsides
Verbal De-escalation	Addressing anger, frustration, or confusion	Requires trained and calm staff; builds trust	Not effective for severe or immediate threats
Environmental Modification	Preventing falls, wandering, or overstimulation	Must be tailored to individual needs; ongoing assessment required	Can sometimes feel restrictive if not implemented thoughtfully
Diversional Activities	Distraction from agitation, boredom, or repetitive behaviors	Needs familiarity with the individual's interests; staff availability	May not be effective for high-level agitation or aggression
Bed/Chair Alarms	Notifying staff of attempted movement; fall prevention	High risk of alarm fatigue and can be disruptive to the environment	Only an alert system, not a preventative measure
Sensory Modulation	Calming individuals with sensory sensitivities or high anxiety	Requires specialized equipment and training; understanding individual triggers	Not a rapid-response solution; may not work for all individuals
Dedicated Staff Presence	Individuals with high anxiety, confusion, or agitation	Requires adequate staffing levels; can be resource-intensive	Staff burnout is a risk if not managed properly

The Critical Role of Staff Training and Assessment

Effective implementation of restraint alternatives is heavily dependent on staff skill and institutional policy. Training in crisis prevention, de-escalation, and trauma-informed care is essential for all personnel. Furthermore, frequent and documented assessment of the individual’s behavior and the effectiveness of interventions is critical for preventing restraint use. This continuous process helps identify triggers, refine strategies, and ensure the least restrictive environment possible.

Conclusion: Fostering a Culture of Prevention

Moving away from restraint as a standard response requires a shift in mindset and a commitment to humanistic, person-centered care. By prioritizing verbal de-escalation, addressing underlying needs, and using environmental and behavioral adjustments, staff can often prevent situations from escalating to the point where restraints are deemed necessary. When alternatives are thoughtfully and consistently applied, safety can be maintained while preserving the dignity and trust of the individual in care. Restraints, though sometimes unavoidable in emergency situations, should always be a last resort, following a thorough and documented effort to use less restrictive methods.

Frequently Asked Questions

What is the very first step to take when a person becomes agitated?

The very first step is to use verbal de-escalation techniques. This involves approaching the person calmly, respecting their personal space, and speaking in a reassuring, non-confrontational tone to identify their underlying needs or feelings.

How can the environment help prevent the need for restraints?

Modifying the environment by reducing noise, dimming bright lights, and maintaining a consistent, predictable routine can significantly reduce anxiety and agitation. Placing beds in low positions or using bed alarms for fall risks are also effective environmental strategies.

Are there non-invasive devices that can replace physical restraints?

Yes, several non-invasive devices can serve as alternatives. These include bed or chair alarms to alert staff of movement, specialized positioning cushions for comfort and safety, and hand mitts that prevent picking at medical equipment without fully immobilizing the hands.

What role does knowing the individual play in preventing restraints?

A thorough understanding of an individual's history, triggers, and preferences is crucial. Involving family members or representatives can provide valuable insights into what helps calm the person and can inform a personalized crisis plan.

What is sensory modulation and how does it prevent the need for restraints?

Sensory modulation is the use of sensory input to help an individual regulate their emotional state. Techniques like providing weighted blankets, stress toys, or soothing music can help calm agitation by providing a therapeutic and grounding distraction.

What if basic needs are the cause of agitation?

If basic needs are the root cause, address them directly. Offer the person food, a drink, or assistance with toileting. Pain management, repositioning, and ensuring a comfortable room temperature can also resolve agitation effectively.

When is it appropriate to consider medication for agitation?

A medication review should be considered as part of the multidisciplinary team's assessment, but only after less restrictive, non-pharmacological methods have been exhausted. Pharmacological interventions should be carefully tailored and administered under strict medical supervision.