Environmental – the control of a person's mobility by restricting the available geographic area.
Mechanical /Physical – the use of any technique, device or mechanism to limit the movement of a person or of a portion of the person's body.
Chemical – the use of a drug to specifically control a person's behaviour.
When can patient restraints be used?
Patient restraints can be used if it is necessary to prevent serious bodily harm to the patient or to another person. They may be applied in an emergency situation where danger is imminent. Restraints should NEVER be used as punishment, as a substitute for nursing care, or as a matter of convenience for the health care provider. Each situation must be dealt with individually and specifically.
Provincial mental health acts may specifically address the use of restraints within a mental health setting.1 A patient has the right to autonomy of his person. A competent patient may prefer to take the risk of injury, rather than be restrained. Nurses must respect this right and take other measures to reduce patient injury.
Usually a physician must order the restraint.2 Standing orders or long term use of restraints are not appropriate except, perhaps, for environmental restraints.
Do restraints prevent patient injury?
The literature does not support this widely held belief. On the contrary, restraints have been proven to increase the number of injuries from falls as patients try to escape them. Some identified harmful effects include: skin abrasions; pressure ulcers; abnormal changes in body chemistry; contractures; decreased muscle mass; cardiac stress; and accidental death from strangulation.3 Patients also incur emotional damage such as loss of self worth, degradation, demoralization and humiliation. Research shows that restricted patients are eight times more likely to die than those who are not restricted.4
Are there legal risks in using restraints?
Yes, but there are also legal risks in failing to take reasonable precautions to prevent injury to the patient and others. The use of restraints requires individual, ongoing assessment of patients resulting in reasonable interventions.5
Patients have alleged that the use of restraints violated their rights under the Charter of Rights and Freedoms. For example, a patient at a mental health facility was given medication by injection when he became threatening and out of control. He sued, alleging the injection violated his Charter, common law and statutory rights. The Court found that the injection was justified in order to ensure the safety of the patient and others and there was no breach of his rights.6
How does the nurse manage risk in the use of restraints?
The nurse manages risk in the use of restraints through the use of policies and procedures, consent, monitoring, professional standards, legislation and documentation.
Policies and Procedures
Facilities should have “least restraint policies” in place that address factors such as comprehensive assessment of the patient to determine if restraint is necessary. These policies should also address whether or not alternative interventions, that do not require mechanical restraint or involuntary confinement of a patient to control aggressive behaviour, could be used.7 These can include verbal techniques, time out, sitters and redirection. Staff must be educated about the appropriate use of restraints and alternative measures.
The patient or the substitute decision-maker must be fully informed of the reason for the restraint and must give informed consent. In an emergency situation, consent must be obtained as soon as possible after the emergency has occurred.
Regular monitoring of a restrained patient is essential. This must be clearly outlined in the facility’s policies and followed in practice.
Nurses must know and follow the professional standards relating to the use of patient restraints. Failure to do so could result in disciplinary action by their licensing body.
Nurses must know and comply with legislation relevant to the use of restraints. Mental health or other legislation may specifically outline the procedure to be used.
Accurate and complete documentation of the use of restraints is essential and is mandated in some legislation.8 Nurses have been disciplined by their licensing body when they failed to document the use of patient restraints.9
The restriction of a person’s freedom is a denial of that person’s basic rights. Such action must only be undertaken after serious consideration has been given to all other possible alternatives.
- For example, Mental Health Act, R.S.O. 1990, c. M.7; Mental Health Act, S.P.E.I. 1996, c. M-6.1; Mental Health Act, R.S.N.B. 1973, c. M-10; The Mental Health Act, S.M. 1998, c. 36, C.C.S.M. c. M110.
- Patient Restraints Minimization Act, 2001, S.O. 2001, c. 16, s. 10 allows for “a person specified by regulation” to write a restraint order but, as yet, there are no regulations.
- L.K. Evans and N.E. Strumpf, “Myths and facts about restraints for the elderly,” Nursing91, 1991, 21(1), 24.
- D. Napierkowski, “Using Restraints with Restraint,” Nursing2002, 2002, 32(11), 58-62.
- Stewart et al. v. Extendicare Ltd.,  4 W.W.R. 559, 38 C.C.L.T. 67, (Sask. Q.B.). The Court held that a nursing home has a duty to make their premises reasonably safe and must take reasonable precautions to prevent injury to their residents.
- Conway v. Fleming,  O.J. No. 880 (Ont. Div. Ct.), online: QL (OJ).
- M.L. Kozub and R. Skidmore, “Least to Most Restrictive Interventions,” Journal of Psychosocial Nursing, 2001, 39(3), 32.
- For example, The Mental Health Act, S.M. 1998, c. 36, C.C.S.M. c. M110, s. 29(4); Mental Health Act, R.S.Y. 2002, c. 150, ss. 18(2)-(3).
- Decision of College of Nurses of Ontario Discipline Committee in action between College of Nurses of Ontario and Members A, B, C, D, E, F. November 27, 2002.
N.B. In this document, the feminine pronoun includes the masculine and vice versa.
THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.
Vol. 13, No. 2, May 2004