Restraint and seclusion activities impede the free movement of a client, either by using a device (mechanical restraint), manual hold (physical restraint), or sedating medication (chemical restraint), or containing a client in a room they cannot freely exit (seclusion). All these activities are a restriction of a client’s rights and should be done only when a nurse has the legal authority to do so.
Nurses may apply physical or mechanical restraint or seclusion interventions subject to any relevant legislation, BCCNM standards, limits and conditions in the Scope of Practice standards, and subject to any employer policies. Chemical restraint requires an order from an authorized health professional such as a physician or nurse practitioner.
To apply restraint or use seclusion, nurses must have consent or some form of legal authority that overrides the requirement for consent. Otherwise, applying restraint or seclusion would be an assault, which is a criminal offence.
When obtaining consent, nurses follow BCCNM's
Consent practice standard.
There may be legislative exceptions to the requirement for consent. For example, if a client is admitted for involuntary psychiatric treatment in a designated facility under the Mental Health Act, the need for consent is limited. Nurses may also be able to obtain consent from a substitute decision maker in certain circumstances. Speak to your employer to ensure you understand your authority. There are also legislative exemptions for emergency situations:
to preserve life, prevent serious physical or mental harm, or treat severe pain when an adult is incapable of giving consent and there is no appropriate substitute decision maker available. For example, a nurse working in an emergency room may apply restraint or seclusion with a physically aggressive adult who is incapable of consenting to treatment because the person is impaired by drugs or alcohol.
to act beyond their scope of practice if they have the competence to do so if there is imminent risk of death or serious harm arising unexpectedly and requiring urgent action. For example, a nurse may apply restraint or seclusion without a doctors’ order for a client certified under the Mental Health Act who is threatening another client, despite BCCNM’s condition normally requiring an order.
Restraint or seclusion initiated in an emergency is governed by different legislation than a non-emergency situation. To minimize client risks, nurses are expected to be aware of applicable BCCNM standards, relevant legislation, best evidence, and employer/organizational policies related to restraint and seclusion use.
In non-emergency situations, LPNs and many RPNs and RNs require an order (or written agreement from a doctor or nurse practitioner) for the use of restraint or seclusion. In addition, employer/organizational policy may require an order for the use of restraint or seclusion.
If restraint or seclusion is being applied for non-health care purposes, legal authority is required.
The use of restraint or seclusion carries certain risks to client safety. Nurses ensure they are monitoring the client’s health and well-being on a regular basis, consistent with employer/organizational policy, and take action when they aren’t sure the client’s safety can be maintained.
It is important to remember that having the legal and regulatory authority to carry out restraint or seclusion is not necessarily reason to do so. Just because you can, does not mean you should. Restraint and seclusion interventions are a restriction on a person’s freedoms and should only be used as a last resort when no other alternative is available.
Nurses need to consider the four controls on practice when using restraint or seclusion. For additional information related to controls on practice, seeyour Scope of Practice standards.
Legislation: Under the Health Professions Act, the nursing regulations allow nurses to apply restraint or seclusion. The law requires consent for these activities except under specific circumstances, such as when the client is in a designated facility under the Mental Health Act.
BCCNM Standards, Limits and Conditions: Nurses must meet the standards, limits and conditions as laid out in their Scope of Practice standards when applying restraint or seclusion.
Employer Policies: Nurses are responsible for following any employer/organizational policies related to restraint or seclusion.
Individual competence: Nurses are responsible for ensuring they have the competencies required to apply restraint or seclusion in both emergency and non-emergency situations and to do so safely.
All controls on practice must indicate that nurses can carry out restraint or seclusion for them to do so.
Having the legal and regulatory authority to carry out restraint or seclusion is not necessarily reason to do so.
Making a decision to carry out restraint or seclusion without an order requires a different level of knowledge, skill, and judgment than when restraint or seclusion is carried out with an order from another health professional.
Here are two scenarios to illustrate the above.
Ally works on the facility’s Special Care Unit. An 86-year-old client living with Alzheimer’s disease has had numerous falls when attempting to get up on his own when sitting in his chair. Ally knows the facility has a least restraint policy and has tried to prevent the client from falling by using the strategies outlined in the policy, however, she has not been successful in keeping him safe.
Ally assesses the client and determines that a non-emergency restraint is needed for client safety and that a lap restraint would be appropriate when he is sitting in his chair. Ally reviews her employer’s policy and asks for input from the health care team.
Ally explains to the client and his family the rationale for using a lap restraint, including the risks and benefits, and they give their consent to use it. Ally obtains an order from the client’s doctor for the use of a lap restraint when the client is up in his chair.
Ally documents her activities and updates the client’s plan of care to include applying a lap restraint while he is up in his chair; the plan of care will be re-evaluated daily to determine if it is still needed. Ally documents provided nursing care, including restraint use assessment, application, monitoring and evaluation, as outlined in the Documentation practice standard.
Lawrence is working in the emergency department when a man is admitted for treatment of a minor head wound. The client is in the custody of two police officers and handcuffed to the stretcher. Uncomfortable with the fact that the client is handcuffed, Lawrence asks the officers to remove them, but they refuse.
While it is true that handcuffs are a restraint, in this scenario the police make the decision regarding the non-health care related use of restraints, not the nurse. The client is in the care and custody of the police. If the restraints interfere with the client’s treatment, the nurse, health care team, and police officers work together to determine a care plan that considers how to allow for care. This includes discussing and planning alternative measures to ensure the safety of the client and others.
Nurses need to understand how relevant legislation may apply in their practice settings.