Unit 6
Difficult Conversations: Refusing and Disagreeing
Workplace English for Nursing Assistants
Meet Mr. Novak
Watch the video about Mr. Novak. Watch what happens.
Mr. Novak — Aggression During Care
Talk about it
- Would restraining Mr. Novak reduce his aggression? Why or why not?
- What risks would restraints create for him?
- What should you do after being hit at work?
The Big Idea: Restraints Are a Last Resort
By law, clients have the right to move freely about their environment. A restraint is anything — physical or chemical — that takes away that freedom.
The most important myth to break: restraints are NOT safety devices. They do not prevent falls. They do not stop outbursts. They do not reduce aggression. Instead, they cause serious harm — including death. The only acceptable reason to use one is safety, only as a last resort, and only with a doctor's order.
| Term | Plain meaning |
|---|---|
| Restraint | Anything (physical or chemical) that stops a client from moving freely about their environment. |
| Physical restraint | A device that limits movement — wrist, waist, vest, or mitt; or a side rail used to keep a client in. |
| Chemical restraint | A drug (anti-anxiety or antipsychotic) that limits the client's ability to function normally. |
| Environmental restraint | Using the surroundings to block movement (a wheelchair trapped against a wall; a tray the client cannot remove). |
Not sure if something is a restraint? Ask one question:
"Can the client purposefully move about their environment?"
If the answer is no — it is a restraint. (Locked brakes they cannot release? A tray they cannot lift off? A restraint.)
Practice 1 — Key Words
1.1 Match the term to its meaning
- 1. Restraint
- 2. Physical restraint
- 3. Chemical restraint
- 4. Environmental restraint
- A. A device that limits movement, such as a wrist or vest restraint
- B. Anything that stops a client from moving freely about their environment
- C. Using the surroundings to block movement, like a tray the client cannot remove
- D. A drug that limits the client's ability to function normally
1.2 In your own words
Write your own one-sentence definition of a restraint:
______________________________________________________________
______________________________________________________________
Practice 2 — What Counts as a Restraint?
The test: "Can the client purposefully move about their environment?" If no, it is a restraint.
2.1 Restraint? Write "Yes" or "No."
- A wheelchair placed so the client cannot move away from the wall.
- Wheelchair brakes the client can easily unlock by themselves.
- A medicine that leaves the client too drowsy to function normally.
- A tray table the client cannot remove by themselves.
- A side rail the client uses to turn and sit up on their own.
2.2 Name the type
- An antipsychotic drug that makes a client unable to function is a restraint.
- Trapping a wheelchair against a wall is an restraint.
3.2 True or False
- 1. A healthcare worker may apply a restraint whenever they think it is needed.
- 2. Restraints keep clients safe and prevent falls.
- 3. When a restraint is on, check below it for warmth, color, and feeling.
- 4. The only acceptable reason to use a restraint is the client's safety.
- 5. If a doctor has ordered a restraint, you should refuse to apply it.
The Risks — Why We Avoid Them
A restraint limits movement, and immobility is dangerous. The worst risk is death — a client trying to escape a restraint can strangle. Side rails are especially dangerous: a client's head or neck can become caught between the rail and the mattress.
Other risks include falls, pressure injuries, muscle weakness and atrophy, incontinence, depression, agitation, loss of dignity, and greater dependence. Important: restraints do not decrease agitation — they often increase it.
Side Rails — A Special Case
A side rail is allowed only if the client uses it to move or get up by themselves. If it keeps them in, it is a restraint.
Even as a positioning aid, it needs both: a doctor's order AND informed consent — a signed waiver by the client or their power of attorney.
Because of the strangulation risk, many facilities have removed side rails and use mounted positioning devices instead. These help the client move without the danger — they are not restraints.
The Hard Part: Saying No
Knowing the rule is the easy half. The hard half is what you actually say when a frightened daughter asks you to tie her mother into the chair — or when a coworker says "just put the tray on, she won't get up."
A bare "No" is a bad refusal. It sounds rude, it does not teach anyone anything, and it leaves the person with the same problem they started with. A good refusal has four parts.
1. Refuse clearly — "I'm afraid that's not possible."
2. Give the reason in plain words — "It would keep her from moving, and that's a restraint."
3. Offer an alternative — "How about we move her chair near the desk so we can watch her?"
4. Refer to the right person — "The nurse can explain the options."
- • How about moving her chair near the nurses' station?
- • What if we bring in something familiar from home?
- • Would it be possible to try a lower bed first?
- • Would this work — we check on her every half hour?
When You Disagree With Someone
Sometimes the problem is not a request — it is a belief. A family member is certain that restraints keep people safe. A coworker thinks a tray table is "not really" a restraint. You need to disagree without starting a fight.
- • I understand what you are saying, but in my opinion ...
- • I respect your opinion, but I think ...
- • I hate to disagree with you, but I believe ...
- • You could be right, but I don't think that ...
Alternatives First — Always
Alternatives must be tried before any restraint, and documented if they fail. Prevention is key: stop aggression before it starts.
- Meet basic needs on a schedule — toileting, food, fluids, and pain relief.
- Keep the environment calm — reduce noise, turn off the TV, avoid alarms and known triggers.
- Communicate gently — speak calmly, offer choices, go slowly, re-approach later, or send a different staff member.
- Engage and comfort — activities, family visits, a familiar object from home, soft music.
- Watch closely — keep an agitated client near the nurses' station where staff can keep an eye on them.
Practice 4 — Alternatives & Side Rails
4.1 Good alternative to a restraint? Write "Yes" or "No."
- Keep the environment calm and quiet.
- Turn on loud alarms near the client.
- Bring a familiar object from home.
- Keep a routine schedule and meet basic needs on time.
- Place an agitated client near the nurses' station.
4.2 Side rails: True or False
- 1. A side rail is allowed only if the client uses it to move themselves.
- 2. Side rails carry a risk of strangulation.
- 3. A side rail used for positioning needs a doctor's order and signed consent.
- Say the one test question from memory.
- A client's wheelchair is parked facing a wall so she cannot turn it. Restraint?
- Name the three types of restraint.
- What do you secure a restraint to? What must you never secure it to?
- The nurse has a doctor's order and asks you to apply wrist restraints. What do you do?
- When is a side rail NOT a restraint?
- What two things are needed before a side rail is used for positioning?
- Why are side rails especially dangerous?
- Name the four parts of a good refusal.
- Which refusal phrases must you never use with a family member?
- A daughter asks you to raise both side rails. Say your whole answer out loud.
- Why is indirect disagreement stronger at work than direct disagreement?
- A coworker says "A tray isn't a restraint." Write a polite disagreement.
- Which disagreeing phrases are only for friends, never for work?
Dialogue Practice
Read the dialogues out loud with a partner.
Mrs. Falconer's daughter has been visiting all afternoon. Her mother keeps standing up from the wheelchair. The daughter is exhausted and frightened.
Daughter: She's going to fall. Can't you just tie her in the chair? Or lock the wheels so she stays put?
You: I can see you're worried about her. I'm afraid that's not possible.
Daughter: Why not? It's for her own good.
You: Let me explain it in simpler terms. If she can't get up on her own, that's called a restraint. In other words, locking the wheels does the same thing as tying her — and by law we can't do that without a doctor's order.
Daughter: But it would keep her safe!
You: That's the part that surprises most people. I understand what you are saying, but in my opinion — and this is what the research shows — restraints don't prevent falls. People struggle against them and get hurt worse.
Daughter: So we just do nothing?
You: Not at all. How about we move her chair near the nurses' station? We can watch her there. What if you bring in her photo album? Something familiar often settles her.
Daughter: She does love those photos.
You: Let's try it. And the person who can really answer your questions is the nurse — shall I ask her to come and talk with you?
Daughter: Yes. Thank you — I didn't know any of that.
In the dining room you see Bea, an experienced healthcare worker, wedge Mrs. Ilunga's wheelchair between the table and the wall, then put a tray table on.
Bea: There. She won't wander off now. Works every time.
You: (quietly, stepping closer) Bea — can I ask you something? Can she take that tray off by herself?
Bea: Probably not. But it's just a tray. It's not a restraint.
You: I hate to disagree with you, but I believe it counts. We learned the test is: can she move about on her own? If she can't take it off, it's a restraint.
Bea: I've done this for twelve years.
You: I respect your opinion, and you know far more than I do. You could be right, but I don't think we can risk it — the rules changed and it's our licenses.
Bea: ... All right. What do you suggest, then?
You: How about we move her to the table by the window? She can see the garden, and we're both right there. Would that work?
Bea: Fine. Help me move her.
Roleplays
Work with a partner.
Situation
Mrs. Adeyemi's son visits and finds his mother has slid down in her wheelchair again. He asks you to put a lap belt on him so he stays upright and cannot get out. Refuse, explain, offer alternatives, and refer.
Your Goals:
- Acknowledge her worry BEFORE refusing.
- Use ONE clear Refusals phrase.
- Explain the reason in plain words, including that restraints do not prevent falls.
- Offer at least TWO alternatives using Discussing Options.
- Refer him to the nurse by name or role.
Situation
A coworker with fifteen years' experience pushes a client's recliner footrest up so the client "can't get out and wander." The client cannot lower it herself. Disagree with him, quietly, and get it fixed.
Your Goals:
- Speak to him PRIVATELY, not in front of clients.
- Use at least TWO indirect Disagreeing phrases.
- Ask the key safety question—“Can she lower the footrest herself?”
- Offer an alternative.
Cumulative Review
Chattybot · Check Your KnowledgeScan to answer these questions out loud.Multiple Choice
Cover the answers, try from memory, then cross out the choices you know are wrong.
1. The use of restraints can
- keep a client safe from falls
- decrease aggressive behavior
- cause depression
2. A restraint may be used only
- because a client hits and yells
- for the client's safety, with a doctor's order
- to stop a client from wandering
3. A client has a wrist restraint. You must check the hand and the area below it every
- 2 hours
- 15 minutes
- 30 minutes
4. A client has ankle restraints. Alert the nurse right away if the client
- says their foot feels numb
- has a warm foot when touched
- moves the foot on their own
5. A healthcare worker may apply a restraint only if
- a client is at risk of falling
- the nurse decides it is needed
- it is ordered by the doctor
6. A client on new anxiety medicine is now too drowsy to eat lunch without help. This is an example of a
- chemical restraint
- environmental restraint
- physical restraint
7. A client asks for the side rail up to help them reposition. You should
- put it up — they are using it to move
- refuse — side rails are never allowed
- put it up after the nurse gets informed consent
8. A healthcare worker helps prevent restraints by
- putting alarms on wheelchairs
- keeping clients on a routine schedule
- telling families to visit daily
9. Restraints may lead to all of the following EXCEPT
- pressure injuries
- decreased agitation
- emotional upset
10. Before a side rail may be used for positioning, staff need
- a doctor's order only
- a signed waiver only
- a doctor's order AND a signed waiver
11. A daughter demands you tie her mother into the chair. The BEST first sentence is
- "I'm afraid that's not possible, and let me explain why."
- "You cannot do that."
- "Fine, I'll ask the nurse."
12. A coworker says a tray table is "not really" a restraint. The BEST response is
- "That's ridiculous."
- say nothing — it is not your business
- "I understand what you're saying, but I think it counts if she can't remove it."
Back to Mr. Novak
Read the case. Answer in complete sentences.
Mr. Novak has dementia. When you help him to the bathroom or try to bathe him, he becomes very aggressive — he spits, pinches, and shouts. Tonight, while you were getting him ready for bed, he hit you in the face.
1. Would restraining Mr. Novak reduce his aggression? Why or why not?
______________________________________________________________
2. What risks would restraints create for him?
______________________________________________________________
3. What are the risks of giving him an anti-anxiety or antipsychotic medicine?
______________________________________________________________
4. List three alternatives you could try instead of a restraint.
______________________________________________________________
5. What should you do after being hit at work?
______________________________________________________________
Instructor Answer Key
Unit 6 — Difficult Conversations: Refusing and Disagreeing
This unit introduces restraints, client rights, and safer alternatives to restricting movement. Learners examine physical and chemical restraints, side rails, restraint risks, required safeguards, and approaches that address the client’s underlying needs. A case study about Mr. Novak explores aggression, worker safety, medication risks, and alternatives to restraint. Through illustrated readings, flashcards, knowledge checks, dialogues, and role-plays, learners practice refusing unsafe requests without rejecting the person, giving a clear reason, offering an alternative, referring the concern appropriately, and disagreeing respectfully with family members and experienced coworkers.
Practice 1–4 and Review
Practice 1.1: 1-B, 2-A, 3-D, 4-C. Practice 1.2: answers vary — accept any wording meaning "anything that stops a client from moving freely about their environment."
Practice 2.1 (restraint?): 1. Yes 2. No 3. Yes 4. Yes 5. No. Practice 2.2: 1. chemical 2. environmental.
Practice 3.1: 1. doctor 2. 15 3. 2 4. bed frame 5. quick-release. Practice 3.2: 1. False 2. False 3. True 4. True 5. False (a properly ordered restraint is applied correctly — refusing is not the student's call).
Practice 4.1 (good alternative?): 1. Yes 2. No 3. Yes 4. Yes 5. Yes. Practice 4.2: 1. True 2. True 3. True.
Multiple Choice: 1-c, 2-b, 3-b, 4-a, 5-c, 6-a, 7-c, 8-b, 9-b, 10-c, 11-a, 12-c.
Back to Mr. Novak Best Response: 1-b (try alternatives; a restraint is never a fix for short staffing). 2-b (once a doctor orders it, apply it correctly — and still do the 15-minute checks). 3-b (side rails need informed consent first). 4-c (speak privately and respectfully, then tell the nurse — not silence, and not a public confrontation).
Call out a request ("Lock her brakes." "Put the tray on." "Tie him in bed." "Give her something to calm her down."). The learner must answer with all four parts in one breath: refuse → reason → alternative → refer. Run it fast, many times. The goal is that a "no" never comes out without the other 3 parts.