Registered Nurses' Association of Ontario

Management of Responsive, Aggressive or Harmful Behaviours

  • If a restraint (including seclusion) is deemed necessary, the nurse 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;
    • 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, 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 of the client on a standardized restraint form; and
    • Debrief with interprofessional team and client/family/SDM
Clinical Management
Promoting Safety: Alternative Approaches to the Use of Restraints
Point of Care Resources