Objective “zero restraining” for the prevention of falls

To control the risk of falling, caregivers can use restraining methods. This delicate practice is not always necessary and can be counterproductive in the management of falls

Falls are often inevitable due to aging. They have serious consequences, both physical and psychological for the elderly and have a heavy impact on the well-being of nursing staff.

How to combine patient safety and respect for freedoms ? Restraining poses many questions to the caregiver. How to constrain while leaving the patients free to make their choices ? Accepting the freedom of movement of our residents often includes accepting risk-taking. It is both an everyday and an insoluble equation.

Restraining is used in 6 to 17% of hospitals.

In those over 65, it concerns 18% to 22% of patients. In the event of dementia, it affects more than 50% of the people.

In retirement homes, 49% of residents are affected.

Although these numbers decline over the years, they still affect too many people. This is why many « zero restraining » plans have been implemented, first in Flanders, then in Wallonia.

What types of restraining methods are we talking about ?

In addition to chemical restraint, present in psychiatry, there are 4 other types of physical restraining methods:

  • Restraints limiting mobility such as ties or abdominal belts
  • Restraints limiting freedom such as isolation or confinement
  • Restraints integrated into the furniture such as bed rails or armchair shelves
  • Virtual restraints such as electronic surveillance

How to protect your patients with kindness

It is often in a strong emotional context that we decide to install a restraint. Patience and method are the key words.

Above all, the decision must be made as a team so as not to be alone faced with this responsibility. Ideally, restraint should require a medical prescription, even if in Belgium, it is considered a nursing act delegated by the doctor (not requiring a prescription). It is therefore important to:

  • Inform the patient and the patient’s family. Restraining methods must be agreed upon to be used
  • Identify the triggers for the episode of confusion. Pain, like that of the bladder, or polypharmacy often initiate episodes of confusion.
  • Seek alternatives and promote calm. This can range from a few benevolent and spontaneous acts of kindness, to setting up wellness workshops.
  • Ensure the safety, monitor and reassess the need for restraining.
  • Choose the appropriate restraining equipment and make sure staff is trained in its implementation.
  • Very regularly monitor the person’s physical parameters: nerve compression points, appearance of redness at the attachment points.
  • Ensure the hydration and continence of the person

The consequences of restraining

If restraining is found to be effective, it should limit the number of falls and bodily harm. However, this is far from the case. The number of serious injuries following a fall while the patient is under restraint even increases (17% versus 5%), (Tinetti, 1992).

And when you stop the use of restraining, the number of falls tends to increase during a period of transition (without the injuries being more serious).

In addition, restraining very often leads, especially if it is prolonged, to a loss of autonomy and an increase in the length of the hospital stay (Frengley 1986).

Thus, the impact of restraining on the health of the person who falls is felt on several levels.


Restraining induces immobility and that is harmful for the patient since bedsores can appear quickly. A week’s immobilization can cause the loss of up to 10% of muscle mass. Restraining also induces loss of bone mass and muscle wasting. This increases the risk of a serious fall.

Other consequences have been reported, such as increased confusion and incontinence.


Restraining is responsible for 1 death in 1000 people in an institution (Miles 1992).

As the severity of injuries increases with restraining, the chances of dying from the injuries are increased. Bed rails are often implicated.

Experience of caregivers

Feelings of anxiety, frustration and guilt often accompany the nurse when placing a patient under restraint.

Paradoxically, the nurse never reports a feeling of security. Restraining is therefore always a risky act, heavy with consequences for the resident and weighed with an enormous sense of responsibility for the nursing staff.

Restraining does not protect against legal action

Here, it is « the need for compliant restraint and patient monitoring appropriate to their condition » that prevails. Limit patient’s movement, yes, in some cases, but with great care and professionalism.

It is possible to succeed without restraints

In certain rest and care homes, restraint is never used. For this to succeed, caregivers must be convinced that they can work without it. It is necessary to discuss other alternatives to be put in place which are more effective and that do not impact the quality of life. These alternatives can be the recognition of risk factors, beds put in very low position, a suitable room arrangement, etc. Modern technology today also offers new techniques that can automatically detect a fall. This technology will be increasingly more available in rest homes and care facilities.

ISA’s interest in the monitoring and evaluation of patients under restraint

Monitoring restraining is the key! With or without restraint, keeping an eye on the patient is the nurse’s responsibility.

Rapid alert in the event of a fall under restraint and direct visualization of what is happening in the room, as enabled by the ISA fall detection system, helps reduce the mortality and morbidity of patients under restraint.

Discover the example from the CHWAPI for the prevention of falls