To restrain or not to restrain?
Tyler is in the first year of his career as a registered nurse and was recently hired into a casual position at a long-term care facility. While completing his morning rounds, he sees Tracey, a licensed practical nurse, at the medication cart.
Tracey tells Tyler that one of her clients, Mr. Brown, who has dementia, is very unsteady on his feet and frequently tries to get out of bed by himself. “He requires assistance getting in and out of bed, and neither I nor the health-care aides have had time to help him yet. He had a fall last week” says Tracey. “I’ve tried persuading him to stay in bed until someone can assist him, but the last time I checked on him, his right leg was practically touching the ground and he was pulling on the bedrail to try and get up.”
Tyler wonders if obtaining an order for a restraint would help ensure Mr. Brown’s safety while staff are busy caring for other clients.
What should Tyler consider first?
There are many clinical, ethical and legal considerations to think about before using restraints. First and foremost, it is Tyler’s responsibility to conduct his own assessment to determine Mr. Brown’s level of understanding about the use of a call bell and his risk of another fall. Based on Tyler’s assessment, there could be other interventions that can be integrated into Mr. Brown’s care plan such as more frequent checks, use of volunteers, health-care aides, or the presence of a family member.
He should also think about the legal considerations that come into play including informed consent of clients, families and/or legal guardians, client safety, and the use of least restrictive options.
Tyler reviews CARNA’s Practice Standards for Regulated Members and is reminded that he is accountable at all times for his own actions and is required to follow legislation, standards and policies relevant to his practice setting. He also remembers his employer has a “restraint as a last resort” policy and procedure. CARNA’s Practice Standards for Regulated Members outline that he is expected to:
- Use appropriate information and resources that enhance client care and the achievement of desired client outcomes.
- Protect and promote a client’s right to autonomy, respect, privacy, dignity and access to information.
- Collaborate with the client, significant others, and other members of the health-care team regarding activities of care planning, implementation and evaluation.
He also finds an ‘ethical model for reflection’ tool in the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses and uses the reflection questions to help guide his decision-making.
What does Tyler do?
Tyler decides to conduct his own assessment of Mr. Brown. He asks Mr. Brown why he wants to get out of bed by himself. Mr. Brown responds, “It’s time for me to go to work. I’m going to be late.” Knowing that Mr. Brown has been diagnosed with dementia, Tyler takes some time to talk with Mr. Brown and replies “well, let’s get you up and out of bed for breakfast so you aren’t late for work.” He tries redirecting the conversation and is successful with encouraging Mr. Brown to eat his breakfast in the dining room. As he continues talking with Mr. Brown, a health-care aide enters the room to help Mr. Brown with his morning care.
After ensuring Mr. Brown’s safety, Tyler returns to the nursing station and calls Mr. Brown’s daughter. He shares his concerns with her and learns more about his daily routine while living at home, in order to better support his care. Tyler also explores ways in which Mr. Brown’s family can work collaboratively with the staff to ensure his safety without the use of restraints. In the meantime, Tyler asks one of the usual volunteers to keep Mr. Brown company, while Mr. Brown’s daughter makes plans to visit later that day.
Disclaimer: Our case studies are fictional educational resources. While we strive to make the scenarios as realistic as possible, any resemblance to actual people or events is coincidental.