Restraints are behavioural management interventions used only when a nurse has the legal authority to do so and as a last resort. Restraints may be physical (manual holds), mechanical (pinel-type restraints), environmental (seclusion or locked rooms), or chemical (sedation). Applying restraint or seclusion without consent or legal authority is assault and a criminal offence.
Restraints are not a substitute for providing a safe environment or proper care and management of any person in care. Nurses are aware of applicable BCCNM standards, limits and conditions, relevant legislation, best evidence, and employer policies related to restraint use.
To carry out a restraint activity, nurses:
Obtain consent from the client or the client's substitute decision maker, or have legal authority overriding the consent requirement.
Have the competencies to use restraints safely.
Follow their employer's restraint policy.
Consent practice standard and employer policies when obtaining consent.
In addition, RPNs have further limits and conditions on restraint use, as per the Scope of Practice for Registered Psychiatric Nurses.
In non-emergency situations, RPNs require an order as outlined in the Scope of Practice standard for the use of restraints. Employer policy may also require an order for restraint use by a nurse.
Emergency and non-emergency restrain use are governed by different legislation. Legislative exemptions for consent in emergency situations include:
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 with a physically aggressive adult who is incapable of providing consent.
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 without a doctor's order for a client certified under the Mental Health Act who is in immediate danger of significantly harming themselves or others.
If a client is admitted for involuntary psychiatric treatment in a designated facility under the
Mental Health Act, the need for consent is limited. However, a nurse should always try to obtain consent even if there is legislation that authorizes a nurse to act without consent.
Nurses do not make decision about restraints for non-health care purposes (i.e., securing a prisoner undergoing care). However, if restraint is being applied for non-health care purposes, legal authority is required (i.e.,
Criminal Code of Canada, and
Corrections and Conditional Release Act).
For example, a nurse working in federal corrections may at times be acting as a nurse and as a peace officer. If a restraint is strictly for security reasons, consent is not required since legislation authorizes the use of reasonable force in the corrections setting. However, if restraint is required for health care, then consent is required, unless an exemption applies (see above).
Nurses have an ethical obligation to inform the client that they are being restrained, even if the person cannot consent (e.g., if they are certified under the
Mental Health Act).
The use of restraint carries risks to a client’s emotional and physical safety. Restraints should be considered as a last resort intervention, used temporarily in behavioural emergencies when other strategies have failed to keep the individual and others safe. Nurses should work to end the use of restraints as soon as possible, and ensure the client’s health, well-being, and condition are monitored, consistent with employer policy.
Nurses need to consider how the controls on practice impact restraint usage:
What does legislation allow? Under the Health Professions Act, the nursing regulations allow nurses to apply restraint. The law requires consent for these activities except under specific circumstances, as outlined above.
What do the BCCNM standards, limits and conditions allow? Nurses must meet the standards, limits and conditions as laid out in the Scope of Practice standards when applying restraint.
What do my employer policies allow? Nurses are responsible for following any employer policies related to restraint.
What does my individual competence allow? Nurses ensure they have the competencies to apply restraint in both emergency and non-emergency situations, and to do so safely.
Ally works on a facility’s special care unit. An 86-year-old client living with Alzheimer’s disease has had numerous falls when attempting to get out of 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 while 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 consent. Ally obtains an order from the client’s doctor for the use of a lap restraint when the client is in his chair.
Ally documents her activities and updates the client’s plan of care to include applying a lap restraint while he is in his chair; the plan of care will be re-evaluated daily to determine if the restraint is still needed. Ally documents provided nursing care, including restraint use assessment, application, monitoring, and evaluation, as outlined in the Documentation practice standard and her employer’s policy.