Which level of health care provider may make the decision to apply physical restraints to a client?

Code of Medical Ethics Opinion 1.2.7

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Code of Medical Ethics Opinion 1.2.7
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RELATED CONTENT
Exemptions for consent: Emergency vs. non-emergency
Duties to a client when using restraints
Restraint and controls on practice
BCCNM standards and resources
What should the nurse do prior to applying physical restraints?
What is the nursing care for a patient in 4 point restraints?
Which sequence is the correct order of actions to ensure safe transport using a wheelchair?
Which factors affecting a patient's environment must be controlled?

Code of Medical Ethics Opinion 1.2.7

All individuals have a fundamental right to be free from unreasonable bodily restraint. At times, however, health conditions may result in behavior that puts patients at risk of harming themselves. In such situations, it may be ethically justifiable for physicians to order the use of chemical or physical restraint to protect the patient.

Except in emergencies, patients should be restrained only on a physician’s explicit order. Patients should never be restrained punitively, for convenience, or as an alternate to reasonable staffing.

Physicians who order chemical or physical restraints should:

Use best professional judgment to determine whether restraint is clinically indicated for the individual patient.
Obtain the patient’s informed consent to the use of restraint, or the consent of the patient’s surrogate when the patient lacks decision-making capacity. Physicians should explain to the patient or surrogate:
1. Why restraint is recommended
2. What type of restraint will be used
3. Length of time for which restraint is intended to be used
Regularly review the need for restraint and document the review and resulting decision in the patient’s medical record.

In certain limited situations, when a patient poses a significant danger to self or others, it may be appropriate to restrain the patient involuntarily. In such situations, the least restrictive restraint reasonable should be implemented and the restraint should be removed promptly when no longer needed.

AMA Principles of Medical Ethics: I, IV

Duties to a client when using restraints

The use of restraint carries risks to a client’s emotional and physical safety. Restraints should be considered as a last resort intervention, used temporarily in behavioural emergencies when other strategies have failed to keep the individual and others safe. Nurses should work to end the use of restraints as soon as possible, and ensure the client’s health, well-being, and condition are monitored, consistent with employer policy.

Restraint and controls on practice

Nurses need to consider how the controls on practice impact restraint usage:

What does legislation allow? Under the Health Professions Act, the nursing regulations allow nurses to apply restraint. The law requires consent for these activities except under specific circumstances, as outlined above.

What do the BCCNM standards, limits and conditions allow? Nurses must meet the standards, limits and conditions as laid out in the Scope of Practice standards when applying restraint.

What do my employer policies allow? Nurses are responsible for following any employer policies related to restraint.

What does my individual competence allow? Nurses ensure they have the competencies to apply restraint in both emergency and non-emergency situations, and to do so safely.

Scenario

Ally works on a facility’s special care unit. An 86-year-old client living with Alzheimer’s disease has had numerous falls when attempting to get out of his chair. Ally knows the facility has a least restraint policy and has tried to prevent the client from falling by using the strategies outlined in the policy; however, she has not been successful in keeping him safe.

Ally assesses the client and determines that a non-emergency restraint is needed for client safety and that a lap restraint would be appropriate while he is sitting in his chair. Ally reviews her employer’s policy and asks for input from the health care team.

Ally explains to the client and his family the rationale for using a lap restraint, including the risks and benefits, and they give consent. Ally obtains an order from the client’s doctor for the use of a lap restraint when the client is in his chair.

Ally documents her activities and updates the client’s plan of care to include applying a lap restraint while he is in his chair; the plan of care will be re-evaluated daily to determine if the restraint is still needed. Ally documents provided nursing care, including restraint use assessment, application, monitoring, and evaluation, as outlined in the Documentation practice standard and her employer’s policy.

BCCNM standards and resources

Consent practice standard
Documentation practice standard
Professional Standards
Scope of Practice
Legislation relevant to nurses' practice

What should the nurse do prior to applying physical restraints?

What should the nurse do prior to administering physical restraints? Initially, provide a restraint-free environment. The nurse manager is reviewing the use of restraints during an in service with the staff.

What is the nursing care for a patient in 4 point restraints?

Monitor the patient in four-point restraints every 15 minutes. Know that these restraints must be reduced and removed as soon as safely possible. To re- duce a four-point re- straint, remove it slow- ly—usually one point at a time—as the patient becomes calmer.

Which sequence is the correct order of actions to ensure safe transport using a wheelchair?

What is the correct order of actions to ensure safe transport using a wheelchair to prevent falls in a health care setting? When transferring a patient in a wheelchair, the nurse should first position the wheelchair on same side of the bed. The next step is to place a wedge cushion in the chair.