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REVIEW ARTICLE

Restraint guidelines for mental health services in India

Bevinahalli Nanjegowda Raveesh, Peter Lepping1,2,3,4
Department of Psychiatry, 4Mysore Medical College and Research Institute, Mysore, Karnataka, India,
1
Wrexham Maelor Hospital, 2Betsi Cadwaladr University Health Board, 3Bangor University, Wales, UK

ABSTRACT

Restraint use in mentally ill patients are regulated by Mental Healthcare Act 2017 in India. At times, persons with mental
disorders become dangerous to self, others or towards the property, warranting an emergency intervention in the form
of restraint. Restraint as a matter of policy, should be implemented after attempting alternatives, only under extreme
circumstances as last resort and not as a punishment. It should be an intervention focused at managing the concerned
behavior for a given point of time. Restraint should always result in safety and should ensure that the human rights of
mental health care users are upheld. This guideline was developed towards Indian mental health services in conjunction
with international evidence-based strategies following a decade of collaborative research work between Indian and
European mental health professionals.

Key words: Guidelines, Indian mental health, restraint

INTRODUCTION Legislation led to the drafting of a new Mental Healthcare

Act (MHCA 2017). The Act of parliament received assent
Mental health experts from India and Europe came on April 7th 2017. Restraints are discussed in Chapter XII
together in Mysore, India, for an international symposium under admission, treatment, and discharge.[7] The Act
on coercion in 2013. The delegation discussed a culturally prohibits seclusion, and the use of restraints should be as
adequate way to address coercion for the Indian medical per subsections (1)‑(9) of section 97. The act requires all
context. As a result, the Mysore declaration was drafted, mental health establishments (care providers) to record all
discussed, and ratified defining coercive measures for the instances of restraint in a report to be sent to the concerned
Indian context and outlining the aims, safe application, review boards every month. Our experiences in research
and ways for minimization of coercion in all medical collaborations with countries that have guidelines and the
settings in India.[1] Following this, there were two more results of the research done allowed us to develop these
international symposia on coercion in mental health restraint guidelines from an Indian mental health services
care. The collaborations encouraged both qualitative and perspective while taking into account the best practice and
quantitative research on coercion in Indian Mental Health up‑to‑date research from around the world. These guidelines
Services.[2‑6] This was a significant development at a time are an attempt to combine best practice, research, and a
when national discussions around Indian Mental Health deep understanding of Indian mental health care to provide
guidance for clinicians, as well as reassurance for patients
Address for correspondence: Dr. Bevinahalli Nanjegowda Raveesh, and relatives in strict compliance with the MHCA 2017.
Department of Psychiatry, Mysore Medical College and Research
Institute, Mysore ‑ 570 001, Karnataka, India.
E‑mail: [email protected] This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
Access this article online which allows others to remix, tweak, and build upon the work non‑commercially,
Quick Response Code as long as appropriate credit is given and the new creations are licensed under
Website: the identical terms.
www.indianjpsychiatry.org For reprints contact: [email protected]

DOI:
How to cite this article: Raveesh BN, Lepping P. Restraint
guidelines for mental health services in India. Indian J
10.4103/psychiatry.IndianJPsychiatry_106_19
Psychiatry 2019;61:S698-705.

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Raveesh and Lepping: Restraint guidelines for Indian mental health services

Restraint may be used only when all less intrusive or This document is completed by the patient, with assistance
restrictive methods have been ineffective or determined from facility staff, if needed.
to be inappropriate. They must be performed in a manner
that is safe, proportionate, and appropriate to the service Physical escort
recipient’s age; size; gender; physical, medical, and A “light” grasp to escort the patient to the desired location.
psychiatric condition; and personal history. The use of If the patient can easily remove or escape the grasp, this
restraint must be evaluated continuously and ended at the would not be considered manual restraint. However, if the
earliest possible, based on an assessment of the service patient cannot easily remove or escape the grasp, this would
recipient’s condition and behaviors.[8,9] be considered manual restraint, and all the requirements for
restraint would apply.
These guidelines are based on the MHCA 2017 requirements
and closely based on the consensus reached in the Mysore Pro Re Nata
declaration, and other international guidelines, namely the An individualized order for the care of a patient
British NICE guidelines and the German guidelines for the which is written after the patient has been seen by a
prevention of coercion. physician (Psychiatrist). The Pro Re Nata sets parameters
for attending staff to implement the ordered intervention
DEFINITIONS according to the circumstances set out in the order.

For the purposes of this guideline, the following terms Prone restraint
shall mean, based on existing guidelines and restraint Brief physical holding of a patient in a facedown position,
protocols;[10,11] usually on the floor, for effectively gaining quick control of
an aggressive and agitated patient.
Assessment
The systematic collection and integrated review of Protective medical device
patient‑specific data, assessment specifically targets A special category of medical restraint that includes
key medical and psychological needs, competency to devices or combinations of devices, to restrict movement
consent to treatment, co‑occurring medical and mental for purposes of protection from falls or complications of
illness (including substance abuse), clinically significant physical care, such as Geri chairs, Posey vests, mittens, belted
neurological deficits, traumatic brain injury, physical wheelchairs, sheeting, and bed rails. A protective helmet
disability, developmental disability, need for assistive could be considered a medical restraint or a behavioral
devices, physical or sexual abuse or trauma, and antecedents restraint, depending on how it is used. The requirements
to violent behavior. for the use and documentation of medical restraints are
different from the general requirements for the emergency
Containment/restraint use of restraints for behavioral management purposes.
The brief physical holding of an aggressive or agitated
patient to effectively gain quick control of and minimize Rapid tranquillization
harm to the patient or others. The use of medication (intramuscular or intravenous),
if oral administration of medication is not possible or
Restraint incident is any event that involves the use of a contraindicated, or if urgent sedation with medication is
physical intervention (excluding observation). needed.

Continuous visual observation Restrictive intervention

A minimally restrictive intervention in which the assigned An intervention that may infringe a patient’s human rights
staff maintains uninterrupted visual contact of the patient and freedom of movement.
at all times to ensure the safety of the patient and others.
GUIDING PRINCIPLES FOR USE OF
Emergency RESTRAINTS
A situation where the patient’s behavior is violent or
physically aggressive and where the behavior presents an The following are the general principles followed for the
immediate and serious danger to the safety of the patient, use of restraints.[11-13]
other patients, staff, or anyone else in the vicinity.
1. The safety and dignity of the patient must be ensured
Personal safety plan/advance directive 2. The safety and well‑being of staff is also a priority
A document containing information regarding calming 3. Prevention of violence is key
strategies identified by the patient as helping avoid restraint 4. De‑escalation should always be tried before the use of
(Advance directives are encouraged under the MHCA 2017). restraint

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Raveesh and Lepping: Restraint guidelines for Indian mental health services

5. Restraint is used for the minimum period circumstances: those which are planned and those which
6. All actions undertaken by staff are appropriate and are unplanned. Unplanned physical restraint refers to those
proportional to the patient’s behavior incidents requiring restrictive physical interventions
7. Any restraint used must be the least restrictive, to which are unforeseen and unexpected. Under these
ensure safety circumstances, immediacy does not allow time to plan.
8. The patient must be closely monitored, so that Staff is guided by best practice guidelines and training.
any deterioration in their physical condition is Planned physical restraint refers to restrictive physical
noted and managed promptly and appropriately. interventions which have been planned through risk
Mechanical‑restraint requires 1:1 observation assessment and where there is an expectation that
9. Only appropriately trained staff should undertake predicted circumstances are likely to occur. There is
restrictive interventions, to ensure the safety of patients time for planning, and restraint plans are structured
and staff. and documented in health‑care records
8. Types of restraint devices include:
RESTRAINTS CONSIDERED 1. Manual restraint: A skilled, hands‑on method of
physical restraint used to prevent patients from
The different restraints to be considered are enumerated harming themselves or others. Its purpose is
below.[1,11,14-17] to immobilize the patient safely. It includes the
application of physical body pressure by another
1. Physical restraint involves direct physical contact person to the body of the patient in such a way as
between persons where force is positively applied to restrict the freedom of movement
against resistance, either to restrict movement or 2. Leather, nylon, or vinyl waist belt and wrist cuff:
mobility or to disengage from harmful behavior Used as a less restrictive method than a four‑ or
displayed by an individual five‑point restraint for patients who engage in
2. Chemical restraint involves the use of medication to severe agitation and primarily involves the hands
restrain. It differs from therapeutic sedation in that or arms. A canvas camisole may be used instead of
it does not have a direct therapeutic purpose but is a waist belt and wrist cuff to effectively provide the
primarily employed to control undesirable behavior same level of restraint
3. Mechanical restraint involves the use of equipment. 3. Leg restraint: A leather, nylon, or vinyl cuff with
Examples include specially designed mittens in intensive connecting strap, which allows ambulation but
care settings, everyday equipment such as using a heavy limits the ability of the patient to run or engage in
table or belt to stop the person getting out of their aggressive kicking
chair, or using bedrails to stop a person from getting 4. Protective helmet: Used to protect the head of a
out of bed. Controls on freedom of movement – such as patient who engages in self‑directed violence such
keys, baffle locks, and keypads– can also be a form of as head banging
mechanical restraint 5. Five‑point restraint: A physical‑restraint technique
4. Environmental restraint involves buildings designed to in which a patient’s wrists and ankles are secured
limit people’s freedom of movement, including locked to four points on a bed with leather, nylon, or
doors, electronic keypads, double door handles, and vinyl cuffs, and straps while the patient is in a
baffle locks supine position on a plastic‑covered mattress
5. Seclusion is an important subtype of environmental with a waist belt to immobilize all movement.
restraint. It is defined as “placing of a person, at any A five‑point restraint comprises the highest level
time and for any duration, alone in an area with the of physical restraint, and its use presupposes a
door(s) shut in such a way as to prevent free exit from judgment by appropriate clinical staff that lesser
that area” restrictive techniques of control, such as verbal
6. Psychological restraint includes constantly telling a intervention, have not or would not be effective.
person not to do something, or that doing what they If head restraints are also used, it may amount to
want to do is not allowed, or is too dangerous. It may seven‑point restraint
include depriving a person of lifestyle choices by, for 6. Restraint chair: A chair specifically designed to
example, telling them what time to go to bed or to get up. restrain a patient who is in danger of hurting himself
It might also include depriving individuals of equipment or others during a severely agitated episode
or possessions they consider necessary to do what they 7. Leather, vinyl, or plastic cuffs: Used instead of metal
want to do, for example, removal of walking aids, glasses, handcuffs to restrain a patient who is in danger of
or outdoor clothing or keeping the person in nightwear hurting himself or others during a severely agitated
with the intention of preventing them from leaving episode
7. Broadly speaking, the need to use restraint, 8. Metal handcuffs, shackles, and chains. These are
particularly physical restraint arises from two distinct abolished in the MHCA 2017 and strictly forbidden.

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STANDARDS REQUIRED restraint practices: assessment of traumatic histories

and symptoms, recognition of culture and practices that
The priority for any health‑care provider must be the are retraumatizing, processing the impact of a restraint
reduction of aggression and coercion in their facilities. with the patient, and addressing staff training needs to
This requires proactive measures to anticipate the risk of improve knowledge and sensitivity
violence with the aim to prevent aggression toward staff and b. Ensure that the safety and dignity of patients and
coercion toward patients. Person‑centered and value‑based the safety of staff are priorities when anticipating or
approaches to care are vital to achieving this. All current managing violence and aggression. When a patient
guidelines convey the same, clear, and unambiguous demonstrates a need for immediate medical attention in
message: Proactive and preventative approaches should the course of an episode of restraint, medical priorities
precede any use of coercive measures. The staff could shall supersede psychiatric priorities
use evidence‑based risk assessment tools such as the c. Restraint must only be used in full compliance of the
Broset Violence Checklist or the Dynamic Appraisal of MHCA 2017
Situational Aggression – Inpatient Version rather than d. Patients should ideally not be restrained in a prone
unstructured clinical judgment alone. Staff should work position. Prone restraint should be used only when
within a framework that allows de‑escalation whenever required by the immediate situation to prevent
possible.[11,17‑19] imminent serious harm to the patient or others. To
reduce the risk of positional asphyxiation, the patient
There may be occasions when staff needs to consider the should be repositioned to a sitting, standing, or supine
use of physical restraint as a management strategy. The position as quickly as possible. Responders should
purpose of restraint is first to take immediate control of pay close attention to the respiratory function of the
a serious, significant, or dangerous situation, and second patient during containment
to contain or limit the person’s freedom for no longer e. Restraint must never be used as punishment, for the
than is necessary to end or significantly reduce the threat convenience of staff, or as a substitute for the treatment
to themselves or those around. Ideally, a multidisciplinary programs
team including psychiatrist, nursing staff, and pharmacists f. Objects should not be placed over a patient’s face.
should develop an individualized strategy to reduce the In situations where precautions need to be taken to
risk of violence, including a pharmacological strategy protect staff against biting and spitting, staff should
appropriate for each patient. Such a strategy should have wear gloves, masks, or clear face shields when possible
clear aims, clarified target symptoms, a likely timescale for for purposes of infection control
the response to medication, and a maximum total dose. g. Unless necessary to prevent serious injury, a patient’s
hands shall not be secured behind the back during
The person in control of the incident will have to carefully containment or restraint. If it is necessary, staff shall be
assess the situation and use their own judgment as to what present, within arm’s reach, to prevent falling or injury
may be deemed “serious” or “significant” before employing h. The criterion for release of a patient from restraint is
physical interventions. Furthermore, any physical restraint the achievement of the objective, i.e., that the patient
used must be justifiable, appropriate, reasonable, and no longer represents an imminent danger to self or
proportionate to a specific situation and should be applied others. Every restrained patient shall be informed of
for the minimum possible duration. Restraint should the behavior that caused his or her restraint and the
be viewed as a last resort and only used when all other behavior and conditions necessary for their release.
interventions have failed. The patient shall be released from restraint as soon
as he/she is no longer an imminent danger to self or
An advance directive can help to develop care plans for others.
emergencies. It should be remembered that person‑centered
care and effective communication should not cease during TRAINING REQUIREMENTS
restraint, as this will help in terms of gaining co‑operation
and returning autonomy as soon as possible, as well as We recognize that training in restraint techniques is
ensuring that the intervention has therapeutic value and not widespread in India. MHCA 2017 should be seen as
that the therapeutic relationship is maintained. encouragement to develop safe and culturally appropriate
a. Each facility should provide a therapeutic milieu that restraint techniques for Indian health settings that are taught
supports a culture of recovery, individual empowerment, in a systematic and standardized way. Certain principles will
and responsibility. Each patient will have a voice in have to apply: Staff responsible for or participating in the
determining his or her treatment options. Facility restraint process will demonstrate relevant competency in
staff should be particularly sensitive to patients with a the following areas before participating in a restraint event
history of trauma and use trauma‑informed care. The or related assessment, monitoring or provision of care
following principles of trauma‑informed care shall guide during an event:[20,21]

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a. Strategies designed to reduce confrontation and to f. A decision that the risks associated with the use
calm and comfort people, including the development of restraint are significantly less than not using
and use of a personal safety plan restraint.
b. Use of nonphysical intervention skills as well as bodily 3. Documentation of the examination required above,
control and physical management techniques based on including the time and date completed, shall be
a team approach included in the patient’s medical record
c. The safe application and use of all types of restraint 4. The written order shall:
devices a. Be written on the order sheet and included in the
d. Observing for and responding to signs of physical and patient’s medical record
psychological distress b. Specify the facts and behaviors justifying the
e. Monitoring the physical and psychological well‑being of intervention and identify the time of initiation and
the patient who is restrained, including but not limited expiration of the authorization
to: respiratory and circulatory status, skin integrity, vital c. Specify the type of restraint ordered
signs, and any special requirements specified by facility d. Specify the positioning of the patient for respiratory
policy associated with the face‑to‑face evaluation and other medical safety considerations; patients
f. Clinical identification of specific behavioral changes should never be restrained in a prone position
that indicate that restraint is no longer necessary e. Specify the physical proximity of the staff member
g. The use of first aid techniques assigned continuous visual observation (i.e., within
h. Certification in the use of cardiopulmonary resuscitation, arm’s length and outside the room.)
including required periodic recertification. f. Include any special care or monitoring instructions,
including medical risk considerations for age and
GENERAL PROCEDURES fragility issues
g. Include the criteria for release.
The points to be considered while using restraint procedures 5. Prior to or immediately after placing a patient in
in general.[22,23] Also, see Table 1 for the checklist before restraint, he/she shall be searched for potentially
initiating any restraint procedure. dangerous or contraband objects by a staff member of
the same gender. Any potentially dangerous/contraband
Preventing the use of restraint objects shall be removed and documented in the
1. Use de‑escalation techniques to divert, distract, or patient’s medical record
withdraw. Use available spaces to distract the patient 6. The patient must be clothed appropriately for
and keep other persons safe temperature and at no time shall a patient be placed in
2. Employ breakaway techniques for staff safety while restraint in a nude or semi‑nude state
continuing to communicate with the patient 7. On the initiation of restraint, the physician/psychiatrist/
3. Only use taught restraint techniques when restraint registered nurse shall inform the patient of the behavior
becomes necessary. that resulted in the restraint and the behavior, and the
criteria reflecting an absence of imminent danger that
Initiating restraint use is necessary for release
1. The implementation of restraint shall only be pursuant to 8. For patients under the age of 18 years, the facility must
an order by a physician (Psychiatrist), if permitted by the notify the parent(s) or legal guardian(s) of the patient
facility to order restraint and stated within their protocol. who has been restrained as soon as possible, but no
The attending physician (psychiatrist) must be consulted later than 24 h after the initiation of each restraint
as soon as possible if he/she has not ordered the restraint event. This notification must be documented in the
2. An examination of the patient should be conducted and patient’s medical record, including the date and time of
shall include: notification and the name of the staff person providing
a. A face‑to‑face assessment of the patient’s mental the notification.
status and physical condition
b. A review of the clinical record for any pre‑existing Restraint
medical diagnosis and/or physical condition which 1. The use of prone restraint must be minimized, and the
may contraindicate the use of restraint duration must be only long enough to gain control.
c. A review of the patient’s medication orders, Sitting on top of any part of a patient during this
including an assessment of the need to modify such process is prohibited. At all times during a prone
orders during the period of restraint containment, the weight of the staff shall be placed to
d. An assessment of the need or lack of need to elevate the side of the patient, rather than directly on top of
the patient’s head and torso during restraint the patient. Staff is prohibited from placing significant
e. A decision of whether to continue or terminate the body weight on the patient, including staff ’s knees,
restraint elbows, and torso

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Table 1: Checklist that may be followed while using restraint

Name and describe the behaviors of concern Justify the use of restraint
 Name and describe the behavior  Is the use of restraint consistent with best practice?
 When did this behavior commence? Is it new?  Are there alternative and less restrictive ways to achieve the stated
 How often does it occur? goals?
 When does it occur?  Is it lack of resources which is informing the use of restraint when there
 What appears to be the trigger? may be alternative ways to achieve the stated goals?
 How is it being interpreted by the patient/people who know him/her?  Is the use of restraint expedient and for the convenience of others?
 How is it being interpreted by caregivers?  Why does the person who is administering or proposing the restraint
 Is the behavior independently observed, i.e., are people forming an consider it to be in the best interests of the person?
opinion based on case notes rather than their own observation?  Are there any risks to the patient if restraint is utilized? How will these
 Would the behavior change if other issues were addressed? For example, risks be managed?
is the patient receiving adequate pain management? Is the patient  How have been the competing rights weighed? For example, has the
suffering from an infection or delirium? right to dignity been sufficiently considered or the right to safety been
 Has a relevant expert assessed the person? considered paramount?
 Has a review been conducted of the medication the patient is being  Has there been compliance with legislation, relevant professional
administered? standards and with organizational policy?
 What is the risk to the patient if restraint is not utilized?
 What are the risks to others?
Communication and documentation Precautions and contraindications for using restraint
 Has the patient been informed about the fact that the restraint is going to  Prevention attempts with alternative restrictive measures
be used and why? What are their wishes/advance directives?  Revise procedures for assessing medical conditions of psychiatric
 Have the people who have an interest in the welfare of the patient to be patients
restrained been consulted (family members, friends, advocate, guardian,  Promote staff training in alternatives to physical restraint and the proper
etc.)? use of holding and restraint
 Have the carers who are involved in the administering of the restraint  Constantly observe all patients in restraint
been informed why the restraint is being utilized?  Avoid prone restraint
 Has the decision to use restraint, and the reasons for it, been documented?  With supine restraints, allow patient’s head to rotate freely. Do not cover
 If guardians are asked to sign forms, they should be clear about what the patient’s face with a towel, bag, etc., during therapeutic holding
they are being asked to authorize and whether it is within their powers  Restraint patient is kept away from all dangerous items
and duties to do so

2. During containment, all staff involved must constantly hour, the observation must be conducted by a duty
observe the patient’s respiration, coloring, and any physician
other possible signs of distress and immediately respond 2. Patients in restraint shall be monitored to ensure that
if the patient complaints of shortness of breath or not his/her physical needs, comfort, and safety are properly
being able to breath, or otherwise appears distressed addressed. Patients must be offered the opportunity
3. When containment is initiated, nursing staff must assess to drink and to go to toilet, as requested, and have a
the patient as soon as possible, including checking the range of motion, as needed, to promote comfort. Staff
patient’s circulation and vital signs. The patient must assigned to do the monitoring shall be competent
be seen and assessed (including respiration and other to recognize the physical and psychological signs of
vital signs) by a nurse within 15 min of the restraint distress
and at least every hour thereafter while the patient is in 3. For each use of restraint, the following information
restraint shall be documented in the patient’s medical record:
4. Unless necessary to prevent patients from injuring a. The emergency situation that resulted in the
themselves or others, the patients’ hands must not be restraint event
secured behind their backs during containment. If this b. Alternatives or other less restrictive interventions
is necessary, the duration must be only long enough to attempted, or the clinical determination that less
gain control. If the patient is lying down, assistance to restrictive techniques could not be safely applied
a standing or sitting position must be provided as soon c. The name and title of the staff member initiating
as possible. restraint
d. The date/time of initiation and release
Monitoring patients in restraint e. The patient’s response to restraint, including the
1. Restrained patients should be on continuous visual rationale for continued use of the intervention
observation. Documentation of the patient’s condition f. That the patient was informed of the behavior that
should occur at least every 15 min by trained staff for resulted in restraint, and the criteria necessary for
behavior, potential injury, circulation, and respiration. release.
Staff shall document their observations, their name, 4. This documentation should be in the patient’s medical
and the date and time of the observation on a restraint record and in a facility, a registry maintained for this
form developed by the facility. At least one time per purpose

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5. A restrained patient must be located in an area not to prevent or reduce the frequency and duration of
subject to view by other patients and where the the use with patients. Even though it is not prescribed
restrained patient is not exposed to potential injury by by MHCA 2017, it would give credibility to the mental
other patients. health establishment.

Releasing the patient from restraint CONCLUSION

1. A patient shall be released from restraint as soon as he
or she no longer appears to present an imminent danger Learning to recognize the signs of assaultive behavior and
to themselves or others and meets the behavioral preventing behavior that can escalate and lead to violence are
criteria for its discontinuation. Every restrained patient essential for safety. The primary goals of learning to manage
shall be informed of the behavior that caused his or her assaultive behavior are to preserve safety and dignity and
restraint and the behavior and conditions necessary to prevent assaultive behavior before it occurs. However,
for their release. Documentation shall also include the in mental health care, there can be clinical situations where
name and title of the staff releasing the patient; and the restraint may be used only in an emergency situation to
date and time of release assure the physical safety of the patient or nearby persons
2. Upon release from restraint, a nurse shall observe, or to prevent significant destruction of property. Restraint
evaluate, and document the patient’s physical and must not be imposed in any form as a means of punishment,
psychological condition discipline, the convenience of or retaliation by staff, or
3. After a restraint event, a debriefing process shall take because of a lack of staff presence or competency. Training
place to decrease the likelihood of a future restraint should be developed to allow standardized and safe
event for the patient and to provide support. Each restraint techniques to be taught throughout India.
facility shall develop policies to address the following:
a. A review of the incident with the patient who Acknowledgment
was restrained. The patient shall be given the We have used existing guidelines and agreed consensus
opportunity to process the restraint event as soon documents for the preparation of this article. The documents
as possible and not beyond 24 h of release. This are all referenced and sometimes quoted verbatim. We have
debriefing discussion shall take place between the ensured that the guidelines are fully compatible with the
patient and a preferred staff member. This review MHCA 2017. We are indebted to the authors of the existing
shall seek to understand the incident within the guidelines and to those who have worked tirelessly to
framework of the patient’s life history and mental develop guidance appropriate for the Indian context.
health issues. It should assess the impact of the
event on the patient and help the patient identify Financial support and sponsorship
and expand coping mechanisms to avoid the use of Nil.
restraint in the future. The discussion will include
constructive coping techniques for the future. Conflicts of interest
A summary of this review should be documented in There are no conflicts of interest.
the patient’s medical record
b. A review of the incident with all staff involved in REFERENCES
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