Spotlight on the Standards

Physical Restraint: Intervention of Last Resort

The National Commission receives many inquiries about the use of physical restraints in correctional facilities. Because of this high interest—and, frequently, confusion—this Spotlight column will focus on the “restraint” component of essential standard I-01 Use of Physical Restraint and Seclusion in Correctional Facilities.

First Things First
Before we delve into interpretation of the standard, a few points must be made clear. First, this standard does not address the custody restraints used to transport inmates or those required due to the inmate’s security classification. In such cases, use of these motion-limiting devices is a routine correctional procedure set by jurisdictional authorities.

Health staff are not involved in these cases unless there is a health-related reason to alert custody of a contraindication or a modification needed for a particular inmate. For example, if an inmate with a broken leg cannot tolerate the usual leg shackle restraint, health staff must alert security that the usual transport protocol needs to be modified for this inmate. (See standard A-08 Communication on Special Needs Patients.)

A second point is that, whether correctional or clinical, all staff who apply restraints must be trained to do so. However, in cases where the restraints are for clinical reasons, there is no requirement that health staff must apply them. In fact, it’s common for a team of trained correctional staff and health staff to be involved, with correctional staff actually applying the clinically ordered restraints.

Third, different devices are used for different types of restraint. Custody ordered restraints include cuffs, belts, leg shackles and chains, as well as leather or “soft” devices. Restraining methods used for clinical reasons are limited to those used in community clinical settings. These include fleece-lined leather, rubber or canvas hand and leg restraints, two-point and four-point restraints, and restraint chairs*. Inmates are not to be restrained in an unnatural position, such as hog-tied, facedown or spread-eagle.

Finally, for both types of restraints, health staff must make a physical assessment of the inmate initially and periodically, usually in coordination with trained security staff monitoring the inmate. This includes checking for circulation and nerve damage, airway obstruction and psychological trauma. Also, each of the inmate’s limbs should be exercised for at least 10 minutes every 2 hours to prevent blood clots.

See the Compliance Indicators for specific actions required of health staff for clinically ordered restraints (Indicator 2) and custody ordered restraints (Indicator 3).

All of this makes sense when we consider the intent of this standard: “[W]hen restraints are used for clinical or custody reasons, the inmate is not harmed by the intervention.”

Custody vs. Clinical Restraints
The usage of physical restraint addressed by this standard is limited to emergency situations in which an inmate’s behavior presents a danger to self, other inmates or staff.

Clinically ordered restraint, by definition and practice, is used only after other interventions have failed as a last resort for the shortest amount of time needed for the inmate to regain control. It may never be used as discipline or as a way to control unruly behavior.

As with clinical restraint, in good correctional systems, custody ordered restraint is an infrequent intervention used as a last resort. Correctional protocols define the circumstances when custody may intervene. If allowed by jurisdictional directive, custody restraint also may be used as a disciplinary measure.

In all circumstances, officers must be trained how to intervene safely. Many jurisdictions provide training in one or more techniques of nonviolent intervention or de-escalation.

Most of the confusion surrounding the use of physical restraints stems from the reason for the behavior that leads to an inmate’s restraint. While such behavior can be caused by any number of reasons, it is the reason for the behavior, not the behavior itself, that dictates the role of health staff.

For example, an angry male inmate yelling and threatening to harm an officer could be psychotic and responding to voices, or simply very upset because his wife did not come to visit as she had promised. A woman refusing to enter her cell may be protesting what she perceives as an unreasonable early termination of her recreation time, or may be experiencing a flashback of being raped in a locked bedroom.

It is not always difficult to distinguish between instances of restraint for custody vs. clinical reasons. In situations where the inmate is known to have behavioral manifestations of mental illness (and communication between health staff and security about special needs must be ongoing, of course), the officers will be quick to alert health staff on duty for the physician’s orders for controlling the situation.

On the other hand, some inmates are well-known among staff for ill temper or violent behavior that’s unrelated to any illness, and unfortunately may need periodic custody restraint to prevent harm to others.

But it can be challenging to determine the reason for out-of-control behavior in inmates newly admitted to facilities, those whose medical or mental health history is not known, and those who present with both clinical problems and difficult personalities. This is why custody staff must alert health staff when an inmate is put into restraint for presumably custody reasons.

Health staff then must review the health record for any contraindications or required accommodations and immediately communicate these to custody staff (Compliance Indicator 3.a.1.). When health staff assessing the restrained inmate note a medical or mental health condition, the physician is notified immediately so that appropriate orders can be given (3.b).

Clinical Restraint Issues
Therapeutic use of physical restraint for medical reasons is relatively rare and generally limited to use in inpatient or infirmary settings. Most commonly it is used for those with mental health disorders, and usually, but not always, related to noncompliance with psychotropic medication.

Before using physical restraint on inmates with mental health disorders, practitioners must first try less restrictive interventions (e.g., talk the inmate down, offer medication), as well as consider changes in the treatment plan. Further, the health record must document those prior interventions and treatment plan changes for each instance of restraint use.

If restraint is used, the question may arise as to whether the use of psychotropic medication can shorten the period of time that restraint is needed. While this may be a justification for emergency administration of psychotropic medication, it should be remembered that a restrained inmate may be willing to accept medication and so the forced technique would not be needed. (See standard I-02 Emergency Psychotropic Medication.)

CQI Monitoring
The facility’s continuous quality improvement program should monitor all incidents of clinical restraint so that patterns not related to individual inmates may be detected. (See standard A-06 Continuous Quality Improvement Program.) For example, frequent use of restraint in a residential unit for those with mental health problems would indicate a need to assess the effectiveness of treatment being provided.

Likewise, higher utilization of physical restraint in one housing unit vs. another of similar numbers and classification of inmates should prompt an examination of factors leading to such interventions, such as the unit officers’ techniques and attitudes.

In the ideal correctional setting, there would be no need for physical restraint. But we must deal with what is real, so keeping the use of this intervention to a minimum—and employing it safely when it is needed—should be the goal.

(This article first appeared in the Winter 2006 issue of CorrectCare.)

Back to Spotlight on the Standards home page

Do you have a question about the NCCHC standards for health services? Contact us at:

Standards Q&A
National Commission on Correctional Health Care
1145 W. Diversey Pkwy., Chicago, IL 60614
Phone (773) 880-1460  •  Fax (773) 880-2424
E-mail accreditation@ncchc.org