Being restrained in hospital can be a traumatic and unpleasant experience. Even if you are not the one restrained, you may feel distress when someone you know has been restrained. Restraints are always used as a last resort. Staff take preventative measures to avoid using them whenever possible. This pamphlet will help answer your questions about what restraints are, why and how they may be used, and how patients and their families should be supported.
What are restraints?
There are three types of restraints that may be used with or without a person’s consent:
Chemical restraints are medications in the form of pills or needles that help relax the patient and may make them drowsy.
- Mechanical restraints are straps that hold a patient to a bed or chair. Straps may be placed the person’s arms, legs or shoulders.
- Seclusion rooms are locked spaces on the unit that a person might be temporarily placed to keep them from hurting themselves or others.
- Chemical restraints may be used at the same time as mechanical restraints and seclusion rooms.
Why are restraints used?
- Ontario’s law permits the use of restraints when there is an immediate need to prevent serious bodily harm to the patient or others. CAMH staff are only allowed to use the least amount of restraint that is necessary to keep the person safe.
- CAMH has its own restraints policy that is based on this law.
- The use of restraints at CAMH is also informed by the CAMH Bill of Patient Rights, which recognizes patient autonomy as a core principle and describes the complaint process that patients may follow if they feel unjustly treated.
- When a patient is feeling upset, not in control, unhappy or agitated, the clinical team will always try to find an alternative to using restraints.
How do staff avoid using restraints?
Staff use several strategies to avoid using restraints. Before they use restraints with a patient who is upset, not in control, unhappy or agitated, they will:
- address patient’s care and treatment needs
- discuss boundaries, behavioural expectations and what staff can offer the patient to keep the unit safe
- refer to the patient’s safety and comfort plan
- speak with the patient to understand their concerns if it is safe to do so
- change the environment to provide a calmer setting
- provide the patient with comfort and wellness items
- offer medication to help the person cope with distressing feelings
When would staff use restraints?
The clinical team will use restraints if:
- the alternatives are ineffective
- there are immediate safety concerns to the patient, to the environment, to other patients or to the clinical care team.
What rules do staff follow when using restraints?
- Restraints are used for the shortest amount of time and only as a last resort.
- They are used to ensure safety and are not meant to be used as a punishment or a threat.
- Restraints will end as soon as it is safe to do so.
- Once the care team assesses that the patient is no longer at imminent risk of hurting themselves or others, they can trial the patient out of restraints.
- Chemical restraints must be ordered by a doctor.
- Locked seclusion and mechanical restraint should not be used together. If mechanical restraints are used in a seclusion room, the door must be unlocked and left open.
- Staff receive special training around the use of restraints that highlights the importance of being trauma-aware in these situations. This training makes sure all clinical staff are knowledgeable
- about keeping patients physically, emotionally and psychologically safe even when they need to use restraints.
- Staff must monitor patients in restraints for their safety.
How do staff keep patients safe while in restraints?
It is staff and the hospital’s responsibility to take steps to make sure patients are safe if restraints are used. They take different steps depending on whether chemical restraints, seclusion or mechanical restraints were used.
Seclusion or mechanical restraints
When a person is in locked seclusion or mechanical restraints staff will:
- regularly check on their physical and emotional well-being
- monitor their activity to ensure that they are not engaging in unsafe behaviours
- provide access to food and drink
- provide the opportunity to use the toilet or a urinal/ bedpan if using the toilet is not safe
The patient will be seen by a psychiatrist within two hours if the initiation of a restraint event happened in their absence.
In addition, the Psychiatric Patient Advocate Office will be notified and see the patient as soon as pos-sible to explain and support them in understanding their rights. The patient can ask for the Psychiatric Patient Advocate Office. Patient Advocates are independent workers who do not work for CAMH but can help navigate situations at CAMH.
Seclusion
Staff will:
- monitor the patient through the seclusion room window for the first hour
- check on the patient every 15 minutes after the first hour
- continue to monitor the patient closely once released from seclusion
Mechanical restraints
Staff will:
- tell the patient why the restraints were used and how and when they will be removed
- stay with the patient while the restraints are in place
- assess fit of restraints at least every 30 minutes to ensure they are not too tight or cause injury
- assess vital signs regularly while awake
- ensure that patient is in a safe upright position for eating and drinking
- offer the patient a chance to change position and move their limbs every hour while awake
A psychiatrist will also check on the patient at least once every 12 hours while they are in restraints to assess the ongoing need for restraint, ensure their safety, review their mental and physical health, and adjust their care plan if needed. For voluntary patients, these checks will occur every 30 minutes.
Chemical restraints
Staff will:
- observe the patient closely and check frequently
- to ensure there are no reactions to the medication used
- record of vital signs while monitoring
- document effectiveness in managing behaviour
- give patients check-ins for them to report on the effects of the medication and side effects.
What happens after someone is released from restraints?
A member of the care team will offer to debrief after any use of restraints. We encourage the person who was restrained to talk about their experience and ask questions, but it is their choice to have this discussion or not.
The clinical team will continue to check in with them, provide support and discuss the following:
- how they are doing
- what happened that led to the use of restraints
- what support they might need
- what can be done differently to prevent the use of restraints in the future
- how can the clinical team help them be safe and feel safe
- how can the clinical team best work with them to discuss the treatment and care plan
Once mechanical restraints are removed, staff check on the patient at least every 15 minutes. For chemical restraints, patients will be monitored to make sure there are no harmful side effects from the medication.
Can family and support networks know when someone is restrained?
At CAMH, family means anyone the patient trusts and chooses as a supportive person in their life.
- If the patient has agreed information can be shared with their family or someone from their support network, staff can share about the restraint event.
- If no consent has been provided or if the patient requests that their support network not be informed of the restraint event, then their wishes will be respected.
- Sharing of information may also depend on a patient’s individual circumstances such as their legal status or whether they have a substitute decision maker.
Can you visit someone who is restrained?
- While the patient is in mechanical restraints or in seclusion or if they are resting after chemical restraints, family and other supports may not be able to visit.
- Family and other supports will be informed when it is deemed safe to visit.
What if you still have questions or concerns about the use of restraints?
If you think your concerns or questions are not fully addressed, you can speak with the clinical team. If you are unsatisfied with the responses, you may wish to connect with the Patient and Family Experience Office or the Psychiatric Patient Advocate Office.
There are more helpful resources listed in the sidebar.
When you speak with the clinical team about a restraint incident, you can ask them:
- Why were restraints used?
- What risks to patient safety did you see?
- What de-escalation strategies were attempted?
- What type of restraint was used? Why?
- How long were they restrained/how long will they be restrained?
- Who was/will be monitoring and providing care to the patient?
- How often were they/will they be checked on?
- What can families and support systems can do to care for the person who was restrained?
How was this pamphlet made?
Our goal at CAMH is to provide care in a manner that respects everyone’s rights and dignity and keeps everyone safe.
This pamphlet was created in collaboration with patients, family members and chosen support systems, and clinical staff to provide resources and education on the use of restraints at CAMH.
Have more questions about restraints?
You can direct your questions about restraints to your CAMH clinical team.
