Restraint and Seclusion
Restraint and Seclusion: What has changed?
Previously, when using mechanical restraint or seclusion interventions, RPNs were limited to acting only with an order, except in an emergency situation. Recently CRPNBC changed the limits and conditions to the following:
In the course of practising psychiatric nursing, RPNs may apply physical or mechanical restraint or seclusion interventions subject to the following CRPNBC Limits and Conditions:
- When using restraint or seclusion interventions, RPNs follow applicable legislation specific to their practice setting.
- When using mechanical restraint or seclusion interventions with clients certified under the Mental Health Act, RPNs are limited to acting only with an order1, except in an emergency situation.
Does this change practice for RPNs?
It is important to understand that even though CRPNBC has changed the limits and conditions, practice will not change for most RPNs. To use restraint or seclusion, RPNs must still follow authorizing legislation applicable to their practice setting. The governing legislation or the employer2 may specify that an order or some form of authorization is required when applying restraint or seclusion. Therefore, RPNs may still be required to act only with an order in a variety of practice settings.
The need for consent or other legal authority
To apply restraint or seclusion, RPNs must have consent or some form of legal authority that overrides the requirement for consent, such as a legislative exemption or a court order. Otherwise, the act of applying restraint or seclusion would be an assault, which could be tort or criminal offence.
The requirement of consent for health care is governed by the Health Care (Consent) and Care Facility (Admission) Act (the “HCCFA”) for adults and the Infants Act for children. Health care is defined in these two acts as anything done for a therapeutic, preventive, palliative, diagnostic, cosmetic or other purpose related to health. When obtaining consent, RPNs should follow CRPNBC’s practice standard on consent3.
Exceptions to the consent requirement, including emergencies
There may be legislative exceptions to the requirement for consent. For example, the HCCFA does not apply to involuntary psychiatric treatment provided in designated facilities under the Mental Health Act.
There are also legislative exemptions for emergency situations:
- Section 12 of the HCCFA permits health care for adults to preserve life, to prevent serious physical or mental harm or to alleviate severe pain when an adult is incapable of giving consent and there is no appropriate substitute decision maker available. For example, the HCCFA may allow an RPN, working in an emergency room, to apply restraint or seclusion with a physically aggressive adult who is incapable of consenting to treatment because the person is impaired by drugs or alcohol.
- Section 14(b) of the Health Professions Act allows RPNs to act beyond their scope of practice if they have the competence to do so. CRPNBC interprets this emergency exemption as overriding CRPNBC limits and conditions or employer policies, if there is imminent risk of death or serious harm arising unexpectedly and requiring urgent action. For example, the emergency exemption may authorize RPNs to apply restraint or seclusion without a doctors’ order for clients certified under the Mental Health Act despite CRPNBC’s condition normally requiring an order in that situation.
It is important to recognize that although restraint or seclusion is often initiated in response to an emergency situation, continuing restraint or seclusion may no longer be an emergency, so different legislation applicable to a non-emergency situation will be required for this continued use.
The CRPNBC Professional Standard4 requires RPNs to know the relevant legislation governing psychiatric nursing practice.
Do RPNs also need an order for the use of restraint or seclusion?
In many practice settings RPNs require an order (or written agreement from a doctor or nurse practitioner) for the use of restraint or seclusion in non-emergency situations. The authorizing legislation may or may not specify whether an order is required. For example, the Mental Health Act does not specify whether an order is required for the use of restraint or seclusion. However, the Residential Care Regulation (Community Care and Assisted Living Act) requires a written agreement from a doctor or nurse practitioner.
In addition, the CRPNBC and/or the employer may also require an order for the use of restraint or seclusion. Below is as an example:
- The Mental Health Act provides for compulsory treatment, such as restraint or seclusion of involuntary patients, but the Act does not specify whether an order is required. However, when clients are certified under the Mental Health Act, CRPNBC has Limits and Conditions on mechanical restraint or seclusion that require RPNs to act only with an order, except in an emergency situation. In addition, employers of designated mental health facilities often have policies that require an order for the use of restraint or seclusion.
Restraint and seclusion for non-health care purposes
If restraint or seclusion is being applied for non-health care purposes, legal authority is required. Some examples of legislation that may be applicable are the Correction Act, Criminal Code of Canada, and Corrections and Conditional Release Act. For example, RPNs working for federal corrections may, as peace officers, use restraint or seclusion for security purposes.
RPNs whose jobs may require restraint or seclusion for non-health care purposes will have to constantly ask themselves whether the particular application of restraint or seclusion is for health care or not, as this may impact whether consent is required. For example, an RPN working in federal Corrections may sometimes be acting as a nurse and sometimes as a peace officer depending on the purpose of the restraint or seclusion. If the restraint or seclusion is strictly for security reasons, then no consent is required since legislation governing the corrections setting authorizes the use of reasonable force. However, if restraint or seclusion is required for health care, then consent is required, unless an exemption applies, such as in an emergency or certification under the Mental Health Act.
The Restraint and Seclusion Decision Tree assists RPNs in identifying the relevant legislation that may authorize the use of restraint or seclusion, and when an order is required.
It is important to remember that having the legal and regulatory authority to carry out restraint or seclusion is not necessarily reason to do so. Just because you can does not mean you should.
Shared Responsibility for Controls on Practice
RPNs need to consider four controls on practice when using restraint or seclusion. For additional information related to controls on practice, see Scope of Practice for RPNs: Standards, Limits and Conditions5. The Restraint and Seclusion Decision Tree provides a visual guide to understanding the shared controls on RPN practice of restraint or seclusion. In addition, the four levels of control on RPN practice, with examples related to the use of restraint or seclusion, have been provided in the diagram and accompanying text below.
Health Professions Act and Nurses (Registered Psychiatric) Regulation: Under the Health Professions Act, the Nurses (Registered Psychiatric) Regulation allows RPNs to carry out a variety of psychiatric nursing activities, including restraint or seclusion. The HCCFA requires consent for these activities, but does not apply to facilities designated under the Mental Health Act.
CRPNBC Standards, Limits and Conditions: The CRPNBC provides the following directions regarding the use of restraint or seclusion:
- Professional Standards:
- Standard 2 on Application and Integration of Theory-based Knowledge4 sets out the expectation for RPNs to apply an evidence-base rationale for all nursing activities including the use of restraint or seclusion.
- Standard 4 on Professional Responsibility4 sets out the expectation for RPNs to adhere to legislation impacting all nursing activities including the practice of restraint or seclusion.
- Section 7 of the RPN Entry-Level Competencies (2014)6 supports the professional standards by identifying the specific competencies related to applying legislation and evidence-based interventions.
- CRPNBC has Limits and Conditions5 on the practice of restraint or seclusion.
- Practice Standards: There are practice standards that an RPN may follow when utilizing restraint or seclusion:
- When obtaining consent RPNs follow CRPNBC practice standard on consent
- Depending on whether an RPN is acting with or without an order, the RPN must follow one of two practice standards, Acting with an Order1 or Acting without an Order7. Practicing without an order entails greater responsibility for the RPN, including assuming the responsibility to interpret and use current evidence from research and other credible sources to support the decision to use restraint or seclusion. It also includes making a nursing diagnosis, accepting sole accountability, considering the risks and benefits to the client, carrying out restraint or seclusion safely and ethically and managing the intended and unintended outcomes of the intervention.
Employer Policies: RPNs are responsible for following any employer policies related to restraint or seclusion (e.g. policies requiring an order).
Individual competence: RPNs are responsible for ensuring they have the competencies required to apply restraint or seclusion in both emergency and non-emergency situations.
- All controls on practice must indicate that RPNs can carry out restraint or seclusion for them to do so.
- Having the legal and regulatory authority to carry out restraint or seclusion is not necessarily reason to do so.
- Making a decision to carry out restraint or seclusion without an order requires a different level of knowledge, skill, attitude and judgement than when restraint or seclusion is carried out under an order from another health professional.
1See Standards for Acting With an Order https://www.crpnbc.ca/wp-content/uploads/2014/04/acting-with-an-order.pdf
2Refers to the employer of an RPN or agencies through which RPNs provide volunteer services.
4CRPNBC Professional Standards: http://www.crpnbc.ca/wp-content/uploads/2011/02/2013-05-29-CRPNBC-Professional-Standards.pdf
5Scope of Practice For RPNs: Standards, Limits and Conditions5 http://www.crpnbc.ca/wp-content/uploads/2017/02/2016-03-15-Revised-Scope-with-disclaimer-updated-Feb-13-2017.pdf
6Registered Psychiatric Nurse Entry-Level Competencies: https://www.crpnbc.ca/wp-content/uploads/2011/02/2015-03-CRPNBC-ELC-Document-FINAL-with-national-cover.pdf
7See Standards for Acting Without an Order: http://www.crpnbc.ca/wp-content/uploads/2014/04/acting-without-an-order.pdf
Standard for Documentation
Standard for Emergency Exemption
Provincial Quality, Health and Safety Standards and Guidelines for Secure Rooms in Designated Mental Health Facilities under the B.C. Mental Health Act found at http://www.interiorhealth.ca/AboutUs/BusinessCentre/Construction/Documents/Provincial%20standards%20and%20guidelines%20for%20secure%20rooms.pdf
For more information on this or any other practice issue, contact CRPNBC’s Practice Consultant by email at [email protected] or call 604.931.5200 or 1.800.565.2505.
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