Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Last Resort, Restraint Use

Only after assessment, prevention and alternative approaches have been considered the nurse should be aware of organizational policy and procedures and legislation around the use of restraints. Please see Resource List of Websites. 

 When restraints are considered as a last resort nurses should:

 • Review client-specific precipitating and predisposing criteria;
 • Identify the client’s responsive behaviour;
 • Document and initiate strategies that include client preferences for use of   alternative approaches and de-escalation strategies to help client with coping;
 • Consult with the interprofessional team and client/family/SDM and initiate only  after attempts to modify or eliminate the risk factors have not been successful and a restraint is required;
 • Initiate a physician’s order -- time limited, specific to the type of restraint and  product used, it is very important that nurses use only the type of restraints  authorized for use within their organization;
 • Advocate for the least restrictive form of restraint and for the earliest trial for the  safe removal of the restraint;
 • Continue to explore new alternative strategies;
 • Review consent with the client/family/SDM;
 • Initiate a plan of care in collaboration with the interprofessional team and  client/family/SDM;
 • Be aware that clients who are not sure why they are being restrained will feel  unsafe and ensure the client is given explanations as to their rights, why they are  being restrained and what needs to happen (behaviour) in order for them to be  removed from the restraints;
 • Provide ongoing monitoring as per organization policy that outlines the  frequency and type of monitoring required for client safety, the client response to   the restraining process (Possible Complications of Restraint Use), any comfort measures given and the process to explore use of  new alternative strategies and trial earliest safe release of the client from  restraints;
 • Document restraint use and monitoring (as outlined by their organization’s  policy and procedures for monitoring, observation and documentation  responsibilities) of the client on a standardized restraint form; and
 • Debrief with interprofessional team and client/family/SDM to support:
The strengthening or re-establishment of the therapeutic relationship from the client’s perspective;
A review of the restraint episode from a mitigation of risk perspective. The review should focus on an analysis of the prevention, de-escalation and best practice strategies used prior to the use of restraints, including environment considerations and an evaluation of what did and did not work, with subsequent adjustments to the client’s plan of care; and
A review of any client complications or safety concerns surrounding the restraining event or as direct result of the use of restraints, as these types of harmful incidents may be prevented with further review, adjustment of policies and procedures and education of staff.
 • Nurses with the interprofessional team should review the use of “as needed medication” to ensure these are not being used as chemical restraint in the clinical setting as reduction in use of physical restraints may result in an increase in use.
 • Overuse of as needed medications in clinical practice can result in loss of the client’s rights and have legal implications.