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Restrictive Practices

“The use of restraint is a significant infringement of a person’s right to free movement, privacy, liberty and freedom from medical treatment without full, free and informed consent. Restraint should only be used as last resort after other options have been considered and excluded, and for the purpose of protecting the person from an immediate, imminent and significant risk to their health or safety.” Victorian Government Department of Health (2010).

Guidelines and regulations in relation to restrictive practices are a recent yet pervasive area of practice for many Allied Health Professionals. In order to help you understand and navigate this area of practice, Allied Health Support Services has compiled some information (to the best of their knowledge) and resources for you!

First and foremost, the National Disability Insurance Scheme (NDIS) Act 2013 (Section 9) defines a restrictive practice as ‘any practice or intervention that has the effect of restricting the rights or freedom of movement of a person with a disability’.

In simple terms, is the purpose to manage a behaviour of concern?

  • If YES, then it is likely a restrictive practice and requires a behaviour management plan and notification to a regulatory body (e.g., the NDIS Quality and Safeguards Commission)
  • If NO (i.e., the purpose is to support, assist transfers, etc) then it is likely a therapeutic support

The NDIS rules (Restrictive Practices and Behaviour Support) 2018 and the Disability Service Act 2006 list five different types of restrictive practices. These include chemical restraint, mechanical restraint, physical restraint, environmental restraint and seclusion. While these five restrictive practices will be the main focus of this blog, it is important to know that literature in this area suggests containment, power control, and consequence control are also ‘a significant infringement of a person’s right to free movement, privacy, liberty and freedom’ and therefore constitute restrictive practices (for more information about these lesser-known restrictive practices, refer to the ‘useful resources’ section).

Seclusion

  • Definition: The person is left alone in a room/space and cannot (or believe they cannot) leave if they want to
  • Examples include:
    • Being locked in a room or area, such as your home or backyard, and being unable to leave
    • Being left alone in a room and believing you cannot leave
    • Being unable to leave a room or area due to inaccessible door handles

Chemical Restraint

  • Definition: The use of medication to control a person’s behaviour
  • Examples include:
    • Use of psychotropic medications when behaviours may not be occurring
    • Over-medication or misuse of medication
    • Giving medications differently to how they are prescribed
    • Long term use of medication without a review to reduce the use of medication for the purposes of behaviour management
    • Menstruation suppression
  • Note, this is the most common form of restraint

Mechanical Restraint

  • Definition: Use of a device to limit someone’s movement or control behaviour. Often to reduce risk of someone hurting themselves or others
  • Examples include:
    • Clothing which limits someone’s movement and which the person cannot remove
    • Velcro straps and belts
    • Seatbelt locks
    • Putting on a person’s wheelchair brakes so they can’t move if they want to

Physical Restraint

  • Definition: Use force and make a person do something or hold them so you can control their behaviour
  • Examples include:
    • A person’s hand is held down to prevent them from hitting themselves
    • Taking someone’s arm and pulling them in a direction they do not want to go
    • Holding down a part of someone’s body to address a behaviour of concern
  • Sometimes emergency physical restraint is necessary if a person is at immediate risk of harm and staff have a duty of care to keep them safe
    • Only used when it is the only available option to reduce the danger
    • Need to consider what the person is trying to tell us through their behaviour

Environmental restraint (= restricted access)

  • Definition: Restricts a person’s free access to all parts of their environment, including rooms, cupboards, items/objects or activities
  • Examples include:
    • Restricting/limiting access to an object (e.g., a kitchen knife) to prevent the person causing harm to self or others
    • The front door being locked, and only staff have the key
    • Restricting access to food in locked cupboards or fridges
    • Not being able to access your own possessions without asking/getting permission
    • Rooms that are locked and cannot be accessed without asking/getting permission
    • Not being able to access the community
    • Not being able to come and go freely in the yard

Generally, staff and family members use restrictive practices for perceive ‘assistance’ and ‘safety’. Use of restrictive practices may be accidental, systemic or purposeful.

Predominanely, Allied Health Professionals are aiming to reduce and/or eliminate the use of regulated restrictive practices in alignment with agreements signed by all States and Territories and the Federal Government. However, in some circumstances, restrictive practices are necessary to protect a client (or others) from harm. The decision to use a restrictive practice needs careful clinical and ethical consideration – i.e., must be trauma-informed, reviewed and updated regularly, used for the shortest possible time, and be the least restrictive response possible in the circumstances to ensure the safety of the person or others. It should consider a client’s sense of belonging, self-determination, empowerment, and participation in activities (i.e., human rights) as well as their physical health (e.g., pressure sores, skin irritation, bruising, muscle weakness) and mental wellbeing.

A regulated restrictive practice can only be deemed clinically necessary if ALL other alternatives have been excluded and a proactive, person-centered, and evidence-informed positive behaviour support plan (written by a behaviour specialist) is in place.

Typically, an appropriate regulatory body (such as the NDIS Quality and Safeguards Commission and/or the Queensland Civil and Administrative Tribunal) needs to be informed of the clinical justification and authorisation process of the regulated restrictive practice prior to implementation.

At any time, these five restrictive practices are subject to oversight and regulation by regulatory bodies. This rigorous process is essential as there are many adverse outcomes of restrictive practices on people with disabilities, some of which are listed below.

  • Restrictive practices do not address the underlying factors that cause the behaviour of concern (LeBel, Nunno, Mohr, & O’Halloran, 2012). For example, people with disabilities who have limited communication skills and/ or emotional regulation skills may self-harm in response to underlying factors such as confusion, anxiety, trauma, sensory impairments, or an underlying illness or pain (Emerson et al., 2014).
  • Controlling one behaviour using a restrictive practice can lead to other behaviours of concern (Deshais, Fisher, Hausman, & Kahng, 2015).
  • A restrictive practice may be triggering to a person with a history of trauma and abuse.
  • A restrictive practice can cause trauma and psychological distress (LeBel et al., 2012).
  • The use of a restrictive practice may result in a loss of dignity for the person with a disability.
  • A restrictive practice can limit personal freedom and the person’s ability to engage in activities of daily life (Deshais et al., 2015).
  • They can reduce meaningful interactions with carers and support staff.
  • Long-term use of restrictive practices may lead to an over-reliance, which could result in the person seeking restraint or becoming anxious without the restraint (Department of Health and Human Services, 2019).

Summary pictures from the NDIS Quality and Safeguards Commission (2020). Regulated Restrictive Practices Guide. Penrith, Australia.

 

Some relevant legislation referred to throughout this blog and for your future reference:

  • The Disability Service Act 2006
  • The National Disability Insurance Scheme (NDIS) Act 2013
  • The Mental Health Act 2016

Useful resources:

https://www.nasmhpd.org/content/six-core-strategies-reduce-seclusion-and-restraint-use

https://www.nds.org.au/zero-tolerance-framework/considering-additional-risk

https://socialequity.unimelb.edu.au/__data/assets/pdf_file/0017/2004722/Seclusion-and-Restraint-report.PDF

https://www.maybo.com.au/training/care/intellectual-disabilities-au/

References:

Victorian Government Department of Health (2010). Working with the suicidal person – A summary guide for emergency departments and mental health services. Victoria [PDF] https://www2.health.vic.gov.au/Api/downloadmedia/%7BA1048C60-5F62-47E6-A933-B27B0BCC801D%7D

Williams, M. S., & Shellenberger, S. (1996). How does your engine run? : a leader’s guide to the Alert Program for self-regulation. Albuquerque, NM: TherapyWorks, Inc

Brown, C., & Dunn, W. (2002). Adolescent-Adult Sensory Profile: user’s manual. San Antonio, Tex.: Therapy Skill Builders : Psychological Corp

Queensland Government, Metro South Health. (2021). Rehabilitation Mental Health. https://metrosouth.health.qld.gov.au/rehabilitation-mental-health?provider=168

Scanlan, J. N., & Novak, T. (2015). Sensory approaches in mental health: A scoping review. Aust Occup Ther J, 62(5), 277-285. doi:10.1111/1440-1630.12224

NDIS Quality and Safeguards Commission (2020). Regulated Restrictive Practices Guide. Penrith, Australia: NDIS Quality and Safeguards Commission.

Risks, C. (2021). Considering Additional Risk – National Disability Services. Retrieved 28 June 2021, from https://www.nds.org.au/zero-tolerance-framework/considering-additional-risk

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