Hospitals, Mental Health Agencies, Residential Treatment Centers and Schools frequently face significant behavioral challenges including dangerous behaviors requiring a safe and humane response from staff to limit harm. Physical, mechanical and chemical restraints are options that have been used both to mitigate immediate harm and to deter future outbursts.
Using any of these techniques should be used only in situations where the person’s behavior poses imminent danger of serious physical harm to self or others.
Physical restraints are a medium to high risk technique that requires significant training and practice to apply, and has significant potential for harm and abuse. Physical restraints should only be used in extraordinary circumstances, under strict supervision.
Mechanical restraints are a high risk, high impact technique, which require significant training to apply and have significant potential for harm and abuse.
Chemical restraints are a high risk, high impact technique. NAPPI does not teach this procedure.
NAPPI believes that using restraints is a last resort option. In most restraint episodes, it is later determined that the restraint could have been avoided. There are many ways to prevent or eliminate the use of restraints. NAPPI’s integrated behavioral safety framework provides staff with safety training that includes de-escalation skills, humane and effective response options, restraint avoidance, and developing a culture of cooperation.
The Dangers of Physical Restraints
A physical restraint is one in which you use bodily force to limit someone’s freedom of movement. It is important to note that restraints should only be used as a last resort to keep everyone safe. The following should be taken into consideration when applying the restraint:
- The type of restraint/hold used should match the level of danger.
- The restraint should be used only when NOT restraining will result in more harm than the restraint.
- The restraint must be terminated as soon as objectively possible.
Restraints can almost always be avoided. Nurses, Care Givers, Educators etc. need many skills to do their jobs; they also need skills to help create environments where restraints are unlikely to happen. NAPPI’s culture helps to develop powerful and positive relationships and creates a culture of cooperation and partnership. In addition, NAPPI’s refocusing, defusing and de-escalation techniques along with our SMART Principles and use of the Lalemand Red Scale teach staff how to assess the early warning signs of violence and make it possible to avoid almost every restraint.
A number of restraint events can occur because a minor event has escalated out of control. NAPPI’s Lalemand Red Behavior Scale along with the SMART Principles empowers staff with strategies to intervene at the earliest antecedent behavior, thus avoiding a restraint. Power struggles between a consumer and staff can escalate and become a volatile or dangerous situation. By using NAPPI’s Principles of Restraint Avoidance, and Developing a Partnership of Cooperation, the power struggle can be avoided. It is possible that situations with the potential of becoming dangerous can be turned into non-restraint events by using the above strategies. Ask yourself, "Will what I am about to do, be safer than what I am doing now?"
Organizations must have clear, objective policies and procedures that state when a restraint can – and cannot – happen, along with a process for release, documentation, debriefing, and improvement. NAPPI’s module “Post Incident Review” is a key component in debriefing the incident to determine what behaviors led up to the incident, who was involved, and how it could be avoided in the future.
Assessing the safety of a restraint technique is very difficult to do, and must take into account the physicality of the restrainer and the restrained. Restraints can place staff and consumer at risk for injury. Assessing the safety of a restraint technique should meet the following NAPPI criteria:
1. Minimum impact on the person being restrained
Minimum impact means there is smooth motion, limited limb movement and just enough control to make the situation safer. Using poor technique transfers energy into the body of the individual being restrained which could result in —jolts, squeezes, twists, pain compliance, and joint locks thus causing injury, re-traumatization or the reenergizing of the individual. This could cause further resistance or an unpredictable reaction.
2. Minimum impact on the environment
The technique should be quick, quiet, and done using the least gross motor activity as possible. This will help to reduce negative reactions of others in the environment such as fear, trauma, resistance, and chaos.
3. A large margin of safety
The technique should be inspected at every step to ascertain what the worst possible injury would be if the hold was done incorrectly. Often systems teach restraints as if the actual scenario were likely to unfold as planned and as practiced in class. In fact, this almost never occurs. Only select the skills with no catastrophic results.
4. Applicable to a variety of situations
Use a protective block to stay safe in a variety of situations such as, punches from the left and right, thrown objects, attempted chokes, and grabs to the face, hair, and glasses . Only use one block in your course, as too many skills take longer to learn and waste valuable practice time.
5. Teach one skill
If multiple techniques are used to control dangerous behavior, choose only one skill. People will gain higher competency levels if they practice only one skill.
6. It should flow from a natural reaction
Almost everyone will react to an attack in a predetermined way. For instance, if an object is thrown at an individual, the automatic reaction is to put both hands up and turn one’s head. Therefore, a good blocking technique’s first element should be to put both hands up. This enhances skill-building and emergency recall. Any blocking technique which requires unlearning the natural response will require many more repetitions, and slow the emergency response.
7. Easy to learn and recall
The technique should have as few steps as possible—three or four in the case of self-protection skills, five or six in the case of a holding/restraint sequence. The skills should not require staff to recall left and right actions – no one will remember such a fine distinction without a lot of practice time.
Effective means that everyone is safer because the technique was used. It should not be based solely on the level of control achieved. All individuals should be safe or the skill should not be used.
Self-Protection and Restraint Training
NAPPI offers Physical Skills training.
- S.M.A.R.T Physical Principles
- X-Shield and Blocking Blows
- Escaping Grabs
- Escaping Chokes
- Hair Pulls and Bites
If a Restraint is necessary two caregivers must be in agreement that at least 3 restraint avoidance techniques were employed prior to the restraint.
- Physical Escort(s)
- Standing Restraint
- Seated Restraint
- Side Floor Restraint (CPR Recovery)
- Modifications for Small Bodies
- Modifications for Large Bodies
- Wrestling Separation
- Mechanical Restraint
NAPPI does NOT and NEVER has supported the use of restraints in the prone or supine position.
Suggested Reading & Resources
The reading below will give you a good sense for how restraints and seclusion affect children and educators, and some tools to begin discussions from a common understanding.
Achieving Better Outcomes for Children and Families – Reducing Restraint and Seclusion (2004), Child Welfare League of America, Washington, DC. www.CWLA.org
Convention on the Rights of Persons with Disabilities (2009). United Nations, New York, NY.
Seclusion and Restraints: Selected Cases of Death and Abuse at Public and Private Schools and Treatment Centers (2009). Gregory D Kutz, GAO-09-719T http://www.gao.gov/new.items/d09719t.pdf
School is not Supposed to Hurt: Investigative Report on Abusive Restraint and Seclusion in Schools (2009). National Disability Rights Network, Washington DC, www.ndrn.org
Six Core Strategies for Reducing Restraint and Seclusion (2005). Technical Assistance Office of the National Association of Mental Health Program Directors, Washington DC http://www.nasmhpd.org/ntac.cfm
In the Name of Treatment (2005). Alliance to Prevent Restraint, Aversive Interventions and Seclusion. Washington DC www.aprais.tash.org