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Promoting Safety: Alternative Approaches to the Use of Restraints Guideline at a Glance (Nursing Practice Guideline)

Promoting Safety: Alternative Approaches to the Use of Restraints Guideline at a Glance (Nursing Practice Guideline) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines




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Guideline Title: Promoting Safety: Alternative Approaches to the Use of Restraints
Effective Date: March 2017
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council

I. Guideline Overview
This content is extracted from the adopted source document: Registered Nurses’ Association of
Ontario. (2012). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto,
Canada. Registered Nurses’ Association of Ontario. Please refer to the source guideline for
complete information.

Target Population

This guideline provides evidence-based recommendations for Registered Nurses (RNs) and
Registered Practical Nurses (RPNs) related to the care of individuals who are at risk for
behaviours that may result in harm to self/others and lead to the possible use of restraints
(physical, chemical, environmental). Unless otherwise indicated in the guideline, the
discussion focus is on physical restraint.

Nursing Practice Guideline Objectives

It is the intent of this document to assist RNs and RPNs to focus on evidence-based best
practices within the context of the nurse-client relationship and on strategies for assessment,
prevention and use of alternative practices (including de-escalation and crisis management
techniques) to prevent the use of restraints, and move towards restraint-free care in diverse
settings such as acute, long-term and home health-care.

This guideline focuses on three areas:
• Assessment, Prevention and Alternative Approaches;
• De-escalation Interventions and Crisis Management; and
• Restraint Use Focused on Client Safety.

This guideline can provide support for nurses who are considering the use of restraints as a
last resort, and for the shortest duration of time when prevention, de-escalation and crisis
management strategies have failed to keep the individual and/or others safe.

Guiding Principles

Guiding Principles/Assumptions in Promoting Safety: Alternative Approaches to the Use of
Restraints:
• Clients (i.e., patient, resident, consumer, family, significant others, substitute
decision-maker [SDM]) – are active partners in care to the extent of their capacity and
in collaboration with the interprofessional healthcare team.
• The philosophy of individualized care is foundational to the therapeutic nurse patient
relationship.
• All client behaviour has meaning that is contributing to the underlying cause.
• Prevention of the use of restraints starts with assessment and use of alternative
approaches.
• De-escalation techniques for crisis management can be used as a prevention strategy
to avoid the use of restraints.
• Leadership is required across all organizational and health care sector levels to create
a move towards restraint-free environments.

University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance



Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 03/2017EArsenaultknudsen@uwhealth.org
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• When restraint use is unavoidable, the least restrictive form of restraint is used for the
shortest duration of time for avoidance of harm to self/others; restraint use is
temporary and alternatives must continue to be considered.
II. Practice Recommendations

RNAO
Recommendation
Number
RNAO Recommendation
(see full guideline for complete list of recommendations)
Type of
Evidence
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.
IIb
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.
IIb
9
Education on working with clients at risk for the use of
restraints should be included in all entry to practice nursing
curricula as well as ongoing professional development
opportunities with specific emphasis on:
• Approaches to care (e.g., trauma informed care);
• Communication and education of client/family/SDM
and key components of debriefing;
• Education on nursing responsibilities for the proper
application of restraints;
• Ethical decision-making;
• Knowledge of diagnoses and common triggers
associated with responsive behaviours putting
clients at risk for the use of restraints;
• Interprofessional collaboration;
• Knowledge of basic prevention, alternative
approaches, de-escalation and crisis management;
• Monitoring and documentation responsibilities;
• Nurses’ responsibilities regarding self-reflection and
exploring their values and beliefs surrounding the
use of restraints and threats to client autonomy and
human rights;
• Therapeutic nurse client relationships; client-centred
care and client rights;
• Types of restraints (least to most restrictive) and
associated safety risks, and the potential
complications from the use of restraints; and
• Understanding of the legal and legislative
requirements governing the use of restraints.
Ib
III. Pertinent Resources
A. Policies
• 8.24, Guidelines for Treating Patients When They Refuse Medical Treatment
• 2.4.2, UWHC Restraint and Seclusion
• 13.23AP, Application of Physical Restraint (Adult & Pediatric)
• Enclosure Bed Resource

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 03/2017EArsenaultknudsen@uwhealth.org
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B. Patient Education Resources
• Health Facts for You (HFFY) 5435, Pediatric Restraints and Other Alternatives
• HFFY 5055, Patient Restraints and Other Alternatives
C. Clinical Tools
• Restraint Resources and Tips Webpage
A. Types of physical restraints used with adults – least to most restrictive
B. UWHC Restraint Types with Photos
IV. References
See full guideline document for list of references.
V. Rating Scheme For The Strength Of The Recommendations
Types of Evidence
Ia
Evidence obtained from meta-analysis or systematic review of randomized
controlled trials.
Ib
Evidence obtained from at least one well-designed randomized controlled
trial.
IIa
Evidence obtained from at least one well-designed controlled study without
randomization.
IIb
Evidence obtained from at least one other type of well-designed quasi-
experimental study, without randomization.
III
Evidence obtained from well-designed, non-experimental descriptive
studies, such as comparative studies, correlation studies and case studies.
IV
Evidence obtained from expert committee reports or opinions and/or
clinical experiences of respected authorities