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.
Psychiatric Mental Health - Nursing Flashcards
Torts
Torts are wrongful acts that cause a patient to suffer harm.
Intentional Torts
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
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.
Battery
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
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
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.
Negligence
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
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
Restraints are means that restrict a patient's freedom and ability to move. A restraint can be physical or chemical.
Physical restraints
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
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.
Before restraints
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.