159. CCA Study Notes: Restraints, Alternatives, and Bed Rail Safety

The Big Picture

A restraint limits a client’s movement or access to their own body. Restraints can cause serious physical and emotional harm, so every effort should focus on protecting the client without using a restraint whenever possible.

When a restraint is necessary, strict rules apply. The care plan, consent, a physician’s order, proper training, close observation, and the client’s comfort and dignity all matter. Bed rails also need careful use because they can restrict movement and create safety risks.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Is a Restraint?

A restraint is a device, garment, barrier, piece of furniture, or medication that limits a person’s freedom of movement or access to their own body.

Restraints are used much less often than in the past. They can cause emotional harm, serious physical injury, and even death. Every effort should be made to protect clients without using restraints.

Unnecessary restraint is false imprisonment. A restraint must be included in the client’s care plan, and written consent must be in the client’s chart.

The Three Types of Restraints

Type	What It Means
Physical restraints	Garments or devices attached to or placed around the body to restrict movement. Examples include mitt restraints and belt restraints. Seatbelts on wheelchairs and in child and infant care carriers are also included under physical restraints.
Environmental restraints	Barriers, furniture, or devices near the body that prevent free movement or keep the client in a particular place.
Chemical restraints	Medications used only to control behaviour or movement when they are not otherwise required for the client’s medical condition.

Examples of environmental restraints include:

• Geri chairs or chairs with attached trays
• a chair positioned near a wall so the client cannot move
• bed rails
• locked rooms or seclusion areas

Chemical restraints must not be used for discipline or staff convenience. They should be used only as long as indicated and must not impair physical or mental function.

Role limit: Administering chemical restraints is outside the support worker’s scope of practice. Support workers are never permitted to administer medications. Only a physician or nurse can administer chemical restraints.

Restraints Are a Last Resort

Restraints are used only in extreme cases when they are necessary to prevent harm. Other measures should be tried first.

Most agencies have a No Restraint policy that staff must strictly follow.

Restraints must never be used:

• to discipline or punish a client
• for staff convenience
• simply to make staff members’ work easier

If a restraint is required, the physician chooses the least restrictive method.

The care plan should include restraint alternatives. The support worker and the rest of the health care team must follow the care plan. If alternatives do not protect the client, a physician may order a restraint as a last resort.

Look for the Cause of the Behaviour

Before turning to restraints, health care providers should try to determine why the client is agitated ⓘ or behaving in a harmful way. Addressing the cause can often prevent restraint use.

Possible questions include:

• Is the client injured or in pain?
• Is the client afraid?
• Is the client seeing, hearing, or feeling things that are not real?
• Is the client confused or disoriented?
• Has a medication change affected the client’s behaviour?
• Has the client missed medication?
• Does the client need to urinate or defecate?
• Is clothing or a dressing causing discomfort?
• Is the client in an uncomfortable position?
• Is the client too hot, too cold, hungry, or thirsty?
• Are body fluids, secretions, or excretions irritating the client’s skin?

Report: A behaviour change following a recent medication change should be reported immediately to the supervisor.

Alternatives to Restraints

Restraint alternatives should match the client’s care plan, needs, and abilities.

Activity and Companionship

Useful alternatives include:

• activities that occupy the client’s time and energy
• TV, videos, music, games, books, relaxation recordings, exercise, outdoor time, or simple tasks
• visits from support workers, family, friends, and volunteers
• frequent visits and observations

Activities should follow the client’s care plan, needs, and abilities.

A Calm and Consistent Environment

The client may benefit from:

• a calm, quiet setting
• reduced noise
• consistent care
• explanations of procedures and care
• supervised areas such as a lounge or an area near the nurses’ station
• lighting that meets the client’s needs and preferences
• uninterrupted sleep

Movement and Orientation

Clients may be allowed to walk in safe areas. The entire staff should be informed when this approach is used.

Clients who are disoriented ⓘ should receive help orienting themselves to people, time, and place. Calendars and clocks should be placed where clients can easily see them.

Meeting Basic Needs

Keep the call bell within the client’s reach. A call bell lets a client in a facility notify staff that assistance is needed.

Food, fluid, and elimination needs must be met. A bedpan, urinal, or commode should be within reach when needed.

Some clients who need toileting may show agitated behaviour. Toileting at regular intervals can help.

Making the Environment Safer

Rooms and furniture should meet the client’s safety and comfort needs. Supported options include:

• a lower bed
• a reclining chair
• cushioned walls or furniture
• warning devices on beds, chairs, and doors
• knob guards on doors
• pillows
• wedge cushions
• posture and positioning aids

Pillows, wedges, and positioning aids can help prevent clients from falling out of bed.

Consent, the Physician’s Order, and the Care Plan

Informed consent is required. A restraint cannot be used without informed consent.

The client must receive information about:

• why the restraint is needed
• how it will help with the planned treatment
• the risks of using it

The client has the choice to give or withhold consent.

If the client cannot give informed consent, a family member or substitute decision maker receives the information and decides whether to give consent.

Role limit: Only the physician or nurse can provide the required information and obtain informed consent.

A restraint also requires a physician’s order. The physician explains why the restraint is needed, which restraint to use, and how long it should be used. This information goes in the care plan and the support worker’s assignment sheet.

The Least Restrictive Method

When a restraint must be used, the least restrictive method is chosen. Most environmental restraints are less restrictive than physical restraints.

The goal is to meet the client’s needs with as little restraint as possible and for as short a time as possible. The care plan must show how restraint use will be reduced.

Safe Restraint Application

Use only the restraint identified in the care plan.

Use only restraints that have manufacturer instructions and warning labels.

Follow:

• the employer’s policies and procedures
• the manufacturer’s instructions
• warning labels
• instructions about correct fit
• instructions about the equipment with which the restraint is designed to be used

Use only intact restraints. Check for tears, cuts, frayed ⓘ fabric, or damaged straps.

Never use sheets, towels, tape, rope, straps, bandages, or other nonstandard items to restrain a client.

Do not use restraints to position a client on a toilet. Do not use a restraint with furniture that prevents correct application.

Position the client in good body alignment before applying the restraint.

Training Is Required

Only knowledgeable workers apply restraints.

You must receive proper training and instruction before applying one. Some facilities also require certification.

More than one staff member may be needed to apply a restraint safely.

Clients in immediate danger of harming themselves or others are restrained quickly.

An agitated or combative ⓘ client can injure themselves or a health care worker during application. Two or more workers may be needed when a restraint must be applied safely and quickly.

Fit, Comfort, and Basic Needs

A restraint should fit snugly and firmly, but it must not be tight. A tight restraint can interfere with circulation and breathing.

The client should remain comfortable and have limited, safe movement of the restrained body part.

The client’s needs must continue to be met, including:

• food
• fluid
• comfort
• exercise
• elimination

The client must continue to receive adequate support even while staff members take breaks.

Monitoring a Restrained Client

Number to remember: Check the client at least every 15 minutes, or more often when the care plan requires it.

Check safety and comfort. Improper restraint use and poor observation can lead to injury or death.

At least every 2 hours:

• remove the restraint
• reposition the client
• meet elimination needs
• provide skin care
• complete range-of-motion exercises or help the client walk according to the care plan
• offer food and fluids

Keep the call bell within the client’s reach.

Mitt Restraint Safety

When a mitt restraint is used, you should be able to slide one or two fingers under the restraint.

Check circulation every 15 minutes. You should feel a pulse below the restraint. The fingers or toes should be warm and pink.

Tell the nurse at once if:

• you cannot feel a pulse
• the client’s fingers are cold, pale, or blue
• the client reports pain, numbness, or tingling in the restrained hand
• the client’s skin is red or damaged

Belt Restraint Safety

A belt restraint is used with chairs or wheelchairs.

Position the client with their hips well back in the chair. Apply the belt restraint at a 45-degree angle over the hips.

Check the client at least every 15 minutes. The client should be able to breathe easily.

Protect the Client’s Quality of Life

Restraints should remain in use for the shortest time possible.

Treat the restrained client with kindness, caring, respect, and dignity. Give repeated explanations and reassurance. Visit often and listen to the client.

A restrained client may be unable to scratch an itch, reach a drink, use the bathroom, change position, or move to safety without help. The client may not understand why movement is restricted.

Restraints do not automatically calm clients or prevent falls. They can make clients more agitated, confused, or combative, and restrained clients are more likely to be injured.

Reporting and Recording Restraint Care

Information about restraint use must be recorded in the client’s chart. When caring for a restrained client, give verbal reports to your supervisor.

Information listed for charting when a restraint is applied or removed includes:

• the type of restraint
• the reason it was applied
• safety measures required by the care plan
• the time the restraint was applied
• the time it was removed
• care given when it was removed
• the client’s skin colour and condition
• the pulse rate in the restrained body part
• complaints of tightness, breathing difficulty, pain, numbness, or tingling

Complaints of tightness, difficulty breathing, pain, numbness, or tingling in the restrained part must be reported to the supervisor at once.

If you are allowed to chart, include:

• safety measures taken according to the care plan
• the client’s skin colour and condition
• the pulse rate in the restrained part

Follow employer policy for recording. Record what was done, the care provided, your observations, and the time and details of information reported to the nurse.

Report to the nurse every time you check the client and every time you release the restraint. Report your observations and the care provided, following employer policy.

What Are Bed Rails?

Bed rails are the metal or plastic sides of a hospital bed used to prevent a client from falling out of bed.

Bed rails may extend half, three-quarters, or the full length of the bed. Half-length rails may include separate upper and lower rails on each side.

Bed rails are raised or lowered according to the care plan.

Bed Rails Are Environmental Restraints

Bed rails can prevent a client from getting out of bed. For this reason, they are considered environmental restraints.

Raised bed rails cannot be used unless they are needed to treat the client’s medical symptoms. The client or substitute decision maker must give consent.

The need for bed rails must be recorded in the client’s chart and care plan.

When Bed Rails Are Used

Your supervisor and the care plan tell you when to raise or lower bed rails.

The source identifies raised rails for clients who are:

• unconscious
• sedated
• confused
• disoriented

Some clients feel safer with bed rails raised. Others use them to help change position in bed.

When the care plan requires raised bed rails, keep them up except while providing bedside care.

The bed should remain at its lowest setting except while bedside care is being provided.

Bed rails should not automatically remain raised for every client. Raised rails can make some clients more restless. Check the care plan and report increased restlessness to your supervisor.

Bed Rail Hazards

A client may fall while trying to climb over bed rails.

Clients may also become caught, trapped, or entangled:

• between the bed rail bars
• between two half-length rails
• between the rail and the headboard or footboard
• between the rail and the mattress

A trapped head, neck, chest, arm, or leg can result in injury or death.

Clients at greatest risk include:

• clients who are confused or disoriented
• clients who are restrained
• small clients
• clients with poor muscle control
• clients who tend to have seizures

Bed Rail Gap Safety

Number to remember: For an adult client, all bed rail gaps should be no more than 10 cm (4 in.).

Padding may cover gaps in bed rails. Gap protectors may be used with split bed rails.

Follow the manufacturer’s instructions and employer policy for padded bed rails and gap protectors.

Checking Clients With Raised Bed Rails

Check clients often when bed rails are raised.

Keep the bed at its lowest position whenever:

• bed rails are in use
• the client is not directly supervised by staff

In some situations, a lower bed frame or a mattress placed directly on the floor at night can reduce the risk of injury from falling out of bed. A mattress placed on the floor overnight should be returned to the bed in the morning to protect the client’s dignity and privacy.

Using Bed Rails During Care

Not every bed has bed rails, and not every client with bed rails needs them.

Your supervisor, care plan, and assignment sheet tell you which clients require bed rails.

When providing care:

1. Lower the bed rail nearest you.
2. Keep the rail on the opposite side raised.
3. If you leave the bedside for any reason, keep both rails raised.
4. Raise the lowered rail again when the procedure is complete.

Common Mix-Ups

Wrong Idea	Better Idea
Restraints calm agitation and reduce falls.	Restraints can increase agitation, confusion, combativeness, and injury.
Bed rails should always stay raised.	Follow the care plan. Raised rails can make some clients restless.
Bed rails are separate from restraints.	Bed rails that prevent a client from leaving the bed are environmental restraints.
A support worker gives a chemical restraint when it is ordered.	Administering chemical restraints is outside the support worker’s scope of practice.
Sheets, towels, rope, or other available items can substitute for a restraint.	Use only proper restraints with manufacturer instructions and warning labels.