Registed Nurses' Association of Ontario


Alternatives to restraints in health care

One of the unfortunate realities about our health-care system is that sometimes restraints are used on patients in the interest of safety. This happens in nursing homes and psychiatric settings.

While the common wisdom is that restraints, which include waist belts, antipsychotic medications and patient seclusion, are used to protect a resident or patient from possible injury or harm to themselves or others, the reality is that restraints can actually have deadly consequences.

RNAO says nurses should look for alternatives to restraints whenever possible.

In 2008, Florence Rose Coxon, a Toronto senior, died after attempting to extricate herself from a waist belt in a wheelchair. Only three years earlier, Jeffrey James, a patient at Toronto’s Centre for Addition and Mental Health, collapsed after five days of being restrained. He later died in hospital after a blood clot formed in his leg.

The incident led to an inquest into James’ death. RNAO’s Past-President Wendy Fucile provided testimony and a nursing perspective at the inquest, sharing the association’s view that restraints should be a last resort. One of the recommendations following the inquest was for RNAO to develop a best practice guideline (BPG). In 2012, RNAO released its Promoting Safety: Alternative Approaches to the Use of Restraints BPG, which focuses on patients – including those with mental illness – who are at risk of harming themselves or others. A fact sheet was developed in tandem with the BPG, which has been implemented by health organizations such as the Hamilton Niagara Haldimand Brant Local Health Integration Network.

Three years before the release of its guideline and fact sheet, RNAO made three recommendations concerning restraints to Ontario’s Ministry of Health. The association was responding to proposed legislation under the Long-Term Care Homes Act, 2007. Two sections under the draft legislation related to minimizing restraining of residents, and RNAO recommended changes to these sections and others.

The first of three recommendations issued by RNAO that pertain to restraints called for mandatory written reporting to the Ministry of Health of incidents where a restraint was used, and any changes implemented to minimize use. The second called for recognition of the use of chemical restraints by extending the requirement of a minimizing restraining policy to apply to drugs. And the third urged better staffing levels that permit directors of care to focus on leadership and operations, and allow full-time rather than replacement nurses to monitor patients in restraints. Read RNAO’s full submission to the ministry.

RNAO believes having more staff will lessen the need for residents to be restrained, and continues to push for staffing increases.

The association encourages nurses and other health-care professionals to always consider alternate solutions to restraints, whenever possible.