Action 5.35

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.

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. 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 illness 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.

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.^5,6 In 2009, the Commission released Preventing Falls and Harm From Falls in Older People: Best practice guidelines for Australian hospitals. 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.

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 2005.⁴

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.

Refer to hospitals tab for detailed implementation strategies and examples of evidence for this action.

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.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.

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. 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 illness 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.

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.^5,6 In 2009, the Commission released Preventing Falls and Harm From Falls in Older People: Best practice guidelines for Australian hospitals. 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.