In hospitals around the world, nurses still sometimes tie patients’ wrists to bed rails, use bed sides to stop people getting up, or hold patients down for procedures. Usually it’s done with good intentions: to stop a confused patient pulling out a drip or falling. But physical restraint carries real risks, including injury, pressure ulcers, worsening delirium, psychological trauma and, in rare cases, death from positional asphyxia. Many countries now expect healthcare services to reduce restrictive practices as far as possible.
What counts as restraint?
- Physical restraint: holding a person or restricting movement by hand.
- Mechanical restraint: using devices such as wrist ties, belts, mittens or straps.
- Chemical restraint: giving medicines mainly to control behaviour rather than to treat an illness.
- Environmental restraint: locking doors, removing walking aids, or using bed rails or chairs to prevent movement.
- Seclusion: confining a person alone in a room (mainly in mental health settings).
Even “small” measures, such as placing a patient in a chair they can’t get out of, can be restraint.
The risks
- Injuries to skin, nerves and joints
- Pressure ulcers and muscle wasting
- Increased agitation and delirium
- Falls (patients may climb over bed rails)
- Aspiration, breathing problems and positional asphyxia, especially in face-down holds
- Loss of dignity, fear, and trauma that can affect trust in health services
- Death in rare but well-documented cases
Legal and ethical principles
Laws differ between countries, but common principles include:
- Human rights: restraint restricts freedom and dignity. It must be lawful, necessary and proportionate.
- Consent and capacity: adults with capacity can refuse treatment. Restraint of someone who lacks capacity must be in their best interests and the least restrictive option (as in the UK Mental Capacity Act 2005, for example).
- Last resort: restraint should only be used when there is a real risk of harm and other measures have failed.
- Shortest possible time with regular review.
- Documentation and accountability.
Know your country’s laws and your employer’s policy. In some places, unlawful restraint can lead to professional and legal consequences.
Why patients need “restraint”: understand the cause
Most situations where restraint is considered involve patients who are:
- Delirious or confused (infection, dehydration, medication effects, alcohol withdrawal, hypoxia)
- Living with dementia and frightened in an unfamiliar environment
- In pain or needing the toilet but unable to communicate
- Experiencing a mental health crisis
- Pulling at lines, tubes or dressings that are uncomfortable
Treating the cause often removes the need for restraint.
Safer alternatives
- Look for and treat delirium: infection, pain, constipation, urinary retention, dehydration, low oxygen, medicines.
- Increase supervision: place the patient near the nurses’ station, use bay nursing, or arrange enhanced observation (sometimes called “specialling”).
- Involve family: familiar faces and voices calm many patients.
- Communicate: calm, simple explanations, repeated as needed. Use interpreters.
- Meet basic needs: toileting, food and fluids, glasses, hearing aids, comfort.
- Review lines and tubes: remove any that aren’t necessary; secure and cover cannulas; use abdominal binders for feeding tubes if appropriate.
- Reduce falls risk without bed rails: low beds, crash mats, sensor alarms and regular toileting.
- Purposeful activity: conversation, music, simple tasks, especially for people with dementia.
- De-escalation: lower your voice, give space, listen, offer choices.
Sometimes, despite every effort, restraint is needed briefly to prevent serious harm, for example to give urgent treatment to a patient who lacks capacity and is at risk of death. In these situations:
- Follow policy and involve senior staff and the medical team.
- Use the least restrictive method for the shortest time.
- Use trained staff and approved techniques. Avoid face-down (prone) holds and pressure on the chest, neck or abdomen.
- Monitor continuously: breathing, colour, circulation, distress and injury.
- Review frequently and remove restraint as soon as possible.
- Document the reason, alternatives tried, method, duration, monitoring and outcome.
- Inform the family and involve them in planning.
- Debrief with the patient (when able), family and staff.
Chemical restraint, giving sedatives to control behaviour, also carries serious risks such as falls, aspiration, breathing problems and worsening delirium. It should be used only according to guidelines and with careful monitoring.
Building a culture of least restriction
- Train all staff in delirium recognition, dementia care and de-escalation.
- Audit the use of restraint and bed rails.
- Encourage staff to challenge routine restraint (“we always tie them”).
- Ensure adequate staffing so patients can be supervised.
Restraint can seem like the quickest option on a busy ward. But keeping patients safe and dignified usually comes from understanding the person, treating the cause and working as a team.