Which situations would require the nurse to obtain a prescription for physical restraints

Patient restraints are measures used to limit the activity or control the behaviour of a person or a portion of their body. More specifically, according to the Patient Restraints Minimization Act of Ontario, “restrain means, with respect to a person, to place the person under control by the minimal use of such force, mechanical means or chemicals as is reasonable having regard to the person’s physical and mental condition”.1

Nurses are legally and professionally accountable for providing appropriate and safe care, including knowing when to act if a patient’s safety or well-being is compromised. This may include applying restraints. Legally, there is generally no distinction between the types of restraints that may be used. This InfoLAW will outline legal, ethical, and other considerations that nurses should be mindful of when using patient restraints.

The types of restraints a nurse will most commonly see are:

• Environmental – the control of a person’s mobility by restricting the available geographic area.
  • This may include placing patients in locked observation rooms, and may be called “seclusion”.2
• 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.
  • These may include physically laying hands on a patient, jackets, straps, beside rails that restrict movement, or handcuffs.
• Chemical – the use of a psychoactive medication to specifically inhibit a person’s movement or behaviour, that is not required to treat medical symptoms.
  • Chemical restraints generally require an order or written agreement from an authorized health professional (for ex: a physician or a nurse practitioner).3

When can patient restraints be used?

Patient restraints can be used if it is necessary to protect the patient from harming themselves or another person. They may be used in an emergency situation where danger is imminent.

Provincial or territorial legislation relating to mental health may specifically address the use of restraints within a mental health setting.4 A patient has the right to autonomy of their person. A competent patient may prefer to take the risk of injury, rather than be restrained. Nurses must respect this right and consider other measures to reduce the risk of patient injury.5

Restraints should never be used as punishment, as a substitute for nursing care, or as a matter of convenience for the healthcare provider. Restraints may have serious negative physical, social and psychological effects on the patient. The use of restraints should be based on the patient’s individual presentation, current condition and behaviors, and other ongoing assessments, resulting in reasonable interventions.6 Further, restraints should only be used for the shortest time necessary when crisis and de-escalation management strategies have failed to keep the person or others safe.7 A physician or nurse practitioner will typically be the one to order the restraint. 8 The use of standing orders or the long-term use of restraints is not generally appropriate.

Are there legal risks related to using restraints?

Yes, inappropriate use of restraints may lead to legal action or regulatory investigation. On the other hand, there are also legal risks in failing to take reasonable precautions to prevent injury to the patient and others. The examples below highlight certain aspects of patient restraints that courts may have to consider.

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.9

In one case, the nurse acted against the physician’s and crisis team’s orders and removed two of the four points restraints that had been imposed to the patient. This resulted in a violent outburst from the patient. The discipline committee found that the nurse “had violated College standards when she removed restraints without doing a psychiatric assessment, the gravity of the situation, the danger that people were placed in and the fact that the [nurse] had willfully removed the restraints and placed staff and herself at risk.” The nurse received a five-day suspension.10

On the other hand, a disciplinary decision from the Nurses Association of New Brunswick found that a nurse had “ordered that patients be restrained without assessing other alternatives,”11 inappropriately administered medications and failed to document according to the standards of practice. Once the Discipline Committee found that the nurse had violated the Code of Ethics, and their provincial standards of practice, they ordered that the nurse be suspended until specific conditions are met. The nurse also had to pay a fine and a portion of the costs incurred during the proceedings.12

How might a nurse manage risk when using restraints?

Policies and Procedures
Facilities should have “least restraint policies” in place that include a comprehensive risk assessment protocol to determine if restraining a patient is necessary. These policies should also address whether or not alternative interventions, which do not require mechanical restraint or involuntary confinement of a patient to control aggressive behaviour, may be used. These can include verbal techniques, time out, monitoring, and redirection. Staff must be educated about the appropriate use of restraints and alternative measures.

Consent
In order to apply restraints, nurses must generally have consent from the patient or the substitute decision-maker. There are certain legislative exceptions to the consent requirement, including if a patient is admitted for involuntary psychiatric treatment under the Mental Health Act in British Columbia13 or if there is an emergency. 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”.14 However, consent should be obtained as soon as possible after the emergency has occurred.15

Monitoring
Regular monitoring of a restrained patient is essential. This should be clearly outlined in the facility’s policies and followed in practice.

Professional Standards and Legislation
Nurses must be familiar with and follow the professional standards and applicable legislation relating to the use of patient restraints. Mental health acts or other legislation may specifically outline the appropriate procedures to be used. Failure to do so could result in disciplinary action by the regulatory body.

Documentation
Accurate and complete documentation of the use of restraints is essential and is mandated in some legislation.16 In fact, nurses have been disciplined by their regulatory body when they failed to document the use of patient restraints according to the applicable standards.17 When documenting the use of restraints, a nurse should document the following in addition to standard documentation:

• Means of restraint (what and how);
• Behaviour of the patient necessitating restraint or to continue to be restrained (why);18
• Time restraint was initiated and discontinued;
• Frequency of observation during the restraint;
• The effects on the patient;
• If using a chemical restraint:
  • Type and dosage of medication, and method of administration.

For more information on general documentation, please consult our InfoLAW on the topic.

Summary

Nurses should be familiar with their nursing regulator’s guidelines and professional standards regarding patient restraints. As the restriction of a person’s freedom may be seen as a denial of that person’s basic Charter rights, such action must only be undertaken after serious consideration has been given to all other possible alternatives.

CNPS beneficiaries can contact CNPS at 1-800-267-3390 to speak with a member of CNPS legal counsel. All calls are confidential.

December 2021

1. Patient Restraints Minimization Act, 2001, S.O. 2001, c. 16.
2. British Columbia College of Nurses and Midwives, Restraints
3. Ibid. 
4. For example, Mental Health Act, R.S.O. 1990, c. M.7; Mental Health Act, R.S.P.EI. 1994, c. M-6.1; Mental Health Act, R.S.N.B. 1973, c. M-10; The Mental Health Act, S.M. 1998, c. 36.
5. A competent patient is defined as one who is able to take decisions for themselves.
6. Stewart et al. v. Extendicare Ltd., [1986] 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.
7. College of Nurses of Ontario, Understanding Restraints, 2018: https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/restraints/; Patient Safety Institute, https://www.patientsafetyinstitute.ca/en/education/PatientSafetyEducationProgram/PatientSafetyEducationCurriculum/Documents/Module%2013d%20Seclusion%20and%20Restraint.pdf
8. Supra, at note 2. Please note that the authorizing health practitioner may differ based on the jurisdiction in which you practice.
9. Conway v. Fleming,[1999] CanLii 19907 (ON SC).
10. North York General Hospital v Ontario Nurses’ Association,  2016 CanLII. 27026 (ON LA)
11. Nurses Association of New Brunswick, Discipline Decisions (2021): http://www.nanb.nb.ca/complaints/discipline/P5
12. Ibid. 
13. Ibid. 
14. College of Nurses of Ontario, Understanding Restraints, 2018: https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/restraints/
15. Please note that legislation surrounding consent differs depending on the jurisdiction. Please consult the appropriate legislation in the province or territory in which you practice, or speak to your employer for more information.
16. 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).
17. For example, please consult this disciplinary decision from the Nurses Association of New Brunswick (2021): http://www.nanb.nb.ca/complaints/discipline/P5
18. Supra, at note 14.

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.