Seclusion and Restraint:

When All Else Fails

 Course Goals
• After completing this course, you should
be able to:
– Define restraint and seclusion.
– List the risks of restraint and seclusion .
– Recognize best practices and regulatory
standards for the use of restraint and
seclusion.
• A major focus of Project BETA (Best practices in Evaluation and Treatment of
Agitation)1 is noncoercive de-escalation, with the goal being to calm the agitated
patient and gain his or her cooperation in the evaluation and treatment of the
agitation.
• Some healthcare providers may view forced medication, seclusion, and restraint as
the safest and most efficient intervention for the agitated patient but are relatively
unaware that these interventions are associated with an increased incidence of
injury to both patients and staff. These injuries are both physical and psychological.
In addition, the use of drugs for the purpose of restraint results in side effects that
can be problematic. Both physical interventions and drugs for the purpose of
restraint have short-term and long-term detrimental implications for the patient
and the physician- patient relationship. Because of this, regulatory agencies and
advocacy groups are pushing for a reduction in the use of restraint. However, there
are clinical situations for which verbal and behavioral techniques are not effective
and the use of seclusion and/or restraint becomes necessary to prevent harm to
the patient and/or staff. When use of restraint and seclusion is unavoidable, there
are measures that can be taken to mitigate some of the negative consequences
that may result when such actions are taken.
• The Centers for Medicare and Medicaid Services (CMS) has adopted
Conditions of Participation for Hospitals. These same conditions have been
endorsed by The Joint Commission (TJC). In doing so, the following
definitions are used:
– Seclusion is the involuntary confinement of a patient alone in a room or area
from which the patient is physically prevented from leaving. Seclusion may be
used only for the management of violent or self- destructive behavior.
– A restraint is any manual method, physical or mechan-ical device, material, or
equipment that immobilizes or reduces the ability of a patient to move his or
her arms, legs, body, or head freely.
– A drug is considered a restraint when it is used as a restriction to manage the
patient’s behavior or restrict the patient’s freedom of movement and is not a
standard treatment or dosage for the patient’s condition.
– Seclusion and restraint must be discontinued at the earliest possible time.
– Within 1 hour of the seclusion or restraint, a patient must be evaluated face-
to-face by a physician or other licensed independent practitioner or by a
registered nurse or physician assistant who has met specified training
requirements.
• Specified also are the following patient’s rights:
– Seclusion or restraint may be used only when less
restrictive interventions have been determined to be
ineffective to protect the patient, a staff member, or
others from harm.
– All patients have the right to be free from restraint or
seclusion, of any form, imposed as a means of
coercion, discipline, convenience, or retaliation by
staff.
– Restraint or seclusion may only be imposed to ensure
the immediate physical safety of the patient, a staff
member, or others.
• In addition to the requirement to conform to these regulations,
there are medicolegal reasons to avoid seclusion and restraint. A
National Association of State Mental Health Program Directors
document on risk management concludes as follows:
– ‘‘Every episode of restraint or seclusion is harmful to the individual and
humiliating to staff members who understand their job responsibilities.
The nature of these practices is such that every use of these
interventions leaves facilities and staff with significant legal and
financial exposure.
Public scrutiny of restraint and seclusion is increasing and legal
standards are changing, consistent with growing evidence that the use
of these interventions is inherently dangerous, arbitrary, and generally
avoidable. Effective risk management requires a proactive strategy
focused on reducing the use of these interventions in order to avoid
tragedy, media controversy, external mandates, and legal judgments.’’
• Behavioural emergency is an instance of violence or
aggressive behaviour that has yet to be "managed" (i.e, no
intervention has been put in place so the behaviour is still
present.

• Behavioural emergencies are often a manifestation of

unmet health, functional, or psychosocial needs that can
often be reduced, eliminated, or managed by addressing
the conditions that produced them.

• Restraint and seclusion are behavioural management

interventions that should be used as a last resort to control
a behavioural emergency.
Restraint:
A restraint is any manual method, physical or
mechanical device, material, or equipment that
immobilizes or reduces the ability of a patient to
move his or her arms, legs, body, or head freely.
• “Restraint” can have different meanings
and interpretations depending on the
setting.
• In the mental healthcare context,
“restraint” typically refers to the
application of some level of restriction to
physical movement, or state of mental
awareness.
 Indications for Restraint:
q Violent behavior that is dangerous to the patient or
others.
q Agitated behavior that cannot be controlled by
medication.
q Threat to physical integrity.
q Patient’s request for external behavior controls,
provided this is assessed to be therapeutically
indicated.
 Types of Restraints:
• Restraints are divided into three categories:
1) Environmental.
2) Chemical (sometimes referred to as acute
control medication (ACM)).
3) Physical/mechanical.
 1) ENVIRONMENTAL RESTRAINT:
• Environmental restraint can include:
– limiting access beyond the unit (i.e., locked unit);
– limiting access beyond the patient’s room (i.e.,
locked room); and
– placement of the patient in a separate room that
is locked (i.e., seclusion).
2) CHEMICAL RESTRAINTS:
• It is the use of medications such as
neuroleptics, anxiolytics, sedatives,
and psychotropic agents to calm or
sedate the client with socially
disruptive behavior.
• Examples of ACMs include
Lorazepam IM or Haloperidol IM.
3) PHYSICAL RESTRAINTS:
• When a person is physically
restrained, that person is
physically/bodily held by
others (e.g., care staff,
security) to restrict his or her
movement for a brief period of
time, in order to calm the
individual.
• This does not refer to holding
a person in order to apply a
mechanical restraint
 PHYSICAL RESTRAINTS:
§ Human Restrain:
§ it is a manual restrain to limit physical mobility of the patient.
§ BACK HOLD:
§ Done by crossing the client’s arms in front while the staff member is in
the back. From this position the staff member can ease the client
down the floor.
§ WALKING THE CLIENT BACK:
§ By having staff member on each side, support the client’s arms at the
elbow and above the wrist. It can be, walking the client backward in
order to have better control.
 Mechanical Restraint:
A mechanical restraint is a device or an appliance that
restricts or limits freedom of movement.

vSuch devices can include:

o Straitjackets/ vest restraints.
o Wrist cuff restraints.
o Ankle cuff restraints.
Straitjacket
Wrist restraint Ankle restraint
• There is a myth in mental healthcare that restraint and
seclusion are part of care.
• Restraint and seclusion are NOT THERAPEUTIC CARE
procedures.
• Use The least restraint approach first?
– What is it?
– How to use it?
– Alternatives to restraints include de-escalation,
redirection, setting limits, using timeouts, the use of
medication to manage symptoms (not as a control
procedure), psychosocial interventions, and safe physical
escort techniques. When such alternatives are deployed
early enough, the patient may respond positively to these
less restrictive options.
 Applying
Restraints to
Psychiatric
Patients
The Figure shows a recommended algorithm in dealing
with agitated patients..
v Overview of the Skill:
This skill explains how to apply restraints to psychiatric patients and
use them appropriately as a protective device to limit their physical
activity.

Purposes:
ü To safely contain patient who is exhibiting uncontrolled behavior.
ü To prevent patient from injuring self or others
 Assessment:
§ Assess the client’s physical and mental status for
signs suggesting danger to self or others.
§ Consult with staff and family.
§ Ensure that a face-to-face assessment is completed
on the client.
§ Check the chart for a physician’s order for the use of
restraints.
§ Review the agency’s restraints policy or procedure.
§ Assess the client’s skin and circulation.
§ Inspect the restraint that will be used and avoid any
that are in poor condition.
 Diagnosis:
Ø Risk for Injury

Ø Risk for Trauma

Ø Disturbed Sensory Perception

Ø Acute Confusion

Ø Impaired Environmental Interpretation Syndrome

 Planning

• Objectives:
• 1. To identify clients who are at risk for injury.
• 2. To prevent a client from injuring himself(herself) or others.
• 3. To employ all safety measures for the client.
• 4. To obtain physician’s order for restraints if deemed absolutely necessary.
• 5. To apply restraints safely and effectively.

• Expected Outcomes:
o Client is prevented from injuring himself (herself) or others.
o Restraints are applied correctly.
o Restraints are released according to policy.
o Basic needs are met.
o Restraints are discontinued when no longer needed
• Equipments Needed:
– Jacket Restraint
– Ankle Restraint
– Wrist Restraint

• Client Education Needed:

o Discuss the use of restraints. If possible, elicit the support of the
family members.
o Explain to the family the procedure, why it is necessary, and how
they can cooperate.
v Implementation—Action/Rationale:
No. STEPS
1. Explain procedure, purpose, period of
intervention to patient and significant
others.
2. Provide for client privacy if indicated.
3. Put on clothes which is safe to use,
remove any jewellery and eye glasses.
4. Remove all items from area that
patient might use to harm self or staff
member.
5. Check vital signs. Bathe the patient
and provide skin care. Take patient to
bathroom or provide bedpan or urinal.
RATIONALE
This is the right of patient to
information.
Maintain dignity and self-esteem.
( Loss of control and imposition of
physical restraint may be
embarrassing to patient.)
For client’s safety.
To provide a safe environment.
To maintain biological integrity.
(Physically restrained patients are
not able to attend to their own
biological needs and are at risk for
complications related to immobility.)
6. Place the client in a position of comfort Maintains functional position and
with proper body alignment. reduces discomfort.
7. Apply and pad the selected restraint Reduces or prevents injury
according to specific directions. Protect
any bony prominences or fragile skin.
8. Monitor restraints area for temperature To maintain skin integrity.
and color.
9. Release restraints at least every 2 To check for circulation and provide
hours depending on the doctor’s order ROM to all joints.
and institutional policy.
10. Ensure that restraint orders are For documentation.
renewed every 4 hours for behavioral
health clients.
11. Offer foods and fluids in non-
breakable container.
12. Observe patient’s behavior
constantly or very frequently every
15 minutes, depending on the
condition of patient.
13. Do not interrupt the client’s sleep
unless indicated by his/her condition.
To provide adequate nutrition and
rehydration.
To maintain a safe environment.
To provide rest period for the
client.

14. Adjust the plan of care as required.To ensure that the client receives
quality care.
15. Record all assessments and findings For proper documentation.
on appropriate forms.
 Evaluation:
o Perform a detailed follow-up of the need for restraints
and the client’s response.
o Evaluate circulatory status of restrained limbs.
o Evaluate skin status beneath restraints.
o Remove the restraints as soon as they are no longer
needed and document.
o Report significant deviations from normal to the
physician.
 Documentation:

o Assessment findings that indicate a need for restraint.

o Types of restraint applied..
o Condition of skin, circulation, sensation, and joint mobility before
restraint application.
o Communication with physician and responsible family member.
o Frequency of release and assessment.
o Nursing measures used to promote skin integrity and to meet
nutritional and elimination needs.
o Assessment indicating an ongoing need for restraints.
ISOLATION AND SECLUSION

Isolation of a person is usually involuntary

due to illness or some other psychological
disorder.

Seclusion is usually self-imposed

isolation for the purpose of hiding away
or getting away from society or the main-
stream.
SECLUSION

• Solitary contain in a fully protective

environment with close surveillance
by nursing staff for purpose of safety
or behaviour management.
Indications for Seclusion
q Control of violent behavior that is
potentially dangerous to the patient or
others and cannot be controlled by other
less restrictive interventions such as
interpersonal contact or medications.

q Reduction of environmental stimuli,

particularly if requested by the patient.
 Characteristic of Seclusion
• WALL • ROOM
* Should be covered by sponge or cotton. * A closed place, doors and windows are
constructed in a way not to allow the patient to
escape.
• FURNITURE
* Only mattress without linen. * The room must be furnished-simply fixed
furniture.
• LIGHTS
* Heavy in order no to allow for danger of
* The lamp should be out of reach of patient. destructivity.
* The light should be slight.
* Away from other patient’s room.
• WINDOWS
* The windows should be out of reach of
patient.

• DOOR
* Not easily opened
* Has a small unbreakable glass window from
above.
Nursing Interventions related to Seclusion:

• Explain procedure purpose and time period

of the intervention to patient and significant
other in understandable terms.
• Assist in putting clothes which are safe and
remove eye glasses and jewelleries.
• Remove all items from seclusion area that the
patient might use to harm self or nursing
staff.
• Assist the needs related to nutrition,
elimination, hydration and personal hygiene.
• Provide foods and fluids in non-breakable
containers.
• Provide appropriate level of supervision
surveillance to monitor patient and to allow
for therapeutic action.
• Administer PRN medication for anxiety or
agitation.
• Monitor seclusion area for temperature,
cleanliness, and safety.
• Arrange for routine cleaning of seclusion
area.
Guidelines for the Use of
Seclusion
and
Restraints
 Clinical Indications & Contraindications

• To safely contain a client who is exhibiting out-

of-control behavior.

• To prevent a client from injuring self or others.

• To prevent serious disruption of the therapeutic

environment or the likelihood of significant
property damage.
Seclusion & Restraint may never be used in the
following circumstances:

• As punishment
• For the convenience of staff
• As a substitute for individualized treatment
Protocols:
• An as-needed order is never permitted.
• A physician or RN authorized by the physician
may make the decision to initiate seclusion
and/or restraint based on the client’s current
behavior. The physician must be notified as soon
as possible but not later than 1 hour after
restrictions are initiated.
• Each order to restrain or seclude must include an
expiration time, and under no circumstance can
the time be greater than 24 hours. A physician
must make a clinical assessment of the client and
sign the order within 24 hours.
• The client must be treated in a manner that
demonstrates respect, maximizes comfort,
minimizes pain, and precludes harm.
 Assessment & Documentation

• Clients in seclusion and/or restraints must be

assessed at regular intervals, usually every 15
minutes, and their behaviour documented.

• Clients in restraints must have circulation of the

limbs checked every 15 minutes.

• Documentation must occur hourly that

the client has been offered the opportunity
to drink water and to void or defecate.
• Documentation must occur three times a day and
in the evening that meals or snacks have been
offered and how much was eaten.

• At least 24 hours, the client has the right to

personal hygiene.
Have a Nice Day!