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Spotlight 5/5

Using force and restraints to respond to challenging behaviours

Several studies conducted during and after the COVID-19 pandemic noted an increase of the use of patient restraints in health care settings both internationally¹ and within Canada² as a result of the strain on the health care system.

Illustration of speech bubble showing a medical professional taking notes and a person talking to a person lying in a hospital bed.

Restraints can be used as a protective measure to keep patients safe (e.g., lap belts to reduce the risk of falls), or in response to behaviours that pose the risk of harm (e.g., wrist restraints) to the person, other patients or residents and their care providers.

Restraints can have negative effects on patients’ physical and mental health, and there have been recommendations to decrease their use across all health care settings in Ontario.³ The Patient Restraints Minimization Act, 2001, and the Fixing Long-Term Care Act, 2021 both outline hospitals’ and long-term care homes’ responsibility to establish clear policies with appropriate monitoring and enforcement for using restraints on patients or residents. These laws highlight the importance of alternative methods to restraints, and ensuring all other options are explored to prevent patients from injuring themselves or others.

Patient Ombudsman has been closely monitoring complaints related to how health care organizations respond to challenging behaviours from patients, long-term care residents and visitors. Challenging behaviour can take many forms, such as communication challenges from overwhelmed or distressed caregivers to emotional distress often associated with individuals struggling with mental health and addiction challenges, and confusion or agitation seen in seniors with dementia or delirium.

Patient experience

The complainant’s parent, who has dementia and in the previous year had an instance of aggressive behaviour, was in hospital and waiting for placement into a long-term care home. Three long-term care homes had initially accepted the parent on their waiting list but ultimately withdrew their approval citing their inability to meet the parent’s needs based on their behavioural history. The complainant had complained to all three homes but had not received a response.

What we did

Patient Ombudsman contacted the regional office of Ontario Health atHome, the agency responsible for coordinating long-term care home placements, as well as the three long-term care homes and collected information. The long-term care homes all confirmed that they had denied approval for the admission based on their assessment that they could not provide the one-on-one monitoring they believed the patient needed. The homes had shared the reasons for their decisions with Ontario Health atHome, but had not responded directly to the complainant because the parent was not currently a resident. Ontario Health atHome was continuing to work with them and the complainant to try to reach a resolution. Based on the parent’s most recent assessment, their behaviours were currently well-managed, but the history remained on the records considered by the homes. While neither Patient Ombudsman nor Ontario Health atHome could override the homes’ decisions, Ontario Health atHome was continuing to work on finding an appropriate placement for the parent. Patient Ombudsman encouraged the complainant to continue to work with Ontario Health atHome and provided referral information for the Ministry of Long-Term Care’s Inspection Program.

Seniors with dementia or delirium may exhibit responsive behaviours such as verbal or physical aggression, wandering or resisting care. In some health care settings, restraints are used to manage responsive behaviours. Many hospitals note patient safety (including preventing falls) and cognitive impairment as the most common reasons for using restraints.⁴ More recently, Patient Ombudsman has noted a small but emerging trend of long-term care homes refusing to accept admissions or readmissions of residents who have had incidents of challenging behaviour in the past. This can increase the strain on individuals and their families and result in delayed access to the appropriate medical and personal care supports.

In 2024/25, Patient Ombudsman saw complaints about the various tools being used to manage patients with challenging behaviours. We received 63 complaints involving isolation, physical and chemical restraints, and security involvement. Within these complaints, 38% involved individuals who were experiencing mental health and/or addiction challenges; 10% involved individuals with dementia and/or experiencing delirium; and 2% involved adults with autism.

Patient experience

The complainant’s elderly parent was taken to hospital with an infection and related delirium. When the patient became agitated, began wandering and resisted care providers’ attempts to direct them back to their room, the providers used chemical and physical restraints. The family was concerned that they were not notified immediately when the restraints were used and the hospital’s documentation of the incidents was not adequate.

What we did

The Early Resolution Specialist requested and examined the hospital’s policies and assessed if it followed its policies in this case. Patient Ombudsman identified three main shortcomings, specifically the lack of timely notification of the family, the lack of documentation to demonstrate compliance with policy, and a lack of a clear explanation that restraints could be used without the family’s consent when there is a safety concern. The Early Resolution Specialist also looked at the hospital’s review of the complaint and noted that the hospital had apologized for the family’s experience, acknowledged the gaps in its process, and took steps to improve, including communicating with families about use of restraints. This included reviewing documentation standards with the nurses on the unit and providing staff-wide education on the use of restraints. The hospital noted the importance of ongoing training and monitoring for adherence. Patient Ombudsman assessed that the hospital’s response and follow-up actions were a fair conclusion to the serious issues raised.

Across these complaints, the methods used to manage behaviour included:

42% involved physical restraints (e.g., ankle/wrist restraints).
50% reported chemical restraints (e.g., sedatives, antipsychotics) being used.
22% involved the use of environmental restraints (e.g., isolation).
32% described security involvement and use of force to restrain individuals.

While many cases were about public hospitals, 6% of complaints were about services and organizations outside of Patient Ombudsman’s jurisdiction, including primary care, community mental health and addiction programs and retirement homes.

The approach health care organizations adopt in response to challenging behaviours can be particularly concerning when it leads to the patient or long-term care resident being injured. This year, Patient Ombudsman initiated an investigation after receiving a complaint and learning of a second incident from the same hospital about patients who were injured during interactions with hospital security (see the investigation summary, Security use of force in the emergency department). As part of our investigation, we recommended that the hospital develop procedures for investigating and resolving complaints about security guards to ensure cases are handled fairly and consistently. We also recommended that the hospital fully implement a body-worn cameras project to provide objective evidence when assessing use of force. The hospital committed to fully implementing these recommendations by the end of 2025. Patient Ombudsman encourages hospitals to review their policies on the use of force and continue to support patients and families to raise concerns and make about their care.

References

¹ Okuno, T., Itoshima, H., Shin, J., Morishita, T., Kunisawa, S., & Imanaka, Y. (2021, November 22). Physical restraint of dementia patients in acute care hospitals during the COVID-19 pandemic: A cohort analysis in Japan. PLoS ONE, 16(11), e0260446. https://doi.org/10.1371/journal.pone.0260446
² Campitelli, M. A., Bronskill, S. E., Maclagan, L. C., Harris, D. A., Cotton, C. A., Tadrous, M., Gruneir, A., Hogan, D. B., & Maxwell, C. J. (2021, August 2). Comparison of Medication Prescribing Before and After the COVID-19 Pandemic Among Nursing Home Residents in Ontario, Canada. JAMA Network Open, 4(8), e2118441. https://doi.org/10.1001/jamanetworkopen.2021.18441
³ Register Registered Nurses’ Association of Ontario. (2012, February). Promoting Safety: Alternative Approaches to the Use of Restraints. https://rnao.ca/bpg/guidelines/promoting-safety-alternative-approaches-use-restraints
⁴ Thomann, S., Zwakhalen, S., Richter, D., Bauer, S., & Hahn, S. (2021, February). Restraint use in the acute-care hospital setting: A cross-sectional multi-centre study. International journal of nursing studies, 114, 103807. https://doi.org/10.1016/j.ijnurstu.2020.103807