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Nurses are accountable for providing, facilitating, advocating and promoting the best possible patient care and to take action when patient safety and well-being are compromised, including when deciding to apply restraints. These are key accountabilities outlined in the Code of Conduct.
There are three types of restraints: physical, chemical and environmental. Physical restraints limit a patient’s movement. Chemical restraints are any form of psychoactive medication used not to treat illness, but to intentionally inhibit a particular behaviour or movement. Environmental restraints control a patient’s mobility.
Health care teams use restraints for a variety of reasons, such as protecting patients from harming themselves or others, after all other interventions have failed. Restraints should be used only for the shortest time when prevention, de-escalation and crisis management strategies have failed to keep the individual and others safe. In emergency situations, nurses may apply restraints without consent when a serious threat of harm to the patient or others exists and only after all alternative interventions were unsuccessful. Restraint use should be continually assessed by the health care team and reduced or discontinued as soon as possible. After the discontinuing restraints, interprofessional teams should debrief with the patient, patient’s family, or substitute decision maker to discuss intervention, previous interventions and alternatives to restraints.
With any intervention, such as restraint use, nurses need to ensure they actively involve the patient, patient’s family, substitute decision makers and the broader health care team. Nurses are also accountable for documenting nursing care provided, including assessment, planning, intervention and evaluation.
Read more about restraint use, alternative approaches to restraints, documentation and consent, in the Patient Restraints Minimization Act , RNAO Best Practice Guideline: Promoting Safety: Alternative Approaches to the Use of Restraints and in CNO’s Documentationstandard and Consent guideline.
It is important to note restraint use also puts patients at increased risk of medical, psychological, and functional complications. To minimize patient risks, nurses are expected to be aware of applicable CNO standards, relevant legislation, best evidence and organizational policies related to restraint use.
CNO also developed the following scenarios to provide nurses guidance around restraint use.
A long-term care facility nurse is admitting a patient transferred from a local hospital. The facility has a least restraint policy and for the past year has not used restraints. To prevent restraint use, they also use an admission of risk assessment protocol to help staff determine an appropriate care plan including identifying interventions that address behaviours. The patient’s children who are the substitute decision makers, insist on restraining their mother for safety. They tell the nurse that if, while restrained their mother falls, they will initiate legal action. What factors should the nurse consider in response to the family’s request?
As highlighted in the practice standard, Therapeutic Nurse-Client Relationship, Revised 2006, nurses are expected to be empathetic.Furthermore, nurses use their knowledge, skill and judgment when giving nursing care. They also modify client care plans, together with clients and the health care team, as outlined in the Code of Conduct.
The nurse in this scenario also must explore the family’s needs and the request’s implications. Nurses are expected to actively include the patient as a partner by identifying their needs and wishes and making them the care plan’s basis. The responsible nurse can collaborate with the broader health care team and the patient’s family to explore alternative ways to meet the patient’s needs, including assessing risk of falls and implementing falls prevention strategies as indicated. The nurse can provide education to the family about restraint use. The nurse needs to explain there are laws governing restraint use and that the facility’s least restraint policy means the health care team must explore alternative measures first; restraint is a last resort. If non-emergency restraints are indicated to preserve the patient’s safety, the nurse takes appropriate measures to ensure key expectations of restraint use are met:
After assessing the patient and determining non-emergency restraints are needed for patient safety, the nurse and health care team are responsible for obtaining consent.
The nurse also must effectively communicate the need for restraints to the patients and patient’s family. As highlighted in the practice standard Therapeutic Nurse-Client Relationship, Revised 2006, nurses use a wide range of effective communication strategies to meet patients’ needs and discuss their expectations. The standard outlines nurses ‘accountabilities for negotiating with the patient about the nurse, patient, family and significant others’ roles, and the goals identified in the care plan.
Finally, the nurse is responsible for documenting any provided nursing care, including restraint use assessment, application, monitoring and evaluation, as outlined in the Documentation, Revised 2008 standard.
Nancy is working in a community hospital’s emergency department when a local correctional facility patient arrives for treatment of a large leg wound. The patient has a history of acute mental illness, is handcuffed and accompanied by two correctional officers. The nurse asks the officers to remove the handcuffs and respect the patient’s privacy while in the emergency department. Although able to assess and treat his leg wound with the handcuffs in place, Nancy is uncomfortable with the patient’s movements being restricted by the handcuffs.
Handcuffs are a restraint. In this scenario, the correctional facility makes the restraint use decision, not the nurse. The patient is in the correctional officer’s custody and care. As outlined in the Scope of Practice standard, nurses are expected to understand relevant legislation and ensure their practice aligns with the legislation. The nurse needs to consider how legislation, such as the Correctional Services Transformation Act, 2018, Patient Restraints Minimization Act, 2001 and the Mental Health Act, may apply to this situation. For example, the Correctional Services Transformation Act, 2018 outlines the correctional officers’ accountabilities. For legislation interpretation, the nurse can consult with her employer or a legal representative.
Should restraints interfere with the patient receiving medical treatment, the nurse, health care team, and correctional officers need to determine a care plan that considers how best to reduce restraint to allow for providing care. This includes discussing and planning alternative measures for implementation while ensuring the safety of the patient and others.
The Code of Conduct highlights, nurses’ responsibility to maintain and advocate for quality practice settings that support safe, effective and ethical care. Nancy would be encourage to advocate within her facility for education on how best to care for patients from correctional facilities, restraint types used and the relevant legislation governing their care. Nancy needs to advocate within her facility for education on how best to care for patients from correctional facilities, restraint types used and the relevant legislation governing their care.
Three-year old Jody is intubated and on a ventilator following brain surgery. To prevent her pulling out the endotracheal tube, Susan, her nurse, collaborated with the physician and obtained an order for mittens. Prior to surgery, the need for mittens was explained to Jody and her parents and consent was obtained. Susan restrained Jody’s hands with mittens after assessing this was the least restrictive mechanism to protect Jody. She also informed the family that reassuring Jody following her surgery would be helpful. Susan documented restraint use in the patient’s chart and care plan. Mark, the nursing student observing Susan, wondered about the appropriateness of this restraint use.
This restraint use is appropriate. In this situation, Susan met the key expectations of restraint use:
Susan assessed the most appropriate restraint for Jody by reviewing individual factors, the patient’s health status and the environment. This aligns with expectations in the Code of Conduct, that nurses use their knowledge, skill and judgment when giving nursing care. They also modify client care plans, together with clients and the health care team.
Susan also obtained consent from Jody’s parents for restraint use. Nurses cannot use restraints without patient consent, except in emergency situations when there is a serious threat to the individual or others. This is outlined in the Patient Restraints Minimization Act, 2001 and Consent practice guideline.
Susan effectively communicated to Jody and the family, by discussing the care plan. Using language Jody understood, Susan explained why she needed mittens. As highlighted in the Therapeutic Nurse-Client Relationship, Revised 2006, nurses use a wide range of effective communication strategies to meet the patients’ needs. The standard outlines nurses’ accountabilities for negotiating nurse, patient, and family and significant others’ roles with the patient, and negotiating the goals identified in the care plan. In certain circumstances, a nurse may need to restrain patients, including when they are incapable of understanding the need for the intervention, as outlined in the Patient Restraints Minimization Act, 2001. The nurse needs to consider these situations carefully and, when possible, use methods of least restraint.
Finally, Susan documented the restraint use in the patient’s chart and care plan, meeting her accountabilities outlined in the Documentation practice standard:
- ensuring documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and collaborative) and evaluation
- ensuring the care plan is clear, current, relevant and customized to the patient’s needs and wishes
- documenting important communication with family members, significant others, substitute decision-makers and other care providers.
CNO Standards and Guidelines
- Code of Conduct
- Scope of Practice
- Therapeutic Nurse-Client Relationship, Revised 2006
- E-laws Ontario: Patient Restraints Minimization Act, 2001
- E-laws Ontario: Mental Health Act
- E-laws Ontario: Fixing Long-Term Care Act, 2021
- E-laws Ontario: Correctional Services Transformation Act, 2018
- RNAO Best Practice Guideline: Promoting Safety: Alternative Approaches to the Use of Restraints
- RNAO Best Practice Guideline: Preventing Falls and Reducing Injury from Falls
- RNAO Long-Term Care Best Practice Toolkit
- Alzheimer Society of Canada, resources on restraints
- Psychiatric Patient Advocate Office, Information Guide: Restraints
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