Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Recommendations

 

1. Nurses establish a therapeutic relationship with the client who is at risk of harm to self/others to help prevent the use of restraints.

 2. Nurses should assess the client on admission and on an ongoing basis to identify any risk factors that may result in the use of restraints.
 
 3. Nurses should utilize clinical judgment and validated assessment tools to assess clients at risk for restraint use.
 
 4. Nurses in partnership with the interprofessional team and client/family/substitute decision-makers (SDM) should create an individualized plan of care that focuses on alternative approaches to the use of restraints.
 
 5. Nurses in partnership with the interprofessional team should continuously monitor and re-evaluate the client’s plan of care based on observation and/or concerns expressed by the client and/or family/SDM.
 
 6. Nurses in partnership with the interprofessional team should implement multicomponent strategies to prevent the use of restraints for clients identified at risk.
 
 7. Nurses in partnership with the interprofessional team should implement de-escalation and crisis management techniques and mobilize the appropriate resources to promote safety and mitigate risk of harm for all in the presence of escalating responsive behaviours.
 
 8. Nurses in partnership with the interprofessional team should engage in care practices that minimize any risk to the client’s safety and well-being throughout the duration of any restraining process.