The Registered Nurses' Association of Ontario was asked to formulate the guidelines by the provincial coroner following the 2008 inquest into the death three years earlier of 34-year-old psychiatric patient Jeffrey James.
James, afflicted with a disorder that led to sexually inappropriate behaviour, had been kept in restraints for five days at the Centre for Addiction and Mental Health in Toronto. While restrained, he developed a blood clot in one leg that later travelled to his lungs and killed him.
The RNAO guidelines, contained in a 145-page report, focus on nurses and other care providers seeking alternatives to restraints, while still keeping patients and themselves safe from injury.
Co-lead author Laura Wagner, an adjunct scientist at Baycrest Centre for Geriatric Care, says physical and medication-based restraints should be the last resort after exhausting the many alternatives that can be used to help keep patients and staff safe.
Wagner, who is also a nursing scientist at the Hartford Institute for Geriatric Nursing at New York University, said patients can be physically restrained using such devices as belts and side rails on beds, put in seclusion in a room or chemically restrained using drugs.
"There are primarily three reasons why a client is restrained," Wagner said from New York. "One is to prevent an interference with treatment, such as a breathing tube or feeding tube or an IV, some kind of therapy."
The others are to prevent falls that could cause injury to the patient and to minimize "behaviours of acting out" that pose a risk of harm to the patient, staff or others, among them hitting, kicking and pushing.
But restraints that curtail movement can have adverse effects, she cautioned. They can lead to reduced muscle strength, joint contractures and severe bedsores from being immobilized.
And the effects aren't only physical.
"We actually know that sometimes when we restrain a patient they become more agitated, more stressed. And just think about having that and wanting to get out of the restraint and how that increases that person's risk for hurting themselves."
Indeed, on rare occasions patients have died trying to free themselves from such devices.
In 2008, for instance, an 87-year-old resident of a Toronto nursing home was strangled as she struggled to wiggle out from a waist belt used to keep her in a wheelchair. Florence Rose Coxon, who had Alzheimer's disease, was asphyxiated when her throat was caught in the strap.
Chemical restraints — typically antipsychotic medications meant to calm agitation — can leave a person feeling groggy, "drugged-up" and physically sedentary, which can exacerbate muscle weakening and raise the risk of falls.
"And it just is a vicious cycle," said Wagner.
"What we wanted to do in the guideline is think about using the restraints as the very last resort after we've thought about all these other issues, after we've done a very thorough assessment in the client and after we've looked at what behaviours could be causing this and maybe how we can think of alternatives."
That primarily means setting up a therapeutic relationship with a patient, getting to know what environmental and emotional triggers could lead to aggressive or even violent behaviours, said co-lead author Athina Perivolaris, an advanced practice nurse at CAMH.
The guidelines encourage nurses and other care providers to have a plan to prevent a patient who is anxious or agitated from escalating into full-blown, potentially harmful behaviour.
For some residents, that could mean quiet time in their room with a mug of hot chocolate, writing in their journal, meditating or doing creative artwork.
"They're not big things, they're little things," she said. "But these little things come together in an important way to support a client," Perivolaris said.
Most acting-out behaviour is a response to an unmet need, fear or some other overwhelming issue that the patient doesn't have the internal resources to cope with, she explained.
When restraint in a psychiatric facility must be used — and that's only on an emergency basis when other alternatives have failed — the goal is to keep the person as comfortable as possible.
"So if they were in a mechanical restraint or a seclusion room and they needed a blanket or they wanted to listen to some music or they wanted a drink, (it's) little things like that to support them so they can regain control and come out as soon as possible," she said.
"You want to be very cognizant of the unique factors of the client. Some clients might have had abuse histories, so maybe mechanical restraint might not be ideal. Other clients might find that the isolation of seclusion might not be ideal."
And after a restraint event, it's important that a staff debriefing occur to discuss what could prevent a repeat of the experience.
A client debriefing is also essential so care providers can re-engage with the patient and give them an opportunity to share their perspective of being restrained. Research has shown that patients often report having felt like a prisoner.
Wagner said being restrained, even for a patient's own safety, can cause severe and undue distress — and that's where alternative thinking comes in.
She recalled the case of a man with cognitive impairment living in a long-term care home. The man had been an acrobat and was constantly out of his chair, said Wagner. Staff at the home had finally restrained him because he had fallen multiple times and suffered repeated brain traumas.
"But he was very active, he had spent his whole life in the circus," she said, and being kept physically constrained was making him extremely unhappy.
The solution was to find a way to stop him hurting his head, so staff put him in a helmet.
"So he was able to walk around with his helmet on. He still fell, but he didn't have another brain injury from falling," she said.
"His family said he had a wonderful quality of life at the end because he was able to still ambulate and be active like he had been his whole life."