A restraint is any method used to restrict a person’s freedom of movement, physical activity, or normal access to their own body. In healthcare settings, restraints are considered interventions of last resort, permitted only when someone poses an immediate danger to themselves or others and no less restrictive option will work. They must be discontinued as soon as the danger passes.
Types of Restraint
Restraints fall into three broad categories, each working differently to limit a person’s movement or behavior.
Physical restraints are devices or actions that prevent free body movement. The international consensus definition describes them as any method, attached or adjacent to a person’s body, that the person cannot easily control or remove. Common examples include wrist and ankle straps that secure limbs to a bed frame, vest restraints that keep a person in a chair or bed, and mittens that prevent someone from pulling out medical tubes.
Chemical restraints involve medications given primarily to control behavior rather than treat a diagnosed condition. These typically include sedatives, anti-anxiety drugs, and antipsychotic medications. There is no universally agreed-upon definition for chemical restraint, which makes it a more contested category. The key distinction is intent: the same medication prescribed to manage a psychiatric diagnosis is treatment, but that same medication given solely to make a patient easier to manage is chemical restraint.
Environmental restraints use the physical surroundings to limit where a person can go. Examples include locked ward doors accessed by keypad, being confined to one’s room, rearranging furniture to block movement, and electronic surveillance systems. Whether these count as “restraints” varies by facility and jurisdiction. Some definitions explicitly exclude barriers like half doors or locked exits, while others include them.
When Restraints Are Legally Permitted
Federal regulations under the Centers for Medicare and Medicaid Services (CMS) set strict boundaries. Every patient has the right to be free from restraint or seclusion imposed as a means of coercion, discipline, convenience, or retaliation. Restraints may only be used to ensure immediate physical safety, and only after less restrictive approaches have failed.
A physician or authorized licensed practitioner must write the order. For situations involving violent or self-destructive behavior, order time limits depend on the patient’s age: 4 hours for adults 18 and older, 2 hours for adolescents aged 9 to 17, and 1 hour for children under 9. These orders can be renewed up to a total of 24 hours, unless state law sets tighter limits. When restraint is initiated for violent behavior, a physician, licensed practitioner, or trained registered nurse must evaluate the patient face-to-face within one hour.
Hospitals are also required to report any death that occurs while a patient is restrained or secluded, notifying CMS no later than the close of business the next business day.
Risks and Complications
Restraints carry serious physical and psychological risks, which is a major reason they’re reserved as a last resort. Skin injuries are among the most common problems, ranging from redness, swelling, and bruising to pressure ulcers and, in severe cases, tissue death. One review of intensive care patients found that restrained individuals had roughly six times higher odds of developing pressure injuries compared to unrestrained patients.
Restraints also increase the risk of delirium, a sudden state of confusion that can worsen a patient’s overall condition and lengthen hospital stays. Neurological deficits, including nerve damage from prolonged compression of the wrists or ankles, have been documented as well.
The psychological toll can outlast the physical one. Post-traumatic stress disorder is a recognized complication of restraint use, with multiple studies confirming elevated rates among patients who were restrained during intensive care. Even a single episode can leave lasting feelings of fear, helplessness, and loss of dignity.
The Ethical Tension
Restraint use creates a genuine moral conflict for healthcare workers. On one side is a patient’s right to autonomy, the fundamental principle that people should control what happens to their own bodies. On the other side is the duty to keep that patient (and everyone around them) safe.
Nurses, who are typically the ones applying restraints, often experience this tension most acutely. Using restraints protects a patient from immediate harm but may cause psychological damage. Respecting a patient’s refusal of treatment honors their autonomy but can put them at risk of injury. What a clinician considers “good” for a patient may not match what the patient considers good for themselves.
The ethical standard most facilities follow is that restraint is only justifiable when the risk of not restraining clearly outweighs the harm of restraining. When restraints are deemed necessary, informed consent and shared decision-making, whenever the patient is capable of participating, help preserve respect for the person’s dignity.
Alternatives to Restraint
A growing body of evidence supports approaches that reduce or eliminate the need for restraints entirely. Verbal de-escalation is a frontline strategy: keeping conversations simple and concise, identifying what the patient needs or feels, respecting personal space by staying at least two arm-lengths away, and setting clear limits in a non-threatening way.
In long-term care settings for older adults, alternatives focus on routine and comfort. Keeping a consistent daily schedule, ensuring regular meals, easing the difficulty of everyday activities like bathing and dressing, and managing pain all reduce the agitation that leads to restraint use in the first place. Simply having staff present and regularly engaging patients in conversation decreases incidents of aggression.
Some facilities have moved toward eliminating mechanical restraints altogether. A 252-bed inpatient behavioral health hospital achieved zero mechanical restraints by the end of 2021 using a structured framework called the Six Core Strategies, which focuses on leadership commitment, data tracking, staff training, restraint-reduction tools, involving patients in their own care plans, and debriefing after incidents. The facility sustained that zero-restraint record through 2022 and eventually removed all mechanical restraint equipment from the building. The project demonstrated that a restraint-free inpatient environment is achievable with sufficient investment in staff development and organizational change.