Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Assessment, Prevention, Alternative Approaches
  •  The therapeutic relationship is foundational for trust, therapeutic communication and understanding the meaning of the client’s behaviour. As trust develops so does the ability of the nurse to effectively utilize therapeutic communication techniques to explore emotions, thought content and behaviour with the client. 
  •   Understanding a client’s history, the circumstances leading to the client’s admission and the potential influences of the environment is very important on initial assessment for the development of a multi-component plan of care.  
  •  The focus of nursing management should be on recognizing an individual at risk for use of restraints while:
    vUnderstanding the factors that lead to behaviours, specifically the factors that contribute to the behavioural presentations of unmet needs and known triggers or factors that are known to influence behaviour e.g. environment;
    vAssessing the client for predisposing and precipitating factors which can contribute towards potential increase in use;
    vDeveloping a client-specific individualized plan of care in coordination with the interprofessional team and the client (to the extent of their capacity) with preferred alternative approach strategies. Please see  Coping Agreement Questionnaire and Example alternative approaches list  Personal De-escalation Plan, Comfort Plan Mental Health and Addictions known to assist the client in coping and managing responsive behaviours;
    vCollaborating and communicating with the interprofessional team to ensure client safety;
    vContinuously assessing the client’s response to implemented interventions or strategies Behaviour Monitoring Log; and
    vUnderstanding their (nurse’s own) personal values and knowledge of the clinical issues (Penn Nursing Science, University of Pennsylvania School of Nursing: Primary Nurse Questionnaire [PNQ]:

  •  Nurses should have the skills to appropriately de-escalate a client’s emerging responsive behaviours. Please see Patterns of Action for De-escalating Client Behaviour & De-escalation tips and Interventions to Assist Patient to Cope   Patterns of Action for De-escalating Client Behaviour  
  • Restraint-free environments require a philosopy where the:
    vfirst focus of care is predominately on assessment, prevention and use of alternative approaches, and
    vsecond focus of care is on de-escalation interventions and crisis management techniques.