Standard 5: Comprehensive Care

Minimising restrictive practices: restraint

Action 5.35

Where restraint is clinically necessary to prevent harm, the health service organisation has systems that:

a. Minimise and, where possible, eliminate the use of restraint

b. Govern the use of restraint in accordance with legislation

c. Report use of restraint to the governing body

Intent

Harm relating to the use of restraint is minimised.

Reflective questions

What strategies does the health service organisation have in place to minimise the use of restraint?

Are members of the workforce competent to implement restraint safely?

How does the health service organisation ensure that the workforce is aware of safety implications of different forms of physical and mechanical restraint with different patient populations?

What processes (for example, benchmarking, routine review) are used to review the use of restraints in the health service organisation?

Key tasks

  • Understand where and when restraint is used in the health service organisation.

  • Benchmark the use of restraint.

  • Demonstrate implementation of strategies to reduce the use of restraint.

  • Ensure that members of the workforce who implement restraint are trained to do so safely.

  • Monitor and document appropriate observations during and subsequent to restraint.

  • When restraint has occurred, offer debriefing for the people involved, including patients, carers and members of the workforce.

Strategies for improvement

Hospitals

Know the types of restraint

Restraint is the restriction of an individual’s freedom of movement.1 It includes mechanical restraint, physical restraint, and chemical or pharmacological restraint.

Mechanical restraint is the application of devices (including belts, harnesses, manacles, sheets and straps) to a person’s body to restrict their movement. This is to prevent the person from harming themselves or endangering others, or to ensure that essential medical treatment can be provided. It does not include the use of furniture (including beds with cot sides and chairs with tables fitted on their arms) that restricts the person’s capacity to get off the furniture, except when the devices are only used to restrain a person’s freedom of movement. The use of a medical or surgical appliance for the proper treatment of physical disorder or injury is not considered mechanical restraint.

Physical restraint is the application by members of the healthcare workforce of hands-on immobilisation or the physical restriction of a person to prevent them from harming themselves or endangering others, or to ensure that essential medical treatment can be provided.2

Chemical/pharmacological restraint is defined in some state and territory mental health Acts, but there are no nationally comparable data supply activities for this category.2 There is a lack of consensus on the definition of chemical/pharmacological restraint3, because of difficulties in determining whether a clinician’s intent is primarily to treat a person’s symptoms or to control their behaviour. For this reason, the Commission does not currently require health service organisations to report on the use of chemical restraint (except when this is directed under state or territory legislation). Nonetheless, organisations should seek to understand if there is inappropriate use of medicines, and note if rates of rapid tranquilisation increase.

Use strategies, tools, resources and training to minimise restraint

Restraint is practised in mental health services and other health service organisations. Minimising and, if possible, eliminating the use of restraint and seclusion were identified as a national safety priority for mental health services in Australia in 2005.4

The key to minimising use of restrictive practices is to be alert to changes in a person’s behaviour or demeanour that may suggest a deterioration in their mental state. Be receptive to information from the person themselves, and from their carers and families. People who have experienced mental health issues, or cared for someone who does, often have detailed knowledge about what can lead to a deterioration in their mental state, and what strategies are most effective for restoring their capacity to manage their mental state without the use of restrictive practices. These principles are outlined in the National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state.5

The National Seclusion and Restraint Project identified six main strategies for health service organisations to minimise restraint:

  • Leadership towards organisational change
  • Use of data to inform practice
  • Workforce development
  • Use of restraint and seclusion reduction tools
  • Improving the consumer’s role
  • Debriefing techniques.

These are described in detail in the Mental Health Professional Online Development training module Reducing and Eliminating Seclusion and Restraint.6 This training module also includes information on strategies to reduce the use of restraint.

The Royal Australian and New Zealand College of Psychiatrists Position Statement 61: Minimising the use of seclusion and restraint in people with mental illness7 supports the principles outlined above, and makes recommendations, including a review of the concept of chemical restraint, and cautions against using prone restraint.

Within mental health services, the use of restraint is governed through state or territory legislation, or mandatory policy. It is critical that health service organisations ensure that, when restraint is practised, members of the workforce are aware of, and practise within, the legislation of their state or territory. Legislative requirements differ between states and territories. The 2014 Seclusion and Restraint Project Report by the Melbourne Social Equity Institute maps these differences.8 Links to current state and territory legislation are provided in the Resources section at the end of this standard.

Outside mental health services, restraint is used, but often with less reporting and oversight. Older people with cognitive impairment are more likely than the general population to be restrained in acute care services, and also more likely to experience adverse outcomes relating to the use of restraint.9,10 In 2009, the Commission released Preventing Falls and Harm From Falls in Older People: Best practice guidelines for Australian hospitals.11 These guidelines explain that, although falls prevention is often cited as a reason for using restraints, research has shown that restraint can increase the chance of falls. These guidelines include strategies to reduce the use of restraint and to prevent falls.

In 2015, SA Health released a suite of documents relating to the use of restrictive practices in health care, including a policy framework, guidelines, implementation tools and fact sheets for clinicians.

Day Procedure Services

For many day procedure services, restraint will rarely be clinically necessary to prevent harm. Strategies to minimise restraint should be applied if pre-admission screening identifies that patients are at risk.

Restraint is practised in mental health services and other health service organisations. Minimising and, if possible, eliminating the use of restraint and seclusion were identified as a national safety priority for mental health services in Australia in 2005.156

The key to minimising use of restrictive practices is to be alert to changes in a person’s behaviour or demeanour that may suggest a deterioration in their mental state. Be receptive to information from the person themselves, and from their carers and families. People who have experienced mental health issues, or cared for someone who does,

often have detailed knowledge about what can lead to a deterioration in their mental state, and what strategies are most effective for restoring their capacity to manage their mental state without the use of restrictive practices. These principles are outlined in the National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state.157

Refer to NSQHS Standards Guide for Hospitals and NSQHS Standards Accreditation Workbook for detailed implementation strategies and examples of evidence for this action.

MPS & Small Hospitals

Know the types of restraint

Understand where and when restraint is used in the health service organisation and benchmark the use of restraint with similar organisations.

Restraint is the restriction of an individual’s freedom of movement.11 It includes mechanical restraint, physical restraint, and chemical or pharmacological restraint.

Mechanical restraint is the application of devices (including belts, harnesses, manacles, sheets and straps) to a person’s body to restrict their movement. This is to prevent the person from harming themselves or endangering others, or to ensure that essential medical treatment can be provided. It does not include the use of furniture (including beds with cot sides and chairs with tables fitted on their arms) that restricts the person’s capacity to get off the furniture, except when the devices are only used to restrain a person’s freedom of movement. The use of a medical or surgical appliance for the proper treatment of physical disorder or injury is not considered mechanical restraint.

Physical restraint is the application by members of the healthcare workforce of hands-on immobilisation or the physical restriction of a person to prevent them from harming themselves or endangering others, or to ensure that essential medical treatment can be provided.2

Chemical/pharmacological restraint is defined in some state and territory mental health Acts, but there are no nationally comparable data supply activities for this category.2 There is a lack of consensus on the definition of chemical/pharmacological restraint3, because of difficulties in determining whether a clinician’s intent is primarily to treat a person’s symptoms or to control their behaviour. For this reason, the Commission does not currently require health service organisations to report on the use of chemical restraint (except when this is directed under state or territory legislation). Nonetheless, organisations should seek to understand if there is inappropriate use of medicines, and note if rates of rapid tranquilisation increase.

Use strategies, tools, resources and training to minimise restraint

Restraint is practised in mental health services and other health service organisations. Minimising and, if possible, eliminating the use of restraint and seclusion were identified as a national safety priority for mental health services in Australia in 2005.4

The key to minimising use of restrictive practices is to be alert to changes in a person’s behaviour or demeanour that may suggest a deterioration in their mental state. Be receptive to information from the person themselves, and from their carers and families. People who have experienced mental health issues, or cared for someone who does, often have detailed knowledge about what can lead to a deterioration in their mental state, and what strategies are most effective for restoring their capacity to manage their mental state without the use of restrictive practices. These principles are outlined in the National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state.5

The National Seclusion and Restraint Project identified six main strategies for health service organisations to minimise restraint:

  • Leadership towards organisational change
  • Use of data to inform practice
  • Workforce development
  • Use of restraint and seclusion reduction tools
  • Improving the consumer’s role
  • Debriefing techniques.

These are described in detail in the Mental Health Professional Online Development training module Reducing and Eliminating Seclusion and Restraint.6 This training module also includes information on strategies to reduce the use of restraint.

The Royal Australian and New Zealand College of Psychiatrists Position Statement 61: Minimising the use of seclusion and restraint in people with mental illness3 supports the principles outlined above, and makes recommendations, including a review of the concept of chemical restraint, and cautions against using prone restraint.

Within mental health services, the use of restraint is governed through state or territory legislation, or mandatory policy. It is critical that health service organisations ensure that, when restraint is practised, members of the workforce are aware of, and practise within, the legislation of their state or territory. Legislative requirements differ across state or territory boundaries. The 2014 Seclusion and Restraint Project Report by the Melbourne Social Equity Institute maps these differences.8 Links to current state and territory legislation are provided in the Resources section at the end of this standard.

Outside mental health services, restraint is used, but often with less reporting and oversight. Older people with cognitive impairment are more likely than the general population to be restrained in acute care services, and also more likely to experience adverse outcomes relating to the use of restraint.9,10 In 2009, the Commission released Preventing Falls and Harm From Falls in Older People: Best practice guidelines for Australian hospitals.11 These guidelines explain that, although falls prevention is often cited as a reason for using restraint, research has shown that restraint can increase the chance of falls. These guidelines include strategies to reduce the use of restraint and to prevent falls.

In 2015, SA Health released a suite of documents relating to the use of restrictive practices in health care, including a policy framework, guidelines, implementation tools and fact sheets for clinicians.

Ensure that members of the workforce who implement restraint are trained to do so safely and, when restraint has occurred, offer debriefing for the people involved, including patients, carers and members of the workforce.

Last updated 29th May, 2018 at 11:49pm
BACK TO TOP
References

Australian Institute of Health and Welfare. Mental health services in Australia: key concepts. Canberra: AIHW; 2012 [cited 2015 Jun 5].

Royal Australian and New Zealand College of Psychiatrists. Position statement 61. Minimising the use of seclusion and restraint in people with mental illness. Melbourne: RANZCP; 2016.

National Mental Health Working Group. National safety priorities in mental health: a national plan for reducing harm. Canberra: Australian Government Department of Health and Ageing; 2005.

Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to deterioration in a person’s mental state. Sydney: ACSQHC; 2017.

Mental Health Professional Online Development. Reducing and eliminating seclusion and restraint. Sydney: Cadre; 2014.

Melbourne Social Equity Institute. Seclusion and restraint project: report. Melbourne: University of Melbourne; 2014.

Australian and New Zealand Society for Geriatric Medicine. Position statement no. 2: physical restraint use in older people. Sydney: ANZSGM; 2012.

Peisah C, Skladzien E. The use of restraints and psychotropic medications in people with dementia. Canberra: Alzheimer’s Australia; 2014.

Australian Commission on Safety and Quality in Health Care. Preventing falls and harm from falls in older people: best practice guidelines for Australian hospitals. Sydney: ACSQHC; 2009.