Patient Restraint and Seclusion

Function

Common Indications for Restraints and Seclusion

Restraints and seclusion are only permissible when there is imminent danger to the patient or others and no other interventions are possible. According to the American Psychiatric Association, restraints and seclusion are considered interventions of last resort.[PSYCHIATRY online. APA Resource Document Outlines Principles on Use of Seclusion, Restraint] The indications for restraints and seclusion have become narrower over time as mental healthcare providers and systems grapple with the physical and psychological dangers of coercive practices.[1][4]

A patient-centered, trauma-informed approach is necessary when making decisions about whether to use restraints or seclusion.

Issues of Concern

Risks to Patients from Restraints and Seclusion

Restraints and seclusion pose psychological and physical risks to patients. Physical complications include suffocation, aspiration, worsened agitation, injury, and death. Prone restraints increase the risk of suffocation, whereas supine restraints increase the risk of aspiration. Restraint for more than 4 hours increases the risk of deep vein thrombosis and pulmonary embolism, especially in patients with preexisting conditions. Restraint-related deaths are due to asphyxiation, aspiration, and cardiac events. Patients often report sleep disturbances, derealization, and memory loss during the event.[1]

Psychological sequelae include trauma, shame, guilt, loss of dignity, diminished self-respect, and autonomy in patients. In a 2019 study, 12.6% of participants had event-related posttraumatic stress disorder.[10] In a 2019 meta-analysis, the incidence of posttraumatic stress disorder after restraints and seclusion was estimated to range between 25% and 47%.[11]

Experiences of Staff and Shared Experiences

Restraints and seclusion are associated with negative consequences for both healthcare staff and patients. The staff perceives their role in providing safe and quality care to patients as an ethical responsibility. The staff suffer from internal conflict when using seclusion and restraints on patients. The staff also experience physical injury, fear, loss of empathy, trauma, and distress.[3]

Some experiences are shared between staff and patients. These shared experiences include both healthcare staff and patients suffering from physical injury and psychological trauma during restraint and seclusion events. These practices disrupt the therapeutic relationship and jeopardize social and emotional engagement.[3] 

Reducing the Use of Restraint and Seclusion in Psychiatric Care

Reducing episodes of violence requiring restraints and seclusion is an important goal of healthcare systems. This priority arises from several concerns—high psychological costs involved; inconsistencies with principles of patient-centered care; lack of efficacy for managing patient aggression; risk of injury to staff and patients, including patient deaths; and high costs to psychiatric staff and institutions.[4]

Programs have been developed to reduce the use of restraints and seclusion, such as the Safewards model and Six Core Strategies.[3][12][13] These programs entail the implementation of change at various levels of organizations, including leadership support, use of data to inform practice, staff development, involvement of leadership, engagement of patients and families, post-incident debriefing, use of alternative methods, and efforts to enhance the therapeutic environment.[3]

A recent study found that the systematic implementation of evidence-based practices significantly reduced the use of restraints without a corresponding increase in seclusion.[4] These practices also led to fewer staff injuries and lower healthcare costs. Key strategies included:

• Active leadership involvement
• Staff training in trauma-informed care
• Development of positive behavioral support plans
• Use of restraint-prevention tools
• Data-driven decision-making
• Patient participation and debriefing

Proactive treatment plans involving patients in identifying support systems, enhancing patient access to services such as sensory integration, and planning for discharge and community reintegration are essential to the success of the intervention. For these efforts to succeed, active engagement from supervisors and top management is necessary to foster a sustained culture change.[4]

Clinical Significance

Practice Recommendations for the Use of Restraint and Seclusion

The following recommendations for the use of restraint and seclusion are based on the Six Core Strategies and the Safewards model, emphasizing trauma-informed care, collaborative problem-solving, recovery-oriented approaches, engagement models, and nonviolent resistance.[8] The use of these preventive strategies has been shown to reduce both the frequency and duration of restraint and seclusion. Key strategies include the following:

• Strong leadership and multidisciplinary team collaboration
• Comprehensive staff training and ongoing education
• Environmental adjustments to support a therapeutic atmosphere
• Frequent risk assessments
• Establishing and maintaining positive staff-patient relationships
• Crisis planning and the use of de-escalation techniques
• Availability of comfort rooms
• Regular post-incident reviews or debriefings with both staff and patients [8] 

Respectful communication during restrictive interventions plays a key role in minimizing harm, including explaining the intervention to the patient, respecting their privacy and dignity, and incorporating their preferences into care decisions.

Additional recommendations include:

• Appointing a designated team leader during interventions.
• Ensuring physical safety by protecting the head and neck and maintaining airway patency.
• Prohibiting inhumane practices such as cage beds, metal handcuffs, or forced undressing.
• Conducting regular observations, including assessing for injuries, addressing nutrition and hydration, checking circulation and range of motion, checking vital signs, addressing hygiene and elimination needs, addressing physical and psychological comfort, and assessing readiness for discontinuation. 
• Maintaining proper documentation.[8]

Time Limits for Restraint and Seclusion

The Joint Commission requires that, as soon as possible after the initiation of restraints and seclusion, qualified staff obtain a time-limited order from a clinician or licensed practitioner in accordance with state and federal laws. Orders are limited to 4 hours for adults aged 18 or older, 2 hours for youth aged 9 to 17, and 1 hour for children younger than 9. Organizational time limits may be more stringent. If the restraint and seclusion must be continued beyond the expiration of the time-limited order, a new order must be obtained, and it is prudent to obtain a second opinion.[JOINT COMMISSION. R3 Report Issue 44: New and Revised Restraint and Seclusion Requirements for Behavioral Health Care and Human Services Organizations]

Removal of Restraints

When the patient is no longer a danger to themselves or others, the restraints should be removed immediately.

Other Issues

Medicolegal and Ethical Issues

According to the WHO, the use of seclusion and restraints should be considered as a failure, a bad outcome, and a human rights violation, even when it seems that all the alternatives to these practices were implemented before resorting to them. There are always alternatives to seclusion and restraint.[World Health Organization. Strategies to End Seclusion and Restraint]

The medical, ethical, and legal implications of restraint and seclusion in healthcare settings are complex and multifaceted. These interventions must never replace patient-centered care and should be guided by clearly defined standards. Healthcare providers are obligated to follow state and federal laws and established institutional protocols when using restraints and seclusion, ensuring that their application is rooted in preventing harm rather than for convenience, punishment, or maintaining order.

According to the American Medical Association, restraints may sometimes be warranted, but never as a punitive measure, for staff convenience, or to compensate for inadequate staffing. The justification for using restraints and seclusion lies solely in the need to prevent imminent harm.[14]

According to the Center for Medicare Services, within 1 hour of the initiation of the seclusion or restraint, a patient must be evaluated face-to-face by a clinician or other licensed independent practitioner or by a registered nurse or physician assistant who has met specified training requirements. This requirement may be more restrictive and vary by state laws.

Evidence indicates that restraints and seclusion do not reduce the problematic behaviors that often prompt their use. Improper or unnecessary application can expose healthcare staff to serious legal consequences, including allegations of battery and false imprisonment. Therefore, preventing escalation to the need for restraint and seclusion is crucial. The need for restraints and seclusion should be carefully and continually reassessed.[14]

Enhancing Healthcare Team Outcomes

Enhancing Staff Competence and Creating a Safe Environment to Prevent Restraints and Seclusion

Coercive practices disrupt the therapeutic relationship between members of the interprofessional team and patients.[3][7]

Staff competency and the care environment are critical factors influencing patients' unmet needs. Ensuring patient safety, promoting dignity, maintaining adequate staffing, and offering opportunities for patients and staff to share their experiences are all essential to improving care quality and creating a safer, more therapeutic environment.[15]

Staff competency encompasses 3 key components:

• Effective communication between staff and patients
• Accurate assessment of patients' conditions and behaviors
• Compassionate care delivered with respect and empathy

Consistent, humane interactions between patients and staff, especially during and after restraint and seclusion episodes, are critically important. These interactions, grounded in regular assessment and dignity-driven care, are vital. Encouraging patient participation in this process can reduce fear, foster trust, and help restore a sense of control.

Role of the Physical Environment

The physical environment plays a significant role in reducing the use of restraint and seclusion in mental health settings. As awareness grows about the impact of environmental factors on patient well-being, these considerations are becoming increasingly important in shaping future health policies.

Key environmental features associated with reduced use of restraint and seclusion include:

• Access to outdoor spaces such as gardens and recreational areas
• Comfort rooms and quiet spaces that offer privacy and a sense of control
• Uncrowded, calm unit layouts that reduce stress and agitation

Thoughtful unit design that promotes mental wellness includes elements such as natural daylight, effective noise reduction, and proper air ventilation. Aesthetic improvements—such as warm color schemes, rugs, indoor plants, updated furniture, increased personal space, private rooms, and views of nature through large windows or balconies—can transform institutional settings into more home-like, calming environments. These changes support patient dignity, reduce distress, and have been shown to lower the incidence of restraints and seclusion.

Providing sensory or comfort rooms ensures that patients have access to soothing, personalized spaces where they can retreat when feeling overwhelmed. Core design principles should emphasize:

• Privacy and personal space
• Avoidance of overcrowding
• Access to natural light and quiet surroundings
• A welcoming, noninstitutional atmosphere

Additionally, providing access to meaningful, engaging activities and facilitating visitation by families are crucial components of a recovery-oriented approach, contributing to emotional regulation and overall therapeutic success.[16]

Nursing, Allied Health, and Interprofessional Team Interventions

Staff members need support in processing their emotions after restraint and seclusion interventions. Initiatives to promote staff well-being include:

• Mindfulness-based continuing education
• Interactive cognitive-behavioral therapy workshops
• Training in restorative supervision [15]

Staff support should be multi-tiered—personal, professional, and organizational. For example, developing a structured debriefing protocol can help staff build resilience and facilitate posttraumatic growth. Timely clinical supervision offers essential professional support. At the organizational level, programs such as the Safewards model and the Six Core Strategies aim to reduce staff stress and enhance mental healthcare quality.[3][12][13]

Improving the environment must go beyond ensuring physical safety—it should also nurture a setting where patients and staff feel respected, dignified, and autonomous. Understaffing contributes to lapses in care, increasing the risk of negative outcomes. A truly therapeutic environment includes:

• A higher staff-to-patient ratio
• Enhancements to the physical and emotional atmosphere
• Policies that prioritize staff debriefing and emotional support
• Staff training in stress management and coping strategies to ensure sustained care quality [15]

Nursing, Allied Health, and Interprofessional Team Monitoring

When necessary, restraints and seclusion should be used in a safe and ethical manner. Staff should receive adequate training in verbal de-escalation techniques, including behavioral and environmental modifications. Adhering to established federal, state, and organizational guidelines and maintaining careful documentation are essential to minimizing harm to patients and staff and ensuring the safe use of restraints when required.[7]