Psychiatric Mental Health, part 3: Torts and Restraints
by Cathy Parkes July 22, 2021 Updated: March 31, 2022 10 min read
In this article, we explain torts and restraints. In the psychiatric/mental health setting, these are important concepts to understand together. Where exactly is the line between false imprisonment (a tort), and putting a patient posing an imminent threat in restraints or seclusion? Read on to find out.
This series follows along with our Psychiatric Mental Health Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Torts in Fundamentals vs. Mental Health
Torts are something that you will need to know about in your Fundamentals of Nursing course, which is why we cover them in our Fundamentals of Nursing Flashcards as well as in our Fundamentals series article on Intentional Vs. Unintentional Torts and Mandatory Reporting. But, torts are also important to consider from the psychiatric mental health perspective, because of the crucial differences between false imprisonment and restraints.
Torts are wrongful acts that cause a patient to suffer harm.
An intentional tort is a willful act that violates a patient's rights. Willful and intentional means that the act was done knowingly and on purpose.
Assault is a threat made against a person that makes them fearful. For example, if you were to say, "If you don't stop acting up, I am going to tie you down," or "I am going to hit you," those would be threats against a patient and thus, assault.
In nursing torts, battery is the touching of a patient, without consent, that causes harm. For example, you administered a medication to a patient after they refused, that would be battery.
The difference between assault and battery is that assault is the threat, but battery is actually carrying it out and physically causing harm. This might be different than what you'd normally assume, as people often say assault when they mean the physical act of battery, but it's important to know the difference.
A before B: Assault (threat) before Battery (harm).
False imprisonment is the inappropriate confinement of a patient with restraints, seclusion, or a medication acting as “chemical restraint," when they should otherwise be free to go. The tort of false imprisonment denies a patient their autonomy; patients have the right to leave even when it's against medical advice.
False imprisonment is an important tort to understand in the context of restraints. After torts we'll explain restraints, then we'll summarize the key differences between false imprisonment and restraints.
Invasion of Privacy
The tort of invasion of privacy is violating a patient’s right to confidentiality. For example, if you were to share patient information with a patient's family member without getting permission from the patient first. That's an invasion of privacy and definitely something to avoid.
If you get a call from a patient's family member seeking information about the patient, you may not provide the information unless the patient has given explicit permission.
Defamation of Character
Defamation of character is the act of making derogatory remarks that harm a patient’s reputation. Want to learn about the different types of defamation of character? Check out our Fundamentals of Nursing Flashcards.
Unintentional torts are unintended acts against a patient that cause them harm. Negligence and malpractice are the two main unintentional torts you'll need to know.
In nursing, negligence is defined as a failure to provide care that a reasonably prudent person would have. Reasonably prudent means someone of sound mind and good reasoning capabilities. Anyone, including nurses, can be liable for negligence.
Malpractice is the specific term for negligence by a professional, like a registered nurse. A professional, or in this case a nurse, has a duty to act to provide care or prevent harm, but failed to act in the correct capacity.
For example, say there is a patient in the hospital with a pressure injury, and there are orders for wound care and to shift the patient's weight every two hours. But you, as the nurse, did NOT do that. If you failed to provide the wound care and did not reposition the patient, which led to wound deterioration and sepsis (patient harm), then you would be guilty of nursing malpractice.
Restraints and seclusion
Restraints and seclusion are only indicated when a patient poses an imminent danger to themselves or others. Restraints and seclusion are only used as a last resort.
Restraints are means that restrict a patient's freedom and ability to move. A restraint can be physical or chemical.
Physical restraints in the mental health setting include hand mittens (they look like club-shaped oven mitts that fasten at the wrist), limb restraints (look like padded cuffs with straps attached), belts (attached to a bed or otherwise), and vests (similar to the belt but restrain the chest/torso too).
Patients have a right to the least restrictive environment, and so the least restrictive restraints possible should always be chosen—in many cases, that option is hand mittens.
Chemical restraints in the mental health setting include medications like benzodiazepines, antipsychotics. If you want to learn more about these medications, including their mode of action, side effects, nursing care and patient teaching, they are covered in our Pharmacology Flashcards for Nursing Students. These flashcards will help you learn and retain the key information.
Again, restraints are only used as a last resort. Before restraints are ever used, deescalation techniques are always used first. Deescalation techniques include using simple, nonthreatening language, setting clear boundaries, decreasing environmental stimuli that may be triggering for a patient (lights, sound), providing diversions.
Another option is offering a patient an appropriate medication (e.g., an antianxiety medication) that is already prescribed to them PRN. PRN means pro re nata, Latin for take as needed. Need a refresh on prescription abbreviations? Check out our Medical Terminology and Abbreviations Flashcards for Nursing Students.
Nursing care for restraints
If you have a patient in restraints, you need to:
Assess your patient visually every 15 minutes.
Every 2 hours, take their vital signs, provide range-of-motion exercises, check their skin integrity under the restraints, and provide fluids and toileting.
Though the exact timing may vary based on facility policy, the timing requirements are extremely important.
Order requirements for restraints
In an emergency, a nurse can apply the restraints without a medical order. But, an order for the restraints needs to be given as soon as possible by the provider after their application. The provider MUST do an in-person assessment within 24 hrs of initiation of restraints or seclusion.
Orders must be renewed by the provider within 4 hours for adults, 2 hours for children and adolescents between the ages of 9 and 17, and 1 hour for children under 9 years old. A new order is required every 24 hours if restraints are still needed.
If that is confusing, think of it like a prescription and refills. The provider initially orders that restraints are needed for a maximum of 24 hours. But every 4/2/1 hours they have to assess the patient and document that they still need to be restrained, which is not a new order, so it's more like a "refill." The 24 hours is like the maximum "number of refills."
The provider can't write a PRN order for restraints, so there is no such thing as an order that says "apply restraints as needed." This means that if a patient has had restraints on, gotten them off, and later became an imminent threat to others again, there is not considered to be an existing order in place for restraints. The correct procedure must be followed every time.
Nursing documentation for restraints
Documentation is extremely important if you have a patient in restraints. You need to document the rationale for why the patient is in restraints, how long they have been in restraints, what care was offered to the patient, what care was provided to the patient, and all at what times.
You will need to document those things clearly in the patient's chart. Because restraints are a last resort, their use is often audited. You want to do it right, and document that you have done it right.
Restraints vs. false imprisonment
Torts like false imprisonment are acts that cause harm to patients. Restraints (as a last resort) prevent patients from causing harm. Restraints used incorrectly could be considered the tort of false imprisonment, so it's extremely important to understand these definitions in psychiatric mental healthcare.
If the procedures of restraints and seclusion are not followed (everything listed above) then it could be considered false imprisonment.
Hi. I'm Cathy with Level Up RN and welcome to our channel. If you have not already done so be sure to subscribe. We have hundreds of free videos to help you with all of the key concepts and facts you need to know in nursing school.
In this video, we are going to cover torts as well as restraints and seclusion.
So when it comes to torts, we have intentional torts and unintentional torts.
Intentional torts are willful acts that violate a patient's rights. So there are five intentional torts. I'm going to go over here.
The first is assault. Assault is where you make a threat against a patient that makes them fearful. So a threat is the key part of assault.
Battery is where you touch a patient without consent and it causes patient harm.
So in my mind assault and battery kind of sound the same and it can be confusing to differentiate the two.
So the way I remember is A comes before B.
So A is for assault and that's where you threaten the patient. And then B is where you carry out that threat and actually do patient harm.
So assault is the threat. Battery is the harm. It's the following through of that threat.
Another intentional tort is false imprisonment. This is where you inappropriately confine a patient with restraints or even a chemical restraint, such as a sedative, when it's not appropriate.
So a nurse who puts restraints on a patient for his or her own convenience, that would be an example of false imprisonment.
The fourth intentional tort that I want to go over here is invasion of privacy. This is where you violate a patient's right to confidentiality, so perhaps you share patient information with a family member of the patient's without getting permission from the patient first.
So that's a big no-no. So if you get a call from a patient's mom, dad, son, brother, whoever, and they're wanting information about the patient, you may not provide that information unless the patient has explicitly told you that you can do so. Okay?
Then we have defamation of character. This is where if you make derogatory remarks against the patient, and it harms the patient's reputation, that would be considered defamation of character.
Now let's talk about unintentional torts.
Unintentional torts are unintended acts against a patient that cause harm.
So the difference between negligence and malpractice, which are unintentional torts, can be a little confusing, so I'm going to try to break it down here.
Negligence is failure to provide care that a reasonably prudent person would do under similar circumstances, whereas malpractice is negligence by a professional, so like a nurse.
So as a nurse, you have a duty to a patient, and you need to provide a certain standard of care. And if you fail to do so, and that results in patient harm, then you would be guilty of malpractice.
So for example, if there is a patient in a hospital with a bedsore, which we call a pressure injury, and there are orders for wound care and also orders to shift the patient's weight every two hours.
If, as a nurse, you don't do that, you fail to provide the wound care and you don't reposition the patient every two hours, and that wound deteriorates and causes sepsis - so that's the patient harm - then you would be guilty of nursing malpractice.
So hopefully, that's helpful. So malpractice is negligence on the part of a professional.
Alright. Now let's talk about restraints and seclusion.
So restraints and seclusion should only be applied when the patient poses an imminent threat to themselves or to others.
Restraints can include physical restraints such as mittens, limb restraints, belts, and vests, or they can be chemical restraints such as benzodiazepines and anti-psychotic medications.
So before we apply any restraints, we, of course, want to try alternative ways to calm down the patient so that we don't have to do so.
So this would include using simple, non-threatening language, setting clear boundaries, reducing environmental stimuli, providing diversions to the patient, and perhaps offering the patient PRN medication such as an anti-anxiety medication if that is ordered.
In an emergency, a nurse can apply the restraints. However, an order for those restraints needs to be given by the provider as soon as possible after their application.
We always want to use the least restrictive restraints possible to solve the situation, so in many cases that includes mittens. Mittens are least restrictive.
While your patient is in restraints, you need to:
assess them, like lay eyes on them every 15 minutes, and then every 2 hours you need to take their vital signs, you need to provide range of motion exercises, you should check their skin integrity like under the restraints, and provide fluids and toileting.
The timing, like the requirements, may vary according to the facility, but in general, it's about every two hours.
And they are not messing around with these things needing to be provided every two hours.
And you need to document those things clearly in the patient's chart because it is likely that those will be audited.
You always want to remove restraints right away, as soon as the patient is no longer requiring those and is no longer a threat to themselves or to others.
In terms of the orders for restraints, providers must do an in-person assessment within 24 hours of initiation of the restraints or seclusion.
PRN orders are not allowed.
So the provider can't write an order that says, "Apply restraints PRN agitation or violence," right? There's no as-needed order for restraints.
And a new order is required every 24 hours if restraints are still needed.
And in terms of documentation, like I shared here a minute ago, you need to be documenting the rationale for why the patient's in restraints, how long they've been in restraints, and what care was offered and provided to the patient.
So those things are going to be really important.
Okay, time for a quiz, little knowledge check.
So I want you to name that tort. Okay? So number one, if you make a threat against a patient, what tort is that?
The answer is... assault.
Number two, if you inappropriately confine a patient with restraints, what do we call that?
We call it... false imprisonment. All right?
So hopefully you did well with that little knowledge check. If not, go back and watch the video.
And next up, we will be talking about the nurse-client relationship and therapeutic communication. Thanks so much for watching!
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